Keloid Questions Answered by a Dermatologist: Keloid Scars and Their Removal

Hello. Today, we will delve into keloid scars, which many people are curious about. Keloid scars have characteristics different from typical scars, requiring proper understanding and management. Based on explanations from a dermatologist, we will answer all your questions about keloid scars.

Keloid scars are pathological scars where skin tissue excessively proliferates during the wound healing process, growing beyond the original wound area and invading surrounding healthy skin. Unlike typical scars, they do not disappear or fade on their own over time; instead, they tend to grow larger.

The term keloid is derived from the Greek word meaning 'crab's claw'. A doctor in the past named it after observing a keloid scar on a patient's chest that spread out like a crab's claw.

Keloid scars can appear in various forms and may be accompanied by several discomforts.

• Size: Varies depending on the size of the wound or when keloid growth stops. While typical scars stop growing once the wound heals, keloid scars tend to grow continuously as they are perceived as ongoing wounds.
• Color: Initially, they may appear red, then change to a deep purple or brown over time. In very favorable cases, they may change to skin color, but often they remain red for a long time.
• Symptoms: They don't just leave a scar but can also be accompanied by itching, pain, or uncomfortable sensations. Especially when itching or pain is present, it could be a sign that the keloid area is growing, so it is advisable to visit a hospital for examination.
• Texture: They can feel soft to the touch, but often they are very hard and have a rubbery, chewy feel. When a rubbery texture is felt, it tends to resist treatment, making early treatment crucial.

Keloid scars frequently occur in areas of the body where skin tension is strong. Of course, for individuals with severe keloid predisposition, they can occur anywhere, but they are particularly common in the following areas:

• Ears: Keloids often form on the ear helix or earlobe due to ear piercings or earrings. In the past, they mainly occurred on the earlobe, but recently, keloid development has become common in cartilage areas due to piercings.
• Shoulders: They often occur on the outer part of the shoulder. In the past, if inflammation occurred at the BCG vaccination site and the person had a keloid predisposition, it often swelled up. Also, acne scars on the shoulder can develop into keloids.
• Chest: If acne occurs on the chest, especially in the center of the chest, keloid scars are prone to forming. This is because when we breathe, the skin is pulled to both sides, continuously irritating the wound and causing the keloid to thicken. Sometimes it is confused with acne, but keloids are characterized by their persistence.
• Chin/Cheeks: Acne on the face usually leaves depressed scars, but acne on the chin or cheek areas often develops into raised keloid scars.
• Other Areas: They can occur in various areas such as C-section scars, minor scratches, tattoo sites, and burn scars.

While the exact cause of keloid scars is not 100% known, it is considered a functional disorder of the wound healing process. When a wound heals, the growth of scar tissue should stop, but collagen is excessively produced, causing it to swell.

Key contributing factors include:

• Skin Injuries: Skin damage due to various causes such as BCG vaccination, acne, insect bites, injections, piercings, tattoos, hair removal, burns, and C-sections.
• Constitutional Factors:
  • Race: Tends to occur more frequently in Asians or Africans than Caucasians.
  • Family History: About one-third of patients report having parents or siblings with keloids.
  • Age: Usually occurs frequently in active ages from around 10 years old when puberty begins until under 30 years old.
  • Pregnancy: There are also reports linking it to pregnancy.

It is important to remember that keloid scars are difficult to predict and can only be known once a scar forms on the body.

Both keloid scars and hypertrophic scars are raised scars, but they are medically distinct.

• Hypertrophic Scars: Scars that grow only upwards without exceeding the boundaries of the original wound. Rarely, they may fade without treatment over time.
• Keloid Scars: Scars that swell more broadly than the wound area, invading surrounding healthy skin. They have a strong pathological tendency and are difficult to improve naturally without treatment.

Initially, the two scars may appear similar, and there may be intermediate forms that are difficult to distinguish clearly. However, if they persist for more than 6 months and increase in size, they are likely keloid scars.

Keloid scars are a skin problem that does not invade systemic organs or affect internal systemic diseases. However, in the following cases, it is advisable to visit a hospital for professional medical attention:

• Immediately after discovering a keloid scar: Starting treatment early can minimize keloid growth and enhance treatment effectiveness. If a scar forms and does not disappear easily, it is good to check if it is a keloid.
• When accompanied by itching or pain: These symptoms often appear when a keloid is about to grow larger. If you feel discomfort, you should visit a hospital.
• When occurring in joint areas: It can restrict joint movement, so early treatment is necessary to prevent problems with joint function.
• When occurring in the chin or cheek areas: These areas move continuously when speaking or swallowing food, so irritation can cause keloids to grow larger. Treatment can be difficult and challenging, so early treatment is desirable.

Hospitals primarily diagnose keloid scars through medical history taking and visual inspection.

• Medical History Taking: Through conversation with the patient, family history, keloid onset time, and cause are identified. When visiting the hospital, it helps with the consultation if you pre-memo the keloid location, duration, cause, and family history.
• Visual Inspection: Keloid scars often have a characteristic appearance, such as being red, raised, and larger than the original wound, so they are often identified visually.
• Skin Biopsy (Tissue Examination): Skin biopsy is performed only in very rare cases where differentiation from skin cancer is necessary to make an accurate diagnosis.
• Ultrasound Examination: Ultrasound examination may also be performed to measure the size of the keloid and objectively confirm treatment effectiveness.

While there is no 100% perfect standalone treatment for keloid scars, combining several methods can achieve satisfactory treatment effects of 80 points or more. The main treatment methods are as follows:

Silicone Gel Sheets and Tapes

• An effective adjunctive therapy for scar reduction, with silicone sheets known to be the most effective.
• Helps reduce redness and is also used for recurrence prevention.
• Effective with consistent application for at least 6 months, 18-20 hours or more per day.

Injection Treatment

• The most commonly recommended treatment, primarily using steroid (Triamcinolone) components. The anticancer drug 5-FU may also be used.
• Shows excellent effects in softening hard scars, flattening raised scars, and improving symptoms such as itching or pain.
• Side Effects: Skin thinning can be a side effect, but this is sometimes utilized to reduce the thickness of keloid scars. Regular treatment in consultation with a specialist can reduce concerns about side effects.
• Pain: There may be pain during injection, but recently, low-pain injection methods are also available to minimize pain.

Compression Therapy

• A method that applies continuous pressure to the keloid scar area to inhibit its growth.
• Utilizes compression dressings, magnetic earrings, compression garments, etc.
• Can be effective by physically preventing the keloid from rising, but has the disadvantage of requiring long-term wear for about 6 months, 20 hours or more per day.

Vascular Laser Treatment

• The redness of keloid scars is caused by blood vessels, so vascular lasers such as V-beam or Synergy laser are used for treatment.
• Not only eliminates redness but also reduces scar height and is effective in alleviating itching or pain.
• Repeated treatments are performed at 4-8 week intervals, and it is even more effective when combined with injection treatment.
• Nd:YAG Laser is also reported to be effective in overall improvement of keloid's pigment, blood vessels, hardness, and height.

Cryotherapy

• A method that freezes the scar area using liquid nitrogen or carbon dioxide for treatment.
• Repeated treatments are performed at 3-4 week intervals.
• Side Effects: Blisters, pain, and hypopigmentation may occur, but when combined with other injection treatments, the intensity can be adjusted to minimize side effects. In some cases, such as ear keloids, removal may be possible with a single cryotherapy session.

Surgical Excision

• Considered when other treatments are unresponsive. Keloid scars have a very high recurrence rate of 45-100% even with small injuries, so surgical excision alone is rarely performed.
• Combination Therapy: Combining surgery with injections, lasers, compression therapy, radiation therapy, etc., is important to reduce recurrence rates and enhance treatment effectiveness.
• Special Cases: Surgery may be considered in cases that severely restrict joint movement or in areas with relatively low recurrence rates, such as ear keloids.

Radiation Therapy

• Performed restrictively in very large hospitals, and rarely combined with surgery. It is considered an excessive treatment for standalone cosmetic purposes.

If you have a keloid predisposition, it is important to be careful to avoid injuries and to respond early if they occur.

• Caution after Ear Piercing: After ear piercing, careful observation is necessary. If the earlobe begins to thicken, remove the earring and wear compression earrings or receive regular injection treatment at a dermatology clinic to prevent the keloid from growing larger. Compression earrings are recommended to be worn for at least 12 hours a day for 4-6 months.
• Avoid Unnecessary Procedures: If you have a keloid predisposition, it is advisable to avoid unnecessary procedures that cause skin injury, such as tattoos, body piercings, and cosmetic surgery. If a procedure is absolutely necessary, it is recommended to perform a test procedure on an unexposed area first. After cosmetic surgery, wearing compression garments or compression dressings may be helpful.
• Early Detection and Treatment: If you notice skin thickening, visit a dermatology clinic immediately to start treatment. The earlier you respond, the easier and more effective the treatment will be.
• Inform Medical Staff During Surgery: If you have a history of keloids, you must inform the medical staff in advance before surgery.

Keloid scars are a condition that requires continuous attention and management. If you have any questions, it is important to consult with a dermatologist at any time to establish an appropriate diagnosis and treatment plan.