Overview

Keloid scarring is a type of raised scar that develops after your skin has been injured. Unlike typical scars that stay within the boundaries of the original wound, keloids grow much larger, spreading beyond the edges of the initial injury. This happens because your body produces too much collagen – a protein that helps skin heal – during the repair process. Keloids are often described as firm, smooth, shiny, and rubbery lumps on the skin.

These scars can appear anywhere on the body where the skin has been damaged, but they are particularly common in the head and neck region, including the ears (especially after piercings), chin, and neck. They can also affect the chest, shoulders, and lower legs. Once a keloid forms, it usually doesn't shrink or disappear on its own, and it can become a permanent feature.

Keloids are different from another type of raised scar called a hypertrophic scar. While hypertrophic scars are also raised, they stay confined to the area of the original wound and often improve over time. Keloids, however, continue to grow beyond the wound's borders and typically do not regress spontaneously.

Symptoms and Causes

Understanding why keloids form and how they appear can help you recognise them and seek appropriate care. Keloids are a result of your body's unique way of healing, and while they are not harmful to your health, they can sometimes cause discomfort and affect your confidence.

Symptoms

Keloid scars have a distinct appearance and can cause various sensations, especially as they grow. Here are the common symptoms you might experience:

• Appearance: Keloids are typically raised above the surrounding skin, feeling firm, smooth, and often shiny or rubbery to the touch. They are usually hairless. Their colour can vary widely; they might be skin-coloured, pink, red, brown, or even darker than your natural skin tone. Early keloids might appear red, later becoming brown or pale.
• Growth Pattern: A key feature of keloids is that they grow beyond the original wound boundaries. They can emerge weeks, months, or even over a year after the initial injury and may continue to grow for several months or even years.
• Sensations: While growing, keloids can often be itchy, prickly, or sore. Some people describe a painful sensation, particularly in the centre of the scar, and itchiness where the keloid meets normal skin. However, it's also possible to have a keloid with no sensation at all.
• Movement Restriction: If a keloid forms near a joint, such as on the neck or shoulder, its firmness and size can sometimes restrict your movement, making it difficult to move that part of your body freely.

Causes

Keloids develop when the skin's healing process goes into overdrive, producing an excessive amount of collagen. While the exact reason for this overproduction isn't fully understood, it's clear that keloids are triggered by skin injury and are influenced by several risk factors:

• Skin Injury: Any damage to the skin can potentially lead to a keloid. Common triggers include:
• • Cuts and scrapes
  • Burns
  • Surgical incisions (cuts made during an operation)
  • Acne and folliculitis (inflammation of hair follicles)
  • Body piercings (especially ear piercings)
  • Tattoos
  • Vaccinations
  • Infected wounds
  • Even minor skin damage
• Genetic Predisposition: There is often a genetic link, meaning keloids can run in families. If close relatives have keloids, you may be more likely to develop them too.
• Ethnicity and Skin Tone: Keloids are more common in individuals with darker skin tones, particularly those of African, African Caribbean, South Asian, Chinese, or Hispanic descent. People with skin types V-VI are at higher risk, though they can affect anyone.
• Age: Keloids most frequently develop in people between the ages of 10 and 30, often during puberty.
• Hormonal Factors: Hormonal changes, such as those occurring during pregnancy or puberty, are also associated with an increased risk of keloid formation.
• Chronic Inflammation: Ongoing inflammation in the deeper layers of the skin (reticular dermis) can be a root cause, with conditions like acne and folliculitis acting as precipitating factors.
• Poor Wound Healing: Factors that complicate wound healing, such as infection or retained suture material (stitches left in the skin), can also increase the risk.

Diagnosis and Investigations

Diagnosing a keloid scar is usually a straightforward process for your doctor, primarily relying on a careful examination of your skin and a discussion about your medical history.

Diagnosis

When you visit your GP or an ENT specialist, they will typically diagnose a keloid based on:

• Visual Examination: The doctor will carefully look at the scar. Keloids have a very characteristic appearance – they are raised, smooth, shiny, and often extend beyond the original wound's edges. This growth beyond the initial injury site is a crucial differentiator from other types of scars.
• Medical History: Your doctor will ask you questions about when and how the scar developed, any previous skin injuries, whether you have a family history of keloids, and if you've had keloids before. They will also ask about any symptoms you're experiencing, such as itching, pain, or discomfort.

The combination of the scar's appearance and your history is usually enough for a confident diagnosis. It's important to differentiate keloids from hypertrophic scars, which, while also raised, do not grow beyond the original wound and tend to improve over time.

Investigations

In most cases, no specific tests or investigations are needed to diagnose a keloid scar. The diagnosis is primarily clinical, meaning it's made by a healthcare professional based on what they see and hear from you. You won't typically need blood tests, imaging scans, or biopsies for a keloid diagnosis. However, if there's any uncertainty or if the scar has an unusual appearance, your doctor might consider further evaluation to rule out other skin conditions, though this is rare for typical keloids.

Management and Treatment

Living with keloid scars can be challenging, as they often don't disappear completely. However, there are many effective treatments available to help manage their appearance, reduce discomfort, and prevent them from growing larger. The goal of treatment is to flatten and soften the scar, relieve symptoms like itching and pain, and improve its overall look. It's important to remember that complete eradication of a keloid is often not possible, and recurrence is a risk, but significant improvement is achievable.

Early treatment is often crucial to help prevent keloids from growing further. Your ENT specialist or dermatologist will discuss the best options for you, often recommending a combination of treatments for the most effective results.

• Steroid Injections (Intralesional Steroids): This is one of the most common and effective treatments. A corticosteroid medication, such as triamcinolone acetonide, is injected directly into the keloid scar (this is what "intralesional" means – into the lesion itself). These injections help to reduce inflammation, flatten the scar, and relieve symptoms like itching and pain. You will usually need a course of injections, repeated every few weeks.
• • Potential Side Effects: While effective, steroid injections can sometimes lead to side effects such as thinning of the skin around the injection site, the appearance of small visible blood vessels (telangiectasia), white patches (hypopigmentation), or darkening of the skin (hyperpigmentation).
• Silicone Dressings or Gels: Applying silicone sheets or gels directly to the keloid can help to soften and flatten the scar over time. These are often used as a preventative measure after surgery in high-risk patients or as a long-term management strategy. They work by hydrating the scar tissue and regulating collagen production.
• Cryotherapy (Freezing): This treatment involves freezing the keloid with liquid nitrogen. The extreme cold helps to flatten and reduce the size of the scar. Cryotherapy can be a good option, especially for smaller keloids or those with a narrow base. It often requires several sessions.
• Laser Therapy: Various types of laser therapy can be used to improve the appearance of keloids. Lasers can help to reduce the redness, flatten the scar, and improve its texture. Laser treatment is often used in combination with other therapies, such as steroid injections, for better results.
• Radiation Therapy (Radiotherapy): In some cases, particularly after surgical removal, radiation therapy may be used. This involves using low doses of radiation to prevent keloid cells from regrowing. It is often combined with surgery to significantly reduce the risk of recurrence.
• Surgical Removal (Excision): While it might seem like the most direct solution, surgical removal of keloids (excision) is generally not recommended as a standalone treatment. This is because keloids have a very high rate of recurrence after surgery, and the new scar can often be larger than the original. If surgery is considered, it should only be performed by experienced surgeons and must be combined with other treatments, such as steroid injections or radiation therapy, immediately before or after the procedure, to minimise the risk of the keloid growing back even larger. The aim of surgery, when combined with other treatments, is to remove the raised lump and replace it with a flatter, less symptomatic scar.
• Other Treatments: In some situations, other medications might be injected into the keloid, such as 5-fluorouracil (a chemotherapy drug) or bleomycin, often in combination with steroids, as these combinations have shown greater effectiveness than steroids alone.

Prevention

Preventing keloid scars, especially if you know you are at risk, is a very important part of managing this condition. Since keloids are triggered by skin injury, the main strategy is to avoid unnecessary trauma to your skin and to manage any skin conditions promptly.

Here are key preventative steps:

• Avoid Unnecessary Skin Trauma:
• • Tattoos and Piercings: If you have a history of keloids or a family history, it is strongly advised to avoid tattoos and body piercings, particularly in high-risk areas like the ears, chest, and shoulders.
  • Unnecessary Cosmetic Surgery: Discuss your keloid tendency with any surgeon before considering cosmetic procedures. They can help you weigh the risks and explore alternatives.
• Prompt Treatment of Skin Conditions:
• • Acne: Treat acne effectively and early to prevent severe breakouts and skin damage that could lead to keloids.
  • Folliculitis: Address any inflammation of hair follicles promptly to reduce the risk of keloid formation.
• Inform Your Healthcare Team: If you are undergoing any surgical procedure, even a minor one, always inform your surgeon and medical team about your history of keloids or if you have a family history. This allows them to take extra precautions during wound closure and consider preventative measures.
• Post-Operative Care for High-Risk Individuals: If you are at high risk for keloids and need surgery, your doctor might recommend using silicone sheets or gels on the wound site after it has healed to help prevent a keloid from forming.

Outlook / Prognosis

Living with keloid scars means understanding that while they are challenging to treat, significant improvement in their appearance and symptoms is very much achievable. It's important to have realistic expectations: keloids cannot be entirely eliminated or cured, and they do not normally regress (shrink) on their own. They can also continue to grow for months or even years after they first appear.

The long-term outlook for keloids involves ongoing management. Even with successful treatment, there is always a risk of the keloid recurring, especially if it has been surgically removed. Recurrence rates can vary, sometimes up to 50%, and if a keloid does return after surgery, it can sometimes be larger than before. This is why combination therapies are often preferred, as they offer the best chance of preventing regrowth and achieving a lasting improvement.

Many people learn to manage their keloids effectively through a combination of treatments like steroid injections, silicone products, and laser therapy. These treatments aim to flatten the scar, reduce its size, soften its texture, and alleviate uncomfortable symptoms such as itching, pain, and prickliness. While the scar may not disappear completely, its appearance can be greatly improved, making it less noticeable and more comfortable to live with.

Managing keloids is often a long-term journey that requires patience and consistent follow-up with your ENT specialist or dermatologist. They will work with you to find the most suitable treatment plan, monitor your progress, and adjust therapies as needed. With the right approach, you can achieve a much better quality of life, with reduced discomfort and improved confidence regarding your skin.