Keloid scars represent an exuberant response to exogenous (ie,
surgery, trauma, piercings) or endogenous (ie, acne, varicella)
insults to the skin. Keloids are red-brown papules and nodules that extend
beyond the point of initial injury, often resulting in disfiguring,
bulky lesions that may be asymptomatic, pruritic, or painful. In
contrast, hypertrophic scars are histologically distinct and clinically
are confined to the borders of the initial injury. Keloids are
more common in people with darker skin, although they can be seen
in any skin type.3 Certain anatomic locations are considered
at higher risk for keloid formation, including the skin of the ears,
shoulder, and upper chest. The etiology is believed to multifactorial.
Genetic predisposition, intrinsic fibroblast abnormalities, growth
factor influences, and wound tension have all been implicated.4 Transforming
growth factor-β (TGF-β) is thought
to play an important role in keloid formation.5 Histologically,
keloids display thick, hyalinized bands of collagen. Therapy is
challenging because recurrence after surgical debulking is common
(45–100%).6 A series of intralesional
steroid injections is commonly used to flatten the lesions. Very
exophytic lesions may benefit from surgical excision followed by
adjunctive therapy such as a series of intralesional steroid injections,
application of topical imiquimod, compression, or radiation to prevent
recurrence.7 Silicon gel sheeting, cryotherapy, and intralesional
interferon can also be used as adjunctive therapy. Carbon dioxide
laser and pulsed dye laser therapy may be beneficial in some cases.8 Prevention
of further keloids is crucial. Inflammatory acne should be appropriately
treated, and elective procedures such as piercing should be avoided.