Keloid scars are clinically common, and because most involve only the skin and the scar itself is not life-threatening, they do not attract the attention of most other specialists. Due to the devastating impact of some keloids on appearance and their inherent difficulty in eradicating them, the pain they cause to many patients is unimaginable.
What exactly is a keloid?
To put it bluntly, keloid is a special type of scar, and keloid is the inevitable result of tissue trauma healing, except that some parts of the healing process lose their normal restraint control, resulting in excessive proliferation of fibrous tissue, which also results in keloid scars. Because of the appearance (in some patients), crab foot shape, it is also called crab foot swelling Because of its growth characteristic of invading normal skin, its appearance resembles a tumor, so some people also call it keloid tumor.
Although many scholars at home and abroad have researched and discovered many factors related to the formation of keloid, the exact cause of its development has not yet been identified. Currently, most scholars believe that the onset of the disease is related to systemic or local factors, with intrinsic factors playing a dominant role. These factors include race, skin color, genetics, individual differences, site of onset, local tension, foreign body irritation, infection, and various traumas.
The incidence of keloid scarring in people of color, especially in blacks, has been found to be significantly higher; some data show that the incidence of keloid scarring is 6-9 times higher in dark-skinned than in light-skinned people. Some patients may have a family history of scarring or a predisposition to scarring. Keloid scarring can be induced by any surgery, burns, insect bites, local microtrauma, boils, BCG injections or folliculitis, ear piercing, acne, and can even grow on normal skin. The disease can occur at all ages, but it is common in young adults and also in the oldest old. The disease can grow on most parts of the body, but is most common on the chest, around the shoulders, earlobes, jaw, perineum, and back.
The clinical manifestations of keloid scars vary widely. They generally appear as a persistent lump growing above the surrounding normal skin and beyond the original injury site, hard and cartilage-like, with poor elasticity, localized itching or pain, a dark red or purplish surface in the early stages, and a reddish-white color in the later stages, with a clear boundary with the surrounding normal skin. The lesions vary in size, from papule-like to large flakes.
The morphology is diverse and can be a relatively flat, symmetrical protrusion with regular edges, or an uneven mass with irregular protrusions, sometimes like a crab foot-like infiltrative growth into the surrounding tissue, sometimes like a butterfly, dumbbell, mushroom, irregular shape, etc. It can grow continuously and continuously, or it can remain in a stable state for a considerable period of time. Keloid scars generally do not degenerate on their own. Occasionally, they degenerate and atrophy on their own, independent of the course, location, cause or symptoms of the disease, for unknown reasons. Malignant degeneration of keloids has been reported, but the incidence is very low.
In terms of classification, keloids can be broadly divided into two categories: primary and secondary types. Primary keloid scars have no obvious history of trauma or surgery and start as small red dots with itchiness, gradually changing from small to large, soft to hard, red or dark red, cord-like, butterfly-like, round, or irregularly shaped.
Secondary keloid scars, also called hyperplastic scars, are caused by burns, trauma, acne, infection and septicemia, or after surgery, laser, freezing, implants, or hormonal medication, causing excessive proliferation of damaged tissues and degeneration of subcutaneous tissues, protruding from the skin, red or dark red with itching or tingling, and some with obvious outward extension of capillaries.
In secondary cases, the shape is variable, often resulting in dysfunction or affecting the appearance due to contracture. Some patients have a tendency to aggravate their symptoms after drinking alcohol or eating spicy foods and other irritants.
As for the question of keloid patients being keloid, opinions differ. The majority of keloid patients are found clinically to be single or less than two. He/she does not have keloid occurrence in other areas of surgery or trauma, or even keloid hyperplasia, and only a few patients are prone to keloid scarring in other areas, so that most of these patients are not keloid, just like a patient who is clinically allergic to a drug, we cannot call him/her allergic. This is the mystery of why keloid scars occur.
Although keloid scars are common, they are still one of the challenges in plastic surgery in terms of treatment. Despite the tantalizing advertisements and the “promise of a cure”, there is no satisfactory cure for keloid scars in China or abroad because of the difficulty in completely controlling their recurrence. Since keloids are unique to humans, no satisfactory animal models can be produced, and research has been slow.
Comprehensive domestic and international treatment methods include.
Surgical excision, intra-scar drug injection, radiation therapy, laser, silicone gel, compression and freezing are the main therapeutic measures. At present, the more unified advocate is the combined application of multiple methods, and only comprehensive treatment can achieve better results.
Surgical treatment.
Including surgical excision and suturing, surgical excision followed by skin grafting or flap transfer, application of skin soft tissue expander, etc. Regardless of the surgical method, surgery alone, without other post-operative treatment is a no-no, because almost 100% recurrence is possible. However, surgery followed by radiotherapy or local drug injection is a recognized and effective method.
Unless malignancy occurs, etc., the purpose of surgery should not be to completely remove the scar, but to control the incision within the scar, so that the scar becomes thinner and smaller, creating a good foundation for later treatment, which can avoid the possibility of enlarging the lesion due to the prolongation of the incision brought by complete removal of the scar, and improve the effect of later treatment, which can be said to get twice the result with half the effort.
Local intra-scar drug injection.
Commonly used is a class of drugs with trimethoprim and compound betamethasone as the main ingredients, which is the most commonly used treatment method at home and abroad. It can flatten and soften the scar, relieve itching and pain; of course, it can also cause local tissue depression or hypopigmentation, menstrual disorders, etc., but these complications are generally reversible, and the symptoms will gradually reduce or subside after stopping the drug. In addition, there are also drugs such as 5-Fu, pinyamycin, benadryl, recombinant interferon (rIFN-r), etc., which have achieved different degrees of effectiveness, but the clinical application is not widespread.
Radiotherapy.
The commonly used 32P, 90Sr dressing, electronic wire, etc., have good effect. At present, radiotherapy is usually combined with surgery, and mostly advocates early radiotherapy after excision, the earlier the radiotherapy, the lower the recurrence rate.
Although radiation therapy has achieved clear results on keloids, there is no detailed conclusion on whether it is superior to other methods. Moreover, the radiation damage that can occur with radiation therapy, such as skin erythema, carcinogenesis, bone marrow suppression, and radioactive ulcers, has led to controversy about the safety and efficacy of radiation therapy for keloid scars. However, with the development of science and technology, radiation therapy machines and techniques are constantly improved and perfected, and the results are bound to become better and better.
Silicone gel, laser, and freezing have also been reported for the treatment of keloid scars, but the efficacy is not yet certain. Systemic therapy with oral or injectable drugs is generally suitable for some patients with multiple and severe cases. Cytokine and gene therapy are still in the research stage, but have a promising future.
In conclusion, the treatment of keloids is now mainly a combination therapy. The combination of surgery, radiotherapy, drug injection, freezing, laser, silicone gel and other therapies in duplex, triplex or even quadruplex for keloid treatment to improve its efficacy is the most effective method for keloid treatment at home and abroad. In particular, the combination therapy represented by surgery + drug injection or + electronic wire or +90S has achieved very good clinical results.
For keloid scars slightly above the skin, the method of drug injection alone or simple superficial X-ray treatment irradiation or dressing with 32P and 90Sr can be used. For those whose keloid is more than 2mm above the skin, it is advisable to surgically thin the keloid first and then perform drug injection or radiation therapy after surgery. For those with obvious contracture, the scar should be loosened while preserving part of the scar tissue as much as possible, and drug injection or radiation therapy should be performed after surgery. For those with recurrent ulcers or malignant changes, complete surgical excision should be performed, followed by postoperative radiation therapy or drug injection.
Finally, it should be noted that there is another type of scar called hypertrophic scar, also known as hyperplastic scar, which is so similar to keloid in appearance that even many medical practitioners sometimes cannot distinguish it from keloid. After a few months of growth, most of them can stop growing, and after a few years, some patients can recede naturally, and those who do not recede will not grow anymore.