I. Diagnosis and differential diagnosis of keloid scars
A keloid is an overgrowth of dense fibrous tissue that usually occurs after a skin injury has healed. This tissue proliferates beyond the original injury, does not regress spontaneously, and recurs after surgical excision (Rusciani, 1993). Diagnostic criteria for keloid scars: (1) invasive growth into the surrounding area beyond the original injury; (2) failure of spontaneous regression even after more than 9 months of disease; (3) recurrence after surgical excision (Darzi, 1992). Chen Xiaodong, Department of Dermatologic Venereology, Nantong University Hospital
(i) Clinical differences between keloids and hyperplastic keloids
Keloid scars
Proliferative keloid
Etiology
Minimal trauma, partly spontaneous generation
Trauma, burns
Time of occurrence
3 months, even years after trauma
4 weeks after trauma
Mode of growth
Beyond the limits of the initial injury
Confined to the limits of the initial injury
Tendency to fade naturally
No
Yes
Scar contracture
Does not occur
Can occur across the joint
Surgical treatment
Difficult
Effective
(ii) Histopathological differences between keloid and hyperplastic keloid
II. Treatment of keloid scars
(i) Non-surgical treatment of keloid: including intra-scar drug injection (hormone, 5-FU, botulinum toxin?) (ii) Radiation therapy, topical application of silicone products, compression therapy, laser therapy, etc.
Intra-scar drug injection: needle-free syringe, Depo-Provera (compound betamethasone injection): 5-FU mixed intra-dermal injection once every 2 weeks, combined with superficial electron beam irradiation (energy 4Mev, dose 7Gy/day for 3 days) after the lesion becomes flat.
(ii) Surgical treatment of keloids
Surgery is definitely not the preferred method of treatment for keloids, but in some cases, surgery removes the aesthetic and sensory/touching keloid, giving psychological or physical comfort to the patient, and creating the conditions for other subsequent treatments. Surgical excision must be combined with other treatments.
The indications for keloid surgery are divided into absolute and relative indications. Absolute indications: keloid tissues with sinus tracts and pus cavities that cause recurrent infections. Relative indications: ①Exposed areas, such as the earlobe, upper chest V-zone, and shoulder triangle obviously affect the appearance. ②Keloid located in the pubic mound. ③Women with large keloids on the anterior chest causing breast strain. ④Patients with obvious self-conscious symptoms and resistance to other treatments. ⑤ keloidal folliculitis of the collar.
Although supplemented with other combination therapies, suture margin tension is the key to recurrence after keloid treatment. Therefore, the choice of any keloid surgical approach should take into account the minimization of incisional suture tension. (1) If the tension of the incision allows, direct excision of the suture is the simplest method. ② For those with large areas but flat surfaces, surgical excision of a portion of the keloid followed by flap retraction (nucleotomy) is a good option. However, for those with large skin lesions, irregular shape and uneven surface, the operation is very difficult and the blood supply of the surface flap is poor, so the postoperative success rate is not high. ③For large keloids, such as anterior chest, soft tissue expansion of the skin, including paracutaneous and subscutaneous expander implantation, is an option, and both have their advantages and disadvantages. ④Free flap implants cause new trauma and are only indicated for some keloids that are not suitable for other surgical methods. ⑤ Local arbitrary flap transfer requires the use of a large adjacent area of normal skin to complete, and the tension of the incision after suturing is high, with a higher risk of postoperative recurrence, and is generally not advocated for keloid patients.
The application of a combination of therapies is currently advocated. First, a reasonable comprehensive assessment should be made in conjunction with the medical history and clinical presentation. Then, the treatment plan is decided according to the stage of progression, size, texture, and conscious symptoms of the lesion. In general, silicone gel sheets and compression therapy can be used as basic adjuvant therapy; intra-dermal glucocorticoid injection is the first line of treatment; surgical procedures should be performed with proper indications, following the principle of minimizing tension at the suture margin, and postoperative treatment with radiation.
This article is authorized by Dr. Xiaodong Chen.