A person's shoulder displaying keloid scars and acnePlantar keloid formationPlantar keloid formation
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Keloids

A keloid scar is a special kind of scar. Keloids are firm, rubbery lesions, and may be reddish or dark in color, or they may be shiny, hard pink-dome shaped lumps. They can result from injury to the skin or may form spontaneously. They often grow, and although they are harmless, non-contagious and usually non-painful, they can be a cosmetic problem. more...

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Occurrence

Keloids expand in clawlike growths into normal skin. They have the annoying capability to hurt with a needle-like jabbing pain or to itch uncontrollably without warning. Although these are temporary sensations that come and go, they can be extremely vexing for the victim.

If the keloid becomes infected, it may ulcerate. The only treatment is then to remove the scar completely. Unfortunately, the probability that the resulting surgery scar will become a keloid is high.

Keloids form within scar tissue. Wound collagen, used in wound repair, tends to overgrow the area, sometimes producing a lump many times the size of the original scar. Although they usually occur at the site of an injury, keloids can arise spontaneously. They can occur at the site of a piercing and have been found on the earlobes, eyebrows, chest and other sites of piercings. They can occur as a result of severe acne or chickenpox scarring. They may also be caused by infection at a wound site, repeated trauma to an area, excessive skin tension during wound closure or a foreign body in a wound. They do not go away on their own, and tend to recur after excision. They affect both sexes equally although the incidence in young female patients has been reported to be higher than in young males, probably reflecting the greater frequency of earlobe piercing among women. There is a fifteen times higher frequency of occurrence in people of color. Black skin is most likely to develop keloids.

History in medicine

Keloids were described by Egyptian surgeons about 1700 BCE. Baron Jean Louis Alibert (1768-1837) identified the keloid as an entity in 1806. He called them cancroide. Later he changed the name to cheloide to avoid the connotation of cancer. The word is derived from the Greek chele, meaning crab's claw, and the suffix -oid, meaning like. His clinic at the Hospital St.Louis was for many years the world’s centre for dermatology.

Intentional keloids

The Olmec of Mexico in pre-Columbian times used keloid scarification as a means of decoration. In the modern era, women of the Nubia-Kush in the Sudan are intentionally scarified with facial keloids as a means of decoration. The Nuer and Nuba use lip plugs, keloid tattoos along the forehead, keloid tattoos along the chin and above the lip, and cornrows. As a part of ritual, the people of Papua New Guinea, cut their skin and insert clay or ash into the wounds so as to develop permanent bumps (known as keloids or weals). This painful ritual makes them well respected members of their tribe who are honored for their courage and endurance.

Locations of Keloids

Keloids commonly occur on the shoulders, chest, arms and upper back even when there has been no apparent injury. These are usually the result of pimples, insect bites, scratching, or any other skin trauma.

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Intralesional 5-fluorouracil in the treatment of keloids: an open clinical and histopathologic study
From Journal of Drugs in Dermatology, 7/1/05

Intralesional 5-Fluorouracil in the Treatment of Keloids: An Open Clinical and Histopathologic Study

Kontochristopoulos G, MD, et al. Journal of the American Academy of Dermatology. 2005;52(3): 474-479.

Summary

The authors present an open-label trial to evaluate the efficacy of intralesional 5-fluorouracil (5-FU) in the treatment of keloids. Objectives included both clinical and histopathologic correlations. The study was comprised of 20 patients with keloids. Keloids were predominantly on the upper arms, back, and chest. The duration of keloids among patients spanned 0.2 to 20 years. Eleven patients had undergone prior treatment. After screening for pregnancy, chronic renal failure, and abnormal liver function tests and complete blood counts, patients underwent once weekly intralesional injections of 5-FU at a concentration of 50 mg/mL for an average of 7 treatments. Depending on the size of the keloid, multiple injections were given at 1-cm intervals. On average, 0.2 to 0.4 mL/[cm.sup.2] was injected at each treatment. In addition, 10 patients had punch biopsies of the injection sites both prior to and after 6 sessions of treatment. Biopsies were evaluated using hematoxylin and eosin staining as well as immunohistochemical staining for Ki-67 and transforming growth factor beta (TGF-beta). Patients were followed for recurrence of keloids up to 1 year. With the exception of one patient, all experienced reduction in the size of keloids. Complete resolution of a keloid was found in one patient, while 8 patients experienced a 75% reduction, 8 had a 50% reduction, and 2 had a 25% reduction in size. The authors state that keloids which had been untreated and were small in size had a more favorable response. Nine patients with improvement had recurrence 1 to 6 months after receiving their last injection. Of note, a statistically significant difference was found regarding duration of the keloid and recurrence. Keloids responding to treatment and of less than 2 years duration were less likely to recur. Regarding histopathology, 4 of 8 patients had complete resolution of thick hyalinized collagen noted prior to treatment and 4 of 6 patients had elimination of whorls of spindle cells seen prior to treatment. Ki-67 showed a statistically significant decrease in expression in all patients after treatment, while TGF-beta showed only a minimal decrease in 6 patients. Pain and hyperpigmentation at the injection site was noted in all patients. Six patients developed superficial ulcerations.

Comment

This was an interesting study as the authors tried to correlate both the histologic and clinical effects of 5-FU in the treatment of keloids. Importantly, recurrence was also evaluated. Although the majority of patients had a decrease in the size of their keloids, only one patient experienced complete resolution. Pain is an important side effect of this therapy; 4 patients needed 5-FU combined with Xylocaine secondary to intolerable pain. It would have been interesting to have compared this therapy with a more widely used treatment such as intralesional triamcinolone (IL-TAC). A comparison study between the two seems warranted to assess whether 5-FU is any more effective than IL-TAC, both in the resolution and recurrence of keloids.

COPYRIGHT 2005 Journal of Drugs in Dermatology, Inc.
COPYRIGHT 2005 Gale Group

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