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Keloids and hypertrophic scars are different expressions of the same derailment of wound healing; their biological behaviors and appearances are quite different. The clinical differences between hypertrophic scars and keloids have long been recognized. However, distinguishing between the two types of scars on histology is sometimes difficult as the...
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Introduction
Keloids are hypertrophic scars that commonly arise in the ear region. The authors’ objectives were to (1) evaluate effectiveness of surgical shave excision followed by intralesional triamcinolone acetonide and onabotulinumtoxinA injections; and (2) evaluate safety and patient satisfaction.
Methods and Materials
This study was a retros...
Background:
Vesicourethral anastomotic stenosis (VUAS) following retropubic radical prostatectomy (RRP) significantly worsens quality of life.
Objectives:
To investigate the relationship between proliferative hypertrophic scar formation and VUAS, and predict more appropriate surgical intervention for preventing recurrent VUAS.
Design and settin...
Citations
... Keloids are observed to occur in people of all races, but are more often found in dark pigmented people, with an incidence of 6% to 16% in individuals from Africa [6,7]. Keloids appear about 15 times greater in dark-skinned people than fair-skinned people [8]. Keloids have a genetic predisposition and autosomal dominant patterns of inheritance [9,10]. ...
Introduction: Keloids are fibroproliferative lesions caused by abnormal wound healing and are characterized by excessive collagen deposits that cannot heal spontaneously. Keloid in the ear is a challenging condition to be treated by doctors, especially the large ones. This condition has a psychosocial impact on the patient and a consideration for appearance is often the main reason for patients seeking to cure keloids, although there is a high possibility of keloid recurrence. Out of various keloid therapy options, one method that can be done is surgical excision therapy with debulking technique. Case report: A case of keloids in left ear lobule measuring 2.5 cm × 3 cm is reported after the patient does ear piercing with complaints of slight itch and aesthetical disturbance. Keloids enlarge 6 months after piercing. The case is treated by debulking excision surgery using local anesthesia Pehacain® (lidocaine 2% + adrenaline 1:80,000). At the end of the wound closure, 40 mg of triamcinolone acetone is given. It is regiven one week after the stitches are removed and repeatedly every 2 weeks for 4 times. Excision surgical results are good and the patient feels satisfied. Conclusion: Excision surgery with debulking technique is chosen because of the large size of the lesion and to ensure there is no residual keloid tissue at the site of predilection. Corticosteroid injection is given immediately after excision to decrease fibroblast proliferation, collagen and glycosaminoglycan synthesis and suppress proinflammatory mediators in order to prevent keloid recurrence.
... Keloid therapy is both complicated and problematic. Until recently, surgical procedure, intralesional steroid (2), compressing silicone gel pads, and radiotherapy (3) have been used in treatment modalities, as having extra experimental treatments like bleomycin, interferons, and 5-fluorouracil (5-FU) (4,5). ...
Aim:
Intralesional triamcinolone is a gold standard in treating the keloids to comparation its effectiveness versus intralesional 5-fluorouracil intralesional verapamil and intralesional platelet-rich plasma.
Patients and methods:
Several 160-cases were categorized into four groups of each Group-Containing 40 cases. Group-A (control) treated with intralesional triamcinolone and Group-B intralesional verapamil, Group-C intralesional 5-fluorouracil, and Group-D intralesional platelet-rich plasma. Patients were assessed for clinical response based on a decrease in the patient and observer scar assessment scale (POSAS) at baseline and the end of treatment.
Results:
The mean base-line POSAS score was 91 ± 10.98 SD check-in Group-A, 90 ± 10.85 in Group-B, 89 ± 10.06 in Group-C, and 92 ± 10.84 in Group-D.POSAS score after 24 weeks 36 ± 12.74 in Group-A, 29 ± 10.91 in Group-B, 39 ± 13.74 in Group-C, 36 ± 12.74 in Group-D. Statistically, a significant difference was observed between groups.
Conclusion:
Intralesional verapamil reported to be the most effective therapy and platelet-rich plasma was effective as intralesional triamcinolone acetonide with no serious side effects and 5-fluorouracil was less effective in treating the keloids.
... The histopathological findings on keloid scars will be briefly summarized in this section. The epidermal thickness in keloid scars has been described as anything from atrophic (Koonin, 1964;Bakry et al., 2014) and normal (Moshref and Mufti, 2009;, to sometimes (Ehrlich et al., 1994;Materazzi et al., 2007) or always increased (Bertheim and Hellström, 1994;Chua et al., 2011;Syed et al., 2011;Sidgwick et al., 2013;Jumper et al., 2015;Suttho et al., 2017;Shang et al., 2018). However, the overwhelming majority supports the observation of increased epidermal thickness in keloid scars, and what is more, this was confirmed when thickness was measured in µm (Hellström et al., 2014) as well as number of viable cell layers (Limandjaja et al., 2017. ...
... Similarly, conflicting findings have been reported with regards to rete ridge formation. Reports range from normal rete ridge formation (Lee J. Y. Y.et al., 2004;Moshref and Mufti, 2009) to reduced (Koonin, 1964;Chong et al., 2015;Jumper et al., 2015;Suttho et al., 2017;Shang et al., 2018) or complete absence thereof (Ehrlich et al., 1994;Meenakshi et al., 2005;, although none have attempted to objectively measure the extent of rete ridge formation. Overall, most studies, including our own histopathological studies (Limandjaja et al., 2017, appear to support the findings of a flattened epidermis with increased thickness. ...
... Histopathological studies of the keloid dermis showed that fibroblasts were present in higher numbers (Ueda et al., 1999;Tanaka et al., 2004;Meenakshi et al., 2009;Jiao et al., 2017). Other dermal cell types residing in keloids include myofibroblasts (Santucci et al., 2001;Kamath et al., 2002;Lee J. Y. Y.et al., 2004;Lee et al., 2012;Moshref and Mufti, 2009;Shin et al., 2016) and fibrocytes (Iqbal et al., 2012;Shin et al., 2016), both were present in increased numbers. In our whole biopsy image analysis of keloid tissue, CD34 expression was found to be absent from the keloid dermis, but constitutively and abundantly present in normal skin and normotrophic scars . ...
Keloids constitute an abnormal fibroproliferative wound healing response in which raised scar tissue grows excessively and invasively beyond the original wound borders. This review provides a comprehensive overview of several important themes in keloid research: namely keloid histopathology, heterogeneity, pathogenesis, and model systems. Although keloidal collagen versus nodules and α-SMA-immunoreactivity have been considered pathognomonic for keloids versus hypertrophic scars, conflicting results have been reported which will be discussed together with other histopathological keloid characteristics. Importantly, histopathological keloid abnormalities are also present in the keloid epidermis. Heterogeneity between and within keloids exists which is often not considered when interpreting results and may explain discrepancies between studies. At least two distinct keloid phenotypes exist, the superficial-spreading/flat keloids and the bulging/raised keloids. Within keloids, the periphery is often seen as the actively growing margin compared to the more quiescent center, although the opposite has also been reported. Interestingly, the normal skin directly surrounding keloids also shows partial keloid characteristics. Keloids are most likely to occur after an inciting stimulus such as (minor and disproportionate) dermal injury or an inflammatory process (environmental factors) at a keloid-prone anatomical site (topological factors) in a genetically predisposed individual (patient-related factors). The specific cellular abnormalities these various patient, topological and environmental factors generate to ultimately result in keloid scar formation are discussed. Existing keloid models can largely be divided into in vivo and in vitro systems including a number of subdivisions: human/animal, explant/culture, homotypic/heterotypic culture, direct/indirect co-culture, and 3D/monolayer culture. As skin physiology, immunology and wound healing is markedly different in animals and since keloids are exclusive to humans, there is a need for relevant human in vitro models. Of these, the direct co-culture systems that generate full thickness keloid equivalents appear the most promising and will be key to further advance keloid research on its pathogenesis and thereby ultimately advance keloid treatment. Finally, the recent change in keloid nomenclature will be discussed, which has moved away from identifying keloids solely as abnormal scars with a purely cosmetic association toward understanding keloids for the fibroproliferative disorder that they are.
... The most common affected areas are the anterior chest, shoulders, flexor surfaces area of the extremities, and the ears 4 . Keloid formation is about 15 times higher in black people than in whites 5 . Surgical excision alone leads to a high recurrence rate between 50-100%, therefore combination of surgical excision with steroids therapy, radiotherapy, mechanical compression, silicon occlusive dressings, cryosurgery, and bleomycin tattooing etc are being used as the treatment modalities for management of keloid 6,7,8 . ...
Background: Ear keloid is one of the challenging problems that affect people of different races with substantial aesthetic outcomes. Various types of treatment modalities, including intralesional corticosteroid injection are advocated to lower recurrence following excision. Objectives: To investigate the efficacy of a combined excision and postoperative intralesional triamcinolone acetonide (TA) injection for treating ear keloid patients. Methodology: This was a descriptive study done to observe the outcome of combined approach of surgical and intra-lesional steroids injection therapy for ear keloids. Age, sex, site, size, duration, recurrence, and aesthetic outcome were evaluated. Results: A total of 18 patients representing 19 ear keloids, with one case having bilateral and 3 pediatric cases were included from February 2018 to January 2019.The mean age was 22 years with female to male ratio of 5:1, site were left sided 9 (50%), right 8 (44%) and 1(6%) bilateral. About 10 (53%) cases were at helix, and 9(47%) at ear lobule. Mean length of ear keloid was 1.53 cm with range of 0.5-3cm and mean breath 1.39cm with the range of 0.5-2.5 cm. The mean duration of ear keloid was 9.47 months. 2 (11%) cases showed a history of recurrence. Injection triamcinolone acetonide hypersensitivity was noted by 1 (5.3%) patient. Evaluation for all patients with aesthetic outcome was mean ± standard deviation (4.38±1.025). Conclusion: Management of ear keloid using the combination of surgical excision and intra-lesional steroids injection therapy can be a good alternative option with low recurrence rate.
... The histopathological evaluation of the tissue revealed that it was a hypertrophic scar. Our observation is supported by previous studies that have shown nodule-structures in the deep dermis are associated with hypertrophic scarring [44][45][46]. ...
Hypertrophic scarring is formed as a result of abnormal wound healing. Efforts have been made to understand the mechanism of hypertrophic scarring for prevention and treatment, mainly by using several model systems. However, animal models do not form effectively hypertrophic scars. Desorption electrospray ionization mass spectrometry imaging enabled label-free elucidation of the spatial distribution of metabolites and lipids in skin tissue samples under ambient conditions of a 36-year-old female. It revealed up-regulation of phospholipid sphingomyelin SM(18:0/16:1), m/z 235.18, and metabolite sphingosine, m/z 310.24, which resulted in skin hardness and defects in the skin barrier function. The scar tissue also showed downregulation of phospholipid cardiolipin CL(62:2), m/z 1322.03 that indicated defects in autophagy function. These findings were supported by histopathological evaluations of scar tissue which showed nodule-like structures in the deep dermis, and disfigured arrangement of collagen bundles. Moreover, the scar tissue showed defects in autophagy function and inflammation. Although, limited by sample number, our results clearly revealed a molecular signature of hypertrophic scarring in this human case study.
... hypertrophic scars which present with only dermal nodules. 2,4 In immunochemistry examination, keloids also present with increased levels of MMP-2 enzyme at the edge of collagen bundle. 2,4 Keloids are more common in African, Asian and Latin American ethnicities. ...
... 2,4 In immunochemistry examination, keloids also present with increased levels of MMP-2 enzyme at the edge of collagen bundle. 2,4 Keloids are more common in African, Asian and Latin American ethnicities. 5 Genetic predisposition also increases the chance of having keloids 15% higher than the general population. ...
... 1,3 A definitive diagnosis is made through histopathological examination where keloids present with dermal nodules and multiple thick eosinophilic collagen bundles. 4 This is in contrary to associated with keloid aggravation. 7 On the other hand, local factors involve delayed wound healing process and presence of skin tension. ...
Author present a case of 22-year-old female with keloid due to previous trauma three years prior. Keloids are excessive fibroblast growth present in pathological scars. Therapy for keloids still remain a challenge requiring an effective intervention. While the first line has always been the use of intralesional triamcinolone, recently intralesional verapamil has also been known to reduce growth of keloids. Aim of the study was to evaluate the efficacy of both of these drug options. Literature searching was performed from three databases namely PubMed, Cochrane library and Science Direct. Findings were systematically narrowed down through inclusion and exclusion criteria into four relevant randomized controlled trials. Selected studies were critically appraised for its validity, importance, and applicability using tools from Oxford Center of Evidence-Based Medicine. Both intralesional triamcinolone and verapamil show their own benefit and risk. Triamcinolone is more effective in reducing keloid with faster improvement as seen in scar height reduction, vascularity, pigmentation and pliability. However, verapamil has fewer side effects which serve as a safer treatment option. More clinical trials in the future may be needed to obtain more conclusive result.
... 1,2 The excessive collagen is due to an imbalance between the formation and degradation of extracellular matrix. [3][4][5] Keloidmore affects African, Asian and Latin American ethnicities. Vulnerability genetically increases the risk of keloid 15% greater than in the population. ...
The histopathologic view of keloid shows dense fibroblasts and bundles of collagen throughout dermis. Treatment that completely cure keloid still not exist, although there are many treatment options. The monotherapy fractional CO2 laser shows good results, but is still as an adjuvant therapy. Fractional CO2 laser affects fibroblast and its functions in producing collagen. The combination therapy will combine the selective phototermolysis effect of CO2 lasers with antimitotic and antiinflammatory effects of corticosteroids. This study was an open trial with parallel design that compared fractional CO2 laser-intralesional triamcinolone acetonide combination therapy (treatment group) and intralesional triamcinolone acetonide (control group) in keloid patients with collagen density as evaluation parameter. The dose of triamcinolone was 10 mg/ml of 0.05-0.1 ml/cm2 of keloid. Fractional CO2 laser energy setting was 10-20 mJ. The decrease of collagen density in control and treatment group was significant (p=0.008 and p=0.001), although the decrease difference between control and treatment group was not significant (p=0.328). The collagen density that decrease in a shorter time shows that fractional CO2 laser could be a good combination therapy.
... Darker complexion has increased inherent risk as has been seen in Africans as well as dark skinned people in the far west with an incidence as high as 16%. [12][13][14] Increased risk is also seen in puberty and pregnancy among genetically predisposed. 15 With this baseline data, further studies will be undertaken to understand the etiology of higher occurrence of keloids in the population specified in the location of this study with regards to genetic predisposition, ear piercing methodology etc. ...
p class="abstract"> Background: Unusually higher number of patients was observed to seek medical attention for keloids over the pinna in a geographical area in Central Karnataka. This study was conducted to find the demographic profile of such patients.
Methods: A retrospective observational study was conducted in two tertiary care centres, in which medical case files of all patients with documented diagnosis of keloid over the pinna between January 2013 to October 2017, were reviewed for their demographic profile and clinical presentation.
Results: A total of 482 patients had presented with keloids of pinna in the duration studied. Of these 474 were females and 8 were males, with a mean age of 29 years. The most common age group of patients (37.3%) was 21 to 30 years followed by 31 to 40 years (25.7%). The most common antecedent event to keloid formation was piercing of the helix of the pinna. The commonest location of keloid formation in the pinna was found to be helix of the pinna (92.7%) The mean time interval between the antecedent event and keloid formation was 14 months.
Conclusions: Higher number of patients seeks medical attention for keloid over the pinna in geographical region of central Karnataka. Most of them had undergone ear piercing and had presented in their early adulthood. Ear piercing over the helix of pinna was more commonly associated with keloid formation. Further studies are intended to be done on the etiological factors for higher incidence of keloids and feasible preventive measures.
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... This can be explained partly, by the phenotypic variations in the study groups. [5][6][7][8][9] Majority of keloid cases in our study show moderate amount of inflammatory cell infiltration (63%) around perivascular location composed mainly of lymphocytes which was similar to findings studied by Borgognoni et al, Blackburn et al and Boyce DE et al. [10][11][12] No significant association was found between VEGFR-2 expression and amount of Inflammatory cell infiltration in keloid in our study. 87.5% of keloid scar in our study demonstrated the presence of large, broad, glassy, eosinophilic focally fragmented and haphazardly arranged collagen complexes referred to as "keloid collagen." ...
... Keloids may present as pedunculated or sessile growths which may be uninodular or multinodular, with no particular sex predilection, most commonly affecting patients in the age group of 20-35 years [4]. Keloid formation is approximately 15 times more frequent in highly pigmented ethnic groups like African-Americans and Asians rather than in Caucasians [5]. The pathogenesis of keloid formation is complex H&E Section 10X and 40X showed hyper-orthokeratinized stratified squamous epithelium with deep dermal sclerosis and haphazardly arranged, thick bundles of mature collagen fibers which showed a glassy hyalinized appearance, characteristic of the keloid. ...
... Small aggregating blood vessels were seen just below the epidermis, and there was seen a moderate degree of perivascular chronic inflammatory cell infiltrate. and involves familial, hormonal, genetic as well as environmental factors [5]. ...
The Keloid is a fibroproliferative anomaly of the cutaneous connective tissue secondary to dysregulation in
the skin healing and repair process, occurring in susceptible individuals. It is characterized by excessive collagen
and glycoprotein deposition in the dermis following any local irritation, inflammation, burn, incision or injury,
thereby leading to a cosmetically unaesthetic, aberrant and exuberant scar formation extending well beyond the
boundaries of the original wound. It usually presents as firm nodules, often pruritic and painful, which do not regress
spontaneously. The condition presents quite a therapeutic challenge owing to its unpredictably aggressive nature,
frequent invasion of adjacent normal dermis, occasional appearance of satellite lesions in nearby non-traumatized
tissue and a remarkable tendency for recurrence following removal.
Various combinations of Pressure therapy, intralesional steroid therapy and surgery have shown promising
results in the treatment of auricular keloids. We report on a young Indian female, aged 19 years, who developed
bilateral auricular keloids subsequent to earlobe piercing, which was successfully managed by careful and
atraumatic surgical excision alone.
