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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 13  |  Issue : 5  |  Page : 871-874  

A case of keloid


1 Department of Preventive Dental Sciences, College of Dentistry, Gulf Medical University, Ajman, United Arab Emirates
2 Department of Oral and Maxillofacial Surgery and Diagnostic Sciences, College of Dentistry, King Faisal University, Al Ahsa, Saudi Arabia
3 Oral Maxillofacial Surgeon, Krishna Dental Clinic, Erode, Tamil Nadu, India
4 Arasan Eye Hospital, Erode, Tamil Nadu, India

Date of Submission14-Oct-2020
Date of Decision15-Oct-2020
Date of Acceptance16-Oct-2020
Date of Web Publication05-Jun-2021

Correspondence Address:
Venkataramana Vannala
Department of Preventive Dental Sciences, College of Dentistry, Gulf Medical University, Ajman
United Arab Emirates
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpbs.JPBS_673_20

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   Abstract 


Keloids are unorganized proliferation of fibrous tissue, usually arising from a site of injury, due to an aberrant healing process. Clinically, it presents as an ugly scar tissue on the skin and shows genetic predilection. They cause esthetic, physical, and psychological disturbances in the affected individuals. Such patients require special precautions during the normal surgical procedures. Keloid treatment is prone to a high degree of resistance and recurrence. In this article, one such a case is reported along with a review of the literature discussing the nature of the lesion, treatment options, and the recommended precautions.

Keywords: Keloid, scar, trauma


How to cite this article:
Vannala V, Mahabob N, Radhakrishnan S, Anbuselvan S. A case of keloid. J Pharm Bioall Sci 2021;13, Suppl S1:871-4

How to cite this URL:
Vannala V, Mahabob N, Radhakrishnan S, Anbuselvan S. A case of keloid. J Pharm Bioall Sci [serial online] 2021 [cited 2021 Oct 16];13, Suppl S1:871-4. Available from: https://www.jpbsonline.org/text.asp?2021/13/5/871/317613




   Introduction Top


Cutaneous scars arising from an aberrant healing process after trauma are often encountered in the head-and-neck region. Keloid is such a scar that represents overgrowth of dense, fibrous tissue, extending outside the borders of the originally existing wound. The common clinical features include esthetic disfigurement, itching, pain, skin color changes, and decrease in the range of movement. The name is derived from the Greek word “chele” meaning “crab claw,” referring to the way in which these lesions grow eccentrically into normal tissue, mimicking the movement of a crab.[1] Although keloids are benign lesions with no malignant potential,[2] it can significantly degrade the patient's physical and psychological quality of life, especially if there is excessive scarring.[3] The initiation may occur from minor injuries such as insect bite, acne, lacerations, tattoos, vaccinations, injections, skin piercing or from major wounds such as surgical incisions, burn wounds, or abrasions.[2]

[TAG:2]Case Report [/TAG:2]

A 57-year-old patient visited the clinic with a chief complaint of multiple missing teeth. He had no significant medical history. On extraoral observation, a taut fibrous scar was detected in the right upper temporal region, as shown in [Figure 1]. The patient gave a history of injury in the region 40 years back. He could not recall the details about the exact nature of injury. According to him, the scar tissue appeared after about 6 months from the day of trauma. The tissue grew slowly for about 4–5 years, extending beyond the initial wound margin. Initially, it was slightly reddish with itching sensation. However, the irritation and growth have subsided since many years.
Figure 1: Keloid-fibrous scar was detected in the right upper temporal region

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On inspection, an elevated irregularly shaped lesion was observed with a smooth shiny surface. It was about 3 cm × 5 cm in dimension. The color of the lesion was slightly darker compared to the adjacent skin. There was no tenderness on palpation, and the lesion was rubbery in consistency. The lesion was freely movable with the skin and showed no signs of underlying attachment. On further questioning, he revealed that his brother also has a similar scar in his forearm.

Based on the history and clinical findings, a diagnosis of keloid was done. Since the patient was having no trouble with the present lesion, he was reluctant to get a biopsy done. However, he accepted to come for regular clinical revaluation of the lesion. His chief complaint was addressed while taking all precautionary measures indicated for a patient with keloid.


   Discussion Top


Keloid is thought to be the output of an abnormal healing process to an injury extending to or beyond the depth of the reticular dermis. The pathophysiology of keloids remains unclear despite the decades of research. There is evidence of more prolonged inflammatory period, and presence of immune cell infiltrate, which might lead to increased fibroblastic activity with more continuous extracellular matrix deposition.[4] Genetic predisposition is well documented. Other promoting factors include the type of injury, melanin pigmentation, anatomical site, age of onset, and gender.[3]

The duration of onset following injury, the path and speed of growth, and the severity of symptoms are determined by the intensity, frequency of occurrence, and duration of the etiological stimuli.[5] Probably, because of melanocyte-stimulating hormone anomalies, dark skin has 15–20 times higher risk of getting keloids. As a result, African, Hispanic, and Asian persons are far more prone to develop keloids when compared to Caucasians.[6] The onset of keloid mostly occurs between the age group of 10 and 30 years (uncommon at extremes of age),[1] especially during elevated hormonal levels (e.g., during puberty or pregnancy).[6]

The diagnosis of keloid is mainly based on the clinical features but may require histopathological analysis.[3] Although the inflammation of the reticular dermis starts almost immediately, it takes about 3 months for the lesion to be visible beyond the epidermis to the naked eye.[5] Hence, the patients usually gave a history of magnified growths of the scar tissue in the areas of previously traumatized tissue, within 3–12 months after injury.[3] Rarely, keloids are detected without any history of trauma or surgery and are called spontaneous keloids. Confirmation of the history may be challenging because the triggering factor might have been an ill-perceived minimal injury or inflammation.[7]

The lesion extends beyond the area of initial wound, which projects above the level of the surrounding skin.[3] It grows slowly for weeks to months[3] and is limited within the dermis (except rare cases in the cornea).[1] However, occasionally, they enlarge rapidly, tripling in size within months and can continue to grow for years.[3] There is associated pruritus, hyperesthesia, or pain in up to 80% of patients.[8] Chances of these physical symptoms increase with positive family history, and greater size or number of the lesion, especially when positioned in the trunk. Exposure to the sun aggravates the symptoms, and most of the relieving factors only provide temporary benefit.[2] On secession of growth, keloid usually becomes symptomless and slightly involutes on some occasions.[3] These lesions are strongly associated with psychological impairment, especially when associated with itch or pain.[8]

Although keloids can be found anywhere on the body,[2] the posterior side of the ear lobule is the most common site of its occurrence.[4] Other susceptible areas include torso, shoulders, head and neck areas, arms, and upper region of the back.[1] They rarely appear in the palms and soles.[4] The cause of higher reported cases in female patients is attributed to the greater esthetic concern and frequent piercing of earlobes.[1]

The consistency of keloids ranges from soft and doughy to the extent of rubbery and hard. The surface is usually shiny and is devoid of hair follicles and other normally functioning adnexal glands. There may be hyperpigmentation in darker-skinned people. Initial lesions are usually erythematous. They usually become brownish red and then turn pale with time. Keloid may be pedunculated (on the ears, at the neck, and abdomen region) or sessile (on the central chest and extremities of the body), and its shape is mostly round, could be oval or oblong with irregular margins. But may show claw like configurations with asymmetrical borders. Keloids situated above a joint can contract and hinder its movement.[3]

The main differential diagnosis is hypertrophic scar.[3] Scar hypertrophy normally appears within 1 month of injury, whereas keloids could take much longer time.[6] Usually, a rapid growth phase could last up to 6 months in hypertrophic scars followed by gradual regression for over a year, resulting in a flat scars with no further symptoms.[4] Unlike keloid scars, hypertrophic scar is restricted to the edges and are less pruritic and painful and lacks genetic predilection.[2] Postsurgical recurrence is rare (10%) in hypertrophic scars.[4] Histopathological, immunohistochemical, and electron microscopic features can be utilized to differentiate the two lesions. In hypertrophic scar, histopathologically, the “keloid collagen” (haphazardly arranged thick hyalinized collagen bundles inside the mucinous ground substance, showing comparatively few fibroblasts) is replaced by collagen fibers, which are parallel to the long axis of the epidermal surface containing the nodules of fibroblasts and collagen and are present in the middle or deeper layer of the scar. Those nodules are absent in keloids. Moreover, small aggregating veins and arteries are present just beneath the epidermis in keloids, whereas the blood vessels are present vertically around the nodules in hypertrophic scars. About 73% of keloids have mast cells in reticular dermis, whereas only 20%–30% of hypertrophic scars have mast cells in them.[4]

Other differential diagnosis includes dermatofibroma, lobomycosis, and multiple kinds of malignant tumors which resemble keloid, that includes dermatofibrosarcoma protuberans, trichilemmal carcinoma, and keloid basal cell carcinoma.[3]

Therapy for keloid is controversial with uncertain results. The preference of treatment is usually guided by the location of the keloid, size and depth of the lesion, age of the patient, and the past therapeutic response.[3] They range from surgical removal, steroid injection, pressure therapy, silicone, cryotherapy, laser, and radiation therapy, among others.[9]

The first-line options include silicone sheeting, pressure treatment, and corticosteroid injections and can be tried for 12 months. Cryotherapy is useful in smaller lesions (like those occurring from acne), but may cause hypopigmentation in dark-skinned patients.[6] Pressure therapy, widely used for ear keloid has shown a recurrence rate of 40% only. The combined modality of cryosurgery and intralesional steroid therapy showed a partial recurrence rate of 21% and complete recurrence rate in 10% cases.[9]

Surgical excision alone is highly susceptible to recurrence (40%–100%)[9] and may stimulate additional collagen synthesis, prompting a more aggressive recurrence. Therefore, intra-marginal surgical excision is recommended,[4] along with lateral undermining. Gentle handling of the tissue and exerting minimum tension while suturing improves the prognosis.[9] Corticosteroid injections, silicone sheeting, or their combination with laser is advocated. Postsurgical corticosteroid injection on the edge of the wound, followed by every week injections for 2–5 weeks and every month injections for 3–6 months is said to reduce the recurrence rate to < 50%.[6] It acts by reducing the proliferation of fibroblasts, inhibits the collagen synthesis, increases the collagenase enzyme production, and reducing the levels of collagenase inhibitors.[9] A “triple keloid therapy” which combines surgery, corticosteroids, and silicone sheeting has shown a recurrence rate of only 12.5% with a 13-month follow-up.[6]

Radiation therapy administered immediately after the keloid excision at a total dose of 10–15 Gy using fractionated therapy has effectively reduced the recurrence rate. However, the risk of inducing malignancy has limited its use. The use of carbon dioxide laser yielded over 50% recurrence and is not considered very effective individually.[9] A few other therapies with a less number of studies include intralesional verapamil, fluorouracil, bleomycin, and interferon alfa-2b injections. Combinations of therapies have proved superior to individual approaches.[6]

Since keloids may arise even with small injuries, good care is required while treating patients with a history of keloid,[3] especially in dark-skinned individuals with a family history.[4] Elective surgeries should be postponed until when compulsory.[2] Unavoidable surgical procedures should ideally be followed by immediate silicone elastomer sheeting or corticosteroid injections. Everything that accelerates wound healing and reduces skin tension will diminish risk.[6] Excised keloid tissues must be examined histopathologically to avoid omitting malignant conditions, especially when unusual features are revealed.[4]

The dark skin color, positive familial history, and age of puberty during the initial injury at the site of the lesion, made the above mentioned patient susceptible to developing keloid. In spite of the marked visibility of the keloid, the patient was not bothered about the lesion due to its asymptomatic character. The poor prognosis and apathy of the patient prevented biopsy of the lesion to confirm its nature.

From the perspective of a dental surgeon, patients prone to keloidal scars of the skin can have a proliferative scarring of the oral mucosa.[10] Keloid can arise following a cleft lip surgery[11] and intraoral keloids have also been reported.[10],[12] In such patients, a dental surgeon is expected to proceed with all necessary precautions mentioned above.


   Conclusion Top


Keloid is a type of nonhealing firm nodular scar that represents unorganized proliferation of fibrous tissue, extending beyond the site of original injury. It is responsible for physical and psychological difficulties in patients, especially when it is prominently visible and is associated with symptoms like pruritus and pain. At present, the treatment options are controversial with questionable prognosis. Diagnosis of such lesion is essential to take the required precautions during any surgical procedure to avert unnecessary complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Berman B, Bieley HC. Keloids. J Am Acad Dermatol 1955;33:117-23.  Back to cited text no. 1
    
2.
Belie O, Ugburo AO, Mofikoya BO. Demographic and clinical characteristics of keloids in an urban center in Sub-Sahara Africa. Niger J Clin Pract 2019;22:1049-54.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Shaheen A. Comprehensive review of keloid formation. Clin Res Dermatol Open Access 2017;4:1-18.  Back to cited text no. 3
    
4.
Hunasgi S, Koneru A, Vanishree M, Shamala R. Keloid: A case report and review of pathophysiology and differences between keloid and hypertrophic scars. J Oral Maxillofac Pathol 2013;17:116-20.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Ogawa R. Keloid and hypertrophic scars are the result of chronic inflammation in the reticular dermis. Epidemiol Etiol Int J Mol Sci 2017;18:1-10.  Back to cited text no. 5
    
6.
Juckett G, Hartman-Adams H. Management of keloids and hypertrophic scars. Am Fam Physician 2009;80:253-60.  Back to cited text no. 6
    
7.
Ali Alajmi AJ. Spontaneous keloids: A literature review. Dermatology 2018;234:127-30.  Back to cited text no. 7
    
8.
Bijlard E, Kouwenberg CA, Timman R, Hovius SE, Busschbach JJ, Mureau MA. Burden of keloid disease: A cross-sectional health-related quality of life assessment. Acta Derm Venereol 2017;97:225-9.  Back to cited text no. 8
    
9.
Kumar A. Earlobe keloid: A new treatment protocol for management. Int J Oral Health Med Res 2016;3:62-4.  Back to cited text no. 9
    
10.
Ow RK. A keloidal scar of the floor of the mouth and its associations. Case report. Aust Dent J 1989;34:522-3.  Back to cited text no. 10
    
11.
Politis C, Schoenaers J, Jacobs R, Agbaje JO. Wound healing problems in the mouth. Front Physiol 2016;507:1-13.  Back to cited text no. 11
    
12.
Swartz EM. Familial idiopathic gingival hyperplasia with keloid formation and ectodermal dysplasia. Dent Stud 1967;45:683-5.  Back to cited text no. 12
    


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