KELOIDS and HYPERTROPHIC

SCARS

DR
DR J.
J. K.
K. SESAY
SESAY
Dip.
Dip. Int.
Int. Health,
Health, M.D.,
M.D., M.Med.
M.Med. Surgery
Surgery
SENIOR
SENIOR REGISTRAR
REGISTRAR @ @ MOHS
MOHS
GENERAL
GENERAL SURGEON
SURGEON
USLTHC
USLTHC –– Connaught
Connaught
RANGE OF ADVERSE SCARS
 Poor alignment
 Stretched
 Contour deformity
 Pigmentry problems
 Stitch marks
 tattooing
 ADVERSE SCARS

 Appearance
 Range of Adverse Scars

 Hypertrophic Scar
RANGE OF ADVERSE SCARS

 KELOID SCAR
 ADVERSE SCARS

 FUNCTION

 BOTH
KELOID DIATHESIS
PHASES IN WOUND HEALING

 Inflammatory phase

 Proliferative phase

 Remodeling phase
 HYPERTROPHIC SCAR
 Scar remains in the remodeling phase more than
normal scar

 There is increased deposition of collagen

 Scar remain red, raised, itchy for much longer

period than normal scar

 Commonly occurs in situations when wound is

sutured under tension or healing has been
delayed
 HYPERTROPHIC SCAR
 Such scars are common in children and black races

 Remain within the zone of original injury

 They are common following burn injuries

 They tend to produce contractures

 They also show pigmentry changes

 However unlike Keloids , hypertrophic scars tend to mature with time

Management of Hypertrophic Scar
 Patience and counseling

 Massage, Pressure, Silicon sheet or gel

will accelerate maturation
 Surgical intervention if hypertrophic scar is
interfering with function
 Surgery involves, scar release or Scar
Revision
 KELOID HISTORICAL
BACKGROUND
•Firstdescription of abnormal
scar formation recorded in the
Smith papyrus in approximately
1700 BC.
•Keloid, meaning “crab claw,”
from Greek word “chele”, first
was coined by Alibert in 1806.
 Clinical Features of KELOID
 Regarded as a different entity from hypertrophic
scar
 Initiating factor is trivial injury
 Occasionally arises spontaneously
 It grows to extend beyond the original scar
 It shows no tendency to regress. Never matures
 Has a high tendency to recur after surgery alone
 Usually does not produce contracture
 Clinical Features of KELOID
 Black races are more prone to this

 Certain areas of the body are more prone

in susceptible individuals.
 May be familial
 Aetiology unknown
 SEX
INCIDENCEIN FEMALES
HIGHER THAN IN MALES
POSSIBLY SECONDARY
TO THE COSMETIC
IMPLICATIONS.
 AGE
ONSET BETWEEN 10 AND
30 YEARS.
OCCUR LESS
FREQUENTLY AT AGE
EXTREMES.
 SITES OF PREDILECTION
PEarlobes
PHead and Neck

DECREASING
Pre-sternal

INCIDENCE
PBreasts
D
P eltoid/upper back
U
P pper extremities
PAbdomen/pubis
Lower
P extremities
PFeet
PGenitalia
 CLINICAL
 HISTORY OF TRAUMA
 LESIONS EXTEND PAST AREAS OF
TRAUMA
 MAY BE TENDER, PAINFUL AND
PRURITIC.
 USUALLY DEVOID OF HAIR
FOLLICLES.
 OFTEN CONTINUES TO GROW OVER
THE YEARS.
 +/- POSITIVE FAMILY HISTORY.
LABORATORY STUDIES
 DIAGNOSISUSUALLY
BASED ON CLINICAL
FINDINGS.
 Differential Diagnosis

 Hypertrophic scar

 Dermatofibrosarcoma Protuberance

 Neurofibromatosis
DD
KELOID IN THE BEARDED AREA

 Infection

 Abcess
EAR LOBE KELOIDS
EARLOBE KELOIDS 2
TRUNCAL KELOIDS
HEAD AND NECK KELOIDS
KELOIDS OF FOOT
ABDOMINAL/PUBIC KELOIDS
 TREATMENT
 NO SINGLE MODALITY IS BEST.
 COMBINATION THERAPY OFTEN
BEST.
 FIRST RULE OF THERAPY IS
PREVENTION.
 AVOID NONESSENTIAL SURGERY IN
KNOWN KELOID FORMERS.
 CLOSE ALL WOUNDS WITH MINIMAL
TENSION.
 Treatment of keloid and
hypertrophic scar
 Pressure
 Intralesional steroid inj [triamcinolone]
 Excision and steroid inj
 Excision and postop radiation
 Silicone gel sheeting
 Laser
 Steroid injection side effects
 Sub cut. Tissue atrophy

 Telangiectasia

 Pigmentary changes
 EXCISION AND STEROID Rx
BEFORE

AFTER
 STEROID THERAPY
 REDUCE COLLAGEN SYNTHESIS.
 REDUCES FIBROBLAST PROLIFERATION.
 TRIAMCINOLONE ACETONIDE MOST
COMMONLY USED.
 RESPONSE RATES VARIED BETWEEN 50 –
100%.
 WHEN COMBINED WITH EXCISION,
RECURRENCE RATE OF 0 – 100%
REPORTED.
 WATCH OUT FOR COMPLICATIONS.
 OCCLUSIVE DRESSINGS
 USE OF SILICONE GEL SHEETS AND
OCCLUSIVE DRESSINGS.
 VARIED SUCCESS.
 EFFECT A RESULT OF OCCLUSION
AND HYDRATION.
 DRESSING WORN 24HRS/DAY FOR UP
TO 12 MONTHS.
 EXCELLENT RESPONSE IN UP TO
35%OF CASES.
 PRESSURE
 KNOWN TO HAVE THINNING
EFFECTS.
 PRESSURE APPLIED 12 – 24
HRS/DAY
 REDUCES COHESIVENESS OF
COLLAGEN FIBRES.
 OVERALL, 60% OF PATIENTS
SHOWED 75 – 100% IMPROVEMENT.
 CRYOSURGERY
 CAUSE CELL DAMAGE VIA
INTRACELLULAR CRYSTALS
LEADING TO TISSUE ANOXIA.
 DUAL BENEFIT TOP THE PATIENT;
ANAESTHETIC EFFECT AND EASE
OF INJECTIONS
 AS A SINGLE MODALITY, REPORTED
TOTAL RESOLUTON IN 51 – 74 %
CASES.
 RADIATION THERAPY
 USE REMAINS
CONTROVERSIAL. SAFETY
HAS BEEN QUESTIONED.
 OFTEN FOLLOWS EXCISION.
 RECURRENCE RATES OF 21 –
53 % REPORTED.
 LASER THERAPY
 CAUSES MINIMAL TISSUE
TRAUMA.
 PHOTOTHERMOLYSIS LEADS TO
MICROVASCULAR
THROMBOSIS.
 WHEN USED AS A SINGLE
MODALITY SHOWED 39 – 92 %
RECURRENCE RATES.
INTERFERON THERAPY
 REDUCE KELOIDAL
FIBROBLAST PRODUCTION OF
COLLAGEN I, III, VI
MESSENGER RNA.
 FEWER RECURRENCES
REPORTED – 18%.
 Keloid and hypertrophic scar
Cinical features Hypertrophic scar keloid
Always preceded by yes no
injury
Anatomical association no yes
Extent of growth limited to wound Extends beyond the
wound
Resolves Spontaneously Yes No
Recurs after surgery No Yes
Associated with Yes No
contracture
Over all Common Common
incidence[blacks]
Associated with race No Yes
 CONCLUSION
 Keloid is still a major problem for
pigmented races
 Differs from hypertrophic scar in its natural
history
 Extends beyond the margin of original
injury
 Does not usually improve with time
 Tend to recur readily with surgery alone
 Combination therapy advocated.