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1. KELOIDS and HYPERTROPHIC
SCARS
DR J. K. SESAY
Dip. Int. Health, M.D., M.Med. Surgery
SENIOR REGISTRAR @ MOHS
GENERAL SURGEON
USLTHC – Connaught

2. RANGE OF ADVERSE SCARS
 Poor alignment
 Stretched
 Contour deformity
 Pigmentry problems
 Stitch marks
 tattooing

3. ADVERSE SCARS
 Appearance

4. Range of Adverse Scars
 Hypertrophic Scar

5. RANGE OF ADVERSE SCARS
 KELOID SCAR

6. ADVERSE SCARS
 FUNCTION
 BOTH

7. KELOID DIATHESIS

8. PHASES IN WOUND HEALING
 Inflammatory phase
 Proliferative phase
 Remodeling phase

9. 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

10. 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

11. 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

15. KELOID HISTORICAL
BACKGROUND
•First description 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.

16. 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

17. 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

18. SEX
INCIDENCE IN FEMALES
HIGHER THAN IN MALES
POSSIBLY SECONDARY
TO THE COSMETIC
IMPLICATIONS.

19. AGE
ONSET BETWEEN 10 AND
30 YEARS.
OCCUR LESS
FREQUENTLY AT AGE
EXTREMES.

20. P
Earlobes
P
Head and Neck
P
Pre-sternal
P
Breasts
P
Deltoid/upper back
P
Upper extremities
P
Abdomen/pubis
P
Lower extremities
P
Feet
P
Genitalia
SITES OF PREDILECTION
DECREASING
INCIDENCE

21. 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.

22. LABORATORY STUDIES
DIAGNOSIS USUALLY
BASED ON CLINICAL
FINDINGS.

23. Differential Diagnosis
 Hypertrophic scar
 Dermatofibrosarcoma Protuberance
 Neurofibromatosis

24. DD

25. KELOID IN THE BEARDED AREA
 Infection
 Abcess

26. EAR LOBE KELOIDS

27. EARLOBE KELOIDS 2

28. TRUNCAL KELOIDS

29. HEAD AND NECK KELOIDS

30. KELOIDS OF FOOT

31. ABDOMINAL/PUBIC KELOIDS

32. 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.

33. Treatment of keloid and
hypertrophic scar
 Pressure
 Intralesional steroid inj [triamcinolone]
 Excision and steroid inj
 Excision and postop radiation
 Silicone gel sheeting
 Laser

34. Steroid injection side effects
 Sub cut. Tissue atrophy
 Telangiectasia
 Pigmentary changes

35. EXCISION AND STEROID Rx
BEFORE
AFTER

36. 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.

37. 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.

38. 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.

39. 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.

40. RADIATION THERAPY
 USE REMAINS
CONTROVERSIAL. SAFETY
HAS BEEN QUESTIONED.
 OFTEN FOLLOWS EXCISION.
 RECURRENCE RATES OF 21 –
53 % REPORTED.

41. LASER THERAPY
 CAUSES MINIMAL TISSUE
TRAUMA.
 PHOTOTHERMOLYSIS LEADS
TO MICROVASCULAR
THROMBOSIS.
 WHEN USED AS A SINGLE
MODALITY SHOWED 39 – 92 %
RECURRENCE RATES.

42. INTERFERON THERAPY
 REDUCE KELOIDAL
FIBROBLAST PRODUCTION OF
COLLAGEN I, III, VI
MESSENGER RNA.
 FEWER RECURRENCES
REPORTED – 18%.

43. Keloid and hypertrophic scar
Cinical features Hypertrophic scar keloid
Always preceded by
injury
yes no
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
contracture
Yes No
Over all
incidence[blacks]
Common Common
Associated with race No Yes

44. 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.