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keloid (hypertrophic scar)
Nodular, firm, movable, non-encapsulated hypertrophic scar tissue. It is tender & frequently painful.
Etiology:
1) unknown
2) generally follows injury to skin
- surgical incision [5]
- lacerations
- burns
- inflammatory skin conditions
Epidemiology:
1) age: childhood through senescent
2) equal incidence in males & females
3) more common in blacks than whites
Pathology:
1) whorls of young fibrous tissue & fibroblasts in haphazard arrangement
2) thick eosinophilic, irregularly distributed bands of collagen (keloid)
3) occurs in the dermis & adjacent subcutaneous tissues
* histopathology images [9]
Clinical manifestations:
1) papules, nodules, tumors, large tuberous lesions
2) generally tender & frequently painful, but may be asymptomatic
3) cosmetically disfiguring
4) color; red, tan, brown, flesh-colored
5) may be claw-like extensions beyond original site of injury (keloids)
6) hypertrophic scars tend to regress, keloids may continue to increased in size for decades
* images [5,6,8,9,10]
Differential diagnosis:
1) scar
2) dermatofibroma
3) dermatofibrosarcoma
4) desmoid tumor
5) foreign body granuloma
6) sarcoidosis
Management:
1) prevention
a) avoid skin trauma
b) triamcinolone acetonide (5 mg/mL) injected at the incision site
2) crytotherapy with liquid nitrogen
3) intralesional triamcinolone acetonide 10-40 mg/mL q month (lesions may be difficult to inject because of collagen)
4) combinations of cryotherapy & intralesional triamcinolone
5) surgical excision:
a) lesions often recur larger than the original lesion
- surgical resection with immediate infiltration of glucocorticoids without recurrence in case report [5]
b) post-surgical irradiation with iridium has been reported to be of benefit
General
abnormal morphologic structure (malformation)
References
- Stedman's Medical Dictionary 26th ed, Williams &
Wilkins, Baltimore, 1995
- Color Atlas and Synopsis of Clinical Dermatology, Common
and Serious Diseases, 3rd ed, Fitzpatrick et al, McGraw Hill, NY,
1997, pg 174-175
- Medical Knowledge Self Assessment Program (MKSAP) 16, 17.
American College of Physicians, Philadelphia 2012, 2015
- Juckett G, Hartman-Adams H.
Management of keloids and hypertrophic scars.
Am Fam Physician. 2009 Aug 1;80(3):253-60.
PMID: 19621835
- Valenzuela Salas I1, Fernandez Miralbell A
Images in clinical medicine. Incisional keloid.
N Engl J Med 2015; 372:1453
PMID: 25853749
http://www.nejm.org/doi/full/10.1056/NEJMicm1407180
- Wikipedia: Keloid (image)
https://en.wikipedia.org/wiki/Keloid
- Manuskiatti W, Fitzpatrick RE.
Treatment response of keloidal and hypertrophic sternotomy
scars: comparison among intralesional corticosteroid,
5-fluorouracil, and 585-nm flashlamp-pumped pulsed-dye
laser treatments.
Arch Dermatol. 2002 Sep;138(9):1149-55.
PMID: 12224975
- MedlinePlus: (images, patient info)
https://www.nlm.nih.gov/medlineplus/ency/article/000849.htm
- Jansen D, Molnar JA (images)
Medscape: Keloids
http://emedicine.medscape.com/article/1298013-overview
- DermNet NZ. Keloids and hypertrophic scars (images)
http://dermnetnz.org/dermal-infiltrative/keloids.html