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Understanding Keloid Scars and Effective Treatment Options

Understanding Keloid Scars and Effective Treatment Options

Introduction

Keloid scars are a unique challenge for those who suffer from them. Unlike regular scars, which usually fade and flatten over time, keloids tend to expand beyond the original injury site and become raised, thick, and often darker. For many, keloid scars bring physical discomfort, such as itching and tenderness, as well as emotional distress, particularly when they form in prominent places like the chest, shoulders, or ears.In this article, we’ll discuss what keloid scars are, why they form, and review the most effective treatment options available. From conservative management to surgery and radiotherapy, understanding the options can help you find a tailored solution that fits your needs.

What are Keloid Scars?

Keloid scars are abnormal, raised, and often firm growths that form as an excessive response to skin injury. Unlike hypertrophic scars, which remain confined to the wound’s original borders, keloids extend beyond the initial injury site, often appearing reddish, purplish, or darkly pigmented. They can continue to grow for months or even years after the initial trauma.
Keloid formation is a complex process influenced by chronic inflammation and dysregulated wound healing. In response to injury, the body initiates an exaggerated inflammatory reaction, resulting in excessive collagen and extracellular matrix production. This overactive healing response leads to the characteristic thickening and spreading of keloids. The exact mechanisms are still not fully understood, making keloid scars particularly challenging to treat.
Keloids most commonly appear on the upper chest, upper arms, shoulders, upper back, suprapubic region and earlobes. Interestingly, keloids very rarely develop on the scalp, eyelids and the anterior lower leg, even if the patient has multiple keloids on the body. Triggers include surgical incisions, acne scars, piercings, burns, BCG vaccination sites or even minor injuries like insect bites or scratches. Certain individuals may have a higher predisposition to keloid formation.

Why Do Keloid Scars Form?

Keloid scars result from an abnormal wound-healing process with an overproduction of collagen. Instead of stopping when the wound is sufficiently healed, the body continues to deposit excess collagen, leading to a raised, often hard scar that extends into the surrounding tissue.
Several factors may increase a person’s likelihood of developing keloids:
  • Local factors such as high wound tension, delayed healing, inflammation, or infection increase the risk of keloid formation. Locations prone to mechanical stress, like the chest, shoulders, and upper back, are more susceptible. Foreign bodies, including sutures or piercings, can also trigger excessive scarring through prolonged inflammation.

  • Genetic factors play a significant role, with a strong family history often seen in keloid cases. Specific gene variants and single nucleotide polymorphisms (SNPs) related to wound healing pathways increase susceptibility. Keloids are more common in individuals with darker Fitzpatrick skin types (IV-VI) and in certain ethnic groups with higher melanin levels. Additionally, studies have suggested a higher incidence of keloid formation in individuals with blood group A.

  • Systemic factors such as hormonal influences (e.g., estrogen), hypertension, and chronic inflammation may also contribute to keloid risk. There is evidence indicating elevated levels of inflammatory cytokines (e.g., IL-6, TNF-α) in keloid tissue, which may be linked to the persistent activation of fibroblasts and excessive collagen production. However, the precise mechanisms remain complex and are not yet fully understood.

Keloid Scar Treatment Options

Keloid scars are challenging to manage and often require a combination of treatments to improve their appearance and reduce symptoms. While complete resolution may be difficult to achieve, advancements in surgical techniques and adjunctive therapies offer effective options for better scar control and improved quality of life.
Silicone Sheets and Compression Therapy
Silicone sheets and compression garments remain the cornerstone of keloid management. Silicone helps hydrate the scar and regulate collagen production, while compression creates a low-oxygen environment that can slow scar growth. While highly effective, these modalities are always best used as adjuncts to other treatments to reduce recurrence risks, with consistent application over several months being key to their success.
Steroid Treatments
Steroid treatments, including intralesional injections, laser-assisted drug delivery, tapes, and topical applications, are widely used to manage keloids. These methods, especially laser facilitated delivery and intralesional injections are supported by the literature for leading to significant improvement by reducing inflammation, softening scar tissue, and slowing excessive collagen production, making them a key component of combination therapy plans. However, steroid treatments can have side effects, such as atrophic changes, skin thinning, pigment changes, delayed wound healing, amongst others, emphasizing the importance of careful application and monitoring
Anti-Mitotic Drugs
Antimitotic-drugs such as 5-fluorouracil (5-FU) and bleomycin are well-documented in the literature for their ability to inhibit fibroblast activity and collagen overproduction in keloids. While these are TGA-approved drugs, they are not specifically approved for the treatment of scars or keloids. Despite this, their efficacy is widely recognised, with 5-FU frequently combined with steroids to enhance treatment outcomes. However, their use requires careful consideration due to potential side effects, particularly with bleomycin, which may carry a higher risk of adverse reactions.
Laser Therapy
Laser treatments, including vascular and fractional ablative lasers, are valuable, minimally invasive options for managing keloids. Vascular lasers, such as pulsed dye lasers and the DermaV, target the blood vessels that supply keloid tissue, reducing redness and inflammation while helping to flatten the scar. Fractional ablative lasers not only remodel collagen and improve surface texture but can also be used to deliver intralesional steroids directly into the scar tissue. This technique allows for precise drug delivery with fewer adverse effects compared to intralesional injections alone.
However, a cautious approach is important when using lasers for keloids, as excessive heat could potentially stimulate inflammation in certain cases. To mitigate this, treatments are carefully tailored to each patient’s needs, often combining lasers with other therapies for optimal safety and effectiveness. With proper planning and execution, laser therapy can be a highly effective tool in keloid management.
Surgical Excision
Surgical excision is an effective way to reduce the bulk of a keloid; however, it can carry a risk of recurrence as high as 100% if used as a standalone treatment. To minimise this risk, if surgery is recommended as the treatment of choice, it has to be combined with adjunctive therapies such as silicone sheets, compression garments, steroid injections, or radiotherapy with a thorough long term follow up plan. When integrated into a well-planned combination approach, surgical excision can play a pivotal role in managing keloids and improving long-term outcomes.
Intralesional Cryotherapy
Intralesional cryotherapy involves freezing keloid tissue from within, leading to tissue shrinkage over time. This treatment is often used for suitable keloids and can be effective in reducing scar volume and symptoms. However, it carries a risk of pigmentary changes, particularly in individuals with darker skin types. While not universally applicable, intralesional cryotherapy can be a valuable option in select cases.
Radiotherapy
Radiotherapy is a specialised treatment option often reserved for severe or recurrent keloids, especially when other therapies have been insufficient. Applied after surgical excision, radiotherapy targets the pathological wound-healing processes by inhibiting fibroblast activity and reducing collagen production. This approach is considered particularly effective when used as part of a comprehensive treatment plan.
Radiation is typically delivered in carefully calculated doses to minimise risks while achieving therapeutic effects. Fractionated protocols are often employed to focus the treatment and reduce exposure to surrounding tissues. While radiotherapy can significantly reduce the risk of keloid recurrence, its use is approached cautiously due to potential long-term effects, such as changes to the treated area or, in rare cases, more serious complications.
Radiotherapy remains a valuable option in select cases, particularly for keloids that are resistant to other treatments, when combined with other modalities in a well-structured treatment plan.
Combination Therapy
No single treatment is universally effective for keloids; the best outcomes are typically achieved through combination therapy tailored to the individual. A personalised approach, factoring in your specific circumstances and keloid characteristics, along with a thorough risk assessment, allows for a multi-faceted strategy. This method can help minimise recurrence and enhance the overall aesthetic and symptomatic outcomes of treatment.

What to Expect from Keloid Scar Treatment

Treating keloid scars requires patience and a long-term commitment, as most therapies involve multiple sessions over an extended period. Long-term follow-ups are essential to monitor for any signs of recurrence and to intervene early if needed, ensuring sustained results. The primary goal is not only to improve the appearance of the keloid but also to address symptoms such as itching, discomfort, and tenderness.
Your treatment plan may include a combination of therapies tailored to your specific needs, often requiring adjustments based on how your keloid responds over time. Consistently following through with the full course of therapy and maintaining communication with your healthcare provider are critical for achieving the best possible outcomes and managing potential recurrences effectively.

Conclusion

Keloid scars can be challenging to manage, but with the right approach, meaningful improvements in appearance and symptoms are often achievable. Treatment outcomes depend on individual factors and a carefully selected strategy tailored to your needs. A thorough consultation with a specialised and qualified healthcare professional is essential to develop a personalised plan aimed at reducing scar bulk, improving texture, and alleviating discomfort, helping you achieve the best possible results.
At Scarless The Clinic, we understand the complexities of keloid treatment and are dedicated to providing personalised care to achieve optimal results. Whether your goal is to reduce the appearance of a keloid or find relief from symptoms, a tailored treatment plan can make all the difference. If you're ready to take the next step in your journey to clearer skin, book a consultation with us and let’s explore the best options for your keloid scar treatment.