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Exuberant keloidal formation BRAD J. ABRAMS, DO ANTHONY v. BENEDE'ITO, DO HARRY M. HUMENIUK, MD Keloids are disfiguring defor ation of multiple keloids. She had a 7-year history of mities that occur after trauma or wounding multiple and extensive keloids on her chest and abdomen. of the skin, most commonly among blacks. The lesion of most concern, both physically and cos The case presented here is unusual because metically, was a giant nodular keloid located on the of the number of keloids and the massive lower aspect of her abdomen. Although she initially size of one. The patient underwent full sur denied having experienced any previous trauma or gical excision together with intraoperative and surgeries at the keloid sites, she remembered having a postoperative steroid injections with good brief, but severe, case of suprapubic folliculitis approx cosmetic results. Various causes of keloids imately 7 years previously. This infection seemed to be are reviewed as are the histopathologic dif the most likely event to initiate the formation of a keloid ferences between hypertrophic scars and in the suprapubic region. keloids. Alternative surgical and nonsurgical The giant nodular tumor, measuring 9.0 X 5.0 cm treatment techniques are examined. in its greatest dimensions, lay transversely. The ses (Key words: Keloid, hypertrophic scar, sile mass was firm and the overlying epidermis was dermis, collagen bands) markedly thinned and hyperpigmented (Figure 1). The patient had not previously sought treatment. She was distraught and self-conscious about this lesion. She Keloids constitute a not infrequent disfigurement complained of episodic dull pain and pruritus along the occurring after trauma or wounding of the skin, most margins of the lesion-a symptom often associated with commonly in the black population. These complex active growth. lesions ofthe human dermis involve excessive col Many treatment modalities have been used to com lagen production, sometimes resulting in debili bat this recurrent deformity. They include cryosurgery, tating cosmetic and physical deformities. surgical excision, laser surgery, local steroid injection, Modalities for treatment of keloids remain ultrasound, penicillamine, retinoic acid, dextran sul diverse because of the difficulty in eradicating fate, asiatic acid, adhesive zinc tapes, silicone gels, and these deformities. The case presented here is radiation therapy.l,2 As is often the case, such a diver unusual because of the number ofkeloids formed sity of treatment regimens suggests that there is no in this patient and the massive size of one. single best treatment. Our patient's keloid was surgically removed, and cor ticosteroids were injected intraoperatively. The lesion Report of case was excised in toto by injection of triamcinolone ace A 34-year-old African-American woman was seen at tonide into the base ofthe keloid's surgical defect. After our outpatient dermatologic surgical center for evalu- extensive undermining, the surgical wound was closed with 4-0 nylon simple interrupted skin sutures. Buried Dr Abrams is a second-year dermatology resident with the sutures were not used because we feared that they Dermatology Center, Philadelphia, Pa; Dr Benedetto is clin might promote further keloid formation through prolonged ical assistant professor of medicine (dermatology), Medical foreign body reaction. College of Pennsylvania, Philadelphia; and Dr Humeniuk is clinical assistant professor of medicine, Division of Derma Forty milligrams (8 mL of 5 mg/mL) of triamci tology, and clinical assistant professor of pathology, Med nolone acetonide was injected into the surgical defect at ical College of Ohio, Toledo. approximately 8-week intervals for 12 months. Three Correspondence to Brad J . Abrams, DO, 1676 Stocton days after each injection, flurandrenolide (Cordran) Rd, Meadowbrook, PA 19046. tape was applied to the entire defect for a period of 4 weeks. Case report • Abrams et al JAOA· Vol 93 • No 8· August 1993·863 Figure 1. Nodular tumor, measuring 9.0 X 5. 0 cm in its greatest Figure 2. Slight residual hypertrophic scar formation after total dimension, located in the suprapubic region. surgical removal of keloid. At the 12-month postoperative follow-up examination, skin.6 Although most keloids appear as a result the site remained clear of recurrent keloid formation. of some form of skin wounding, there are reports Ho~ever , a slight hypertrophic scar had formed at the of spontaneous keloid formation without an operative site (Figure 2 ). antecedent history of trauma. These reports remain The patient was satisfied with the appearance of her unsubstantiated, and most clinicians believe "spon new surgical scar and refused further treatment. We chose full surgical excision with intraoperative injection of taneously formed" keloids arise from long-forgot triamcinolone acetonide because of the size of the keloid ten skin wounds. and our own past success with this specific procedure. Minor trauma- including insect bites, acne, Since the removal of this giant keloid, the patient has folliculitis, hidradenitis suppurativa, ear piercing, had two other abdominal keloids removed by the same hair waxing, hypodermic needle penetration, tat technique with excellent cosmetic results toos, chickenpox, and increased tension of surgical wounds-only partially accounts for events respon Discussion sible for keloid formation. In general, small keloids Keloids have plagued humans for centuries. African do not cause pain or discomfort for the patient. proverbs and folk medicine offer their own ver However, they may be associated with intense sions of the etiology and treatment of these benign pruritus and may become painful, particularly cosmetic deformities. Although most of these dis when they are very large. These symptoms are orders are found in blacks, keloids occur in all usually associated with active growth. The time races. Albinos and whites are least affected. Sites lag between the inducing injury and the forma of predilection include the mid chest, back, and tion of the keloid remains extremely variable. posterior aspect of the neck. These locations also The BCG vaccine, still given in some coun tend to be the sites of the most severe and exten tries for tuberculosis, has been known to form sive keloids. keloid scars years later. Conversely, ear piercing, Regions moderately susceptible to keloid for acne, or shaving injuries may lead to keloid for mation include the ear lobes (particularly occurring mation within a few weeks after injury.3 Some many months after ear piercing), the skin overly clinicians believe keloids to be benign lesions of ing the deltoid muscles, the chest, and the beard cosmetic importance only. However, keloids can area of the face and neck. Regions of lesser sus be associated with more serious problems, includ ceptibility include abdominal skin, forearms, and ing pseudomelanomas, suppuration, and Rubinstein the remainder of the face. 3-5 Taybi syndrome. Rubinstein-Taybi syndrome is Clinically, keloids are thick scar tissues of the associated with mental retardation, abnormal human skin that evolve secondary to wounding. By facies, broad terminal phalanges, and a predilec definition, they grow beyond the normal bound tion for the formation of exuberant keloids.6 aries of the original wound and invade normal Keloids and hypertrophic scars are principal- 864· JAOA· Vol 93 • No 8· August 1993 Case report • Abrams et al ly lesions of the dennis. Histologically, they appear The mucoid matrix tends to be less pronounced as relatively similar processes, whereas clinical in hypertrophic scars, as does the number of thick ly there are several quantitative differences. Keloids ened collagen bands. The nodular condensation typically expand beyond the boundaries of the of the collagen in keloids persists indefinitely, original wound. They develop over months to years whereas in hypertrophic scars, the collagen grad and may then persist indefinitely as thickened ually becomes thinner and ultimately "straight excrescences. Conversely, hypertrophic scars remain ens out," leading to what is seen as a clinically within the boundaries of the initiating wound, flattened and softer lesion. 1 progress for only a few months, and usually become soft and flatten spontaneously within a few years. Comment Keloid formation is found to be two to 20 times Keloids should be distinguished from hypertrophic greater in blacks than in whites, whereas hyper scars because if they are improperly diagnosed, trophic scars occur with similar frequency in all races. overly aggressive therapy may prove counterpro Some dermatologists believe keloids have a famil ductive and may cause unnecessary atrophy. ial predisposition, especially in persons with mul Although keloids are often difficult to resolve, suf tiple keloids. The incidence ofHLA-B14 and HLA ficient therapeutic options are usually available BW16 in white patients with keloids has been should one treatment regimen prove ineffective. found to be significantly greater than in those without keloids. Although a keloid-familial link has been established, clearly there needs to be 3 References more research in this area. 1. Lever WF, Schaumburg-Lever G: Histopathology of the Skin, ed By histopathologic analysis, keloids and hyper 7. Philadelphia, Pa, JB Lippincott Co, 1990, pp 668-669. trophic scars have a number of elements in com 2. Brown LA, Pierce HE: Keloids: Scar revision. J Dermatol Surg Oncol 1986;12:5-55. mon. Both

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