eMedicine Specialties > Dermatology > Benign Neoplasms

Keloid and Hypertrophic Scar

Author: Brian Berman, MD, PhD, Professor, Departments of Dermatology and Internal Medicine, University of Miami School of Medicine
Coauthor(s): Sadegh Amini, MD, Volunteer Clinical Research Fellow, Skin Research Group, Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, Miami; Martha H Viera, MD, Senior Clinical Research Fellow, Department of Dermatology and Cutaneous Surgery, University of Miami
Contributor Information and Disclosures

Updated: Feb 25, 2009

Introduction

Background

Keloids are the result of an overgrowth of dense fibrous tissue that usually develops after healing of a skin injury. The tissue extends beyond the borders of the original wound, does not usually regress spontaneously, and tends to recur after excision. The first description of keloids (recorded on papyrus) concerned surgical techniques used in Egypt in 1700 BCE. Subsequently, in 1806, Alibert used the term cheloide, derived from the Greek chele, or crab's claw, to describe the lateral growth of tissue into unaffected skin.

In contrast, hypertrophic scars are characterized by erythematous, pruritic, raised fibrous lesions that typically do not expand beyond the boundaries of the initial injury and may undergo partial spontaneous resolution. Hypertrophic scars are common after thermal injuries and other injuries that involve the deep dermis.

Related eMedicine articles include Laser Revision of Scars; Wound Healing, Keloids; and Wound Healing, Widened and Hypertrophic Scars.

Pathophysiology

Hypertrophic scars and keloids can be described as variations of typical wound healing. In a typical wound, anabolic and catabolic processes achieve equilibrium approximately 6-8 weeks after the original injury. At this stage, the strength of the wound is approximately 30-40% that of healthy skin. As the scar matures, the tensile strength of the scar improves as a result of progressive cross-linking of collagen fibers. At this point, the scar is usually hyperemic and it may be thickened, but it tends to subside gradually over months until a flat, white, pliable, possibly stretched, mature scar has developed. When an imbalance occurs between the anabolic and catabolic phases of the healing process, more collagen is produced than is degraded, and the scar grows in all directions. The scar is elevated above the skin and remains hyperemic. Excessive fibrous tissue is classified as either a keloid or a hypertrophic scar.

Kischer and Brody declared the collagen nodule to be the identifying structural unit of hypertrophic scars and keloids.1 The nodule, which is absent from mature scars, contains a high density of fibroblasts and unidirectional collagen fibrils in a highly organized and distinct orientation. In addition, keloids and hypertrophic scars differ from healthy skin by a rich vasculature, high mesenchymal cell density, and thickened epidermal cell layer. Attempts to clinically differentiate keloids from hypertrophic scars have proved to be difficult in the early phases of formation. Clinical differences become more apparent as lesions mature. The most consistent histologic difference is the presence of broad, dull, pink bundles of collagen in keloids, which are not present in hypertrophic scars.

Frequency

International

Only humans are affected by keloids, and both dominant and recessive modes of inheritance have been described. Although keloids occur in all age groups, they are rarely found in newborns or elderly persons and have the highest incidence in individuals aged 10-20 years.

Mortality/Morbidity

Keloids and hypertrophic scars located at most sites are primarily of cosmetic concern; however, some keloids or hypertrophic scars can cause contractures, which may result in loss of function if overlying a joint or in significant disfigurement if located on the face. Keloids and hypertrophic scars can be both painful and pruritic.

Keloids and hypertrophic scars are associated genetically with HLA-B14, HLA-B21, HLA-Bw16, HLA-Bw35, HLA-DR5, HLA-DQw3, and blood group A.

Race

Keloids form more frequently in Polynesian and Chinese persons than in Indian and Malaysian persons. As many as 16% of people in a random sampling of black Africans reported having keloids. White persons are least commonly affected.

Sex

The prevalence has been reported to be higher in young females than in young males, probably reflecting the greater frequency of earlobe piercing among females. Keloids and hypertrophic scars affect both sexes equally in other age groups.

Age

Onset occurs most commonly in individuals aged 10-30 years. Keloids occur less frequently at the extremes of age, although an increasing number of presternal keloids have resulted from coronary artery bypass operations and other similar procedures now undertaken in persons in older age groups.

Clinical

History

Keloids and hypertrophic scars do not usually cause symptoms, but they may be tender, painful, or pruritic or they may cause a burning sensation. In addition to symptomatic relief, cosmetic concern is the primary reason patients seek medical intervention.

Physical

  • Origins of lesions
    • Keloids manifest as exaggerated growths of scar tissue, usually in areas of previous trauma. Keloids extend past the areas of trauma, projecting above the level of the surrounding skin, but they rarely extend into underlying subcutaneous tissue.
    • Hypertrophic scars remain limited to the traumatized area and regress spontaneously within 12-24 months, although regression may not necessarily be complete.
  • Clinical findings in lesions
    • Keloids range in consistency from soft and doughy to rubbery and hard. Studies have demonstrated how to differentiate and classify keloids according to how they feel.
    • Early lesions are often erythematous.
    • Lesions become brownish red and then pale as they age.
    • Lesions are usually devoid of hair follicles and other functioning adnexal glands.
    • Once lesions occur, the clinical course varies. Most lesions continue to grow for weeks to months and others grow for years. Growth is usually slow, but keloids occasionally enlarge rapidly, tripling in size within months. Once they stop growing, keloids do not usually cause symptoms and remain stable or involute slightly.
    • Keloids on the ears, neck, and abdomen tend to be pedunculated.
    • Keloids on the central chest and extremities are usually raised with a flat surface, and the base is often wider than the top.
    • Most keloids are round, oval, or oblong with regular margins; however, some have clawlike configurations with irregular borders.
    • Most patients present with 1 or 2 keloids; however, a few patients, especially patients with spontaneous keloids, have multiple lesions, as do patients who develop keloids as a consequence of acne or chickenpox.
    • Keloids overlying a joint can contract and restrict movement.
  • Frequency of lesion sites
    • In white persons, keloids tend to be present, in decreasing order of frequency, on the face (with cheek and earlobes predominating), upper extremities, chest, presternal area, neck, back, lower extremities, breasts, and abdomen.
    • In black persons, the descending order of frequency tends to be earlobes, face, neck, lower extremities, breasts, chest, back, and abdomen.
    • In Asian persons, the descending order of frequency is earlobes, upper extremities, neck, breasts, and chest.

Causes

The exact mechanisms of keloid and hypertrophic scar pathogenesis continue to be an enigma for physicians and researchers alike, and no specific gene or set of genes has been identified; however, the increased prevalence of keloids paralleling increased cutaneous pigmentation suggests a genetic basis or, at least, a genetic linkage. Trauma to the skin, both physical (eg, earlobe piercing, surgery) and pathological (eg, acne, chickenpox), is the primary cause identified for the development of keloids. The presence of foreign material, infection, hematoma, or increased skin tension can also lead to keloid or hypertrophic scar formation in susceptible individuals.

More on Keloid and Hypertrophic Scar

Overview: Keloid and Hypertrophic Scar
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Treatment & Medication: Keloid and Hypertrophic Scar
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Multimedia: Keloid and Hypertrophic Scar
References
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Further Reading

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Keywords

keloid, hypertrophic scar, scarring, atypical wound healing, scars, poor wound healing, keloids, hypertrophic scars, excessive scar tissue, compression dressing, Scarguard, Cordran tape, triamcinolone acetonide, intralesional steroid therapy, intralesional interferon therapy

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Contributor Information and Disclosures

Author

Brian Berman, MD, PhD, Professor, Departments of Dermatology and Internal Medicine, University of Miami School of Medicine
Brian Berman, MD, PhD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Collagenex Grant/research funds Other; Collagenex Honoraria Review panel membership; Collagenex Fee to Department Consulting; Graceway Fee to Department Consulting; 3M Fee to Department Consulting; 3M Honoraria Speaking and teaching; Beilis  Consulting; UCB Fee to Department Consulting; Shionogi None Consulting; Astellas Honoraria Review panel membership

Coauthor(s)

Sadegh Amini, MD, Volunteer Clinical Research Fellow, Skin Research Group, Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, Miami
Sadegh Amini, MD is a member of the following medical societies: American Society for Dermatologic Surgery, International Society for Dermatologic Surgery, and International Society of Dermatology
Disclosure: Nothing to disclose.

Martha H Viera, MD, Senior Clinical Research Fellow, Department of Dermatology and Cutaneous Surgery, University of Miami
Martha H Viera, MD is a member of the following medical societies: American Medical Association and Women's Dermatologic Society
Disclosure: Nothing to disclose.

Medical Editor

Kathryn Schwarzenberger, MD, Associate Professor of Medicine, Division of Dermatology, University of Vermont College of Medicine; Consulting Staff, Division of Dermatology, Fletcher Allen Health Care
Kathryn Schwarzenberger, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Contact Dermatitis Society, American Dermatological Association, Dermatology Foundation, Medical Dermatology Society, and Women's Dermatologic Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University School of Medicine; Consulting Staff, Mountain View Dermatology, PA
Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

John G Albertini, MD, Consulting Staff, Dermatologic Surgery, The Skin Surgery Center
John G Albertini, MD is a member of the following medical societies: American Academy of Dermatology and American College of Mohs Micrographic Surgery and Cutaneous Oncology
Disclosure: Nothing to disclose.

CME Editor

Joel M Gelfand, MD, MSCE, Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania
Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology
Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds None; Genentech Consulting fee Consulting; Centocor Consulting fee Consulting; Centocor Grant/research funds None; Covance Consulting fee Consulting; Shire  Consulting

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

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