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.

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. Note the images below.

Keloid. Courtesy of Dirk M. Elston, MD.

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Keloid. Courtesy of Dirk M. Elston, MD.

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Keloid. Courtesy of Dirk M. Elston, MD.

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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. Keloids overlying a joint can contract and restrict movement.

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 may be distinguished from hypertrophic scars by their clawlike projections, which are absent in the hypertrophic scar.

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.

Complications

Trauma to the keloid may predispose the lesion to erosion and localized bacterial infection.

Differential Diagnoses

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Media Gallery

Clawlike outline of a keloid. Courtesy of Dirk M. Elston, MD.
Keloid. Courtesy of Dirk M. Elston, MD.
Keloid. Courtesy of Dirk M. Elston, MD.
Keloid. Courtesy of Dirk M. Elston, MD.
Histology of keloid demonstrating central zone of hyalinized collagen (hematoxylin and eosin stain). Courtesy of Dirk M. Elston, MD.
Histology of keloid demonstrating thick hyalinized collagen bundles (hematoxylin and eosin stain). Courtesy of Dirk M. Elston, MD.

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Author

Brian Berman, MD, PhD Dermatologist and Partner, Skin and Cancer Associates; Professor Emeritus of Dermatology and Cutaneous Surgery, University of Miami, Leonard M Miller School of Medicine

Brian Berman, MD, PhD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Aclaris; Bifrontera; Aiviva; Pulse; Celumigen; Dermira; DUSA Sun; Exeltis, Ferndale; Galderma; GSK; Halscion; Klara; Leo; Medimetriks; Miragen; Novan; Novartis; TopMD; Aclaris; Menlo; Cara; Lemonex; Mediwound; Almirall; Pfizer; Sirnaomics; Minolab<br/>Serve(d) as a speaker or a member of a speakers bureau for: Sun; Exeltis, Ferndale; Galderma; GSK; Halscion; Leo Pharmaceuticals; Medimetriks; Miragen; Novan; Novartis; Valeant Pharmaceuticals; Anacor; Clark; Aclaris; Sensus;Almirall<br/>Received research grant from: Dermira; DUSA; Exeltis, Ferndale; Galderma; Leo; Menlo; Anacor; Clark; Pulse; Miragen; Sensus; Minolab<br/>Received income in an amount equal to or greater than $250 from: Bifrontera; Aiviva; Pulse Biosciences; Dermira; DUSA; Sun; Menlo; Exeltis, Ferndale; Galderma; GSK; Halscion; Leo; Medimetriks; Miragen; Novan; Novartis; TopMD; Anacor;Aclaris; Sensus; Cara; Lemonex; Mediwound;Almirall;Minolab;.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Steven R Feldman, MD, PhD Professor, Departments of Dermatology, Pathology and Public Health Sciences, and Molecular Medicine and Translational Science, Wake Forest Baptist Health; Director, Center for Dermatology Research, Director of Industry Relations, Department of Dermatology, Wake Forest University School of Medicine

Steven R Feldman, MD, PhD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, North Carolina Medical Society, Society for Investigative Dermatology

Disclosure: Received honoraria from Amgen for consulting; Received honoraria from Abbvie for consulting; Received honoraria from Galderma for speaking and teaching; Received consulting fee from Lilly for consulting; Received ownership interest from www.DrScore.com for management position; Received ownership interest from Causa Reseasrch for management position; Received grant/research funds from Janssen for consulting; Received honoraria from Pfizer for speaking and teaching; Received consulting fee from No.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Sadegh Amini, MD Dermatologist, Skin Cancer Associates; Voluntary Assistant Professor, Department of Dermatology and Cutaneous Surgery, University of Miami, Leonard M Miller School of Medicine.

Sadegh Amini, MD is a member of the following medical societies: American Academy of Dermatology, American Society for Dermatologic Surgery, International Society for Dermatologic Surgery, International Society of Dermatology

Disclosure: Own stocks at NYSE for: AbbVie Inc.

Martha H Viera, MD Resident Physician, Department of Dermatology and Cutaneous Surgery, Jackson Memorial Hospital, University of Miami, Leonard M Miller School of Medicine

Martha H Viera, MD is a member of the following medical societies: American Medical Association, Women's Dermatologic Society

Disclosure: Nothing to disclose.

Arash Taheri, MD Research Fellow, Center for Dermatology Research, Department of Dermatology, Wake Forest University School of Medicine

Disclosure: Nothing to disclose.

Andrea D Maderal, MD Resident Physician, Department of Dermatology and Cutaneous Surgery, Jackson Memorial Hospital, University of Miami, Leonard M Miller School of Medicine

Andrea D Maderal, MD is a member of the following medical societies: American Academy of Dermatology, Florida Society of Dermatology and Dermatologic Surgery, Medical Dermatology Society, Miami Society for Dermatology, Rheumatologic Dermatology Society

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Whitney Valins, MD, to the development and writing of the source articles.