A large keloid (Figure 141-1A) has been present on the upper ear of this 14-year-old boy for more than 2 years, since he experienced trauma to this area. The keloid was excised in the office with local anesthetic and the defect sutured using 5-0 Prolene (Figure 141-1B). The cosmetic result was excellent and the patient was happy.

Keloids are benign dermal fibroproliferative tumors that form in scar because of altered wound healing. They form as a result of overproduction of extracellular matrix and dermal fibroblasts that have a high mitotic rate.

Cheloid.

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  Individuals with darker pigmentation are more likely to develop keloids. Sixteen percent of black persons reported having keloids in a random sampling.¹

  
  
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  Men and women are generally affected equally except that keloids are more common in young adult women—probably secondary to a higher rate of piercing the ears (Figure 141-2).²

  
  
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  Highest incidence is in individuals ages 10 to 20 years.^2,3

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  Keloids are dermal fibrotic lesions that are a variation of the normal wound-healing process in the spectrum of fibroproliferative disorders.

  
  
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  Keloids are more likely to develop in areas of the body that are subjected to high skin tension such as over the sternum.

  
  
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  These can occur even up to a year after the injury and will enlarge beyond the scar margin. Burns and other injuries can heal with a keloid in just one portion of the area injured.

  
  
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  Wounds subjected to prolonged inflammation (acne cysts) are more likely to develop keloids.

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  Darker skin pigmentation (African, Hispanic, or Asian ethnicity) (Figure 141-3).

  
  
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  A family history of keloids.

  
  
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  Wound healing by secondary intention.

  
  
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  Wounds subjected to prolonged inflammation.

  
  
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  Sites of repeated trauma.

  
  
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  Pregnancy.

  
  
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  Body piercings (Figure 141-4).

Clinical Features

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  Some keloids present with pruritic pain or a burning sensation around the scar.

  
  
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  Initially manifest as erythematous lesions devoid of hair follicles or other glandular tissue.

  
  
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  Papules to nodules to large tuberous lesions.

  
  
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  Range in consistency from soft and doughy to rubbery and hard. Most often, the lesions are the color of normal skin but can become brownish red or bluish and then pale as they age.⁴

  
  
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  May extend in a claw-like fashion far beyond any slight injury.

  
  
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  Lesions on neck, ears, and abdomen tend to become pedunculated.

Typical Distribution

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  Anterior chest, shoulders, flexor surfaces of extremities, anterior neck, earlobes, and wounds that cross skin tension lines.