A keloid scar is a raised scar that forms when the skin’s healing process becomes aggressive, causing tissue to grow beyond the boundaries of the original wound. This overgrowth creates a firm, rubbery mass that can be painful or itchy. While plastic surgery can remove a keloid, the procedure is rarely a standalone solution due to the scar’s high tendency to return. Effective treatment requires surgical removal to be immediately followed by specialized therapies to prevent the scar from regrowing.
Understanding Keloid Scars
Keloids represent an abnormal healing response characterized by the excessive production of collagen. Unlike a hypertrophic scar, which remains confined to the injury site, a keloid spreads into the healthy surrounding tissue and rarely regresses spontaneously. This aggressive growth pattern makes them challenging to manage.
The risk of developing a keloid is significantly higher in individuals with darker skin tones, such as those of African, Asian, and Hispanic descent. Genetics play a strong role, and keloids commonly form in areas of the body under tension, like the earlobes, chest, shoulders, and upper back. Any type of skin trauma, including acne, piercings, burns, or surgical incisions, can trigger keloid formation months after the initial injury has healed.
Surgical Removal Procedures
The primary surgical approach for keloids is surgical excision, where the entire scar tissue is carefully cut away. Plastic surgeons employ meticulous techniques to close the resulting wound, aiming for minimal tension on the new scar line, as skin tension is a known factor in recurrence. For very large keloids, a skin graft or local flap may be needed to cover the defect left after the mass is removed.
Surgery alone is associated with a high rate of recurrence, ranging from 45% to nearly 100%. Making a new incision triggers the same inflammatory and healing cascade that created the original keloid. For this reason, surgery is almost never performed without a planned regimen of follow-up treatments to interrupt this cycle. A specialized technique, intralesional excision, removes the bulk of the keloid while leaving a small layer of scar tissue behind, which may offer a lower recurrence rate.
The Critical Role of Recurrence Prevention
Because surgical excision creates a new wound highly susceptible to keloid recurrence, combined therapy is the established standard of care. This immediate post-operative management, known as adjuvant therapy, is designed to suppress aggressive collagen production.
The most common and effective component involves intralesional corticosteroid injections, typically using triamcinolone acetonide. These injections are administered into the new scar site immediately following surgery and repeated monthly for several months to reduce inflammation and inhibit fibroblast activity.
Superficial Radiation Therapy (SRT) is another highly effective adjuvant treatment that can significantly lower the recurrence rate. The radiation is delivered at a low dose to the surgical site, ideally within 72 hours post-excision, to target and suppress the overactive fibroblasts.
Pressure therapy, involving specialized garments or clips, must be worn nearly constantly for months to apply consistent pressure. This continuous pressure reduces blood flow and inhibits the growth factors that contribute to excessive scarring. Finally, silicone sheets or gels are applied topically to the site, which helps with hydration and provides a mild occlusive pressure that modulates the healing environment.
Non-Surgical Treatment Options
For smaller or newer keloids, or for patients who are not candidates for surgery, several non-surgical interventions are available.
Intralesional Injections
Intralesional injections of medications other than steroids are often used, such as 5-fluorouracil (5-FU) or bleomycin. These drugs inhibit the proliferation of the cells responsible for keloid growth. Combining 5-FU with a corticosteroid injection can improve efficacy compared to using steroids alone.
Cryotherapy and Laser Treatments
Cryotherapy involves freezing the keloid tissue using liquid nitrogen, which destroys the cells and blood vessels within the scar. Repeat treatments are often necessary, and this method can effectively flatten the scar, though it may cause loss of skin color. Laser treatments, particularly the pulsed-dye laser, are used to reduce the redness and bulk of the keloid by targeting the blood vessels that feed the scar. Treatment must be highly individualized, with a specialist determining the best combination of therapies based on the scar’s size, location, and maturity.