Keloids

Keloids can appear after any type of trauma, inflammation, surgery or burn on the skin, although they can occur spontaneously. This abnormal scarring may be unavoidable and independent of surgical technique or wound care after their appearance. They are usually seen on the trunk and may appear late rather than at the beginning of the healing process.

The treatment of keloids can be complex and the results can be unpredictable. Although complete resolution is unlikely, we can significantly improve their appearance. The choice of treatment for keloids will depend on the location, extent, evolution, appearance of the scar and patient preference.

Specifically, to decide on the most appropriate tools, we must take into account characteristics such as keloid tension (to assess whether surgery is necessary to release this tension), redness (which is maximum at the beginning of its formation and will improve progressively) and the texture of the keloid. Reoperation on a keloid is not usually recommended except in cases of high tension, so the best option is a combination of some of these treatments, depending on the characteristics of each patient:

• Lasers
  • Vascular lasers: KTP laser, pulsed dye laser and Nd:YAG. These lasers selectively treat the haemoglobin in the blood vessels present in keloids, so they are appropriate for those of recent appearance or for the most reddened ones. When used in the early stages, they can limit excessive and abnormal collagen production. In addition, these devices have the ability to improve the texture of keloids and can be combined with other techniques, and are painless.
  • Non-ablative fractional laser: This device heats the dermis without damaging the epidermis (avoiding the appearance of scabs) generating columns that stimulate the regeneration of abnormal collagen. It improves the overall appearance of the scar (colour, pigment, thickness and texture) although it must be combined with other treatments for its effects to be evident. It is a safe and fast device.
  • Fractional ablative laser: These devices generate small columns of epidermis and dermis, from which the synthesis of new collagen in the scar will be stimulated over the following weeks. Its use improves the colouring and texture of the keloid, although scabs may be visible after treatment for a few days. It is more effective than non-ablative fractional laser, is better tolerated, and can be used in later stages of keloid.
• Injections of corticosteroids and cytostatics: these reduce the volume of keloids. In particular, corticosteroid infiltration is the treatment of first choice as it reduces the overgrowth of collagen, fibroblasts (cells involved in the origin of these scars) and certain inflammatory mediators. It also reduces the itching of the scar. It is a quick and safe procedure, slightly uncomfortable, and can be combined with other treatments.
  The use of cytostatic drugs such as 5-fluorouracil are useful to decrease the excessive division of fibroblasts in these scars. In addition, they can be combined with corticosteroids in varying proportions depending on the appearance of the lesion to be treated. The main contraindication to 5-fluorouracil infiltration is its incompatibility with an antiviral drug called brivudine.
• Cryotherapy: This consists of the application of liquid nitrogen with the intention of reducing volume thanks to the vascular contraction and cell damage it causes in the treated area. Although it may be somewhat uncomfortable for the patient, it is a quick and safe technique.
• Botulinum toxin: Indicated in areas of tension and in combination with other treatments.

Generally, scars can develop over a period of about a year, so they should be treated as soon as possible, especially during the first 3 months of their formation.

Although each scar has its own particular characteristics, several combined treatment sessions spaced approximately 4 to 8 weeks apart are necessary. Once again, an early approach allows us to improve the prognosis and establish a more adjusted treatment schedule.

Patients can promote the evolution and improvement of the keloid by keeping the skin properly hydrated, using topical corticosteroids or applying silicone gels or dressings. However, these tools are much less effective than the combination of treatments carried out in the doctor’s office.