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Keloid Diagnosis

Information to Help Diagnose Keloids

Keloids have many unique clinical, cellular, and molecular features that make them a distinct type of abnormal scar process. Unlike hypertrophic scars, keloids undergo a process of transformation that allows them to grow beyond the normal limits of the initiating skin injury. The clinical features of a keloid often do not resemble the original scar. Over time, keloids can go through a process of growth, maturation, plateau, and degeneration. The exact timing of these processes is arbitrary and unpredictable, making keloids very difficult to prevent and treat. 

One of the most pressing issues regarding scar treatment is the initial diagnosis. A correct diagnosis can help you identify the problem and source out treatments that can modulate your scar.  The keloidexpert.com website facilitates both physician and patient understanding of the disease process inherent in keloid formation. As you read through the material in this section, you may find that your keloid scar meets more than one criteria for categorization.  This is commonplace with keloids, as they may manifest many different types of morphologies and clinical behaviors. Take the time to read and understand keloid morphology and then schedule an appointment in our Santa Monica office to help diagnose your keloid-type, the degree of inflammation, and the treatment options that would help regress your keloid. 

Keloid Morphology: Understanding the different subtypes of keloids

Morphology is a means by which the internal and external structure and shape is categorized. Keloids are progressive, and may go through various morphologic changes that can alter the clinical appearance of a keloid over time. 

Butterfly Keloids: Keloid scars that occur on the central chest or breast can often take the shape of a butterfly with two lateral wings that expand and a central area connecting the two lateral portions. If the concavity of the chest wall is moderate to severe, or if the butterfly keloid is located within the cleavage of the breast, the central area of the keloid may form a scar contracture and band. The central band of scar tissue may actually grow above the plane of the skin in response to tissue dynamics and tension. The challenge with butterfly keloids is often the degree of inflammation. Butterfly keloids are often not responsive to surgery as they tend to grow back over time. Options include injection therapy, lasers, topical treatment with Plato's Scar Serum, and scar modulation protocols developed by Dr. Karamanoukian. The amount of scar inflammation can make butterfly keloids very difficult to treat.  Patients often complain of itching, burning, and pain with these central chest keloids. Butterfly keloids are often a morphism of flat keloids, superficial spreading keloids, and kissing keloids. 

Dumbbell Keloids: Earlobe and Ear helix keloids can take on a very interesting shape in which they resemble a workout dumbbell. We usually see dumbell keloids that begin with an inflamed or infected ear piercing. The keloid usually begins on the anterior or posterior surface of the ear, follows the tract of the ear piercing,  and then begins to grow on the opposite side of the ear. These dumbbell keloids are usually composed of three parts, with growth within the ear and on the front and back of the ear. They are called dumbbell keloids because they resemble a dumbell that is used in weightlifting. The most common locations for these types of keloids are on the helix of the ear and the earlobe. If the dumbbell ear keloid occurs on the helix of the ear, there is usually cartilage involvement, whereas if it occurs on the earlobe, there is only soft-tissue involvement. The goal of ear dumbbell keloids is the complete removal of the keloid and the tract that connects the two sides of the keloid together. If the inner tract is not removed, there will likely be some form of recurrence. Most dumbbell keloids are responsive to surgery with postoperative injections and lasers. 

Flat Keloids: Flat keloids are often seen along the extremities (arms, elbows, knees, and legs) or along the chest, shoulders, or back. Little is known about the mechanisms of keloid growth, but it is though that tissue dynamics, wound healing mechanics, and tension lines help determine whether a keloid will grow in a flat pattern or whether they will form nodules above the plane of the skin. Many times, external pressure, as seen with keloids on the back, will tend to flatten and resurface keloids so as to stunt the vertical growth phase of scar formation. Flat keloids are generally invasive in that they tend to 'invade' adjacent areas of skin and soft tissue. Clinical reports have demonstrated keloid growth patterns of flat keloids in which the keloid can either grow on the surface of the skin or surreptitiously grow underneath the skin in the soft tissue. If the latter occurs, the flat keloids can spread to encompass a wider area without any external signs on the skin. 

Another clinical feature of flat keloids is the presence of inflammation and redness. Many flat keloids tend to grow with erratic patterns of growth and resorption. Flat keloids are often red and inflamed, with patients experiencing severe symptoms including pain, itching, burning, and continuous discomfort. We have seen many patients who have unremitting itching and burning that may contribute to insomnia and a lack of sleep. If your flat keloid is causing you to lose sleep because of itching and pain, your keloid may be responsive to non-surgical treatments to modulate the symptoms.

Giant Keloids: Clinicians have categorized some keloids as 'giant keloids' based on size criteria. There is no minimal size or dimension that would delineate a giant keloid, making this a questionable keloid-subtype. Giant keloids can be found on any part of the body, but are most prominent and problematic when they occur on the head and neck. Large keloids can present functional, cosmetic, and medical problems to a patient with this condition. Of particular importance to clinicians is the remarkable ability of giant keloids to recruit blood vessels and vasculature to support growth of the tumor. This ability of angiogenesis allows a keloid to grow even though it has theoretically outgrown its native blood supply. Treatment of giant keloids is usually surgical and places importance on preserving function and form in the surrounding normal tissue. 

Hypertrophic Keloid Scars: There are some scars that seem to be a fusion of both hypertrophic scars and keloid scars. Attempts have been made to categorize hypertrophic and keloid scars into solid black and white categories but these have naturally failed because there is a subset of scars that naturally fit both criteria. Hypertrophic keloid scars are usually inflamed and tend to be linear. They are natural responses to surgical incisions or traumatic lacerations and usually lie within the scar margins but have features which demonstrate a propensity for inflammation, scar growth, and scar progression. These scars are extremely unpredictable and it is our belief that they transition between hypertrophic and keloid scars and may regress back and forth into each category. Treatment of hypertrophic keloid scars is first begun with application of Plato's Scar Serum twice daily followed by intense laser and topical therapy to modulate scar formation and growth. 

Linear Keloids: A linear keloid is a very interesting problem as the keloid grows along the line of an incision or cut in the skin. Unlike nodular keloids, linear keloids have some type of inhibitory mechanism that allows them to not progress beyond the borders of the the original incision line. With time, linear keloids may expand vertically and horizontally to form nodular points of growth. Some clinicians believe that linear keloids are a variant of hypertrophic scars and that the presence of inflammation makes them assume keloid-like patterns of growth and progression. Linear keloids can often be mistaken for hypertrophic scars. Some surgeons mistakenly excise and resuture linear keloids, only to find that the keloid returns in a very rapid time interval. The presence of inflammation and symptoms may limit the surgical options for linear keloid excision. 

We have found that linear keloids are responsive to laser therapy, injection therapy, and application of Plato's Scar Serum. Scar modulation protocols that we use in our Santa Monica office allow for scar resorption and remodeling. The goal of linear keloid treatment is to restore, the best extent possible, the texture, contour, and color of the scar. 

Kissing Keloids: Adjacent keloids have a tendency to grow towards each other and eventually coapt together. Keloid surgeons often refer to these keloids as 'kissing keloids.' The presence of keloids that are fusing together is usually an ominous sign of keloid progression because the process of keloid fusion can alter the time course needed to complete treatment. Kissing keloids often grow towards each other as a result of tension lines. It is also thought that wound healing cellular mechanisms contribute to fibroblast migration and stimulation, prompting adjacent keloids to coapt into one large process. Examples of "Kissing Keloids" can be seen on the chest, back, and shoulders of patients with multiple traumatic keloids or acne keloids. The goal of successful treatment is to recognize patterns of keloid coaptation and to prevent the connection and unification at the line of contact. This is particularly important for keloids that occur on the central chest, shoulder, neck, and along joints. 

Nodular Keloids: A nodule is an abnormal, round mass of soft tissue that is found on the body. A nodular keloid is a keloid type that forms as a ball and ultimately grows above the plane of the skin. Early nodular keloids are usually felt as subcutaneous masses underneath the skin, until they begin to erupt vertically outward and form a mushroom type mass above the skin. Nodular keloids can occur on any part of the body, but are most commonly seen in the ear. Most nodular keloids can be surgically removed without signficant recurrence rates. The presence of a pedicle stalk can make nodular keloids easier to remove than those with a wide base. A study in the British Journal of Plastic Surgery identfiied patterns in Afro-Caribbean keloids and found nodular keloids on the deltoid region of the shoulder and in the face and neck. Scientists are still not clear as to why certain keloids form nodules whereas others grow in a more flat pattern. It is likely that the keloids respond to specific tension lines that affect wound healing mechanisms. 

Painful Keloids: Once Dr. Karamanoukian examines your keloids, he will make a distinction between those keloids which are actively inflamed and painful, and those that are quiescent and non-painful. The presence of pain in a keloid is usually associated with inflammation. Any type of keloid can become painful once it begins to grow and advance in size.  Unlike hypertrophic scars, keloid scars may have a continuous growth period in which they begin to advance beyond the original 'footprint' of the original skin injury. If there is associated inflammation, these keloids may become painful as they encroach on the surrounding tissue. A combination of lasers and multi-injection therapy can help control the inflammation and reduce symptoms of painful keloids. 

Raindrop Keloids: Some keloids form as a result of acne pustules and are numerous throughout a given anatomic area. Acne keloids often form on the chest, shoulders, and back. As the keloids begin to grow, they form small nodules that appear as tiny raindrops on the surface of the skin.  We characterize this pattern of keloid growth as 'raindrop keloids' because they appear as clusters of lesions on the skin. Raindrop keloids usually respond best to early intervention with lasers, topical application of Plato's Scar Serum, and injection therapy. Surgical removal of the keloids is likely not the first line treatment. 

Small raindrop keloids often occur on the shoulders and chest and that is mainly because raindrop keloids are associated with acne or cystic lesions. Acne occuring on the shoulders, back, and chest can cause individual keloid nodules that can sometimes coalesce into bigger units. The goal of treatment is to laser and inject the small, active keloids before they become bigger and compromise adjacent normal skin. 

Copyright Raffy Karamanoukian MD FACS. All rights reserved. 

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