DISCUSSION
Although the exact cause is still unknown, there appears to be an inheritable tendency to develop keloids. They are far more common, and grow to larger size, in patients with darker skin. Certain anatomical locations are especially at risk, such as the sternum, earlobes, shoulders (especially the deltoid areas), neck, and trunk. Keloids of the central face are almost unknown.
Keloids lie at the extreme end of the scarring continuum, with normal scars at the other end and so-called hypertrophic scars in the middle. The latter often resolve spontaneously within months of their initial formation, while true keloids never do.
Keloids are irregularly shaped, fibrous hyperpigmented (red to brown) excresences covered by thin, shiny skin. They often send out clawlike projections that ultimately obscure the original causative trauma. These tendencies help to distinguish them from mere hypertrophic scars. Biopsy, when necessary, can also help, as well as eliminate other items in the differential, including cancer (eg, dermatofibrosarcoma protuberans or metastatic cancer).
Early on, keloids are often red and uncomfortably tender. As they mature, they become less red and stabilize in size. They can become huge, especially on the chest, arms, and earlobes.
A case for surgical excision can be made, since large keloids are so cosmetically disfiguring and obvious. This patient was willing to accept the attendant risk for an even bigger postoperative keloid. With excision, primary closure, good wound care, and periodic injection of the wound edges with steroid suspension, however, he has an excellent chance to avoid this outcome.
Prior to his surgery, we reviewed alternate treatment choices, which include postexcision radiation treatment of the site, injection of the wound edges with 5-fluorouracil, or treatment of the keloid with flashlamp pulsed dye laser.
As with virtually everything we remove surgically, the keloid was sent for pathologic examination. It revealed the expected dense collection of myofibroblasts arranged in a whorled pattern, as well as a notable lack of elastic tissue.
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