– The first written mention of keloids in history came about 4,500 years ago. But there is still so much more to be learned about keloids, according to dermatologist Hilary E. Baldwin, MD.

Yes, there is more information about who gets keloids and where they appear on the body. “What we do not know is everything else,” Dr. Baldwin said at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar. “We don’t even know which treatments work. Not a single treatment has any evidence basis behind it. It’s all fly-by-night, seat-of-your-pants, based on your knowledge and that of those who treat keloids frequently.”

While keloids are caused by trauma to the skin, even by something like acne, she pointed out that trauma alone is not the entire explanation. Cases show an unknown factor serves as a contributing factor, she said.

There’s no gender disparity in keloids, she said, and they’re more likely to occur after puberty than before. Family history isn’t helpful.

Also, while darker skin produces keloids more easily and consistently than other skin types, these keloids aren’t the hardest to treat, said Dr. Baldwin, medical director of the Acne Treatment and Research Center in Morristown, N.J. “From my personal experience – but not from data or papers – keloids are the most difficult to treat and recur the most when you see them in a Caucasian patient.”

Patients want the keloids to disappear forever along with any evidence that they ever existed. “Virtually every patient says ‘I want this cut off, I want it gone,’” Dr. Baldwin said. “And they want it gone yesterday. Few understand this is a long process. I tell them we’ll become extraordinarily good friends over the next 6-12 months while we get rid of this thing.” Moreover, it’s not possible to eliminate keloids without leaving a sign behind. “Most want it eradicated with normal skin,” but the skin beneath a keloid “will never look normal,” she observed.

The following are some tips for treating patients with keloids that she provided during her presentation:

  • Surgery is usually not an option, and it may be necessary to convince patients about other treatment options. “Most don’t want corticosteroid injections, but that is how we treat them and keep them from coming back,” Dr. Baldwin said.
  • Surgery may be appropriate in certain cases, such as keloids that are shaped like mushrooms and are attached to the skin via a stalk. Patient compliance with adjunctive therapy (injected corticosteroids) is crucial to prevent recurrence after surgery. Be aware that some patients – such as those who are afraid of needles – may refuse to return. Earlobes, a common site of keloids because of earrings, are a special case in surgery. Patients with earlobe keloids often fare well after surgery, Dr. Baldwin said, and recurrence is less common than in other parts of the body, especially when corticosteroids are added. It helps that patients are often more compliant with adjunctive therapy, she added, because the keloids are highly visible, and they want to wear earrings again.
  • Ask patients what bothers them the most about the keloids. Some may want to eliminate burning, itching, or stinging, and Dr. Baldwin attempts to treat those issues. Patients may want keloids to be softer, flatter, or lighter, she said.
  • Modification of the keloid’s appearance may be enough for some patients. For example, one of her patients objected to extensive keloids around his breasts because they gave him the appearance of cleavage. Another believed – accurately – that his keloid looked like male genitalia. Dr. Baldwin treated it with the keloid equivalent of castration (surgically removing its “testicles”) and circumcision of sorts (a flattening of its “glans penis” with corticosteroids). “It didn’t look pretty,” she said, “but it no longer looked offensive to him.”
  • Many patients present with keloids on the chest, back, and deltoids, “which have to have been from acne, but you can’t actually see the pimples,” Dr. Baldwin said. In these cases, she may turn to isotretinoin. This is not for treatment of keloids, but is a preventive strategy to stop further lesions from appearing and causing more keloids, she explained.
  • In addition to corticosteroids, other postsurgical options include freezing, interferon, pressure dressings, dextran hydrogel scaffolding, and radiation therapy.

Moving forward, researchers “are looking at biologics, TNF-alpha inhibitors, and tyrosine kinase inhibitors in hopes that we can find something that will stop the incessant forward movement of some of our keloid patients,” Dr. Baldwin noted.

Dr. Baldwin reported no relevant disclosures.

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