As discussed, wounds should be closed with minimal tension and the use of adjunctive measures following surgical excision including the use of silicone gel sheets may reduce recurrence. The pathogenesis of keloids is complex and involves both genetic and environmental factors. It is widely accepted that keloids develop subsequent to injury or inflammation of the skin, but the exact pathogenesis is still unknown. Inflammatory skin conditions such as acne vulgaris, folliculitis, varicella infection, or vaccinations may induce keloid formation. Keloids often develop months after a wound or inflammatory process, but may develop as far out as a year later .
Nevertheless, close monitoring and assiduous re-application of steroid tape/plasters have an excellent chance of converting postoperative keloid sites into mature scars. If the keloid scar is not responsive to nonsurgical management options, surgery may be performed. One type of surgery directly removes the scar formation with an incision, and stitches are placed to help close the wound. Sometimes, skin grafts are used to help close the wound. This involves replacing or attaching skin to an area that is missing skin. First-line options include silicone sheeting, pressure treatment, and corticosteroid injections, but all of these require exemplary adherence and follow-up. Cryotherapy is useful, but only for smaller lesions, such as those resulting from acne. Cryotherapy may cause hypopigmentation in patients with dark skin. Small needle sticks such as those during local anesthetic injection seemingly do not evoke keloid formation. In many cases, patients may not recall an inciting traumatic event or inflammatory process. These “spontaneous keloids” are postulated to have occurred in response to some form of inflammatory process perhaps forgotten or unrecognized by the patient.
Both conditions respond to the same therapies, but hypertrophic scars are easier to treat. The large number of treatment options is a reflection of the poor quality of research on this topic, with no single proven best treatment or combination of treatments. Skin grafts are performed by taking a piece of healthy skin from another area of the body and attaching it to the needed area. Scars may be treated with a variety of different lasers, depending on the underlying cause of the scar. Lasers may be used to smooth a scar, remove the abnormal color of a scar, or flatten a scar. Most laser therapy for scars is done in conjunction with other treatments, including injections of steroids, use of special dressings, and the use of bandages. Thus, after the operation, both the donor and recipient sites of the flap should be irradiated to prevent the new formation of keloids. Notably, when partial resection or core extirpation is followed by postoperative radiotherapy, any remaining keloids around the flap also improve . This reflects the fact that the flap releases tension, which in turn decreases the inflammation in the remnant keloids. The high risk of recurrence in these severe cases can be further reduced by the routine application of corticosteroid tape/plasters on the operated area that are changed daily.
Multiple treatments may be required, regardless of the initial type of therapy. Radiation is also useful in the treatment of keloids and hypertrophic scars as a postsurgical modality. In general, we recommend patients to use tape/plasters for at least 6 months after the surgery and radiotherapy, or until the scar becomes soft. Long-term follow-up is necessary because if the scars start to stiffen again, corticosteroid tape/plasters should be re-applied. In general, it will take at least 2 years before combination therapy-treated keloids and hypertrophic scars mature. It is important to make clear to the patient before this therapy starts that the protocol has a long duration. A variety of other choices are emerging, but are less well studied. Patients with a previous keloid or a family history of keloids are at increased risk for developing abnormal scars. These patients should be counseled against body piercing and should avoid elective cosmetic procedures with a risk for scarring.