Consequently, with large lesions, they are best performed after surgery that rapidly removes the lesion mass. Radiation on its own also has mass-reducing effects because it appears to suppress angiogenesis, and therefore dampens the influx of inflammatory cells and factors into the scar.

However, when used as the solitary form of treatment there is a large recurrence rate of between 70 and 100%. It has also been known to cause a larger lesion formation on recurrence.

The addition of radiation and steroid tape/plaster to surgery reflects the point made above, namely, that keloids and hypertrophic scars are inflammatory disorders, and not tumors. Consequently, anti-inflammatory treatments are most effective for these lesions. However, steroid treatments take a long time to achieve mass reduction.

Although the pathogenesis of keloid disease is not well understood, it is considered to be the end product of an abnormal healing process. There are several molecules and cells implicated in keloid mechanism in relation to the normal wound healing process.

These anti-inflammatory properties of steroid and radiation mean that their application after mass-reducing surgery will prevent the recurrence of excised keloids and hypertrophic scars. Radiation is also useful in the treatment of keloids and hypertrophic scars as a postsurgical modality . As mentioned above, the main problem of surgery for pathological scars is recurrence. However, postsurgical radiation therapy can dramatically reduce these rates of recurrence.

Some people are prone to keloid formation and may develop them in several places. Keloid is a benign fibrous growth, which presents in scar tissue of predisposed individuals.

They occur where trauma, surgery, blisters, vaccinations, acne or body piercing have injured the skin. Less commonly, keloids may form in places where the skin has not had a visible injury. Keloids differ from normal mature scars in composition and size.

Pressure therapy following surgical excision has shown promising results, especially in keloids of the ear and earlobe. The mechanism of how exactly pressure therapy works is unknown at present but many patients with keloid scars and lesions have benefited from it. Keloids are raised overgrowths of scar tissue that occur at the site of a skin injury.

However, if keloids and hypertrophic scars have infected areas, such as inclusion cysts, these should be removed surgically. Another key indication for surgery is keloids and hypertrophic scars that result in scar contracture of the joints or mobile areas such as the neck. In this case, the contractures should be released by a combination of subcutaneous/fascial tensile reduction sutures, z-plasties, and regional/local flap transfer. Surgical excision is currently still the most common treatment for a significant amount of keloid lesions.

Since surgical treatment itself induces inflammation, surgery alone associates with high rates of keloid and hypertrophic scar recurrence. Worse, the recurrent scars are often much bigger than the original lesions. Thus, unless the scar is a minor hypertrophic scar, the decision to surgically remove a pathological scar should be made very carefully and postoperative radiation therapy should always be performed.

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. Nevertheless, close monitoring and assiduous re-application of steroid tape/plasters have an excellent chance of converting postoperative keloid sites into mature scars. At present, I believe that the most reliable approach is a combination of three therapies, namely, surgery, followed by radiation, and prolonged daily use of steroid tape/plaster.

While not always successful alone, surgical excision when combined with other therapies dramatically decreases the recurrence rate. Examples of these therapies include but are not limited to radiation therapy, pressure therapy and laser ablation.