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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 5  |  Issue : 1  |  Page : 32-34

Keloid – A case report and its limited management brief overview


1 Department of Oral Surgery, Pacific Dental College and Hospital, Udaipur, Rajasthan, India
2 Department of OMDR, Pacific Dental College and Hospital, Udaipur, Rajasthan, India
3 Department of Orthodontics and Dentofacial Orthopadiecs, Goenka Research Institute of Dental Science, Gandhi Nagar, Gujarat, India
4 Department of Oral and Maxillofacial Surgery, Ahmedabad Dental College and Hospital, Ahmedabad, Gujarat, India
5 Iqraa International Hospital and Research Centre, Kozhikode, Kerala, India
6 Department of Periodontics, Aditya Dental College, Beed, Maharashtra, India

Date of Submission19-Jan-2021
Date of Decision06-Mar-2021
Date of Acceptance24-Mar-2021
Date of Web Publication18-Jun-2021

Correspondence Address:
Dr. Zibran Khan
Department of Oral and Maxillofacial Surgery, Pacific Dental College and Hospital, Debari, Udaipur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sidj.sidj_1_21

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  Abstract 


Keloids are an unorganized proliferation of fibrous tissue, usually arising from a site of injury due to an aberrant healing process. Clinically, it presents as ugly scar tissue on the skin and shows genetic predilection. They cause esthetic, physical, and psychological disturbances in the affected individuals. Such patients require special precautions during routine surgical procedures. Its treatment is associated with a high degree of resistance and recurrence. In this article, one such case is reported along with a literature review discussing the nature of the lesion, treatment options, and the recommended precautions.

Keywords: Hypertrophic injury, scar keloid, trauma, wound healing


How to cite this article:
Khan Z, Mukherji A, Shah K, Malik P, Haroon T M, Joshi S. Keloid – A case report and its limited management brief overview. Saint Int Dent J 2021;5:32-4

How to cite this URL:
Khan Z, Mukherji A, Shah K, Malik P, Haroon T M, Joshi S. Keloid – A case report and its limited management brief overview. Saint Int Dent J [serial online] 2021 [cited 2021 Nov 28];5:32-4. Available from: https://www.sidj.org/text.asp?2021/5/1/32/318801


  Introduction Top


Cutaneous scars arising from an aberrant healing process after trauma are often encountered in the head-and-neck region. Keloid is such a scar that represents the overgrowth of dense, fibrous tissue extending beyond the original wound's borders. Presenting clinical features comprise cosmetic disfigurement, pruritus, pain, skin discoloration, and movement restriction. The name is derived from the Greek word "chele" meaning "crab claw," referring to how lesions grow laterally into normal tissue, mimicking the movement of a crab.[1] Although keloids are benign lesions with no malignant potential,[2] it can significantly degrade the patient's physical and psychological quality of life, especially if there is excessive scarring.[3] The initiation may occur from minor injuries such as insect bites, acne, lacerations, tattoos, vaccinations, injections, and skin piercing or major wounds such as surgical incisions, burn wounds, or abrasions.[2]


  Case Report Top


A 38-year-old male patient visited the clinic with a chief complaint of pain in his teeth. He had no significant medical history. On extraoral observation, a taut fibrous scar was detected on the neck's right side [Figure 1]. The patient gave a history of bruises caused by scratches made by his pet cat in the same area 20 years before. According to him, the scar tissue appeared after about 6 months from the day of injury. The tissue grew slowly for about 4–5 years, extending beyond the initial wound margin. Initially, it was slightly reddish with an itching sensation. However, the irritation and growth have subsided for many years.
Figure 1: Keloid in the right neck region

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On inspection, an elevated linear lesion was observed with a smooth, shiny surface. It was about 0.7 cm × 2.5 cm in dimension. The lesion was darker than the surrounding skin and was devoid of hair follicles. There was no tenderness on palpation, and the lesion was rubbery inconsistency. The lesion was freely movable with the skin and showed no signs of underlying attachment. On further questioning, he revealed that his brother also has a similar scar on his forearm.

Based on the history and clinical findings, a diagnosis of keloid was made. Since the patient was having no trouble with the present lesion, he was reluctant to get a biopsy done or any management of the lesion (surgical or medicinal). However, he agreed to come for regular clinical revaluation of the lesion. His chief complaint was addressed while taking all precautionary measures indicated for a patient with keloid.


  Discussion Top


Keloid is considered to be the end product of an abnormal healing process to an injury extending to or beyond the depth of the reticular dermis. The pathophysiology of keloid remains unclear despite decades of research.[4] Genetic predisposition is well-documented. Other promoting factors include the type of injury, melanin pigmentation, anatomical site, age of onset, and gender.[3]

The duration of onset following injury, the direction and speed of growth, and the intensity of symptoms are determined by the intensity, frequency, and time of the causative stimuli.[5] Individuals with higher melanin pigmentation (e.g., – Africans and Asians) are more prone to develop keloids than low melanin pigmentation.[3] The onset of keloid mainly occurs between 10 and 30 years of age (uncommon at age extremes).[1]

The diagnosis of keloid is mainly based on clinical features but may require histopathological analysis.[3] Although the reticular dermis inflammation starts immediately, it takes about 3 months for the lesion to be visible through the epidermis to the naked eye.[5] Rarely keloids are detected without any history of trauma or surgery and are called spontaneous keloids. Confirmation of the past may be challenging because the triggering factor might have been an ill-perceived minimal injury or inflammation.[6]

There is associated pruritus, hyperesthesia, or pain in up to 80% of patients.[7] These physical symptoms increase with positive family history and greater size or number of lesions, especially when positioned in the trunk.[2] On secession of growth, keloid usually becomes symptomless and slightly involutes on some occasions.[3]

Although keloids can be found anywhere on the body,[2] the posterior aspect of the ear lobule is the most common site of its occurrence.[4] The cause of higher reported cases in female patients is attributed to the greater cosmetic concern and frequent piercing of earlobes.[1]

The consistency of keloids ranges from soft and doughy to rubbery and hard. The surface is shiny and is usually devoid of hair follicles and other functioning adnexal glands. There may be hyperpigmentation in darker-skinned individuals. Early lesions are traditionally erythematous. They become brownish red and then turn pale with time. Keloid may be pedunculated (on the ears, neck, and abdomen) or sessile (on the central chest and extremities), and its shape is mostly round, oval, or oblong with irregular margins but may show claw-like configurations with irregular borders.[3]

The primary differential diagnosis is the hypertrophic scar.[3] Scar hypertrophy usually appears within a month of injury.[5] Usually, a rapid growth phase lasts for up to 6 months in hypertrophic scars followed by gradual regression for over a year, resulting in a flat scar with no other symptoms.[4] Unlike keloid scars, the hypertrophic scar is restricted to the edges and is less pruritic and painful and lacks genetic predilection.[2] Postsurgical recurrence is rare (10%) in hypertrophic scars.[4] In hypertrophic scar, histopathologically, the "keloid collagen" (haphazardly arranged thick hyalinized collagen bundles within the mucinous ground substance, showing relatively few fibroblasts) is replaced by collagen fibers, orientated parallel to the long axis of the epidermal surface containing nodules of fibroblasts and collagen and are located in the middle or deeper layer of the scar. Moreover, small aggregating blood vessels are present just below the epidermis in keloids, while the blood vessels are oriented vertically around the nodules in hypertrophic scars.[4]

Other differential diagnoses include dermatofibroma, lobomycosis, and various kinds of malignant tumors that resemble keloid.[3]

Therapy for keloid is controversial with uncertain results. The choice of treatment is guided by the location, size, depth of the lesion, patient age, and past therapeutic response.[3] They range from surgical excision, intralesional steroid injection, pressure therapy, silicone sheet application, cryotherapy, laser, radiation therapy, mechanical pressure application, to intralesional interferon injection.[8],[9]

Surgical excision alone is highly susceptible to recurrence (40%–100%)[8],[9] and may stimulate additional collagen synthesis, prompting a more aggressive recurrence. Therefore, intramarginal surgical excision is recommended,[4] along with lateral undermining. Gentle handling of the tissue and exerting minimum tension while suturing improves the prognosis.[8] Furthermore, whenever surgical excision is carried out, it is advisable to combine it with other modalities mentioned above such as cryotherapy, intralesional steroids, and pressure therapy.[9]

The dark skin color, positive familial history, and puberty during the lesion site's initial injury made the patient, as mentioned earlier, susceptible to developing keloid. Despite the keloid's marked visibility, the patient was not bothered about the lesion due to its asymptomatic character. The poor prognosis and apathy of the patient prevented biopsy of the lesion from confirming its nature.

From a dental surgeon's perspective, patients having susceptibility to keloidal scars of the skin can have some bearing on proliferative scarring of the oral mucosa. Keloids have been reported to arise following cleft lip surgery.[10] In such patients, a dental surgeon is expected to proceed with all necessary precautions mentioned above.


  Conclusion Top


Keloid is a type of nonhealing firm, nodular scar representing unorganized proliferation of fibrous tissue extending beyond the original injury site. It is responsible for physical and psychological difficulties in patients, especially when it is prominently visible and associated with pruritis and pain. At present, the treatment options are controversial with questionable prognosis. Diagnosis of such lesion is essential to take the required precautions during any surgical procedure to avert unnecessary complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Berman B, Bieley HC. Keloids. J Am Acad Dermatol 1955;33:117-23.  Back to cited text no. 1
    
2.
Belie O, Ugburo AO, Mofikoya BO. Demographic and clinical characteristics of keloids in an urban center in sub-Sahara Africa. Niger J Clin Pract 2019;22:1049-54.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Shaheen A. Comprehensive review of keloid formation. Clin Res Dermatol Open Access 2017;4:1-18.  Back to cited text no. 3
    
4.
Hunasgi S, Koneru A, Vanishree M, Shamala R. Keloid: A case report and review of pathophysiology and differences between keloid and hypertrophic scars. J Oral Maxillofac Pathol 2013;17:116-20.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Ogawa R. Keloid and hypertrophic scars are the result of chronic inflammation in the reticular dermis. Epidemiology and etiology. Int J Mol Sci 2017;18:1-10.  Back to cited text no. 5
    
6.
Jfri A, Alajmi A. Spontaneous keloids: A literature review. Dermatology 2018;234:127-30.  Back to cited text no. 6
    
7.
Bijlard E, Kouwenberg CA, Timman R, Hovius SE, Busschbach JJ, Mureau MA. Burden of keloid disease: A cross-sectional health-related quality of life assessment. Acta Derm Venereol 2017;97:225-9.  Back to cited text no. 7
    
8.
Kumar A. Earlobe keloid: A new treatment protocol for management. Int J Oral Health Med Res 2016;3:62-4.  Back to cited text no. 8
    
9.
Himaja S, Agarwal A, Ramtenki N. Management of head and neck keloids – A case report and review of literature. J Den Sci Res 2015.  Back to cited text no. 9
    
10.
Politis C, Schoenaers J, Jacobs R, Agbaje JO. Wound healing problems in the mouth. Front Physiol 2016;507:1-13.  Back to cited text no. 10
    


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