How to manage keloids

Keloids are benign overgrowths of dense fibrous tissue that develop at the site of skin injury. They rarely regress and usually extend beyond the original wound boundaries (unlike hypertrophic scars). There are no medical indications for the treatment of keloids. However, these growths often cause discomfort, cosmetic concerns, and psychological distress. For most affected patients, GPs are the first point of contact. That is why GPs play a crucial role in the early management and referral of keloids.

How to identify keloids

Keloids typically present as shiny, raised, and firm skin nodules. They can be pink, red, or darker than the surrounding skin. Common sites include the chest, shoulders, earlobes, and upper back.

Important points to cover during the assessment are:

• History, including the onset, progression, previous injuries, family history (keloids can be hereditary), and associated symptoms like itching or pain.
• Physical examination to evaluate the size, location, color, and signs of secondary infection.

Differential diagnoses may include:

• Hypertrophic scars,
• Dermatofibromas, and
• Dermatologic malignancies.

Suspicious lesions (rapidly growing, ulcerated, or irregular) should be referred for dermatology evaluation or biopsy.

It is vital to educate patients about the chronic nature of keloids, treatment goals (control, not necessarily cure), and the risk of recurrence even after successful therapy. Individuals prone to keloids should avoid unnecessary skin trauma, including:

• Piercings,
• Tattoos, and
• Elective surgeries

First-line treatments for keloids

GPs can initiate first-line conservative treatments, such as:

These can help flatten and soften keloids, especially if started early, but daily, consistent use is crucial.

For keloids in accessible areas, such as earlobes, pressure earrings or garments may reduce growth.

Triamcinolone acetonide (10–40 mg/mL) can be injected directly into the keloid every four to six weeks. This is often effective in reducing inflammation and size. GPs trained in the technique can perform this or refer appropriately.

How to manage the symptoms of keloids

Some symptoms of keloids, such as irritation and pruritus, may be successfully controlled with topical corticosteroids, antihistamines, or emollients.

When to refer to a specialist

Referral to a dermatology specialist or a plastic surgeon is appropriate in the following situations:

• Large, painful, or functionally limiting keloids
• Failure of first-line therapies
• Diagnostic uncertainty

The advanced treatments that can be considered for keloid scars include:

• Laser therapy,
• Cryotherapy,
• Radiation, and
• Surgical excision (with adjunct therapy)

Prevention of keloids

The best prevention strategies for patients with a history of keloid formation include:

• Meticulous wound care after injuries or surgeries
• Use of silicone therapy during wound healing
• Early intervention at the first signs of abnormal scarring
  
  

GPs play an essential role in the early identification and management of keloids. With sufficient training in general dermatology, patient education, initial therapies, and timely referrals, GPs can significantly reduce patient distress and improve outcomes. However, individuals prone to keloid formation can achieve plenty by maintaining a proactive, preventive approach.

– Dr Rosmy De Barros

What's next?

For further information on this topic, you may be interested to learn more about the HealthCert Professional Diploma program in General Dermatology.

Or explore more research in primary care General Dermatology.

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