Dermatology Book

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KeloidAka: Hypertrophic Scar

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  1. Definition
    1. General
      1. Excessive fibrous repair response to skin injury
    2. Hypertrophic scar
      1. Isolated to site of skin injury
      2. Can occur anywhere, but have a predilection for extensor surfaces
      3. Onset within 1 month of wound and regress and flatten with time
    3. Keloid (derived from Greek "cheloides" or crab's claw)
      1. Extension of lesion beyond skin injury site
      2. Typically on sternum, upper arms, ear pinna and cheeks
      3. Onset >3 months after wound and tend to worsen overtime, maintaining depth>4 mm
  2. Epidemiology
    1. More common in African-American descent or other dark skin (keloids)
      1. Confers >15 fold increased risk
    2. Most common onset over age 30 years
  3. Risk Factors
    1. Dark skin as noted above (keloids)
    2. Delayed healing (longer than 3 weeks)
    3. Burn injury
    4. Severe acne
    5. Ear Piercing
    6. Varicella vaccination
  4. Pathophysiology: Stages
    1. Stage 1: Inflammation occurs for up to first 10 days
    2. Stage 2: Proliferation occurs over next 14 days
    3. Stage 3: Maturation and remodeling may continue for years
  5. Signs
    1. Firm Papules or Nodules at or near prior skin injury
  6. Differential Diagnosis
    1. Dermatofibroma
    2. Dermatofibrosarcoma protuberans
    3. Desmoid tumor
    4. Scar Sarcoidosis
    5. Foreign body granuloma
  7. Course
    1. Hypertrophic scar
      1. Regress over time
    2. Keloid
      1. May continue to enlarge for years
  8. Management: First-Line therapy
    1. Intralesional Corticosteroid Injection
      1. Consider combining injection with Cryotherapy pretreatment below
      2. Triamcinolone Acetonide 10 mg/ml
        1. Dilute in 3 cc Lidocaine 1%
        2. Repeat injection monthly until improvement (typically 2-3 injections)
    2. Cryotherapy
      1. May be adjunct to Corticosteroid
      2. Lightly freeze hard keloid before injection (may soften the lesion)
    3. Silicone Elastomer Sheeting (e.g. Kelo-cote)
      1. Applied to closed wound site for 12-24 hours over everyday for 2-3 months
  9. Management: Refractory after one year
    1. Surgical Excision
      1. Not recommended as first-line therapy due to very high recurrence rate after excision
      2. Combine surgical excision with adjunctive measures
        1. Corticosteroid Injection
          1. First injection at time of excision, then
          2. Reinject weekly for 3-5 weeks, then
          3. Reinject monthly for 3-6 months
        2. Consider also applying Silicone Elastomer Sheeting
        3. Consider applying Imiquimod 5% cream (Aldara) on alternate nights for 8 weeks after surgery
          1. More effective in low skin tension areas such as ear lobes
          2. Chuangsuwanich (2007) J Med Assoc Thai 90(7):1363
    2. Other measures
      1. Pulsed dye laser
      2. Intralesional Verapamil (2.5 mg/ml) in combination with Silicone Elastomer Sheeting
      3. Intralesional fluorouracil (50 mg/ml) injected 2-3 times weekly
      4. Intralesional Bleomycin (1.5 IU/ml, 0.1 ml) injected on up to 6 consecutive sessions
      5. Intralesional Interferon alfa-2b 1.5 Million IU twice daily for 4 days
    3. References
      1. Atiyah (2007) Aesthetic Plast Surg 31(5):468
  10. Prevention
    1. Avoid Ear Piercings and other unnecessary procedures in those with keloid or scar risk
    2. Wound closure techniques have similar scarring results (dermabond vs Sutured closure)
    3. Silicone Elastomer Sheeting (e.g. Kelo-cote)
  11. References
    1. Atiyah (2007) Aesthetic Plast Surg 31(5):468
    2. Brissett (2001) Facial Plast Surg 17(4):263
    3. Juckett (2010) Am Fam Physician 80(3):253
    4. Leventhal (2006) Arch Facial Plast Surg 8(6):362
    5. Sherris (1995) Otolaryngol Clin North Am 28(5):1057

Keloid (C0022548)

Definition (MSH)A sharply elevated, irregularly shaped, progressively enlarging scar resulting from formation of excessive amounts of collagen in the dermis during connective tissue repair. It is differentiated from a hypertrophic scar (CICATRIX, HYPERTROPHIC) in that the former does not spread to surrounding tissues.
Definition (CSP)progressively enlarging scar resulting from formation of excessive amounts of collagen in the dermis during connective tissue repair; spreads to surrounding tissues.
Definition (NCI)(KEY-loyd) A thick, irregular scar caused by excessive tissue growth at the site of an incision or wound.
ConceptsAcquired Abnormality (T020)
ICD9701.4, 701.4
MSHD007627
EnglishCheloid, Cheloid of skin, Keloid, Keloid cicatrix, Keloid of skin, Keloid scar, Keloid scar of skin, keloid skin disorder, KELOIDS
Spanishcicatriz queloide cutanea, cicatriz queloide de la piel, queloide, queloide cutaneo, queloide de la piel
Parent Conceptsskin disorder (C0037274), Other hypertrophic and atrophic conditions of skin (C0157727), Cicatrization (C0008767), Collagen Diseases (C0009326), Reactive Cutaneous Fibrous Lesion (C1335666), Scar Tissue (C0241158), Excessive repair (C0334161), Duplicate concept (C1274013)
SourcesCOSTAR, CSP, CST, DXP, ICD9CM, MEDLINEPLUS, MSH, MTHICD9, NCI, NDFRT, OMIM, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)


Cicatrix, Hypertrophic (C0162810)

Definition (MSH)An elevated scar, resembling a KELOID, but which does not spread into surrounding tissues. It is formed by enlargement and overgrowth of cicatricial tissue and regresses spontaneously.
ConceptsAcquired Abnormality (T020)
ICD9701.4
MSHD017439
EnglishHypertrophic Cicatrices, Hypertrophic Cicatrix, Hypertrophic Scar, Hypertrophic scar of skin, Hypertrophic Scars
Spanishcicatriz hipertrofica, cicatriz hipertrofica de la piel
Parent ConceptsCicatrization (C0008767), Reactive Cutaneous Fibrous Lesion (C1335666), Scar conditions and fibrosis of skin (C0036278), Ambiguous concept (C1274012)
SourcesMSH, MTHICD9, NCI, NDFRT, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)



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