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Updated: Apr 6 2020

Hypertrophic Scars and Keloids

  • Snapshot
    • A 26-year-old Chinese woman presents to her dermatologist for a persistent growth on her chest. She had previously burned a small portion of her pre-sternal skin while curling her hair 2 years ago. While the burn healed without any problem, she noticed a protuberance where the burn previously was. She reports that this growth seems to be larger than the original burn. On physical exam, she has a 5 cm elliptical firm, pink, and shiny growth. While counselling that this may not go away completely, her dermatologist agrees to start intralesional steroid injections. (Hypertrophic scars)
  • Introduction
    • Clinical definition
      • abnormal and excessive scarring in response to dermal injury, resulting in hypertrophic scars or keloids
    • Epidemiology
      • incidence
        • keloid
          • 6-16% of African population
      • demographics
        • most commonly in ages 10-30
      • risk factors
        • keloid
          • ↑ in groups with darker skin
          • patients of African, Hispanic, or Asian descent
          • family history
          • wounds on chest, shoulders, upper arms, earlobes, or cheeks
        • hypertrophic scar
          • wounds on areas of high skin tension
            • shoulders, neck, knees, and ankles
        • both
          • dermal injury caused by burns
          • wounds that take > 3 weeks to heal
    • Etiology
      • keloid
        • previous trauma
        • spontaneous
      • hypertrophic scar
        • previous trauma
    • Pathogenesis
      • dysregulation of wound healing
        • recall normal wound healing stages are
          • inflammation, proliferation, and remodeling/maturation
      • keloid
        • ↑↑ type I and type III collagen
          • this is disorganized and extends beyond the original wound
          • abnormalities in melanocyte stimulating hormone may contribute
      • hypertrophic scar
        • ↑ type III collagen
          • this is organized as parallel and confined to the original wound
          • increased activation of myofibroblasts may contribute
    • Prognosis
      • keloid
        • recurrence is frequent
        • will not regress over time
      • hypertrophic scar
        • recurrence is rare
        • may regress over time
  • Presentation
    • Symptoms
      • abnormal scarring occurs after trauma or injury
      • often itchy or painful (keloids > hypertrophic scar)
      • keloid
        • may take months to years to develop
      • hypertrophic scar
        • usually appears within 1 month
    • Physical exam
      • scarring along previous site of wound
      • well-defined, firm, and shiny
      • pink, purple, or hyperpigmented
      • irregular borders
  • Studies
    • Biopsy
      • indications
        • only if clinical diagnosis is uncertain
    • Histology
      • keloid
        • thick collagen fibers with abundant mucoid matrix
        • disorganized type I and III collagen
      • hypertrophic scar
        • thin collagen fibers with minimal mucoid matrix
        • myofibroblasts
        • parallel type III collagen
  • Differential
    • Basal cell carcinoma
  • Treatment
    • Medical
      • intralesional corticosteroid injections
        • indication
          • first-line for treatment that is often used with silicone sheeting
      • silicone sheeting
        • indication
          • first-line for treatment that is often used with intralesional corticosteroid injections
    • Operative
      • surgical excision
        • indication
          • for scars that are associated with contractures
  • Complications
    • Contractures limiting mobility
      • associated with hypertrophic scars
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