Keloids & hypertrophic scars
Also called keloid, hypertrophic scar, keloid scarring
Wound healing that forgot to stop: excess dermal collagen building a raised scar. The boundary rule carries the whole distinction, hypertrophic scars respect the wound's border and settle with time, keloids invade beyond it and do not, which changes every treatment decision.
How it looks
A firm, smooth, raised scar extending claw-like beyond the borders of the original wound over the earlobe, with surrounding normal skin invaded rather than merely stretched.
Rose is the lesion, grey the pattern the lesions make, green where on the body it lives.
Across skin tones
Keloids are substantially more common in deeply pigmented skin and cluster on the earlobes, jawline, chest, shoulders, and upper back; this epidemiology should shape counselling before elective piercings and procedures at high-risk sites, and makes cavalier excision without adjuvant therapy a setup for a larger recurrence.
Forms & variants
Hypertrophic scar
Raised, red, sometimes itchy scar that stays WITHIN the wound's boundary, appears within weeks of injury, and tends to flatten and fade over a year or two.
Keloid
Scar tissue that outgrows the original wound and invades normal skin like a claw, often months after trivial injury (piercings, acne, vaccination), rarely regresses, and recurs readily after simple excision.
Symptoms & course
- Itch and tenderness, often out of proportion to size
- Cosmetic and psychological burden, especially on visible sites
- Restriction of movement over joints when large
Diagnostic approach
- Clinical; the injury history and the boundary behaviour decide it
- Biopsy only when a 'scar' appears without injury or behaves like a tumour
Differential, and how to separate them
- Squamous cell carcinoma
Favours it: A firm growing nodule on damaged skin
Against it: A keloid grows from a wound it remembers and stays smooth-surfaced; a scar that ulcerates, crusts, or changes character earns a biopsy
- Basal cell carcinoma
Favours it: A firm pearly nodule, and morphoeic BCC can look scar-like
Against it: A scar-like plaque with NO history of injury at that site is the suspicious one, not the scar with a clear story
Management principles
- Silicone sheeting and pressure therapy early, especially post-surgical prevention at known risk
- Intralesional corticosteroid injections as the workhorse for established lesions
- Excision only WITH adjuvant therapy (steroid injection, pressure, or superficial radiotherapy), because excision alone regrows the keloid larger
Clinical pearl: Draw the original wound in your head and ask whether the scar stayed inside the lines: within is hypertrophic and will likely settle, beyond is keloid and will not.
Clinical pearl: Never promise a keloid patient that cutting it out fixes it; recurrence after bare excision approaches the rule, not the exception.
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