What’s New in Keloids?

In a presentation at the Skin of Color Update 2021, held virtually September 10-12, Hilary Baldwin, MD, dermatologist, medical director at the Acne Treatment and Research Center in Brooklyn, New York, and assistant professor at Rutgers Robert Wood Johnson Center in New Brunswick, New Jersey, explained that as keloids pharmacogenetics are not well known, it can cause keloids to not respond to corticosteroid (CS) treatment.¹ Other reasons for this can be attributed to poor technique, insufficient dosing/concentration, and reduced genetic sensitivity to glucocorticoids (GC). 

She quoted a study in which 19 patients were evaluated, 12 of the patients had CS responses in the past and 7 patients did not. The study found that GC receptors were less sensitive in those who did not respond in treatment and continued to be downregulated as time moved on. They also found at week 4 that melanin decreased in patients, and it might be related to treatment success. Baldwin summed up the results by stating that if a patient is not responding, then it is time to try another treatment.

Baldwin said that she does not believe hypopigmentation is a worry for darker skinned patients, as it is a sign that treatment is working and usually ends up going away. She explains to her patients that the hypopigmentation is from the treatment.

“I have never had a patient say to me, ‘You know, I hate this whiteness. I don’t want you to do this anymore,” Baldwin said, “Not one person ever has said [to me] they would rather have the keloid than the hypopigmentation.”

Baldwin commented that lighter skinned patients are harder for her to treat than patients with darker skin and she believes this may be because of the melanin in the skin. 

For keloids, according to Baldwin, size does not matter, but patients tend to be more impressed when larger keloids are removed versus smaller ones. This relates to the residual scarring left behind. A patient with a smaller keloid may be more unhappy with the residual scarring, but a patient with a larger keloid will be less critical. She warned to watch for large blood vessels as they can be hidden inside cuboidal material. 

Baldwin also recommends being careful when deciding to stitch or not to stitch after removing a keloid. She said she avoids it when she can, but in some cases it is unavoidable, and in those cases to keep in mind that every place the suture was put is a potential keloid to the patient. 

For post-surgical therapy, Baldwin uses:

• CS 40 mg/cc every 2 weeks until fully healed
• Interferon 1.5 mg/linear cm day 1 and day 7
• Radiation therapy day 1 and days 4-10
• Pressure dressings

When deciding on which one to use, she advises to look at the location of removal, and from there chooses the appropriate method. If possible, she will use all 4.

In some cases, keloids will occur after acne develops. If this happens, Baldwin will first treat the acne, to prevent more keloids from forming, and thereafter treat the keloids.

She then brought up the question of pods, an occurrence of keloid edges after injecting the middle portion of an existing keloid. Baldwin started to inject from the outer edges of a keloid to prevent this phenomenon.

The issue of distinguishing between a keloid and a piercing bump was discussed. With growing amount of ear piercings, Baldwin explained, it can be hard to know the difference between the two.

“Well, the piercing bumps occur early, and they are slightly tender,” Baldwin said. “They are often pus filled and they usually resolve spontaneously with warm soaks.” She went on to explain that CS can speed the resolution of piercing bumps, so she will inject the bump as this way if it is a keloid, it will be the start of treatment and if not, the piercing bump is still being treated.

This also brings up the issue with hypertrophic scars (HS) and keloids. Often, it is hard to spot the difference between these, according to Baldwin, and the papers on them often do not distinguish the results of treatment for HS vs keloids. She believes this needs more investigation. 

Lastly, she brought up dupilumab. There was a case of a 53-year-old male patient with both atopic dermatitis (AD) and keloids (2 of them) who was treated with dupilumab for his AD and spontaneously, according to Baldwin, the keloids improved after 7 months. She thinks that may this needs to be investigated as a treatment for keloids.

Disclosures:

Hilary E. Baldwin, MD, had no relevant disclosures.

Reference:

1. Baldwin H. What’s New in Keloids. Presented at the: Skin of Color Update; September 10, 2021; Virtual.