Hypertrophic scars/Keloids

Scarring typically follows an injury to the dermis, but the patient's narrative will differ based on the scar type and their genetic predisposition.

• Triggering Event:
  Patients often report a history of skin trauma, surgery, or inflammation (such as severe acne, chickenpox, or piercings).

• Symptoms:
  Unlike "normal" scars, these are often symptomatic. Patients frequently complain of pruritus (itching) or tenderness/pain at the site.

• Timeline: 

  • • Hypertrophic Scars: Usually appear within 4 to 8 weeks following injury, grow rapidly for several months, and may eventually regress over years.

    • Keloids: May appear months or even years after the initial insult and rarely regress spontaneously.

• Family History:
  A strong family history is often noted, particularly in patients with keloids, suggesting a genetic component.

1. Hypertrophic Scars:

   • Appearance: Raised, firm, erythematous (reddish) lesions.

   • Boundary: These remain strictly confined to the margins of the original wound or surgical incision.

   • Location: Can occur anywhere on the body but are common at sites of high skin tension (e.g., joints).

2. Keloids:

   • Appearance: Firm, rubbery, shiny, and irregular nodules or plaques. They may range in color from flesh-toned to hyperpigmented or dusky red.

   • Boundary: Pathognomonic for keloids is that they extend beyond the original wound boundary, invading surrounding healthy tissue in a "claw-like" fashion.

   • Common Sites: Frequently found on the earlobes (from piercings), deltoids, pre-sternal area, and upper back.

Crucial Note for Skin of Colour

• Prevalence: Keloids are significantly more common in individuals of African, Asian, and Hispanic descent (up to 15 times more frequent than in Caucasians).

• Pigmentary Changes: The scar itself is often significantly hyperpigmented. However, treatment (like cryotherapy or steroids) carries a high risk of permanent hypopigmentation (loss of color), which can be more cosmetically distressing than the scar itself.

• Differential Diagnosis: In the scalp, keloids must be distinguished from Acne Keloidalis Nuchae, a chronic inflammatory condition leading to keloid-like papules and plaques on the occipital scalp.

Treatment for hypertrophic scars includes:

1. Silicone gel sheets (12–24 hours/day, for 3–6 months).

2. Intralesional corticosteroid injections (e.g., Triamcinolone acetonide 10–40 mg/mL every 4–6 weeks).

For keloids:

1. Cryotherapy combined with corticosteroid injections for smaller lesions.

2. Laser therapy for reducing pigmentation and size.

3. 5-Fluorouracil (5-FU) injections (50 mg/mL, weekly or biweekly) as an adjunct to corticosteroids.

Other options include surgical excision, often combined with radiation therapy, though recurrence is common.