While scars have a negative connotation due to the imperfect appearance of the skin, they are a normal result of most injuries and surgeries. This is part of the wound healing process and their appearance (or perpetuation) is the expected result of this dynamic process. It is only deviations from normal wound healing, hypertrophic scars and keloids, that should be considered abnormal.
The differences between hypertrophic scars and keloids is a confusing one for most people. One is often thought of as the other, most commonly hypertrophic scars being confused as keloid scarring. But they are in both appearance and biology distinctly different. Hypertrophic scars appear raised but stay within the confines of the original wound. They are more likely to occur in wounds that cross the so-called relaxed skin tension lines or in wounds that have been left open to heal on their own or have become infected.
Conversely, keloids extend beyond the confines of the original wound (mushrooming from the wound edges) and are often associated with ongoing growth. They may stop growing but many do not. It is this progression in size that is the hallmark of their behavior. They often cause pain and other symptoms such as itchiness. This is due to the tight scar tissue and a sign of ongoing growth. They may also be a family history of keloids due to a genetic inheritance. They are often associated with traumatic wounds such as ear piercings, tattoos and burns.
Just like their biology the treatments for hypertrophic scars and keloids is different. While hypertrophic scars may improve with time, significant improvement in their appearance is usually only going to come from excision and closure, with or without some form of geometric rearrangement.(e.g., z-plasty, running w-plasty) This almost always solves this particular scar problem or, at the least, provides significant in its appearance. While the same issue for improvement applies to keloids, careful consideration needs to be given to how recurrence is going to be prevented as the propensity for so occurring is remarkably high.
Combining some recurrence prevention strategy with keloid excision is standard and most commonly is the injection of steroids along the wound edges. This is best done before surgery to get some regression of the keloid and then the excision is performed. At the time of excision the wound edges may be injected with steroid followed by repeat injections every several weeks after surgery for a few intervals. This is far more successful that just excising a keloid alone but is still associated with a near 50% recurrence rate.
For the refractory keloid, radiation therapy is the one known alternative approach that is often better than steroids. It is combined with scar revision and is started immediately, even on the day of surgery. It is known as low dose radiation and, while there is no standard dosing regimen, most patients receive between 1500 and 2000 rads over several sessions done daily for the first week after the surgery. This radiation-induced disruption of collagen synthesis at its inception has the best chance of preventing new keloid formation although it is not foolproof and recurrences have been known to recur .
Dr. Barry Eppley