JRSM >
Volume 96, Number 11 >
Pp. 554-555
1 Department of Plastic and Reconstructive Surgery, South Manchester University
Hospital Trust, Manchester, UK
2 Department of Plastic and Reconstructive Surgery, University of West Indies,
Mona, Kingston, Jamaica
3 Centre for Integrated Genomic Medical Research, School of Biological Sciences,
University of Manchester, Manchester, UK
4 Division of Cell, Immunology and Development, School of Biological Sciences,
University of Manchester, Manchester, UK
Correspondence to: Mr A Bayat, Department of Burns, Plastic and Reconstructive Surgery, Wythenshawe Hospital, South Moor Road, Wythenshawe, Manchester M23 9LT, UK E-mail: ardeshir.bayat{at}man.ac.uk
Keloid scars are nodular skin lesions that in severe forms resemble neoplasms and cause much physical and mental distress. Attempts at treatment can make them worse.
CASE HISTORIES
Case 1
A woman aged 21, of black Jamaican origin, had experienced keloid scarring
from her early teens after minor trauma. Now she was much troubled by multiple
large scars on the back, deltoid regions, lower legs, arms, upper buttocks and
chest. Her sister and her brother also had keloid scarring. Treatments had
included surgical excision, radiotherapy and steroid injections; none of these
had given lasting benefit, and the recurrent lesions were worse, causing
physical and psychological distress.
Case 2
A woman of 44, of black Jamaican origin, had experienced multiple keloid
scarring from the age of 8. Existing scars had continued to grow and new ones
had developed even after minor abrasions. When seen by us she had extensive
keloid scars on her chest (Figure
1), arms, back, lower legs, pubis, and buttock. Most of the scars
were sessile, in parts lobulated and of hard consistency. The scars were
functionally disabling as well as emotionally distressing. In the past,
unsuccessful treatments had included pressure garments, silicone gels, steroid
injections, surgical excisions, and superficial radiotherapy. The only other
medical history of note was recent diagnosis of a uterine fibroid. Having left
Jamaica as a child she was unsure of her family history, but her father was
believed to have been affected by keloid scarring. So too was her only
daughter, who had multiple but less severe lesions than our patient.
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Case 3
A 90-year-old man of black Jamaican origin sought advice about multiple
keloid scars in his armpits and on his lower legs, face, feet, groin and pubic
region. He had first noticed a lumpy scar after a minor shaving injury as a
teenager. He had later developed bilateral axillary keloids as a result of
irritation from use of deodorants. At age 55 years, after bilateral hernia
repairs, keloid scars had appeared in the groin. Some of the scars,
particularly on the face and neck, had become smaller in his 80s. His father
had had multiple large keloid scars in several anatomical locations. Three out
of his four sons had keloid scars; three out of four daughters were also
affected and one granddaughter had a keloid.
COMMENT
The pathogenesis of keloid scarring remains an enigma.1 The three cases reported here illustrate the association of severe scarring with a positive family history and black African ethnic origin2-5 (though a similar condition can arise in Europeans).
The special feature of the cases reported here is their unusual extent and severity, reminiscent of neoplastic disease. In such cases even an experienced clinician may have difficulty ruling out malignancy. However, in the present series and in a previous case from Kingston, Jamaica,6 the histology was typical of a keloid scar—i.e. nodular fibroblastic proliferation of the dermis. Several familial syndromes have been associated with keloid scars including Rubinstein-Taybi7 and Goeminne syndrome8 and conjunctivo-corneal dystrophy9 but none of these conditions was found in any of our cases. Patient 2 had a uterine fibroid, a benign fibrous growth which like keloids seems most common in dark-skinned individuals and tends to recur after treatment.
As regards treatment, all three patients had been unresponsive to conventional strategies, with the recurrent lesions sometimes worse than the original. Two patients (1 and 2) had experienced psychosocial difficulties requiring counselling and are being considered for novel treatments such as local or systemic chemotherapeutic agents. 5-fluorouracil and bleomycin have been previously used with variable success.10
Acknowledgments
We thank the clinical and clerical staff at the Department of Plastic Surgery based at the Kingston Chest and University of West Indies, Mona, for their help and the Medical Research Council, UK, and the Royal College of Surgeons of Edinburgh/Ethicon Travel Award for financial support.
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