Prevention of Keloids
Unlike many skin disorders discussed in textbooks, keloids have been described in detail dating back to 3,000 bc .1 The Yoruba tribe of Western Africa recorded their knowledge of keloids in painting and sculpture ten centuries prior to modern times.2 Desp
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24
Hillary E. Baldwin
24.1 Introduction
24.2 Epidemiology
Unlike many skin disorders discussed in textbooks, keloids have been described in detail dating back to 3,000 bc.1 The Yoruba tribe of Western Africa recorded their knowledge of keloids in painting and sculpture ten centuries prior to modern times.2 Despite this considerable head start, we have made remarkably little progress since the Yorubas toward understanding keloid etiology. This fundamental ignorance is partially responsible for our current lack of consistently reliable, safe treatment, and prevention measures. Since treatment methods are inadequate in many and challenging in all, prevention becomes vitally important. Here, too, our efforts may be thwarted. There are aspects of keloids that are preventable; one can avoid trauma resulting from voluntary and elective procedures to adorn, augment, or improve. Aggressive prevention of keloids after accidental trauma and necessary surgery is also within our abilities. However, some putative causative factors of keloid formation are out of our control: ethnicity, skin pigmentation, age, gender, and genetic makeup. This chapter will focus on two aspects of prevention: avoidance techniques for the keloid prone and prevention of recurrence after surgical intervention. First, it will briefly review what is known about keloid epidemiology and pathogenesis to gain insight into the development of a rational prevention plan for these unsightly lesions.
The reported incidence of keloid formation has ranged from a low of 0.09% in England to a high of 16% in Zaire.3 Such variation is explained by numerous variables, including race and degree of skin pigmentation. In predominately black and Hispanic populations, incidences between 4.5 and 16% have been reported.4 Darkly pigmented individuals form keloids 2–19 times more frequently than Caucasians.5, 6 But ethnicity, regardless of pigment intensity, is also a factor. In Aruba, more children of the lighter-skinned Polynesian population form keloids than those of African descent.7 In Malaysia, those of Chinese decent are more prone to keloid formation than are the darker-skinned Indians and Malays.8 Although Caucasians form keloids less frequently, those who do can have a very light complexion. These patients are often among the most difficult to treat. Keloids can occur at any age. New keloid formation is relatively less common in the very young and the elderly. In young children, this may be a function of low trauma frequency and severity. Aging fibroblasts may be less capable of collagen over production.9, 10 Keloid regression after menopause has been reported.11 In an unpublished study of 212 Caribbean-American and African-American keloid-formers at Kings County Hospital, we found that age as an isolated factor did not correlate with keloid frequency. Rather, the timing of the pierce relative to puberty was predictive of keloid incidence. Small gender differences that have been reported in the literature are likely to have resulted from cultural trends and repo
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