Pathogenesis and pathophysiology
Keloids are not actually a skin tumour but is a kind of vegetation of the connective tissue of the skin. Most lesions occur on scars wrought by external wounds, burns, infections, and surgery. Primary cases are also possible. Keloids are constructed of living, growing tissues which enmeshes and expands. With proper treatment, the keloid can be prevented from spreading and gradually soften and flatten. Chinese medicine practitioners consider the keloid a living organism that does not conform to metabolic processes. When it first forms, it is pink or dark red in colour and will gradually harden. It has a shiny and smooth surface, enlarged blood vessels which rises to the surface. There are different degrees of pain, itch and prickling sensations. Some for into a butterfly shape. The deeper the injury to the skin, the thicker the keloid forms as it spreads over the surface. Keloids which form along joints may hamper movements while keloids which form on the face may be disfiguring.
Common age groups for keloid formation
< 6 years 7.6%
6-12 years 5.0%
13-20 years 12.2%
21-30 years 43.2%
31-50 years 25.0%
51-70 years 5.7%
>70 years 1.3%
Being hairless, the scar is raised above the skin. It is pink or dark red, smooth, and shiny. Capillary dilation is often noted. Keloids feels hard and substantial and vary in size and shape. Pain or itching may also be felt subjectively. Note the following symptoms: 1. the scar did not dissipate after 2 months 2. the scar is larger than the original wound 3. recurrence of the scar after surgery, freezing, injections or radiation The usual location of such a scar is on the upper body, especially in the chest area. It will start from a red dot and formed to a large collagen mass, from soft tissues to hard, from a pinkish shade to a dark red color.
Keloids can be formed from acne, cuts, surgery and any form of skin puncture. However, scars on different parts of the body will have different chances of forming into keloids. Patients are advised to avoid irritating the keloid with jewellery, clothing, chemicals, etc. If the keloid bleeds easily, or shows abnormal symptoms like blisters, the case is more complicated. Patients are advised to seek advanced medical attention.
Keloids are different from hypertropic scars. It is said that when there is a deep wound (below two thirds of the dermis), in emergency collagen is produced in large amount to cover the wound. But if collagen is produced in such amount that is far exceeding the necessary amount, collagen lump formed far over the range of the wound is called keloid.
Hypertrophic scarring develops due to tissue tension, persistent inflammation, and the exaggerated response of the fibroblasts to healing. Fibroblasts deposit excessive amounts of disorganized collagen which then become adhesive to other structures. The scar is characterized by three R’s:
- It is Red because it is hypervascular.
- It is Raised because there is four times as much collagen in a wound.
- It is Rigid because the collagen is disorganized and does not allow for pliability.
Hypertropic scars are metabolically active for approximately eighteen months. After that time the scar is mature. This type of scarring is more pronounced in African Americans, Native Americans, Asians, and Hispanics as they are secondary to increased pigmentation. Keloids, unlike hypertropic scars come in 2 forms: raised or bulbous. Bulbous is a ball shaped growth and is commonly formed at the ear. Its appearance is the result of gravitational pull that cause the scar tissues to form away from the ear. Raised keloids are usually about 2-4mm raised above skin level but can spread over a wider surface area.
Difference between keloids and other scars similar in appearance
The main difference between a hypertropic scar is that keloids encroach upon surrounding tissues and ‘grow’ along the perimeter of the scar or reaches out with tentacles-like tissues. More
Please note the difference between keloids and Xanthomatosis, which are closer to hypertropic scars than keloids. More
Formation of scars
Scars, as part of a living organism, undergoes a complex process of formation. More
Hypertropic scars and Keloids
Both keloids and hypertropic scars are almost identical in appearance. The only difference is that keloids can grow indefinitely. Hypertropic scars are confined to the area of tissue damage. Both pictures show the spread of a keloid beyond the perimeter of the original wound.
Both pictures show untreated keloids that grew over a period of years. It also appears to be irritated by incision or repeated injections. It is important to seek treatment early as the keloid can harden, making it difficult to treat. Often the lower levels of the keloid is dense and take longer to treat (as they were formed much earlier). The above shows abnormal formation of the collagen matrix due to incorrect therapy.Under correct treatment, the keloid will resemble a centipede, where the center of the keloid is flattened with the 2 ends of the keloid red and slightly swollen.
Spreading keloid (1)
Spreading keloid (2)
Below picture shows hypertropic scars on a child who suffers from a scalding incident. Hypertropic scars usually appear ‘plump’.
Steroids and other invasive treatments
Scars and keloids do not usually cause medical problems. One exception is cesarean (c-section) scars. Some women experience spotting after their menstrual flow has finished due to their cesarean scars. Other people experience chronic pain that is associated with a scar. Even if a scar or keloid is not causing a medical problem, they are unsightly and unappealing from an aesthetic point of view, and often creates mental discomfort. It is therefore important that at the first sign of a scar formation, treatment must be instituted to prevent it from growing. A small scar the size of 0.5cm can grow and ‘spread’ to over 900% of its original size.
We also advise that the patient not seek traumatic treatments like surgery or injections without an effective post surgery treatment plan. Recurrence level is very high, often leading to ‘hyperplaxia’, a condition of acute keloid formation. (See pictures below: a single patch of keloid has deteriorated to a severe formation of collagen matrix).
Courtesy of Zhenzhou Western-Eastern Medical Hospital One customer, ( L.) noted: ” I have been suffering with chest kel(o)ids for a number years. It started with 1 small keloid about 8 years ago, it had grown and then flattened with the passage of time, but then about 3-4 years after the first keloid I began to develop more keloids below the first place, it seems like keloids are recurring on the roots hair of my skin and I don’t know how to stop the upcoming keloids. I am currently (for the past 2 months) undergoing treatment i.e. Injecting steroids (which is very painful) directly into the keloids.”
Steroids will flatten the keloid for a prolonged duration and the skin puncture caused by the needle will more usually than not form another keloid. It would have been better had ( L.) not gone for the injections and to focus on treating the keloid with non-invasive means. Through haste in wanting to see a flattened keloid, many opt for surgery and injections, only to complicate matters. A formed keloid made up of numerous collagen matrixes cannot be removed form the skin (unless temporarily through surgery). It can be managed to look like a normal scar. A scar that does not itch, hurts, spread or is raised. Generally, traditional and alternative schools do not advocate invasive or traumatic treatments to scars.
It is a regret that scars, being such a common occurrence in everyone’s experience that little attention is paid to them unless a large area of the skin is involved or a cosmetic or functional problem results from the location of the scar. Scars are regarded as products of the natural repair of injured tissue. The healing of the wound begins with the body’s outpouring of blood and serum into the defect, the formation of fibrin from fibrinogen, and the migration of fibroblasts and blood vessels into this matrix. New collagen is laid down by the fibroblasts, and a new epidermal surface forms from the migration of epidermal cells across the wound gap. Keloids and hypertrophic scars result from an abnormal growth of collagen tissue in a scar.
The collagen remodelling had been impaired, leading to a raised growth. Keloids cannot be cured but through the supply of herbal actives, we can help the skin remodel the keloid so that it becomes flatter and softer, thus mitigating the problems associated with keloids. Chinese treatments attempt to remodel the collagen matrix and to accelerate the self-healing mechanism of the skin.
A keloid will flatten on its own as the body tries to adjust itself but it can take decades. Our remodelling process will reduce the time needed to treat a keloid. External treatments influence the formation and/or reformation of the collagen mesh while internal treatment improves the flow of vital energy to the location of tissue repair. Extended therapy is needed in cases of scar tissues infiltrating into surrounding muscles. Surgery or other traumatic treatment may, in the short term, remove the appearance of a keloid, but it will not remove the cause of the formation.
An impaired weave of collagen matrix may still form at the point of invasion. Multiple injection points often cause the worse form of reformation. Forced flattening with steroids, freezing, bruising will only complicate the process of repair. Steroid injections, for example, have already caused the wounding of the skin and the consequence is for scar tissues to develop over the wound.
Our remodelling treatments, however, will accelerate the process, hence, the regrowth is visible within a shorter period. Once the steroids wear off, the keloid will start to reform. Our treatments accelerate the process of removing the steroids within the keloids. In this process, the treatment can mitigate the regrowth but not completely eradicate the reformation. Under the influence of steroids, the keloid is very susceptible to the food substances consumed, eg, garlic, seafood, etc. Because of the high Blood content with the keloid mass, they can easily respond to these food substances by becoming red (temporary).
Please note that steroid injections and cryotherapy are invasive methods of treatment which suppresses and force the dissipation of the scar tissues. This traumatize the skin to a great extent and is not a natural treatment for the skin but is the manipulation of chemicals to bring about a mechanical change. It is recommended that keloids which have been treated with steroids or other invasive treatments should delay our treatment until the steroids wear off.
Old TCM practitioners used the example of a tree burl to illustrate the nature of keloids. Examine the similarity of this tree with wound ‘scars’ with the picture above. These burls are caused by any number of natural factors that include: knot location, genetic components or naturally occurring damage to the bark.
The mechanism of keloids and burls are almost similar in that removal by physical excision will stimulate the formation of more growths. A cut through a burl reveals tight bunches of small knots or eyes. Similarly, a cut through a keloid will reveal a dense built up of fibrous dense tissues arrange tightly around each other. Some species of trees like Walnut and Redwood are prone to forming burls. Burls are prized for their unique appearance in furniture manufacture.
Keloids formed at mid-chest can be the most daunting of keloids to treat. On the left is a normal chest muscle structure. There is a ‘bridge’ of muscular tissues across the 2 chest muscles. 95% of chest keloids are formed at this precise location. This location is where the muscles are already raised and easily developed through physical activities. Keloids at this location grow at an accelerated rate and will take the longest amount of time to flatten. Moreover, it will not flatten to normal skin level as the tissues at this location is already raised to begin with. Non-invasive treatment is necessary to prevent an exponential growth of scar tissues at this location.
If we subscribe to the Western theory of keloid formation, ie. tension, chest keloid best illustrates the mechanics of this theory. Tension prevented the collagen matrix from forming into an organized mass in the process of wound healing. The delay resulted in the scar tissues being formed in disarray. Physical exercises will accelerate its growth and reach. Common area for keloid formations is at the chest, earlobes and jawlines. Scars at the knees and elbows are often hypertropic scars.
Below picture shows keloid formation which are not incurred from tissue damage. These small hard nodules usually formed on the upper body and arms
Treatment strategy for mature keloids
In addition to internal medication, keloid patients also have access to external therapies. Effective keloid and hypertropic scar treatment aim to remove the granulomas from scars, reduce the collagenous fibers, rehabilitate the growth of cutaneous and subcutaneous tissues, soften and disintegrate the cicatrizant tissues, increase the quantity of cells division of the pertinent parts, improve the flow condition of blood vessels, promote microcirculation, and prevent the scar from inflammation.
A variety of treatment is available for keloids but the principle is similar. We use a process of collagen matrix remodeling. The collagen matrix, which is composed of scar tissues, are gradually flattened and the the shape modified. As a result, the appearance of the keloid can be reduced into a normal scar. Selecting and appropriately using them is important to a successful treatment.
Treatment for keloids
Tension on scar tissue will result in a thickened scar and will be responsible for a more extensive inflammatory reaction in the scar. Therefore support of the scar is necessary to prevent the development of exaggerated (hypertropic) scarring. The use of microporous silicon sheet has consistently proved effective in preventing hypertropic scars by control or elimination of the stretch forces on the scar.
Keloid Prevention strategy
An immature scar, if put on intermittent stretch, remains immature and many may become exaggerated. A preferred scar is one that has matured rapidly without contracture, thickening and without forming more collagen than is necessary for its strength. How, then, do we accelerate scar maturity in a controlled manner? Two critical factors have been isolated as major factors in wound healing modulation, namely ‘hydration’ and ‘processes of repair’.
Hydration has been shown to be the principal mode of action of silicone gel, but more importantly, it was found that silicone was not essential to the process, – hydration alone significantly inhibits fibroplast proliferation (which results in less scar tissue formation). Hydration is believed to reduce water vapour loss and restore homeostasis to the scar. Hirudoid leech cream and the the silicon gel sheet has also been effective in this function.
Processes of repair
As a general rule, the phases of skin repair can be described as follows: 1. The keloid is first softened. 2. The center of the keloid flattens; caving towards the normal skin level. 3. The two ends of a keloid swells lightly and is slightly redder, resembling a centipede (This stage is critical as the toxins are channeled to the two ends of the keloids) 4. The center of the keloid flattens further. 5. The two ends retracts into the scar and gradually flattens. 6. The keloid will look like a shiny, pigmented patch of skin. It may still be slightly raised off the skin. 7. There will be no recurrence.
Users are advised that treatment for mature keloids can take up to 18 months. It is important to initiate treatment as an untreated keloid has the potential to grow and spread, causing more inconvenience. Physical exercises (which stimulate the surrounding tissues of the keloid) and an incorrect diet will also cause temporary ‘puffiness’ to the keloid.
Common areas of keloid formation
Keloids often form at these areas : 1. the jawline, the chest and the upper arms. If you are keloid prone, do take care that any wounds or other skin punctures in these areas are tended to promptly and gently. For example, do not squeeze or scratch any pimples as these may cause damage to the deeper layers of the skin, encourgaging keloid formation.
Keloids that have encroached and fused with surrounding tissues, eg. chest keloids, will require a significant amount of time and treatment to initiate softening and flattening. Such keloids may not flatten completely. We believe that keloids are not just scars.
They should be taken seriously and care must be taken not to make them worse than they already are. So, when you have a skin puncture from a mosquito bite, pimple, please take care not to squeeze or pinch them as the thickness of the keloid corresponds to the damage inflicted on the skin tissues. Use antiseptics or pimple creams to quickly close the wound.
In Chinese medicine, diet plays an important part in keloid formation. The keloid is filled with capillaries and the type of food consumed is quickly reflected on the keloid, triggering sensations of itch, pain and inflammation. Individual sensitivity to certain foods can be translated as temporary swelling, itch and pain.
As a general rule, avoid seafood, beef, mutton, alcohol and chillies during treatment. Fruits and vegetables to avoid include: garlic, grapes, durians, pineapples, cranberries and pumpkins. These foods can stimulate the keloid and accelerate collagen activity, causing aggravated itch and pain.
Therefore, collagen supplements should be avoided too. Keloid prone persons are seriously advised against inflicting wounds to the skin and to reduce inflammatory acne as these can often give rise to keloids. With effective treatment, a keloid can remain small and even unnoticeable, elastic and less irritable. Seek treatment early. Early treatment can make a difference as to the time and expense needed to treat a larger keloid.