Keloid Disorder (KD) is a genetic illness of wound healing process with a highly variable clinical presentation that spans from individuals with one or very few small keloidal lesions to those with numerous and very large lesions involving large portions of their skin.
Genetics of KD remains poorly understood, however, clinical observation suggests that the genetic predisposition to KD has a wide spectrum, from individuals who suffer from mild form of the disorder who in their lifetime only develop one or few slow-growing keloidal lesions, to those with very severe form of the disorder who develop numerous large and fast growing keloids; and of course, there are many others who fall somewhere in between these two extremes. Similar to most other genetic illnesses, there also exist many individuals who are simply carriers of the gene, who may never become symptomatic.
In addition to the genetics, several other factors play critical roles in clinical presentation of KD. Most importantly, there must exist an injury to the skin that would trigger abnormal wound healing response which leads to formation of keloidal lesions. Obviously, there is a wide spectrum to the severity and extent of skin injuries, ranging from very minor insults to the skin from acne, or piercing, or vaccination; to more severe forms of skin injury from surgery or burns. Besides genetics and skin injury, other important factors are age, race, gender, chronicity, therapeutic interventions as well as location of the keloidal lesions. The wide spectrum of all these factors contributes to highly variable phenotypes of KD.
By far, the most important factor in development of a primary keloidal lesion is the injury to skin that leads to triggering of pathological wound healing response. Piercing of the ears is a well-recognized triggering factor for development of primary ear keloids. Knowing that KD is a genetic disorder of wound healing processes, it is counter-intuitive to resort to surgery as the mainstay of treatment. Surgical removal of keloids is a commonly practiced intervention, not only by ear-nose-throat specialists, but also by plastic surgeons as well as general dermatologists. Surgical intervention however, defies the very basic principal in keloid formation. The injury and insult from surgery to the skin that surrounds a keloidal lesion, on its own, will undoubtedly trigger a keloidal wound healing response that often leads to formation of a new keloid.
Additional treatments in form of post-operative steroid injections, or even radiation therapy are commonly incorporated in management of every KD patient who undergoes surgery, simply to counter the fully expected recurrence after surgery. Yet despite diligent use of all available additional methods, a significant number of keloid patients will have a recurrence, which is often worse than the original keloid they had, and they undergo second, third or fourth surgery. In many unfortunate instances, keloids keep relapsing and at some point, either the surgeon, or the patient, or both, give up and the unfortunate patient ends up accepting the truth about inability of surgery to treat their keloids and see no other choice but to surrender to living with huge tumoral keloids on their ears. Almost all very bad cases of keloid that you may see, those with the most horrible keloids, are among this unfortunate group of patients.
Successful treatment of keloids requires patience and perseverance, and utilization of non-surgical methods. As keloids are chronic skin conditions, their treatment also takes time. Each keloid may require more than one method of treatment to achieve a desirable result. Choice of treatment for a given keloid will depend on its location, size and thickness and also, all prior treatments.