When I got my first-ever secret tattoo at the tender (and under) age of 16, I expected my mom to be livid. I braced myself for the typical parental admonishment around how I would feel about it on my wedding day in 20 years. What I did not foresee, however, was a sobering reminder that keloids run in my family and that what seemed like a fun, rebellious moment could quickly become a saga of frustration and suffering if I wasn’t careful.
A keloid is a type of raised scar that grows larger than the original wound, often becoming a rounded, solid mass that can be painful, itchy, obstructive, and generally unwelcome. Any type of trauma to skin, from an ear piercing to a surgical incision, can trigger a keloid that can continuously expand over the course of months to years. Like hyperpigmentation, keloids are more common in people of color, namely those of African ancestry. “Some people believe that in darker skin you have larger fibroblasts and this plays a role in being more likely to have keloids,” says Dr. Michelle Henry, clinical instructor of dermatology at Weill Cornell Medical College. Fibroblasts are skin cells responsible for creating the skin-supporting and wound-healing protein called collagen. “There is some genetic tendency, but sometimes it’s just spontaneous.”
Although I was lucky to come out of that tattoo unscathed, the reality of a predisposition to keloidal scarring is not lost on me. Darker-skinned individuals develop keloids 15 times more frequently than others, according to research done on plastic surgery on ethnic skin. These scars have a high rate of recurrence, and no single treatment method has proved superior. Consequently, many people resign themselves to living with smaller keloids their entire lives, while others endure more serious complications following severe acne or C-sections and other procedures.
“I wish people knew there are actual keloid treatments,” Dr. Henry reassures us. “They think they’ve just inherited them and there’s nothing to do, but we have many viable options and, in most cases, you get significant improvement.” Those looking to treat and prevent keloids can expect to undergo a combination of the following approaches for best results.
Steroid injections are the first line of attack against keloids at Henry’s practice. The diluted steroid solution causes the keloid to break down and flatten out. This procedure is minimally invasive, inexpensive, and generally successful on its own. “Every keloid is different, so my most common approach is to inject because it’s inexpensive [for] the patient and there’s really no aftercare,” says Henry.
Surgically removing a keloid is a risky yet quick solution in certain cases. “Sometimes you can excise them, but you have to be careful because they can come back,” says Henry. “I will typically excise and also inject if the keloid doesn’t respond to the original injection, if the patient has a functional impairment, or if they are just willing to take the risk to get rid of it.”
Despite exposure risks, localized radiation continues to be a popular keloid treatment because it slows growth and promotes shrinkage. Henry notes this treatment is more common in resistant and recurrent cases and is most often paired with surgical excision to improve results.
Although pricier, many types of lasers have proved successful in treating keloids. Pulsed dye lasers soften keloid tissue and reduce blood flow, while fractional lasers improve the penetration of steroid injections for a more effective combination treatment.
Cryotherapy involves direct contact with or injection of liquid nitrogen. Over the course of several days, the keloid swells and scabs over before shrinking in size. This procedure may take several treatments to achieve desired results and comes with the risk of discomfort and the depigmenting of skin.
On the cutting edge of keloid treatment lies Botox. Early studies suggest that direct Botox injection reduces the size of keloids and other abnormal scarring and may help reduce itching and uncomfortable skin tension.
A favorable treatment that can be done at home is the use of silicone bandages that compress the keloid to encourage flattening and discourage growth. “We don’t completely understand why it works, but we believe occlusion and hydration [of the top layer of skin] helps better mediate the fibroblast,” says Henry. Silicone sheets are most successful on smaller keloids or as preventative care.
While the general inaccessibility of dermatology services paired with a cultural mistrust of medicine poses unique obstacles for Black people looking for answers, Henry is adamant about spreading the word on keloid care: “A lot of people with keloids come in for something else and just don’t believe they can fix it, but we end up talking about it and being able to treat it.”