Keloids in Skin of Color: Pathogenesis and Multimodal Treatment

Overview / Definition Keloids are raised fibrous tissue growths that occur at the site of skin injury, resulting from an exaggerated healing response. Unlike hypertrophic scars, keloids extend beyond the original wound margins and can continue to grow over time. They are particularly prevalent in individuals with skin of color, including those of African, Hispanic, and Asian descent. Epidemiology Keloids affect approximately 10-15% of the population, with a significantly higher incidence in individuals with darker skin types. The prevalence is estimated to be: African descent: 16-20% Hispanic/Latino descent: 6-10% Asian descent: 5-10% Factors contributing to the higher incidence in these populations include genetic predisposition and differences in collagen metabolism. Pathophysiology / Mechanism The exact mechanism of keloid formation remains unclear, but several factors are believed to contribute: Genetic predisposition: Family history is a significant risk factor. Growth factors: Elevated levels of transforming growth factor-beta (TGF-β) and fibroblast growth factor (FGF) stimulate collagen synthesis. Inflammatory response: Prolonged inflammation at the injury site may trigger excessive fibroblast activity. These factors culminate in a dysregulation of the normal wound healing process, resulting in the production of excessive collagen and other extracellular matrix components. Clinical Presentation Keloids typically present as: Firm, rubbery nodules or plaques that may be skin-colored, red, or dark brown. Itching or pain in some cases, particularly if the keloid is inflamed. Occur commonly on the chest, back, earlobes, and shoulders, but can develop anywhere on the body. It is important to differentiate keloids from hypertrophic scars, which are raised scars that do not extend beyond the wound margins and typically regress over time. Diagnosis / Workup The diagnosis of keloids is primarily clinical, based on the characteristic appearance and history of skin injur