Diagnosis: Keloid scar
A 30-year-old male presents with a progressive, pink, firm tumor at the site of an old acne scar. Over the past year, the lesion has gradually enlarged and become symptomatic with occasional pruritus. The clinical findings are consistent with a keloid scar, which is characterized by excessive collagen deposition and can occur after skin trauma.
A 30-year-old male presents with a progressive, pink, firm tumor at the site of an old acne scar that has been present for one year. The lesion has gradually enlarged and is occasionally itchy. On examination, the lesion measures approximately 4 cm in diameter and is elevated above the surrounding skin, exhibiting a smooth surface.Location: Occurs at the site of a previous acne scar.Color: Pink to red, indicating vascularity.Texture: Firm and rubbery to palpation.Size: Approximately 4 cm in diameter.Symptoms: Occasionally itchy but not painful.
The patient reports that the lesion developed about one year after he experienced significant acne in his teenage years. He has a history of keloid formation after minor skin injuries and has previously attempted treatment with topical steroids without significant improvement. There is no family history of keloids, and he denies any other significant medical history. The patient does not smoke and has no known allergies.Onset: Developed approximately one year post-acne.Prior treatments: Topical steroids with minimal effect.Family history: No reported family history of keloids.Social history: Non-smoker, no significant drug use.Exposure history: No recent skin injuries or infections.
Acute / First-Line ManagementIntralesional corticosteroids, such as triamcinolone acetonide at a concentration of 10-40 mg/mL, can be administered every 4-6 weeks until improvement is noted.Silicone gel sheeting applied daily for 12-24 hours can help flatten the keloid over time.Workup and Diagnostic ConfirmationClinical diagnosis is generally sufficient; however, a biopsy may be performed if the lesion's characteristics are atypical or if there is concern for malignancy.Assess for any underlying conditions that may predispose to abnormal scarring, such as connective tissue disorders.Long-Term ManagementConsider combination therapy, including laser treatments such as pulsed dye laser or fractional laser resurfacing, for persistent cases.In refractory cases, surgical excision may be warranted, followed by adjuvant therapy such as radiation or corticosteroid injections to prevent recurrence.
Hypertrophic scar: Similar appearance but typically remains within the confines of the original wound and may improve over time.Dermatofibroma: Firm, benign nodule that is often brownish in color and demonstrates the 'dimple sign' on palpation.Basal cell carcinoma: May present as a firm, pearly nodule; biopsy needed to confirm diagnosis.Malignant melanoma: Can present as an atypical lesion; history of change in size or color is significant.Angiolipoma: Soft, tender subcutaneous nodule that may be painful; associated with vascular components.Fibromatosis: More aggressive and infiltrative; may require imaging for assessment.Granuloma annulare: Presents as annular plaques; often self-limited and typically does not exhibit significant elevation.Cutaneous lymphoma: May manifest as a firm, red plaque or nodule; requires biopsy for diagnosis.
High-Yield PearlsKeloid formation: Often occurs after skin trauma, including surgical incisions, acne, or piercings.Intralesional steroids: First-line treatment for keloids, effective in reducing size and symptoms.Recurrence risk: High after excision; adjuvant therapies are crucial to minimize recurrence.Prevention: Patients with a history of keloids should be counseled on minimizing skin trauma.Consideration of ethnicity: Individuals of African, Hispanic, and Asian descent are at higher risk for keloid formation.Understanding the complexities of keloid pathophysiology is essential for effective management and prevention strategies.
Tags: keloid, scarring