Keloid scarring on the vulva, vagina, and pubic area

A keloid is a type of scarring/skin growth due to a proliferation of scar tissue at a cut or wound site, which can occur anywhere, including the vulva, vagina, and pubic or anal area. A keloid scar does not go away, and becomes bigger than the normal scar outline should be. A hypertrophic scar is not the same thing – a hypertrophic scar does not go outside its normal scar outline and tends to become lesser over time.

Word meaning and origin
Keloid = crab claw
Coined by Alibert in 1806 to try to describe the way the tissue expanded into normal tissue.

What do we know about keloids?
Keloids only occur in humans and in up to 15 per cent of wounds of both genders equally. Women tend to have more, but it’s believed that is because women tend to have more cosmetic procedures that break the skin, thus resulting in more abnormal healing and scar tissue.

Keloid tissue occurs more frequently in those with more pigmentation in their skin – 15 times more frequently. Most of us will get our first keloid scar between the ages of 10 and 30, and our oldest people don’t tend to develop it later in life. Some races are more likely to get keloid scar formation than others; these are Asians and African descendents, as well as Hispanics. Those with paler skins are affected far less, and albinos not really at all. Chinese are more likely than their Indian or Malaysian neighbours to develop keloid scarring.

There is some evidence that genes dictate our predisposition for keloid scarring, and it can run in families.

Symptoms and characteristics of keloids

• Thickened, raised scar tissue
• Appears at the site of skin trauma of some kind
• Red, raised skin
• May be itchy or cause a burning sensation
• Appears possibly out of the blue and in isolation, where other cuts may have healed easily
• Often appears where there is no hair follicles or sebaceous glands to pinpoint the problem
• Lesions are soft and doughy or hard and rubbery, or anywhere in between
• Keloids grow slowly over months and years
• Eventually stops growing

So what are keloid scars, exactly?
A keloid is described as a fibrotic lesion that is an abnormality of healing, particularly of a deep skin wound in the dermal layers. A keloid scar and a hypertrophic scar are both known as ‘fibroproliferative disorders’, which results from an out-of-control regulatory mechanisms of our skin and tissue repair and renewal.

When skin tissue overgrows, keloid or hypertrophic scarring is the result. The flesh is made up of proteins, collagen, elastin and proteoglycans. This is believed to be due to prolonged inflammation in the damaged tissue.

Hypertrophic scars
A hypertrophic scar is made up of the same material as a keloid scar, but sticks to within its boundaries; it does not surpass its borders, unlike a keloid scar. A hypertrophic scar also tends to appear months after the first wound, and stays the same or regresses over time.

Keloid scars
Keloid scars, on the other hand, appear up to a year after the initial skin trauma and grow far outside the normal scar border. The most common areas for this to occur are the chest, shoulders, and neck, with any injury that crosses skin tension lines more susceptible.

Risk factors for keloid scarring anywhere on the body
The key factor for keloid scarring is wound healing that takes some time, say more than three weeks. A wound that takes longer than that to heal sees a longer inflammatory process for whatever reason, which might include an infection, burn, or poor wound closure (such as piercings). Anywhere that suffers repeat trauma can result in keloid scarring. From time to time, no trauma is necessary for a keloid to appear.

There are vast differences in normal scar tissue and how it heals compared to keloids. Keloids have a lot of dense blood vessels, pre-lymphatic cells, and connective tissue elements (ground substance). The collagen in keloids is irregular and very thick, with its fibres not organised. Collagenase, the enzyme that breaks the bonds of collagen fibres, is significantly higher in keloids than hypertrophic scars and normal skin scarring. Collagen synthesis is also dramatically increased in keloid scars and hypertrophic scars. The process of scar formation is vastly different to a normal scar.

Mast cell production in keloids is overenthusiastic, which results in histamine release. There are more fibroblasts at the damage site, which means more special fibronectin receptors. The fibroblasts themselves seem to be normal. Mild, chronic inflammation may exist in the keloid. The inner portion of a keloid is likely to have very little oxygen supply, with less blood supply than on the outside portions of the keloid.

The chemical and hormonal cocktail of growth factors, cytokines and other components in the keloids is warped compared to normal skin.

We know exists: 

• Greater production of tumour necrosis factor (TNF)-alpha, interferon (INF)-beta, and interleukin-6, immunoglobulin G
• Lesser production of INF-alpha, INF-gamma and TNF-beta (these elements actually reduce the action of fibroblasts in producing certain types of collagen)
• A relationship between immunoglobulins and keloids

Being examined for and diagnosed with keloid scars
When you visit the doctor to be examined, the scar will need to be differentiated from a hypertrophic scar. Sometimes the scar will be itchy or feel like it burns. Generally people see a doctor about keloids because they aren’t happy with how they look, and most keloid scars are – besides their appearance – symptom-free.

Keloid treatments
There is no ‘cure’ for keloids, but there are definitely things that can be done to help reduce their appearance and try to manage their existence. Keloids can be quite distressing, since they can appear anywhere on the body, including the face and vulva. If you can be cut there, you can get a keloid scar there.

Treatment strategies vary, but the most important thing you can do is prevent skin from being broken. Any nonessential surgery should be avoided. Anyone who has just earlobe keloids is not necessarily a ‘keloid former’, and thus other forms of surgery may be performed in those people with less risk of keloid formation on other areas of the body. Earlobes tend to be a key area, with ear piercings. Some sites will be more high-risk than others. Prevention includes radiation therapy to a wound prior to surgery, plus antibiotics.

Silicone dressings – useful
Gel sheets and dressings have been used with some success, with the sheets being worn for up to a full day up to a full year. A concern with these sheets is skin irritation. Silicone doesn’t enter the skin, so hydration is increased and a blocking mechanism is upheld. The increased temperature of the keloid possibly increases collagenase activity (the enzyme that breaks down collagen fibres, which in this case is useful), with increased pressure possibly being useful too. The response rate (in some studies) was up to nearly 80 per cent with a vast reduction in itchiness, redness and bulge of the scar.

Compression garments – very useful
Pushing on the keloids using compression is effective for some keloids, particularly on the earlobe. You will need these compression garments to be made just for you, and are most useful if worn all day every day, even during sleep. Spandex is a favourite. The compression garments begin as soon as the wound is at a certain stage and once the scar is mature, the pressure garments can be left off. Pressure is thought to be ideally between 15 and 25 mm Hg. This might work by reducing blood flow into the keloid, thus quashing the fuel for cell proliferation.

Corticosteroid treatment – pretty good, with some caveats
Used with other therapies, corticosteroids are a useful treatment, particularly at onset of keloids. Steroids are injected into the keloid and reduce collagen synthesis, ground substance, and inhibit inhibitors (collagen). This means the keloid is far less thick than it would otherwise have been. Your doctor will have the latest, most appropriate schedule for your scars. Steroid injections have a pretty good response rate (between 50 and 100 per cent) and recurrence rates of between nine and 50 per cent. So, a vast spectrum of results, but definitely a path worth considering. It takes repeat treatments, and can have negative side-effects like problems with pigmentation, skin atrophy, blood-vessel conditions, ulcers, and sometimes greater impacts on the body.

Surgical removal – pretty good
It might seem counterproductive to cut off a thing that exists because of a skin cut, but if minimal trauma and proper wound care is observed, a new keloid can be avoided, since the main contributing factor seems to be ongoing inflammation. Grafts have been used, but with only partial success. Recurrence rates after surgery again vastly differ, from between 45 per cent to 100 per cent success. Surgery may be considered plus some other treatments like steroid injections or radiation treatments.

Radiation therapy – not that good
Radiation is not used alone, since recurrence rates are sitting at 100 per cent. Malignancy at the site has been observed decades after treatment, so large-dose radiation therapy has been largely abandoned. Catching the fibroblasts in the first two weeks after surgery seems to be the most effective.

Liquid nitrogen (cryotherapy) – pretty good
Cryotherapy is the use of liquid nitrogen to ‘freeze’ off the offending skin. Pain and pigmentation issues were the most common results, though the treatment was quite effective when used every month. The rate of recurrence was zero, with the success rates about 85 per cent.

Laser treatments – not that good
Laser is a very precise treatment that barely or does not affect non-targeted tissue. This results in much less inflammation than other types of treatments. There are many types of lasers that are suitable for the job, and these lasers shrink collagen, and can inhibit collagen metabolism and production. None have proved good enough to last the distance, with recurrence rates at past 90 per cent.

Interferon treatment – somewhat useful
Interferon injections can stop fibroblast synthesis, reduce ground substance, and increase collagenase enzyme activity. Immediately postoperatively, quite useful in reducing the size of keloids.

5-Fluoruracil (cancer treatment) injections – pretty painful, but ok
5-FU has been used to successfully treat small keloids, but these injections can be quite painful and are frequent – five to 10 injections per week.

Imiquimod therapy – ok but side-effects are not great
Imiquimod causes interferons to be produced at the injury site, used as a cream immediately after surgery and kept up for eight weeks. The area usually becomes quite irritated with use of this cream, so two days on two days off is usually required. Pigmentation issues often develop.

Other options to discuss with your doctor:

• Flurandrenolide tape (Cordran) – special tape, helps with itching, causes skin damage after a long time
• Bleomycin for small keloids
• Tacrolimus – a twice-daily treatment
• Methotrexate – useful with surgery
• Pentoxifylline (Trental) – some use
• Colchicine – inhibits collagen synthesis and stimulates collagenase
• Zinc application
• Injections of verapamil, cyclosporine, D-penicillamine, relaxin, and topical mitomycin C

If you suspect you have keloids, see your doctor, who can refer you to a specialist dermatologist.