Clinical Challenge: Multiple Nodules on Back and Chest

Keloids are fibroproliferative growths that extend beyond sites of trauma. These lesions form as a result of excessive accumulation of extracellular matrix components such as collagen in response to aberrant expression of growth factors and cytokines.1 Keloids present as firm papules...

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Keloids are fibroproliferative growths that extend beyond sites of trauma. These lesions form as a result of excessive accumulation of extracellular matrix components such as collagen in response to aberrant expression of growth factors and cytokines.¹ Keloids present as firm papules and nodules.

Keloids may appear at any age but most commonly arise in adolescence through the third decade.² Patients of African descent are disproportionately affected by the condition;  keloids are 15 times more frequently among Black individuals than White individuals.² Common locations include the earlobes, chest, shoulders, upper back, lower scalp, and posterior neck.

Keloids can significantly impair quality of life.³ Although the majority of keloids are asymptomatic, lesions may interfere with range of motion and may cause pain, itching, bleeding, or ulceration. Further, lesions are often cosmetically disfiguring.

Therapeutic options for the management of keloids range the gamut from application of silicone gel sheeting to surgical excision.⁴ No treatment is universally successful. One of the most widely used modalities is intralesional injection of triamcinolone; repeated injections at periodic intervals may reduce scar volume and height.

Steroid injections often precede surgical removal, although even with this combined modality, a significant percentage of keloids recur.⁵ A recently published study documented that single-dose radiation therapy following surgery prevented keloid recurrence in a majority of patients.⁶

Stephen Schleicher, MD, is director of the DermDox Center for Dermatology in Pennsylvania, as well as associate professor of medicine at Commonwealth Medical College and clinical instructor of dermatology at Arcadia University and Kings College.  

References

1. Andrews JP, Marttala J, Macarak E, Rosenbloom J, Uitto J. Keloids: the paradigm of skin fibrosis — pathomechanisms and treatment. Matrix Biol. 2016;51:37-46. doi:10.1016/j.matbio.2016.01.013
2. Chike-Obi CJ, Cole PD, Brissett AE. Keloids: pathogenesis, clinical features, and management. Semin Plast Surg. 2009;23(3):178-84. doi:10.1055/s-0029-1224797
3. Furtado F, Hochman B, Ferrara SF, et al. What factors affect the quality of life of patients with keloids? Rev Assoc Med Bras. 2009;55:700-704.
4. Ojeh N, Bharatha A, Gaur U, Forde AL. Keloids: current and emerging therapies. Scars Burn Heal. 2020;6:2059513120940499. doi:10.1177/2059513120940499
5. Mustoe TA, Cooter RD, Gold MH, et al. International clinical recommendations on scar management. Plast Reconstr Surg. 2002;110(2):560-571. doi:10.1097/00006534-200208000-00031
6. Son Y, Phillips EON, Price KM, et al. Treatment of keloids with a single dose of low-energy superficial X-ray radiation to prevent recurrence after surgical excision: an in vitro and in vivo study. J Am Acad Dermatol. 2020;83(5):1304-1314. doi:10.1016/j.jaad.2020.06.023