Patient Presentation
A 12-year-old female came to clinic with a history of having her ears pierced 4 months before, and who now complained of having both ears with soft bumps on the back of her ears for the past 3-4 weeks. Her right side was more affected than her left and they were not painful but were somewhat itchy. There was no discharge from the piercing sites and the jewelry was freely moving. She had no systemic problems. The past medical history was negative for any significant skin problems and she had had normal wound healing in the past. The family history was positive for her mother having problems with keloid formation in a couple of scars that she had not sought treatment for.

The pertinent physical exam showed a well-appearing female with growth parameters between 10-25% and normal vital signs. Her ear lobes anteriorly appeared normal without evidence of infection, but posteriorly both had an overgrowth of flesh-colored tissue that was emanating from the piercing site but was also involving skin laterally to the holes. The right side was about 7-8 mm in height and width. The left side was about 4-5 mm in height and width. There was no erythema, edema or fluid that could be expressed. Her jewelry moved freely. The skin overlying the skull and mastoid areas was normal. She had some shotty anterior cervical nodes.

The diagnosis of keloids was made. The pediatrician recommended to see a dermatologist for possible steroid treatment. In the meantime she recommended keeping the jewelry in place, and to use an H-1 antihistamine to help with pruritis.

Discussion
Wound healing is a complex process and abnormalities are common. Hypertrophic or keloid scarring are the two types of excessive scarring with both having excessive scar tissue that is elevated above the normal skin. Hypertrophic scarring occurs usually only within the wound and can regress. They are common after burns and develop within 3 months of skin injury. Keloid scarring spreads beyond the original wound and does not regress, and often recur. They can occur even 1 year after injury.

Keloids have an incidence of 5-15%. “Compared to normal fibroblasts, keloidal fibroblasts have longer lives, higher proliferative activity and decreased apoptosis rates, resulting in excess product of cytokines and collagen.” Various growth factors and inflammatory proteins are responsible for the excessive growth. They can be seen in all ages but are more common in second and third decades, and are more common in darker-skin pigmented individuals. They are also associated with some genetic conditions such as Ehler-Danlos type III and Noonan syndrome.

Keloids can occur anywhere except mucous membranes and are more likely on the ear lobes, upper back, and sternum. They can be flesh-colored, hyperpigmented, or erythematous. In addition to mechanical problems due to their location or size, they often cause pain, tenderness, burning or pruritis.

Learning Point
Treatment of keloids can be difficult because of their predilection to recur. Keloids can be prevented by avoiding unnecessary wounds (such as piercings) and surgical incisions should be in skin creases when possible, not across joint lines or located mid-chest if at all possible.

Treatments for keloids can include:

• First line especially for small keloids
  • Dressings – silicone (sheeting or gels) or pressure
  • Intralesional corticosteroid injections
  • Cryotherapy
• Second line
  • Surgical excision
  • Combination therapies such as corticosteroid injection and cryotherapy and/or dressings
• Newer therapies and their known or proposed mechanism of action on fibroblasts or factors that modulate fibroblast
  • Botulinum toxin – growth factor modulation
  • Interferons – regulates cell metabolism
  • Bleomycin – inducing apoptosis
  • 5-Flurouracil – inhibits cellular proliferation
  • Mitomycin C – has antiproliferative effect
  • Calcium channel blockers – accelerating the degradation of scar tissue
  • Angiotensin-converting enzyme inhibitors – collagen production modulation
  • Imidazoquinolines – regulates cell metabolism through interferons
  • Growth factors – regulates cell metabolism
  • Fat grafting – promotes tissue regeneration
  • Mesenchymal stem cell therapy – produce growth factors that help wound repair
  • Photodynamic therapy – reduces cellular proliferation and increases apoptosis
  • Microneedling – induces directed collagen remodeling
  • Laser therapies – promotes wound remodeling

Questions for Further Discussion
1. How should new piercing being taken care of? A review can be found here
2. What are good wound complication prevention procedures?
3. How is burn treatment different than other wounds?

Related Cases

Disease: Keloids | Scars

Symptom/Presentation: Mass or Swelling | Trauma

Specialty: Dermatology

Age: School Ager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Scars

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Ekstein SF, Wyles SP, Moran SL, Meves A. Keloids: a review of therapeutic management. Int J Dermatol. 2021;60(6):661-671. doi:10.1111/ijd.15159

Elsaie ML. Update on management of keloid and hypertrophic scars: A systemic review. J Cosmet Dermatol. 2021;20(9):2729-2738. doi:10.1111/jocd.14310

Naik PP. Novel targets and therapies for keloid. Clin Exp Dermatol. 2022;47(3):507-515. doi:10.1111/ced.14920

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa