Keloids are firm, rubbery lesions or shiny, fibrous nodules that can form anywhere on the body in places where the skin has healed from an injury. They extend beyond the original injury into surrounding healthy skin and rarely regress spontaneously. While some minor keloids may flatten somewhat over time, most keloids do not flatten significantly without treatment. Several factors determine whether a keloid may flatten without intervention.
What are keloids?
Keloids are excessive scar tissues that grow past the boundaries of the original wound or injury. They are benign skin growths that occur due to an overgrowth of collagen during the skin’s healing process. Keloids may initially appear pink or purple in color, but often turn brown or tan over time. They can vary greatly in size and shape.
Keloids tend to be firm, rubbery lesions that are slightly elevated above the skin surface. They may continue to enlarge over time and can cause pain, itching, and discomfort. Keloids do not usually regress spontaneously and often persist indefinitely unless treated.
What causes keloids to form?
The exact cause of keloids is unknown, but they are thought to have a genetic component. Keloids are more common in people with darker skin tones. Additional risk factors include:
- Family history of keloids
- Younger age (10-30 years old)
- Injuries that penetrate deep through the skin
- Wounds under tension that take longer to heal
- Severe acne or chickenpox scars
- Burn injuries
- Ear piercings
Keloids form when skin is injured and the wound healing process becomes dysregulated. Fibroblasts, which are cells that produce collagen, become overactive and deposit excessive collagen fibers at the site of injury. This abnormal healing response leads to enlarged scars that grow past the original wound borders.
Do keloids flatter over time without treatment?
In most cases, keloids do not significantly flatten without treatment. Only about 10-50% of keloids regress partially on their own. Several factors determine whether a keloid may flatten spontaneously:
- Size – Smaller keloids (less than 2 cm) are more likely to flatten compared to larger lesions (greater than 5 cm).
- Location – Keloids on the upper back and shoulders flatten more often than those on the chest, neck, or earlobes.
- Duration – Newly formed keloids (less than 1 year old) may flatten more over time versus older keloids.
- Puberty – Some keloids in teenagers may flatten after puberty when hormone levels change.
- Pregnancy – Hormonal changes during pregnancy sometimes cause temporary keloid flattening.
However, most keloids persist and remain elevated without intervention. Spontaneous keloid flattening is difficult to predict.
Treatments for flattening keloids
While some keloids may flatten slightly over time, most require active treatment to reduce in size and become less noticeable. Treatment options for flattening keloids include:
Corticosteroid injections
Intralesional steroid injections directly into the keloid every 4-6 weeks is the most common first-line treatment. Steroids help reduce inflammation and keloid collagen synthesis. This can effectively flatten keloids in some cases.
Cryotherapy
Freezing the keloid with liquid nitrogen helps destroy its tissue and may flatten it when used along with steroid injections. However, cryotherapy alone has high recurrence rates.
Silicone gel sheeting
Applying silicone gel sheets to keloids can hydrate and compress the tissue to help reduce thickness and texture over time. Continuous use for 12 hours a day yields the best flattening results.
Radiation therapy
Superficial radiation applied externally to the keloid can help shrink the scar tissue. It may require multiple treatments to significantly flatten the keloid.
Laser treatment
Laser and light therapies can help reduce vascularity and cellular activity within keloids. This helps soften and flatten the lesion when combined with other therapies.
Surgical excision
Surgically removing the keloid and closing the wound with careful techniques can provide immediate flattening. However, keloids tend to recur after excision alone. Combining surgery with other treatments helps prevent recurrence.
Compression therapy
Wearing adhesive tape, silicone sheets, or elastic wraps/garments over the keloid applies gentle pressure to help soften and flatten the scar over time.
Interferon injections
Interferons are proteins that can help regulate fibroblast collagen production. Injecting interferons into keloids may improve flattening when combined with excision or steroids.
5-FU chemotherapy
Injecting the chemotherapy drug 5-fluorouracil (5-FU) into keloids can reduce fibroblast activity and collagen deposition, leading to some flattening over a course of treatment.
Preventing new keloid formation
In addition to treating existing keloids, preventing new keloid formation after injury or surgery is also important. The following techniques may be used:
- Avoiding unnecessary trauma or irritation to known keloid-prone areas
- Using minimal Scar revision techniques to close wounds where possible
- Applying silicone gel sheeting over incisions during healing
- Giving steroid injections at the time of injury when needed
- Avoiding piercings, tattoos, elective surgeries in keloid-formers when possible
Conclusion
Only a minority of keloids flatten significantly without treatment. Smaller, newer keloids on certain body areas have the highest chance of flattening spontaneously over time. However, most keloids require proactive treatment like steroid injections, surgery, radiation, or laser/light therapies to achieve significant scar reduction and flattening. With current treatment modalities, even larger, mature keloids can often be softened, minimized, and made flatter and less noticeable.