Keloids are a type of raised scar that grows beyond the boundaries of the original wound or injury site. They are benign skin growths that do not disappear over time and often continue to grow larger over months or years. Keloids tend to be firm, rubbery lesions that are slightly raised, pink or purple in color. They commonly occur after trauma or injury to the skin, including cuts, burns, acne, piercings, insect bites, vaccinations, or surgery. Keloids can develop on any part of the body but are most common on the chest, shoulders, upper back, and ears.
Can keloids recur after removal?
Yes, one of the biggest challenges with keloids is that they often recur after surgical removal. Recurrence rates are estimated to be up to 80-100% after surgical excision alone. This means there is an extremely high chance that keloids will grow back even if they are cut out or removed surgically.
When a keloid is surgically removed, the body views this as another skin injury and triggers increased collagen and scar tissue production during the healing process. This leads to regrowth of the keloid scar. Certain factors can increase the risk of recurrence, including:
- Large or wide keloids
- Keloids that have been present for many years
- Surgical removal technique – some methods cause more recurrence than others
- Location on central chest or shoulder area
- Younger age, as teenagers and those under 30 are more prone to regrowth
- Genetic predisposition to excessive scarring
Due to this tendency to recur, most surgeons recommend combining other scar prevention treatments along with keloid removal surgery to reduce regrowth.
Treatments to prevent keloids coming back after removal
Various non-surgical and post-surgical treatments may help lower the risk of keloid recurrence after surgical removal. Common options include:
Corticosteroid injections
Steroid injections help reduce inflammation and collagen production. Injections are often given monthly before and after surgery. Triamcinolone and other corticosteroids may be injected directly into the keloid lesion. Studies show recurrence rates of around 50% when surgery is combined with steroid injections versus 80-90% with surgery alone.
Chemotherapy creams
Chemotherapy creams like 5-fluorouracil (5-FU) also reduce excessive scar tissue formation when applied daily after keloid excision. One study found it decreased recurrence to 65% when used after surgery.
Cryotherapy
Freezing the surgical site with cryotherapy may help reduce the risk of keloids returning. Liquid nitrogen is typically applied during and after the procedure. Cryotherapy can help destroy fibroblasts that generate scar tissue.
Radiation therapy
Radiation is often used to prevent keloid recurrence, especially on the ears and chest. Low-dose radiation is applied to the surgical wound site. This helps decrease fibroblast activity and lessen collagen production. When combined with excision, recurrence rates can be reduced to around 30-50%.
Laser therapy
Lasers can help shrink and flatten keloid scars when used after surgery. Pulsed-dye laser treatments may help reduce scar redness and minimize the risk of recurrence.
Silicone sheets or gel
Applying silicone sheets or ointment over the excision site for 12-24 hours daily can aid healing and reduce excessive collagen synthesis. Using silicone after surgery may lower recurrence risk to around 30%.
Compression
Wearing compression garments or bandages over the area for 6-12 months post-surgery can help prevent keloids from returning by flattening and smoothing the scar.
Chemical peels
Superficial peels with salicylic acid or TCA applied 4-6 weeks after surgery can aid scar healing and may prevent recurrence when combined with other modalities.
Recurrence rates with combined treatment approaches
Utilizing a combination of surgical excision plus adjuvant therapies offers the best chance of preventing keloids from growing back. Studies show recurrence rates of:
- Surgery alone: 80-100%
- Surgery + steroid injections: Around 50%
- Surgery + radiation: 30-50%
- Surgery + steroid injections + radiation: Less than 10%
By combining excision with 2 or more preventative treatments, like radiation, injections, and silicone gel, recurrence risk can be reduced to less than 10-30%. However, even with multiple treatment modalities, there is still a possibility keloids may return.
When do keloids recur after removal?
Keloids typically recur within the first year after surgical excision, if they are going to come back. Most recurrences develop within the first 4-6 months post-surgery.
Some factors that may influence when recurrence occurs include:
- Size of original keloid – Larger scars take longer to regrow, while small keloids may recur within 2 months
- Location – Chest and shoulder keloids tend to recur faster than those on the face, ears, or hands
- Age – Younger patients usually re-develop keloids more quickly than older individuals
- Genetics – Some ethnic backgrounds scar more readily, with earlier recurrences
Careful monitoring and follow-up during the first 12 months after surgery is important to check for any signs of regrowth and initiate preventative treatments early to avoid re-excision.
Can keloids be permanently removed?
There is no single treatment method that can guarantee permanent keloid removal or prevent recurrence forever. Even after multiple excision attempts and adjuvant therapies, some keloids may still persist and regrow. However, the risk of recurrence can be significantly lowered by combining surgery with several preventative modalities.
Some of the more effective keloid scar treatment protocols that may offer longer-term reduction include:
- Excision + monthly corticosteroid injections + radiation therapy
- Excision + 5-FU or interferon injections + compression + silicone gel sheeting
- Surgical removal + cryotherapy + laser therapy + radiation
With an intensive combination treatment plan before and after surgery, including follow-up laser or steroid injections for a year or longer, many keloids can be successfully minimized and prevented from returning permanently. But some high-risk cases may still require periodic surgery or injections to keep recurrence under control.
Should keloids be removed?
In many cases, surgical removal is warranted to treat uncomfortable or unsightly keloid scars, despite the risk of recurrence. Indications for keloid excision include:
- Significant pain, tenderness, or itching
- Restriction of movement when over a joint
- Ulceration or bleeding from growing scar tissue
- Infection risk in large lesions
- Earlobe keloids causing a stretched, distorted ear
- Very large or disfiguring scars causing emotional distress
However, surgery may not be advised in minor, asymptomatic keloids that do not cause pain or functional impairment. The decision to excise keloids depends on evaluating each case individually, taking into account the location, size, symptoms, and patient preferences.
In many instances, a combined approach of surgical reduction followed by several preventative therapies can significantly improve keloid scars. But the risk of recurrence and need for ongoing treatments must be discussed so patients have realistic expectations before undergoing surgery.
Preventing keloids from returning: New treatments
Ongoing research is investigating better ways to prevent keloids from recurring after surgical removal. Some promising new approaches include:
- Onion extract gel – Topical onion extract may help reduce keloid recurrence when applied after excision due to its anti-inflammatory and antiscarring properties.
- Interferon injections – Interferons help inhibit fibroblast proliferation and improve results when injected intralesionally after keloid removal surgery.
- Bleomycin tattooing – Multiple microinjections of bleomycin during surgery may prevent re-growth of keloids.
- Anti-metabolite creams – Fluorouracil and imiquimod creams can reduce fibroblast activity when used post-surgery.
- Botulinum toxin – Injecting Botox after keloid excision may help paralyze muscle tension and minimize recurrence.
Further studies on these and other new treatment approaches may eventually help lower keloid recurrence rates after surgical excision closer to zero.
Conclusion
Keloids have a strong tendency to recur after surgical removal, with regrowth rates as high as 80-100% without additional scar prevention treatments. Applying adjuvant therapies like radiation, steroid injections, and silicone gel sheeting in combination with excision can significantly reduce but not fully prevent recurrence. With an intensive multi-modal treatment protocol, the risk of keloids returning can potentially be lowered to under 10-30% in some cases. Continued research is investigating more effective options to minimize keloid recurrence after surgery.