Keloids are abnormal scars that result in excessive scar tissue formation at the site of an injury. They often continue to grow beyond the boundaries of the original wound and do not regress over time. Keloids can occur after any type of skin injury, but are more common after severe wounding or trauma that damages the deep layers of skin. They are firm, rubbery lesions or shiny, fibrous nodules that can vary from pink to flesh-colored or red to dark brown in color. Keloids tend to be itchy, painful, and tender to the touch.
While keloid scarring is benign and not life-threatening, keloids can be disfiguring and lead to significant psychosocial distress. Many people with severe keloids suffer from pain, pruritus, restriction of movement if over a joint, and poor self-esteem because of their appearance. Therefore, treatment is often pursued for cosmetic reasons. However, keloids are notoriously difficult to treat and have a high rate of recurrence after surgical excision.
What Happens When Keloids Are Left Untreated?
When keloids are left untreated, they tend to progress in size and thickness over time. The natural course of keloids is often enlargement because of a continued excessive production and deposition of collagen and extracellular matrix. A study published in 2015 followed 24 patients with 39 untreated keloids over a period of 12 to 72 months. The results showed that 76.9% (30/39) of the keloids continued to expand during the follow-up period. The study concluded that keloids tend to progressively enlarge if left untreated.
Another study published in 2016 in the Journal of Cutaneous and Aesthetic Surgery assessed the progression of 51 keloids in 31 patients over 10 years. They found that 67.6% of keloids increased in size over the 10 years, with a mean increase of 275.7% in surface area. Notably, keloids on the back showed the greatest increase. This provides further evidence that keloids tend to grow bigger and more raised over time without treatment.
Some of the possible outcomes when keloids are left untreated include:
– Continued expansion beyond the original wound boundaries, sometimes growing to very large sizes
– Increased thickness and elevation above the skin surface
– Darkening of the scar color
– Spreading of the scar into surrounding normal skin
– Worsening symptoms like pain, itchiness, and tenderness
– Restriction of movement if the keloid forms over a mobile joint
– Psychological distress due to disfigurement
While some keloids may spontaneously stop growing at some point, it is impossible to predict their progression. Most doctors recommend treatment to prevent worsening of keloids.
What Causes Keloids to Get Bigger Over Time?
Keloids get bigger over time when left alone because the processes that cause excessive scar formation persist in the wound area. Keloids form due to an overgrowth of granulation tissue that extends beyond the boundaries of the original wound. They are composed of abnormally high levels of collagen, fibronectin, elastin, and proteoglycans.
Some of the factors that are thought to contribute to this keloid growth include:
– Increased fibroblast activity: Fibroblasts are cells in the skin that produce collagen and other extracellular matrix proteins. In keloids, fibroblasts exhibit abnormal behavior, becoming hyperproliferative and depositing excessive connective tissue.
– Prolonged inflammation: Inflammation during wound healing activates fibroblasts. But chronic inflammation in keloids stimulates ongoing fibrosis and scar formation.
– Tension on the wound: Skin tension promotes directional collagen deposition by fibroblasts. This can stimulate keloid growth and spreading in the direction of tension.
– Growth factors: Growth factors like TGF-beta and PDGF encourage collagen and extracellular matrix production. They are found at higher levels in keloids.
– Genetic susceptibility: Many genes have been implicated in keloid formation, notably genes involved in wound healing, inflammation, and extracellular matrix regulation. Genetic abnormalities predispose some to excessive scarring.
As long as these processes persist at the wound site, collagen and extracellular matrix will continue to accumulate, causing the keloid to progressively expand over time.
Factors That May Impact Keloid Progression
Certain factors can influence the speed and degree of keloid growth when left untreated:
Location
Keloids on the chest, shoulder, earlobes and back grow more aggressively than those on other body sites. One study found the earlobe keloids expanded by an average of 87% over 5 years. Facial keloids also enlarged significantly.
Age
Younger individuals, between the ages of 10-30 years, tend to develop larger and more aggressive keloids. Growth slows with increasing age.
Skin pigmentation
Those with darker skin pigmentation seem to have higher keloid prevalence and more significant growth. One study found keloid surface area increased by 310% in African Americans vs. 203% in Hispanics over 10 years.
Genetic factors
People with a family history of keloids may experience faster progression. Specific gene mutations involved in wound healing pathways also play a role.
Puberty
Keloids first appearing around puberty often rapidly worsen. Hormonal changes influence fibroblast activity and inflammation during this time.
Skin tension
Keloids under high tension areas like over joints experience more collagen deposition and growth in the direction of skin tension lines.
Trauma
Repeated trauma or injury to an existing keloid can stimulate expansion by reactivating the wound healing cascade. Even minor skin trauma like scratches, piercings or burns can make keloids grow larger.
Pregnancy
Hormonal fluctuations during pregnancy often lead to new keloids or worsening of existing ones. Up to 75% of keloids enlarge during pregnancy.
Understanding these risk factors can help predict keloid progression so prompt treatment can be initiated when needed.
Can Keloids Go Away or Reduce on Their Own?
In most cases, keloids do not go away on their own without intervention. Once pat, keloids typically persist indefinitely because the metabolism of keloid fibroblasts and collagen is abnormally low. Unlike normal scars, keloids do not follow the usual wound healing trajectory of regression and remodeling over time.
However, there are rare cases where keloids have spontaneously flattened or shrunk without treatment. According to one study, about 6.9% of untreated earlobe keloids demonstrated some regression over 5 years of follow up. Researchers proposed that mechanical tension on the keloids may have reduced due to the weight and elasticity of the earlobe tissue, allowing regression. But spontaneous resolution is uncommon for keloids in areas with high skin tension like the chest or back.
Some additional reasons keloids may improve naturally include:
– Reduced inflammation – Inflammation during wound healing activates fibroblast production of scar tissue. If this inflammatory phase ends earlier, less fibrosis may occur.
– Apoptosis – Normal cell death of excessive fibroblasts and release of their deposited collagen could result in keloid shrinkage.
– Decreased growth factor and cytokine activity – Lower levels of TGF-beta, PDGF, and other growth promoters may halt pathologic growth.
– Gene mutations – Rare genetic abnormalities may predispose some keloids to suddenly halt their expansion.
– Mechanical regression – Gradual stretching of tissues surrounding the keloid may mechanically flatten lesions over time.
However, most doctors advise against watching and waiting, since spontaneous resolution is uncommon and unpredictable. Early treatment provides the best results for halting keloid progression and avoiding the need for more invasive procedures later on.
When Should Keloids Be Treated?
Doctors recommend treating keloids as early as possible for the best results. The American Osteopathic College of Dermatology suggests:
– Initiating treatment within the first 6 to 12 months after a keloid appears
– Treating younger patients under age 22 more aggressively due to higher growth potential
– Intervening promptly when a lesion starts expanding rapidly or causing worsening symptoms
– Operating on keloids while they are small whenever possible
– Ensuring keloids are fully healed after trauma or procedures before performing scar revision
Early intervention can help minimize complications like enlarging growth, spreading beyond wound borders, pain, itchiness and restricted movement. Smaller keloids also tend to respond better to nonsurgical techniques like steroid injections or silicone sheeting. Larger, older keloids often require excision followed by radiation, steroid injections or other adjunctive therapies to prevent recurrence.
Some signs that a keloid needs prompt treatment:
– Sudden growth in size, thickness or elevation
– Darkening scar color
– Spreading into normal tissue around the scar
– Worsening symptoms like pain, itching or tenderness
– Restricting movement if located over a joint
– Causing significant psychological stress
Catching problematic keloids early and starting treatment within the first year offers the best chance of halting abnormal scar progression and avoiding extensive surgery. Since keloids rarely disappear without intervention, delaying too long can compromise outcomes.
Risks of Leaving Keloids Untreated
While not life-threatening, leaving keloids untreated can lead to complications including:
Progression in size
Without treatment, keloids often steadily enlarge. The longer it is left alone, the bigger a keloid may grow. Large scars are harder to treat and resect.
Increased pain and itching
As keloids expand, symptoms of pain and pruritus typically intensify over time. This can significantly impact quality of life.
Limited range of motion
Untreated keloids over joints can limit mobility as they swell and spread. This may impair daily activities.
Infection
The dense, avascular scar tissue of keloids is prone to infection, especially if the skinbarrier is compromised by fissures or ulcers.
Psychological effects
Enlarging, disfiguring keloids may negatively impact self-esteem and body image without treatment. Some experience severe emotional distress.
Higher treatment intensity
The longer keloids grow unchecked, the more invasive treatments like surgical excision or radiation may be required. Smaller keloids can often be managed more conservatively.
Higher recurrence rates
Older, larger keloids are more stubborn to treat and have higher recurrence after scar revision surgery, sometimes 100%. Treating early may help prevent re-growth.
While the risks are not acute, most doctors advise against a “wait and see” approach, since keloids rarely resolve spontaneously. Early treatment provides the best chance of halting progression and avoiding future surgical procedures.
When to See a Doctor
People with keloids should consult a dermatologist or plastic surgeon when:
– A new keloid appears – Treatment within the first 12 months is ideal
– An established keloid seems to be getting bigger
– Keloid symptoms like pain or itch are worsening
– A keloid is restricting movement when located over a joint
– A keloid is causing significant distress due to its appearance
– A keloid develops signs of infection like pus, increasing redness or heat
– You are considering getting piercings or tattoos, which may trigger new keloid formation
Doctors can determine the best course of treatment based on the keloid size, location, symptoms, and other factors. While not always preventable, early intervention offers the best chance of halting keloid progression.
Treatment Options for Keloids
Many treatment options exist for shrinking or removing keloids. The approach used depends on the scar size, location, and extent of symptoms. Some options include:
Corticosteroid injections – Steroids help inhibit inflammation and reduce excessive collagen deposition. They are most effective on small, new keloids.
Cryotherapy – Freezing keloids with liquid nitrogen causes localized injury, initiating wound healing and collagen remodeling.
Silicone sheets/gel – Silicone may compress keloids and decrease inflammation and itching. It works best on smaller lesions.
Compression therapy – Compressive garments worn over keloids helps flatten and may reduce collagen production.
Radiation – Radiation is used adjunctively after surgical excision to prevent recurrence. It helps impair aggressive fibroblasts.
Laser therapy – Vascular lasers may reduce redness. Ablative lasers vaporize scar tissue but have risks of hypopigmentation.
Surgical excision – Cutting out the keloid is often done for larger lesions. Adjunct treatments are required to prevent recurrence.
Chemical peels – Superficial peels with salicylic or glycolic acid can help reduce keloid thickness and symptoms when combined with other modalities.
Interferon injections – Interferons reduce fibroblast growth and may prevent recurrence when combined with surgical excision.
Combining therapies often provides better results than a single treatment alone. The key is halting excessive collagen and extracellular matrix production that causes keloids to expand over time.
Preventing New Keloid Formation
Since those prone to keloids form them after any skin injury, prevention aims to avoid unnecessary skin trauma whenever possible. Recommendations include:
– Avoiding elective procedures like piercings and tattoos
– Using caution with aesthetic treatments like laser procedures, chemical peels or fillers
– Letting wounds heal completely before re-injuring the area
– Avoiding unnecessary surgery when feasible
– Preventing burns, lacerations or other injuries
– Managing conditions like acne to prevent deep lesions
– Using sun protection to prevent skin damage from UV radiation
– Treating any wounds at risk for keloids with prophylactic measures like pressure dressings, silicone sheets or corticosteroid injections
Genetic predisposition plays a major role, so those with a family history of keloids should be extra cautious about skin trauma. However, unpredictable keloid formation can still occur even with prevention efforts. Early treatment provides the best chance of halting progression.
Conclusion
When left untreated, keloids tend to progressively enlarge and worsen over time. Continued inflammation, skin tension, growth factors, and fibroblast activity drive ongoing scar proliferation beyond normal wound boundaries. While some keloids may spontaneously regress, this is uncommon without intervention. Early treatment within the first 12 months offers the best results for halting progression and avoiding extensive surgery. The risks of leaving keloids untreated include larger size, more symptoms, limited mobility, infection risk, and greater psychological distress. Multiple treatment options exist for improving keloids, including steroid injections, cryotherapy, radiation, laser therapy, surgical excision and more. Preventing unnecessary skin injury whenever possible is also advised for those prone to keloids. With an appropriate treatment plan initiated early, the prognosis for keloid scars can be good. Many achieve significant improvement in keloid appearance and associated symptoms with proactive management.
