Keloids: Symptoms, Causes, Treatments, and Natural Approaches

Keloids affect 10 percent of Americans and often run in families.

Keloids vary in color, from pink and purple to brown or hyperpigmented, changing as they grow and mature. Illustration by The Epoch Times, Shutterstock

Also known as keloid scars, keloids are raised formations of excessive scar tissue that result from abnormal wound healing following skin trauma or inflammation.

They typically occur at sites of skin injury, including trauma, surgery, blisters, vaccinations, acne, or body piercings. In some cases, keloids may even form in areas without visible injury.

The development of keloids is influenced by both genetic predispositions and environmental factors. Approximately 10 percent of people develop keloid scars in the United States. The condition affects both genders equally.

Keloids form due to abnormal wound healing, where the tissue-building stage continues unchecked, causing excessive scar growth. Illustration by The Epoch Times, Shutterstock

What Are the Different Types of Keloids?

Several types of keloids exist, including:

Fresh Nodular Keloids

A fresh nodular keloid is a firm, growing scar with undefined borders, often accompanied by itching. These keloids continue to grow over months or even years and are characterized by inflammatory cells, limited blood flow, thin collagen fibers, and a disorganized tissue structure. Notably, fresh nodular keloids have a 30 percent recurrence rate after surgical removal.

Nodular Earlobe Keloids

A subtype of nodular keloids, nodular earlobe keloids are firm and can be either new or mature. They may show signs of bacterial infection, usually on just one side, and are characterized by good blood flow and thick collagen fibers. These keloids have the lowest recurrence rate when completely removed with clean edges.

‘Butterfly’ Keloids

A superficial spreading keloid, also known as a “butterfly” keloid, is flat with a faded center and noticeable blood vessels. These keloids have a soft tissue structure, good blood flow, and extend into the skin in a finger-like pattern. They may continue to grow at the edges over many years.

Mature Keloids

Mature keloids, which are no longer growing or are “burned out,” have a low recurrence rate of about 4.5 percent. They are soft, with clear boundaries, a faded center, and edges that resemble the surface of a brain. These keloids have not grown for years and contain thick, organized collagen fibers, few active skin cells, and limited blood vessels.

Transition Keloids

Transition keloids refer to multiple keloids in different stages of development. They can appear at different times, in various forms, and may show a mix of characteristics as they evolve.

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What Are the Main Causes of Keloids?

Keloids result from abnormal wound healing. Normally, skin healing happens in three stages: inflammation, tissue building, and maturation. In keloids, the tissue-building stage or fibroblastic phase, continues unchecked, leading to excessive scar formation.

The cells that produce collagen in keloids, called fibroblasts, are overactive, live longer, and don’t die off as they should. This causes an overproduction of collagen—20 times more than in healthy skin and three times more than in other scars.

In addition to excess collagen, keloid formation is believed to involve an overproduction of elastin, a protein in connective tissue that provides elasticity, and other tissue components. This occurs due to disruptions in the normal healing process and is associated with an increase in mast cells.

The exact causes of keloids are not fully understood, and the condition possibly develops from a combination of different factors. Potential causes, which are also risk factors, include:

• Skin trauma: People prone to keloids may develop them after any type of skin trauma, such as surgery, piercings, chickenpox, acne, tattoos, insect bites, burns, cuts, scrapes, vaccinations, topical therapies, cryotherapy (a treatment using extreme cold to destroy or reduce abnormal tissue), or any condition causing skin inflammation. Dental surgery can also cause keloids to form on the skin inside the mouth. Wound tension can also increase the likelihood of keloid formation.
• Skin infections: Infections that cause skin inflammation can lead to abnormal scarring in people prone to keloids. Examples include folliculitis (infection of hair follicles), acne on the face, neck, chest, and back, infected earlobe piercings, shingles, and burn wounds.
• Friction: Wearing ear-loop masks has been linked to the development of keloids behind the ears, likely due to friction from the straps. Some people also develop keloids after shaving their beard area, possibly due to similar friction.
• Hormones: Higher estrogen levels have been suggested as a factor in keloid growth, particularly during puberty and pregnancy.
• Hypertension: High blood pressure may contribute to keloid formation by damaging blood vessels and making them more leaky or permeable. This allows inflammatory substances and cells to enter the wound or scar area, worsening inflammation and affecting the healing process.

Additional Risk Factors:

Various risk factors contribute to this condition, including genetic predispositions, demographic characteristics, and even dietary influences.

• Skin color: Dark-skinned people of African, Asian, and Hispanic descent are more likely to develop keloids than Caucasians. Albinos are the least affected.
• Age: The condition most commonly develops between puberty and age 30.
• Pregnancy: Hormonal changes during pregnancy can increase the risk of developing keloids or worsen existing ones.
• Family history: About one-third of people with keloids have a parent, sibling, or child who also develops them, especially among those of African or Asian descent. Research suggests that 5 to 10 percent of Europeans with keloids have a family history of the condition.
• Genetics: Keloid formation appears to have a genetic component, as they often run in families. While specific genes responsible for keloids haven’t been identified, studies suggest certain genetic regions are linked to keloid susceptibility in different populations, such as Japanese, African American, and Chinese families.
• Rare genetic syndromes: The occurrence of multiple spontaneously arising keloids has occasionally been linked to rare genetic conditions, including Rubinstein-Taybi syndrome, Dubowitz syndrome, and Noonan syndrome.
• Mesh skin grafts: This procedure, which stretches donor skin to cover a large wound, can increase the risk of keloid formation.
• Nutrient deficiencies: People with keloids often have an imbalance in their dietary intake of omega-6 and omega-3 fatty acids and tend to have significantly lower vitamin D levels compared to those without keloids.

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What Are the Symptoms and Signs of Keloids?

After a skin injury, it may take three to 12 months or longer for the first signs of a keloid to appear, with the initial indicator typically being skin thickening. Keloids take weeks or months to grow, and in some cases, they continue expanding slowly over several years. Approximately 20 percent of keloid scars develop more than a year after the injury.

Physical Signs

• Color: Keloids can range in color from pink, purple, or brown to flesh-toned or hyperpigmented, evolving as they grow and mature. Some people notice that their keloid darkens more after sun exposure, and this change can be permanent.
• Location: Keloids typically develop over the site of a wound or injury. They can form anywhere on the body but most commonly appear on the shoulders, chest, upper back, lower legs, neck, and ears.
• Shape: Keloids are typically round, oval, or oblong. On the chest, arms, or legs, they are usually raised with a flat surface, while those on the ear, neck, or abdomen may hang from the skin. Keloids often form in specific shapes based on the direction of local stretching forces.
• Size: Keloids vary in size, ranging from smaller than an inch to 12 inches or more.
• Texture: Keloids typically feel firm, rubbery, and smooth to the touch, often projecting above the skin. Some may have a doughy texture, while others can feel harder. Generally, keloid scars are hairless, raised, smooth, and shiny.
• Disfigurement: Keloids can become large, unsightly, and disfiguring, leading to cosmetic concerns for many affected people.

Once a keloid stops growing, it usually stays the same size and rarely fades on its own without treatment.

Symptoms

Keloids are benign but often cause discomfort and can significantly impact daily life. While they grow, they may cause:

• Itching: A 2004 study involving 28 patients with keloid scars found that 86 percent experienced itching, and among those, 92 percent reported that the itch was concentrated at the edges of their keloids.
• Pain: In the same study, 46 percent of participants experienced keloid-related pain, with 77 percent feeling it at the center of the keloid. Additionally, 43 percent reported mechanical allodynia, in which even light touch caused discomfort.
• Tenderness: Excessive collagen deposition can compress and irritate surrounding nerves, leading to tenderness and soreness.
• Burning sensation: Inflammation releases chemicals that irritate nerves, causing a burning sensation.
• Irritation: Keloids can rub against clothing, leading to irritation.
• Prickliness: Scar tissue pressing on nerves may cause a prickling sensation.

These symptoms typically subside or stop once the keloid stops growing, although not always.

How Are Keloids Diagnosed?

A dermatologist can usually diagnose a keloid by examining its shape, size, and growth pattern.

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In most cases, no additional tests are needed after the clinical evaluation. However, a doctor may recommend a biopsy to rule out other skin conditions.

A skin biopsy is a simple procedure in which a dermatologist numbs the area and removes a small piece of skin for examination. The sample is then sent to a lab, where it is analyzed under a microscope, and a report is provided to the dermatologist with the findings.

What Are the Complications of Keloids?

Complications of keloids may include:

• Movement restriction: When a keloid forms over a large area or joint, the tight, hardened scar tissue can restrict movement, potentially affecting activities such as reaching, walking, or other actions.
• Keloid infections: Keloids rarely open on their own, but they may bleed if injured. If a keloid becomes open, it can get infected. Keloid infections, also known as suppurative keloids, can cause redness, intense pain, tenderness, and the discharge of pus and fluids. If the wound doesn’t heal, it’s important to see a dermatologist.
• Cosmetic disfigurement: Keloids can be problematic when they develop on visible areas such as the face, neck, and ears. In these locations, they can cause significant emotional distress and impact a person’s self-esteem.
• Hindered limb growth: Thick, tight keloids can hinder limb growth in children.

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What Are the Treatments for Keloids?

Dermatologists often recommend a combination of treatments to achieve the best results for keloid patients. Depending on the size of the keloids, treatments may include:

• Steroid injections: A first-line treatment using triamcinolone injections every four to six weeks for four to six months. Effective in 50 to 80 percent of cases, but recurrence is common within five years.
• Topical ointments: Topical steroid ointments can help reduce symptoms such as itching and burning. However, they must be applied several times a day, making them less practical for long-term treatment.
• Steroid-soaked tapes or plasters: An easy-to-use option that should be worn continuously for at least three months, with changes every one to two days.
• Surgery: Provides cosmetic improvement but has a high recurrence risk unless combined with other treatments.
• Chemotherapy injections: Fluorouracil or bleomycin, often combined with steroids.
• Cryotherapy: Freezes the keloid to reduce size and hardness but may cause light spots on darker skin.
• Silicone gel sheets: A noninvasive option that may flatten keloids over several months.
• Compression: Applying pressure by using a pressure dressing, pressure garment, or pressure clothing for 12 to 20 hours daily for six to 12 months to reduce keloid size.
• Ligature treatment: Uses surgical thread tied around the keloid, which is changed every two to three weeks until the keloid falls off.
• Radiation therapy: Quickly alleviates symptoms such as pain and itching and gradually improves the keloid’s appearance over 12 months.
• Laser treatment: Uses high beams of light to resurface the keloid and surrounding skin, helping to reduce its height and fade its color.
• Autologous fat grafting: Fat grafting, which involves moving fat from one body part to another, has been used in plastic surgery since the 1980s. Some studies suggest it might improve keloid appearance and function, but the evidence remains limited.
• Platelet-rich plasma (PRP): PRP injections use concentrated blood platelets to promote healing. Studies show PRP, combined with surgery and other treatments, can significantly flatten keloids and reduce recurrence.

Treatment Options to Prevent Recurrence: 

Even after treatment, keloids have a high risk of returning. To help prevent recurrence, dermatologists may recommend the following approaches:

• Pressure earrings: Wearing a pressure earring can help reduce and prevent the return of a keloid on the earlobe by applying consistent pressure to the area
• Steroid-soaked tapes or plasters: Highly effective in preventing keloids from returning after treatments such as surgery have removed the lesion
• Superficial external beam radiotherapy: Uses low-dose, focused X-rays to target collagen-producing cells, limiting their growth without affecting deeper layers of skin or healthy tissue
• Immunomodulators: Medications that alter immune system activity, such as imiquimod, have been used to prevent the formation or regrowth of keloids

Keloids usually remain stable after they stop growing unless reinjured. They can worsen during puberty, pregnancy, or with higher physical activity, such as in athletes. Improvement often occurs after age 50 due to reduced skin tension.

How Does Mindset Affect Keloids?

Mindset doesn’t directly cause or cure keloids, but it can significantly impact how the condition is managed.

Chronic stress can impair wound healing and potentially worsen keloid formation, while a positive mindset can help people better cope with emotional challenges and follow treatment plans more effectively.

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Additionally, stress-reducing practices such as mindfulness and meditation may promote healing by lowering inflammation and improving circulation. Although mindset isn’t a treatment, it plays a key role in overall well-being and improving outcomes.

What Are the Natural Approaches for Keloids?

Please consult your dermatologist before trying any of the following natural approaches.

Herbal Ointments and Extracts: 

• Onion extract: A 2007 study involving 60 patients with hypertrophic and keloid scars evaluated the effects of a topical onion extract, silicone gel sheets, and their combination. The onion extract was effective in improving scar color but did not significantly reduce scar height or itching. Silicone gel sheets were more effective in reducing scar height. The combination of both treatments provided the best results, suggesting that using them together offers the most effective therapy for improving scars.
• Wubeizi ointment: Wubeizi (Rhus chinensis), traditionally used in Asian folk medicine, has preventive and therapeutic benefits for many ailments, including antiviral, antibacterial, anticancer, hepatoprotective, antidiarrheal, and antioxidant properties. A 2020 study using a mouse model and human keloid-derived fibroblasts found that wubeizi ointment helps prevent keloid formation by inhibiting excessive growth of fibroblasts and encouraging their apoptosis (programmed cell death). It works by lowering the activity of proteins that promote cell growth while boosting the action of a tumor suppressor gene that helps control cell growth. A 2014 in vitro study by the same research team also found that wubeizi ointment can reduce the growth of keloid fibroblasts in a time- and dose-dependent manner.
• Indian pennywort extract: Indian pennywort (Centella asiatica) has been used for thousands of years in India, China, and Indonesia to treat wounds, improve mental clarity, and address skin issues such as leprosy and psoriasis. A 2013 in vitro study found that asiatic acid, a component of Indian pennywort, can reduce collagen production and block excessive fibroblast activity in keloids by activating a protein called PPAR-gamma.
• Roselle flower extract: Roselle (Hibiscus sabdariffa) flower extract is rich in polyphenols, which may help reduce excessive scar tissue by slowing fibroblast cell growth and lowering TGF-beta1 levels, a protein involved in scar formation. A 2020 study found that roselle flower extract helps reduce scar cell growth in keloids and encourages the natural death of scar-related cells without harming healthy cells.

Vitamins

Vitamins such as A, C, E, and niacinamide, naturally found in the skin, have strong antioxidant and anti-inflammatory properties. Skin care products containing these vitamins help protect against oxidative stress and are effective in treating conditions such as acne, pigmentation issues, and inflammatory skin disorders, and supporting wound healing.

• Vitamin E-enhanced silicone gel sheets: An earlier study involving 80 patients with hypertrophic scars or keloids found that silicone plates can help vitamin E penetrate the skin more effectively. Vitamin E helps protect and stabilize cell membranes, which is beneficial for healing. When vitamin E was added to silicone gel sheets, it worked better than silicone alone in treating and preventing hypertrophic scars and keloids, especially in the short term.
• Vitamin D: Vitamin D helps slow scar tissue growth and reduces collagen production, which can help manage keloid scars. In a 2022 study, 40 patients with keloids received weekly vitamin D injections directly into their scars. The treatment significantly improved the appearance and severity of the scars, demonstrating that it could be an effective option for keloid management.
• Vitamin A: Retinoic acid and other vitamin A derivatives significantly reduce the growth of human fibroblasts by disrupting DNA synthesis in lab studies. They also inhibit the production of type I collagen in human fibroblasts, which is triggered by the TGF-beta1 protein. Daily application of a 0.05 percent retinoic acid solution has been shown to reduce the size of keloid scars, with effects ranging from slight to significant improvement, while also alleviating symptoms such as itching in most patients.

How Can I Prevent Keloids?

Keloids will not disappear by themselves. There is no cure for keloids, and treating them can be challenging. Incomplete treatment may cause keloids to worsen, and recurrence is common. Preventing them from developing in the first place is essential.

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To prevent keloids after a minor skin injury or skin condition takes place, you can take the following steps to promote faster healing and reduce the risk of keloid formation.

• Care for new wounds immediately: Apply a thin layer of petroleum jelly and cover with a nonstick bandage. Keep even pressure with tape and clean the area daily with soap and water.
• Apply silicone gel bandages on healed wounds: Wear them 12 to 24 hours daily for two to three months to prevent keloid growth, as keloids take about three months to form.
• Avoid activities that harm healing wounds: Refrain from stretching scars (especially on the chest or abdomen), and avoid hot baths that may worsen inflammation.
• Manage acne promptly: Seek appropriate medical treatment to reduce the chances of scars forming.
• Limit unnecessary piercings, tattoos, or surgeries: Those prone to keloids should take extra care before undergoing cosmetic or elective procedures.
• Use compression therapy: Applying pressure can reduce collagen production and restrict blood flow, which may help minimize scar tissue formation.
• Wear pressure earrings after ear piercings: Monitor the area closely. If you notice skin thickening, remove the earring immediately and switch to a pressure earring. Wear it for 12 to 20 hours daily for four to six months. Be aware that using a pressure earring may cause the piercing to close, and re-piercing could lead to another keloid.
• Test a small area before a tattoo or cosmetic procedure: If the skin begins to thicken, wear a pressure garment immediately to prevent further issues.
• Protect healing skin with sunscreen: Regularly apply sunblock when exposed to sunlight to protect healing skin.
• Opt for minimal tension surgery: Surgeons can reduce keloid risk by everting wound edges during suturing and using as few stitches as possible.
• Incorporate products that can help prevent keloid formation: Examples include imiquimod cream, Kelulut honey, hypoallergenic paper tape, topical corticosteroids, and silicone gel bandages.