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ORIGINAL ARTICLE
Year : 2019  |  Volume : 22  |  Issue : 8  |  Page : 1049-1054

Demographic and clinical characteristics of keloids in an urban center in Sub-Sahara Africa


Plastic Surgery Unit, Department of Surgery, College of Medicine, University of Lagos/Lagos University Teaching Hospital, Lagos, Nigeria

Date of Acceptance27-May-2019
Date of Web Publication14-Aug-2019

Correspondence Address:
Dr. O Belie
Plastic Surgery Unit, Department of Surgery, Lagos University Teaching Hospital, IDI-Araba, Lagos State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_395_18

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   Abstract 


Background: Keloid is a major complication of wound healing. The clinical spectrum ranges from unaesthetic lesions minimally invading the adjacent skin to large grotesque lesions sometimes associated with contractures. Subjects and Methods: The patients were seen over 2 years in a tertiary hospital setting. The following information was obtained with a proforma: the biodata, etiology of keloid, region affected, symptoms, and treatment prior to presentation. The keloids were examined and the sizes were grouped into small, medium, and large keloids; the severities of symptoms were determined using the visual analog scale. Results: 159 patients with 224 keloids were seen over 2-year period with male-to-female ratio of 1:1.24. The most common causes of keloid were trauma and acne (27.0% and 20.1%, respectively). The trunk had a statistically significant higher number of symptomatic keloid compared with other regions keloids. The larger keloids were more symptomatic compared with the smaller ones, P = 0.000. There were more pruritic keloids than painful ones. About 25% of patients had positive family history in first-degree relative, 16% in second-degree relative, and their keloid are more symptomatic than those without family history. Conclusion: In view of the burden of keloids, early treatment is advised. Unnecessary trauma and extra piercing should be avoided; elective surgeries that are deferrable should be postponed until when necessary.

Keywords: Keloid, pain, pruritus


How to cite this article:
Belie O, Ugburo A O, Mofikoya B O. Demographic and clinical characteristics of keloids in an urban center in Sub-Sahara Africa. Niger J Clin Pract 2019;22:1049-54

How to cite this URL:
Belie O, Ugburo A O, Mofikoya B O. Demographic and clinical characteristics of keloids in an urban center in Sub-Sahara Africa. Niger J Clin Pract [serial online] 2019 [cited 2019 Sep 21];22:1049-54. Available from: http://www.njcponline.com/text.asp?2019/22/8/1049/264413




   Introduction Top


A keloid is an abnormal dermal tumor-like lesion characterized by accumulation of extra cellular matrix with abundant collagen as a complication of cutaneous healing. The types of wounds that may heal and become keloidal range from minor injury such as insect bite, vaccinations scars and acne to lacerations, tattoos, vaccinations, injections, ear piercing to major wounds such as surgical incisions, burn wounds, and abrasions.

It is commoner in the darker-skinned races and in populations of Asian origin.[1],[2],[3] The incidences vary greatly from one geographical region to another and it was estimated to range from 0.09% to 16% in African population.[4] Keloid is rare in pre-adolescent age group and first onset in the elderly; however, infants under 1 year and adults over 70-year old have been found to be affected.[5]

Keloid accounts for one of the most common outpatient presentation to the Plastic Surgery Clinics in people of African descent. The Problems of these scars are functional and aesthetic in these patients. They can be found anywhere on the body; but are more common in the sternum, sternum, nuchal region, ear lobes cheeks, and shoulders. It has a high recurrence rate despite many modalities of treatment. This study on the presentation, site, and associated symptoms of keloids from a plastic surgery clinic of a tertiary hospital in Lagos. Lagos is an urban cosmopolitan city in Nigeria, West Africa.[6],[7]


   Materials and Methods Top


Setting and study population

The study was carried out in the Plastic Surgery Clinic of Lagos University Teaching Hospital, Lagos, Nigeria. It provides Plastic Surgical services to patients drawn mainly from people residing in South Western Nigeria and part of the South-Southern States of Nigeria.

All patients who presented to the clinic with keloids were recruited into the study. The duration of the study was 24 months from June 2015 to May 2017. All patients with keloids that presented within this period had equal opportunity to be recruited into the study.

Aerospace Digital Electronic Gauge Stainless Steel Vernier caliper (150 mm/6 in. μm). Measuring range 0.01–150 mm was used to determine the dimensions of the scar. The keloids were categorized into small, medium, and large sizes with widest dimension ≤2.5, >2.5 to 5, and >5 cm, respectively. The pain and pruritus severities were determined using the visual analogue scale. Score of zero indicates no pain or itching and score of 10 worst pain or itching ever experienced.

Data collection and statistical analysis

Data were entered into a proforma and manually transferred into statistical package for social science (SPSS) version 20. The results for continuous variables were presented as mean + SEM, where the results for discrete variables were presented as ratios, percentages, and proportions. The confidence interval was 95% and significance level was P < 0.05. The data were further presented in descriptive format using tables and figures.

Ethical approval

Ethical approval was obtained from the Hospital Research and Ethical Committee.


   Results Top


Demography

In total, 159 patients were seen and diagnosed with keloids at the Burns and Plastic Surgery outpatient clinic over the study period. The youngest was 5 years and the oldest 62 years (30.19 ± 0.74 years). The age distribution showed 73% of the patients were between the ages of 21–40 years [Figure 1]. The mean body mass index (BMI) of the patients was 23.21 ± 0.23 kg/m 2, whereas the mean duration of keloid before presentation was 3.16 ± 0.275 years [Table 1]. There were 88 (53.3%) females and 71 (44.7%) males giving male-to-female ratio of 1: 1.24.
Figure 1: Age range

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Table 1: Summary of clinical data of the patients

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Etiology

The most common cause of keloids was trauma (including indoor and outdoor cutaneous injuries), accounting for 27%. Acne (20.1%) and barbing/shaving (18.9%) were the next most common cause of keloid [Table 2].
Table 2: Etiologies of keloids

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Number of keloids

There were 224 keloidal scars among all patients, 114 patients had single keloid, 31 patients had 2 keloids, 8 patients had 3 keloids, 2 patients had 7 keloids, and 2 patients had 5 keloids. The dimension of the keloids ranged from 1.57 to 43.05 cm (4.81 ± 0.81 cm).

Sizes of keloids

Among the 224 keloids, there were 63 (28.1%) small keloid, 96 (42.9%) medium, and 65 (29%) large keloids.

Pattern of distribution

The trunk was the commonest site affected by keloids with 75 (47.2%) patients having keloids in this region, slightly higher than the head and neck with 71 (44.6%) patients having keloids in the head and neck. There were more patients with multiple keloids in the head and neck with 29 (18.2%) patients having multiple keloids in this region, slightly higher than the trunk with 28 (17.6%) patients having multiple keloids in the trunk. However, the trunk has the highest number of multiple keloids, having 49 keloids compare to head and neck with 38 keloids. The chest keloid accounted for 67% of keloids in the trunk and 31% in the pubis mostly due to shaving [Figure 2]. In the head and neck region, the most common site of presentation is the ear lobe keloid due to ear piercing seen in 33 (56.9%) patients and the second most common site was the nuchal keloid found in 19 (32.8%) patients. The lower limbs had the least number of keloids with 19 (12%) patients having 19 keloids [Table 3].
Figure 2: Clinical photographs. (a) A male with multiple chest keloids (b) A female with a single pubic keloid. (c) Single large keloid on the Chest discharging pus (area of discharge covered with cotton wool)

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Table 3: Regional distribution of keloids

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Family history

There were 41 (25.8%) patients whose first-degree relatives had keloid, 25 (15.7%) patients had history of keloids in their second-degree relative, whereas 93 (58.5%) patients had no family history of keloid. Multiple keloids were more common in patients with history of keloid in their first-degree relative (41.5%) than those with second-degree (36%) or no relatives (22.5%). These differences were found to be statistically significant with P value = 0.029. Patients with positive family history have more keloids in the head and neck region with 31 (19.5%) patients involved. The trunk was the second most common region affected in patients with positive family history; there were 28 (17.6%) patients in this group.

Pain

Eighty-seven patients (54.7%) had pain in the keloid scars, whereas 72 (45.3%) patients had no pain. There were 41 (57.7%) males and 46 (52.3%) females with painful keloidal scars out of total 71 male patients and 88 patients, respectively. The percentage of male with painful keloid was slightly higher than that of the females.

There were significantly higher numbers of patients with painful keloids in their trunk compared with other regions of the body (P-value < 0.05). The larger keloids were found to be significantly more painful than the smaller ones (P-value < 0.05) [Table 4]. Patients with positive history in the first-degree relatives also tend to have more painful keloids than those with second degree or no family history. The keloids in the extremities are less painful than in the central portion of the body [Table 4].
Table 4: Comparison of demographic parameters with pain and pruritus in patients with keloids

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On the visual analog scale, the minimum pain score was 2 and maximum of 8 (4.31 ± 0.13). The most common type of pain experienced by patients was biting pain. This was noticed in 58 (66.7%) patients, 21 (24.1%) patients had dull aching pain, and 8 (9.2%) had burning pain in their keloids.

The most common aggravating factor was exposure to sunlight and application of pressure. This was seen in 24 (27.6%) and 17 (19.5%) patients, respectively. It was relived mostly by ingestion of analgesia. The pain relive in the patients was temporary [Table 5].
Table 5: Clinical characteristics of pain and pruritus

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Pruritus

There were 115 (72.3%) patients with pruritic keloids, 65 (56.5%) female, and 50 (43.5%) males. There were more patients with pruritus compared to pain (72.3% and 54.7%, respectively). The large sized keloids are more pruritic than the medium and smaller sized ones with statistically significant P Value = 0.000. Patients with family history also had more pruritic keloids (P value = 0.012) [Table 4]. The trunk has the highest proportion of pruritic keloids with 83.3% of keloids in this region pruritic [Table 4].

The mean minimum duration of pruritus per day was 1-h, maximum duration of 12 h (mean ± SEM = 3.9 ± 0.238) per 24-h period. Using the visual analog scale, the minimum score was 1 and the maximum score was 7 (mean ± SEM = 3.68 ± 0.168). The pruritus was not severe enough to prevent daily activities. Exposure to sunlight was the commonest aggravating factor in43.5% of cases similar to the symptoms of pain and the use of oral antihistamine provided temporary relief. The patients experience pruritus more in the afternoon similar to the symptoms of pain [Table 5].

Other symptoms

Other symptoms experienced by the patients included infection with purulent exudate seen in 28 (24.3%) patients. Of all the patients with exudate 21 (75%) of the keloids are large ones [Figure 2]c. The chest was the most common site of infected keloids, with 19 (67.9%) patients with this symptom. The rest were in the nuchal region with 5 (17.9%) patients having infected keloids and 3 (10.7%) patients with infected keloids in the chin. All keloids with discharge were painful and pruritic.

All patients complained of the ugly nature of the lesion and their dissatisfaction about its presence on the body especially on the exposed part of the body.


   Discussion Top


Keloids are benign lesions with no malignant potential. Histologically, they have excessive fibroplasia within the dermis.[8] This results from imbalance between collagen deposition and degradation during the process of wound healing with deposition in excess of degradation. Keloid scars invade beyond the borders of the original wounds; this is in contrast to hypertrophic scar which are restricted to the edges of the wound. Keloids unlike hypertrophic scar rarely regress with time.[9] They have specific areas of predilection which include the chest, shoulders, upper back, back of the neck and earlobes, rarely on the palms or soles. They are more pruritic and painful than hypertrophic scars. Keloid scars have been shown to have genetic predilection unlike hypertrophic scars.[10]

Olabanji [11],[12] and other authors have reported higher incidence in patients <30 years. In this study, it was found out that about 85% of patients recruited were 30 years and below which is in support of findings from previous studies.[11],[12] The number of affected patients decreases with increasing age of patient as shown in this study. This may be due to the fact that older people are less bothered about the aesthetic nature of their scar as they are less likely to present for treatment as compared with younger patients. Olabanji [12] explained that the reason for this may be due to the fact that individuals <30 years are more adventurous and are more prone to trauma but that may not be likely because a cumulative effect of trauma and keloids would result in increased keloid prevalence in the older patient. It might be due to progressive reduction in the dermal reaction to injuries with advancing age. All stages of wound healing including proliferative phase are reduced with advancing age making the elderly patient less likely to form keloid.[13] We propose that reduction in the mast cell activities and associated peripheral neuropathies seen with advancing age may make them less symptomatic with less pain and pruritus hence reduction in presentation with increasing age. There was slight higher female preponderance in this study with total male-to-female ratio of 1:1.2. This is similar to what was obtained in Calabar by Udo-Afah [14] with male to female ratio of 1:1.1. Allah [1] in Abidjan reported male-to-female ratio of 1:1.8 in a study done over 22 years. Some previous studies, however, showed equal male and female ratio.[2],[3] The reason for the female preponderance may be due to the fact that females are more concerned with their appearance and are more likely to present to the hospital compared to male individuals.

The causes of scar ranged from trivial indoor and outdoor trauma, piercing, barbing, and acne among others. In this study, etiological agents causing direct trauma to the skin accounted for the highest cause of keloidal scars. Moshref [15] reported trauma as the commonest etiology of keloid among 125 Saudi and non-Saudi population residing in Saudi Arabia in a study conducted in King Abdulaziz Hospital Jeddah, Saudi Arabia. In a similar study by Shanthi [16] among Indian population of age between 10 and 50 years, accidental trauma and earlobe piercing were the most common causes of keloid.

The most common symptoms at presentation in this study were esthetic, pruritus, and pain. The keloids tend to be more pruritic than painful. The specific reason for this has not been fully explained in the literatures for keloid; however, it is known that pruritus has a multimodal pathway of presentation, which include Pruritoceptive from inflammation, neuropathic, neurogenic (due to irritations from circulating chemical as seen in ureamia and hyperbilirubinemia), and psychogenic pruritus.[17] They are all present in keloids except the neurogenic pruritus; hence, effective treatment for pruritus will be multimodal. Pain on the other hand has a simpler pathway compared with pruritus. This may be a reason why pruritus is more common than pain in keloids. Presence of purulent discharge was also seen in some keloids, which were mostly located in the hair bearing area. It was found out in this study that the keloids in the central portion of the body are more painful and pruritic (with the trunk taking the lead) than the extremities. The reason for this awaits further histological studies. This is similar to the result obtained by Olaitan [18] in Ogbomosho South western Nigeria. He prospectively studied 121 patients and found out that the trunk has the highest number of painful scars.


   Conclusion Top


In this study, it can be concluded that keloid is more common in the younger age group with slight female preponderance. Patients with first-degree relation tend to have multiple keloids with larger size scars. Larger keloids, multiple keloids, those in the trunk, and associated with positive family history are more symptomatic. Most of the relieving factors are temporary and exposure to sun worsens the symptoms of these patients. In view of the burden of keloids, early treatment is advised. Unnecessary trauma and extra piercing should be avoided; elective surgeries that are deferrable should be postponed until when necessary.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Allah KC, Yeo S, Kossoko H, Assi Dje Bi Dje V, Richard KM. Keloid scar on black skin: Myth or reality. Ann Chir Plast Esthet 2013;58:115-22.  Back to cited text no. 1
    
2.
Oluwasanmi JO. Keloids in Ibadan Trop Geogr Med 1974;26:231-4.  Back to cited text no. 2
    
3.
Moustafa M, Abdel-Fattah M, Abdel-Fattah D. Presumptive evidence of the effect of pregnancy estrogens on keloid growth. Case report. Plast Reconstr Surg 1975;56:450-3.  Back to cited text no. 3
    
4.
Alhady SM, Aivanankaraja K. Keloids in various races: A review of 175 cases. Plast Reconstr Surg 1969;44:564-7.  Back to cited text no. 4
    
5.
Ramakrishnan KM, Thomas KP, Sundararajan CR. Study of 1,000 patients with keloids in South India. Plast Reconstr Surg 1974;53:276-80.  Back to cited text no. 5
    
6.
Juckett G, Hartman-Adams H. Management of keloids and hypertrophic scars. Am Fam Physician 2009;80:253-60.  Back to cited text no. 6
    
7.
Uzair M, Butt G, Khurshid K, Suhail Pal S. Comparison of intralesional triamcinolone and intralesional verapamil in the treatment of keloids. Our Dermatol Online 2015;6:280-4.  Back to cited text no. 7
    
8.
Adrian B, David T. Wound healing. In: Brunicardi FC, editor. Schwatz's principles of surgery, 9th ed. USA: McGraw-Hill Inc; 2010;241-71.  Back to cited text no. 8
    
9.
Richard TE, Mimi L, Linda G, Phillips. Abnormal Wound Healing. In: Townsend M, editor. Sabiston Textbook of surgery, 18th ed. USA: Saunders; 2007;191-216.  Back to cited text no. 9
    
10.
Paul EH, Alexis D, Robert F, Diegelmann T morphological and immunochemical differences between keloid and hypertrophic scar Am J Pathol 1994;145:105-13.  Back to cited text no. 10
    
11.
Shanthi FX, Ernest K, Dhanraj P. Comparison of intralesional verapamil with intralesional triamcinolone in the treatment of hypertrophic scars and keloids. Indian J Dermatol Venereol Leprol 2008;74:343-8.  Back to cited text no. 11
    
12.
Olabanji JK, Onayemi O, Olasode OA, Lawal OAR. Keloids: An old problem still searching for a solution. Surg Pract 2005;9:2-7.  Back to cited text no. 12
    
13.
Gerstein AD, Phililips TJ, Rogers GS, Gilchrest BA. Wound healing and aging. Dermatol Clin 1993;11:749-57.  Back to cited text no. 13
    
14.
Udo-affah GU, Eru EM, Idika CI, Uruakpa KC, Njoku CC. The age and sex incidence of keloid and hypertrophic scars in calabar metropolis cross river state from 2001 to 2006. J Biol Agric Healthcare 2014;4:2224-3208.  Back to cited text no. 14
    
15.
Moshref S. Clinical and morphological differences between keloid and hypertophic scar in patient treted at King Abdulaziz University Hospital-Jeddah. Egyptian J Surg 2006;25:56-9.  Back to cited text no. 15
    
16.
Shanthi FX, Ernest K, Dhanraj P. Comparison of intralesional verapamil with intralesional triamcinolone in the treatment of hypertrophic scars and keloids. Indian J Dermatol Venereol Leprol 2008;74:343-8.  Back to cited text no. 16
    
17.
Parnell LKS. Itching for knowledge about wound and scar pruritus. Wounds 2018;30:17-26.  Back to cited text no. 17
    
18.
Olaitan PB, Olabanji JK, Oladele AO, Oseni GA. Symptomatology of keloids in Africans. Sierra Leone J Biom Res 2013;5:29-33.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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