Keloid Formation After Ear Piercing

Photoclinic

A 17-year-old girl presented to the clinic with painless growths on her ears that had gradually enlarged over the past 3 years. The lesions first appeared as small bumps a few months after she had her ears pierced. The patient reported no family history of hypertrophic scar formation or keloids. When she was 8 years old, she underwent open heart surgery for a congenital valve abnormality repair with no complications. Medical history was otherwise unremarkable.

Physical examination findings were normal except for 1 3 2-cm, oval, flesh-colored, well-circumscribed, nonexcoriated, nontender, firm masses on the inferior lateral aspect of both ear lobes. The patient had a well-healed scar over her sternum with no evidence of scar hypertrophy or keloid formation. A 5-mm preauricular tag was present anterior to her left tragus.

Keloids are benign fibrous growths that usually occur after trauma or surgery in predisposed persons. The lesions may extend beyond the initial site of injury and do not regress spontaneously. They should be differentiated from scar hypertrophy, which also presents as raised scars. However, hypertrophic scars remain within the boundaries of the original wound and unlike keloids may reduce over time.

Keloids occur primarily in young people between 10 and 20 years of age and rarely in newborns or elderly persons. They affect both sexes equally; however, they occur 15 times more often in persons with increased skin pigmentation (eg, African Americans, Asians) than in those with less pigmented skin.

Keloids are characterized by excessive fibroblast and collagen proliferation in the dermal and subcutaneous tissues. The characteristic histopathological finding is a collagen nodule that is not typically found in normal mature scars. These nodules consist of densely packed fibroblasts and unidirectional collagen fibrils in a highly organized pattern. They also have rich vasculature, high mesenchymal cell density, and a thickened epidermal cell layer. The most consistent histological finding is the presence of broad, dull, pink bundles of collagen.

In general, the growths appear to be regionally isolated to keloid-prone areas, specifically the chest, ears, and deltoid regions, whereas the hands, feet, and penis are usually spared. The reason for this predisposition is unclear. Familial tendencies have been reported, and the presence of foreign material in the wound is associated with keloid formation. In this patient, the foreign material (ie, earring) along with the fact that keloids are more likely to occur at older ages is probably the reason why keloids did not develop on her chest after cardiac surgery. Studies have suggested a recessive and dominant pattern of inheritance, specifically associations with HLA-B14, HLA-B21, HLA-Bw16, HLA-Bw35, HLA-DR5, HLA-DQw3, and blood group A.

Keloids are typically a cosmetic concern, as they were for this patient; however, some keloids can
cause contractures and decreased mobility when excessively large or located over a joint. They also have been described as painful and pruritic in some patients. Keloids have no malignant potential, although when treated with radiation, there may be a very small risk of malignancy.

Management of keloids is difficult. The response to therapy is not optimal, and the lesions tend to recur after resection. Persons known to form keloids should be treated preemptively with occlusive pressure dressings after surgical procedures, and treatment with intralesional or topical corticosteroids should be considered. Once keloids develop, intralesional corticosteroids may be used to cause regression, with or without surgical excision and skin grafting. Surgical excision alone, without corticosteroid augmentation, has a very high relapse rate.

Other useful modalities include radiation, laser therapy, cryotherapy, and topical silicone gel. Immunomodulator therapies, such as interferon and tumor necrosis factor-a inhibitors, also have shown promise in keloid regression. Targeted therapy using inhibitors to growth factors is another option that may become commercially available in the future. This patient was referred to plastic surgery for further management because of the location of the keloids and the likelihood of a poor response to medical measures without surgical excision.

Preauricular tags are commonly found at birth as pedunculated skin lesions typically located anterior to the ear around the tragus, as in this patient. They have no bony or cartilaginous components and do not communicate to the ear canal or middle ear. They are associatedwith a higher incidence of conductive or sensorineural hearingimpairment and urinary tract abnormalities, especially when accompanied by other malformations or dysmorphic features or by a family history of deafness or auricular and/or renal malformations.

A renal ultrasonogram should be considered in these patients at birth to evaluate for urinary tract abnormalities. This teenage girl had no hearing loss or recurrent urinary tract infections. n

FOR MORE INFORMATION:

■Bermueller C, Rettinger G, Keck T. Auricular keloids: treatment and results. Eur Arch Otorhinolaryngol. 2010;267:575-580.

■Lane JE, Waller JL, Davis LS. Relationship between age of ear piercing and keloid formation. Pediatrics. 2005;115:1312-1314.

■Ogawa R, Yoshitatsu S, Yoshida K, Miyashita T. Is radiation therapy for
keloids acceptable? The risk of radiation-induced carcinogenesis. Plast Reconstr Surg. 2009;124:1196-1201.

■Roth DA, Hildesheimer M, Bardenstein S, et al. Preauricular skin tags and ear pits are associated with permanent hearing impairment in newborns.
Pediatrics. 2008;122:e884-e890.

■Wang RY, Earl DL, Ruder RO, Graham JM Jr. Syndromic ear anomalies and renal ultrasounds. Pediatrics. 2001;108:E32.

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