Keloidal atypical fibroxanthoma of the scalp.

Atypical fibroxanthoma (AFX) is a rare low-grade sarcoma that occurs mainly in the elderly and may recur locally. There are multiple variants including keloidal AFX (KAF). KAF is characterised by a proliferation of atypical spindled and epithelioid cells admixed with bizarre pleomorphic cells. These cells intersect among broad bands of keloidal collagen. AFX is a diagnosis of exclusion so a broad panel of immunohistochemical staining should be applied to rule out other differentials (squamous cell carcinoma (SCC), melanoma, leiomyosarcoma, etc). There is added difficulty with the diagnosis of KAF as it may mimic multiple keloidal lesions, including exuberant scarring, as in this case. p53 immunohistochemistry staining can be useful in highlighting the presence of tumour cells. Additionally, next generation sequencing can detect genetic mutations identified in clonal proliferations consistent with tumour formation. KAF is easily overlooked and it should be included in the differential diagnosis for keloidal lesions showing even mild atypia.

[Keloid nomogram prediction model based on weighted gene co-expression network analysis and machine learning].

Keloids are benign skin tumors resulting from the excessive proliferation of connective tissue in wound skin. Precise prediction of keloid risk in trauma patients and timely early diagnosis are of paramount importance for in-depth keloid management and control of its progression. This study analyzed four keloid datasets in the high-throughput gene expression omnibus (GEO) database, identified diagnostic markers for keloids, and established a nomogram prediction model. Initially, 37 core protein-encoding genes were selected through weighted gene co-expression network analysis (WGCNA), differential expression analysis, and the centrality algorithm of the protein-protein interaction network. Subsequently, two machine learning algorithms including the least absolute shrinkage and selection operator (LASSO) and the support vector machine-recursive feature elimination (SVM-RFE) were used to further screen out four diagnostic markers with the highest predictive power for keloids, which included hepatocyte growth factor (HGF), syndecan-4 (SDC4), ectonucleotide pyrophosphatase/phosphodiesterase 2 (ENPP2), and Rho family guanosine triphophatase 3 (RND3). Potential biological pathways involved were explored through gene set enrichment analysis (GSEA) of single-gene. Finally, univariate and multivariate logistic regression analyses of diagnostic markers were performed, and a nomogram prediction model was constructed. Internal and external validations revealed that the calibration curve of this model closely approximates the ideal curve, the decision curve is superior to other strategies, and the area under the receiver operating characteristic curve is higher than the control model (with optimal cutoff value of 0.588). This indicates that the model possesses high calibration, clinical benefit rate, and predictive power, and is promising to provide effective early means for clinical diagnosis.

Phyllodes tumour initially diagnosed as keloid.

It is unusual to find a breast tumour in a keloid, as the management of both is distinct. In this case, a young woman was operated on 4 years ago, for a right chest wall swelling, situated near the inframammary fold. The histopathological report revealed a granuloma, for which anti-tuberculosis treatment was given. However, the swelling recurred and progressed in size over the next 3 years. Then, she consulted the dermatology department, where the swelling was managed as a keloid. There was no remission. Consequently, the possibility of a breast tumour was suspected, and the patient was referred to breast services (subdivision of the surgery department).Triple assessment of the breast lump was suggestive of a phyllodes tumour (PT). Surgical excision of the tumour was done, which showed a malignant PT. Radiotherapy was given and delayed breast reconstruction was planned.

[Status of diagnosis and treatment of hypertrophic scar and keloid].

In recent years, many high-quality studies have been conducted on the pathomechanism and treatment of hypertrophic scar and keloid. This article briefly summarizes the status in these two aspects. Hypertrophic scar and keloid belong to pathological scar, which is characterized by fibrous dysplasia of reticular layer of dermis. This abnormal hyperplasia is due to the chronic inflammatory reaction in the dermis caused by injury. Some risk factors affect the process and outcome of the scar by increasing the intensity and duration of the inflammatory reaction. It is effective to understand the relevant risk factors to conduct patient education and prevent the occurrence of pathological scars. In view of these risk factors, a comprehensive treatment system, including multiple methods, has been established. Recent high-quality clinical research has provided evidence-based medical evidence for these treatments and prevention methods, which has confirmed the effectiveness and safety of the system.

The Detroit Keloid Scale: A Validated Tool for Rating Keloids.

Background: Comparing keloid treatment modalities and assessing response to treatments may be predicted by a better classification system. Objectives: To develop and validate the Detroit Keloid Scale (DKS), a standardized method of keloid assessment. Methods: Forty-seven physicians were polled to develop the DKS. The scale was validated in 52 patients against the Vancouver Scar Scale (VSS), Patient and Observer Scar Assessment Scale (POSAS), and Dermatology Life Quality Index (DLQI). Results: The inter-rater reliability was "substantial" for observer DKS and only "moderate" for VSS and observer POSAS (intraclass correlation coefficient were 0.80, 0.60, and 0.47, respectively). Pearson's correlation indicated "moderate" association between observer DKS with observer POSAS (ρ = 0.56, p < 0.001) and "substantial" relationship between observer DKS and VSS (ρ = 0.63, p < 0.001). Pearson's correlation indicated "moderate" association between patient portion of DKS and patient portion of POSAS and patient portion of the DKS and DLQI (0.61 and 0.60, respectively, p < 0.05). DKS total score consistently showed significant "substantial" relationship with POSAS total score (ρ = 0.65, p < 0.001). Conclusions: The DKS offers a validated keloid-specific outcome measure for comparing keloid treatments.

A Nomogram with the Keloid Activity Assessment Scale for Predicting the Recurrence of Chest Keloid after Surgery and Radiotherapy.

BACKGROUND: Patients with chest keloids undergoing surgery and adjuvant radiotherapy still have a high recurrence rate, which is a critical problem. The level of keloid activity has not been studied, and a nomogram model for predicting keloid recurrence has not been established in previous studies. METHODS: A total of 145 patients with chest keloids who underwent surgery and radiotherapy between January 2015 and January 2019 at Peking Union Medical College Hospital were included in our study. Demographic and clinical features and the score of KAAS were analyzed. We compared the area under the curve (AUC) and decision curve analysis (DCA) between KAAS and the Vancouver scar scale (VSS) and established a nomogram model for predicting the risk of recurrence. We used bootstrap and calibration plots to evaluate the performance of the nomogram. RESULTS: The KAAS can predict recurrence in patients with chest keloids after surgery and radiotherapy. Areas under the curve (AUCs) of KAAS and VSS were 0.858 and 0.711, respectively (p < 0.001). Decision curve analysis (DCA) demonstrated that the KAAS was better than the VSS. Complications after treatment may be risk factors for keloid recurrence. We created a nomogram by using complications and KAAS. The AUC was 0.871 (95% CI 0.812-0.930). The ROC of the model's bootstrap was 0.865 and was well calibrated. CONCLUSIONS: The KAAS can be used to predict the recurrence and we developed a nomogram for predicting the recurrence of chest keloids after surgery and adjuvant radiotherapy. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Primary Ectopic Breast Carcinoma in Man Mimicking Keloid.

Background: Ectopic breast tissues (EBT) are developmental abnormality found in 1-6% of normal population. Like an orthotopic breast tissue, ectopic breast may have similar pathological changes including malignancy. Breast cancer as well as ectopic breast tissue in male are extremely rare. We present a case of ectopic breast carcinoma (EBC) in middle aged man mimicking keloid. Case report: A forty-two-year-old Indo-Aryan male referred from primary health care to the dermatology clinic with firm multi-nodular, non-tender, fleshy sessile mass on his right axilla measuring two by three cm in diameter. Excision of this lesion revealed moderately differentiated ductal carcinoma consistent with ectopic breast carcinoma. Conclusion: We report this case to shed light on such a rare condition and to keep in mind that ectopic breast carcinoma should be in differential diagnosis of any suspicious mass in axillae.

[Atypical keloids with an unusual myofibroblastic differentiation in a patient with acne vulgaris]. / Atypische, Myofibroblasten-reiche Keloide im Rahmen einer Acne vulgaris.

We present the case of a patient with a discreet acne and multiple keloids in the area of the upper trunk, histologically showing an unusual myofibroblastic differentiation. So far, the clinical course shows a poor response to the treatment, including cryotherapy, intralesional corticosteroid injections, occlusive silicone dressings and dye laser.

The Most Current Algorithms for the Treatment and Prevention of Hypertrophic Scars and Keloids: A 2020 Update of the Algorithms Published 10 Years Ago.

BACKGROUND: In 2010, this Journal published my comprehensive review of the literature on hypertrophic scars and keloids. In that article, I presented evidence-based algorithms for the prevention and treatment of these refractory pathologic scars. In the ensuing decade, substantial progress has been made in the field, including many new randomized controlled trials. To reflect this, I have updated my review. METHODS: All studies were evaluated for methodologic quality. Baseline characteristics of patients were extracted along with the interventions and their outcomes. Systematic reviews, meta-analyses, and comprehensive reviews were included if available. RESULTS: Risk factors that promote hypertrophic scar and keloid growth include local factors (tension on the wound/scar), systemic factors (e.g., hypertension), genetic factors (e.g., single-nucleotide polymorphisms), and lifestyle factors. Treatment of hypertrophic scars depends on scar contracture severity: if severe, surgery is the first choice. If not, conservative therapies are indicated. Keloid treatment depends on whether they are small and single or large and multiple. Small and single keloids can be treated radically by surgery with adjuvant therapy (e.g., radiotherapy) or multimodal conservative therapy. For large and multiple keloids, volume- and number-reducing surgery is a choice. Regardless of the treatment(s), patients should be followed up over the long term. Conservative therapies, including gel sheets, tape fixation, topical and injected external agents, oral agents, and makeup therapy, should be administered on a case-by-case basis. CONCLUSIONS: Randomized controlled trials on pathologic scar management have increased markedly over the past decade. Although these studies suffer from various limitations, they have greatly improved hypertrophic scar and keloid management. Future high-quality trials are likely to improve the current hypertrophic scar and keloid treatment algorithms further.

Is Hypertrophic or Keloid Wound Scar a Risk Factor for Stricture at Esophagogastric Anastomosis Site after Esophageal Cancer Operation?

Background/Aims: Anastomotic stricture at the esophagus and the conduit anastomosis site after the surgical resection of esophageal cancer is relatively common. This study examined whether a hypertrophic scar or keloid formation at a surgical wound is related to an anastomotic stricture. Methods: From March 2007 to July 2017, 59 patients underwent curative surgery for esophageal cancer. In 38 patients, end-to-end anastomosis (EEA) of the esophagus and the conduit was performed using EEA 25 mm. A hypertrophic wound scar was defined when the width of the midline laparotomy wound scar exceeded 2 mm. The relationship between the hypertrophic scar and stricture and the other risk factors for anastomotic stricture in these 38 patients was analyzed. Results: Of the 38 patients, eight patients (21.1%) had an anastomotic stricture, and a hypertrophic skin scar was observed in 14 patients (36.8%). Univariate analysis revealed lower BMI and hypertrophic scars as risk factors (p=0.032, p=0.001 respectively). Multivariate analysis revealed a hypertrophic scar as an independent risk factor for an anastomotic stricture (p=0.010, OR=27.06, 95% CI 2.19-334.40). Conclusions: Hypertrophic wound scars can be a risk factor for anastomotic stricture after surgery for esophageal cancer. An earlier prediction of anastomotic stricture by detecting hypertrophic wound healing in patients undergoing esophagectomy may improve the patients' quality of life and surgical outcomes by earlier treatments.

Laser Speckle Contrast Imaging for the Objective Assessment of Blood Perfusion in Keloids Treated With Dual-Wavelength Laser Therapy.

BACKGROUND: Most of the widely used methods for the assessment of keloid treatment are subjective grading scales based on the opinion of an individual clinician or patient. There is a growing need for objective methods to evaluate keloid treatment. OBJECTIVE: This study aimed to evaluate the value of laser speckle contrast imaging (LSCI) as an objective method for the assessment of dual-wavelength laser therapy for keloids. METHODS: This prospective study included 21 patients with 54 keloids. All patients were treated with a combined 585-nm pulsed dye laser and 1,064 nm neodymium-doped yttrium aluminum garnet dual-wavelength laser at 4 weeks to 6 weeks intervals. Keloids were assessed using the Vancouver Scar Scale (VSS) and LSCI. RESULTS: The total VSS score significantly decreased after 4 sessions of treatment (p < .05). Blood perfusion in keloids as measured by LSCI was significantly reduced after treatment (p < .05). The improvement of chest keloids in terms of the total VSS score and blood perfusion was significantly greater than that of scapular keloids (p < .05). There was a positive correlation between decreased perfusion and reduced total VSS score (R2 = 0.84). CONCLUSION: Blood perfusion in keloids significantly decreased after dual-wavelength laser therapy. Laser speckle contrast imaging is a promising objective method for assessing the improvement of keloids treated with laser therapy.

Scalp Reconstruction in Delayed Diagnosed Dermal Leiomyosarcoma Mimicking Keloid Scar.

ABSTRACT: Leiomyosarcoma (LMS) of the skin is a rare smooth muscle neoplasm of all soft tissue sarcoma. Because of its prognostic importance, early diagnosis is critical for successful treatment. Since several features and clinical manifestations are similar to those of a keloid scar, the differential diagnosis between these two diseases is difficult, especially in the early stages of cancer that do not show any remarkable features in appearance, or when the patient has a history of previous wounds or surgery.In our case report, a 71-year-old female patient who underwent a scalp reconstruction using an anterolateral thigh flap turned out to have, because of delayed diagnosis, a dermal LMS mimicking a keloid scar. The case emphasizes careful physical examination for early intervention, even if a lesion looks like a typical keloid scar. After resection, the appropriate reconstruction method can be selected based on the complexity of the defect site.

Arthrofibrosis after total knee arthroplasty: patients with keloids at risk.

BACKGROUND: Arthrofibrosis remains one of the leading causes for revision in primary total knee arthroplasty (TKA). Similar in nature to arthrofibrosis, hypertrophic scars and keloid formation are a result of excessive collagen formation. There is paucity in the literature on whether there is an association between keloid formation and the development of arthrofibrosis following TKA. Therefore, the purpose of this study was to utilize a large nationwide database to identify and compare the rates of postoperative complications related to arthrofibrosis after primary TKA in patients with history of hypertrophic scar and keloid disorders versus those without. METHODS: Patient records from 2010 to the second quarter of 2016 were queried from an administrative claims database, comparing rates of arthrofibrosis, manipulation under anesthesia (MUA), lysis of adhesions (LOA), and revision TKA in patients with chart diagnosis of keloids versus those without in patients who underwent primary TKA. Data analysis was performed using R statistical software (R Project for Statistical Computing, Vienna, Austria) utilizing multivariate logistic regression, chi square analysis, or Welch's t- test where appropriate with p values < 0.05 being considered statistically significant. RESULTS: Of 545,875 primary TKAs, 11,461 (2.1%) had a keloid diagnosis at any time point in their record, while 534,414 (97.9%) had not. Patients in the keloid cohort had a significantly higher association with ankylosis within 30 days (OR, 1.7), 90 days (OR, 1.2), 6 months (OR, 1.2), and 1 year (OR, 1.3) following primary TKA. The keloid cohort also had a significantly greater risk of MUA (90-day OR, 1.1; 6-month OR, 1.1; 1-year OR, 1.2) and LOA (90-day OR, 2.2; 6-month OR, 2.0; 1-year OR, 1.9). CONCLUSION: Patients with keloids have increased odds risk of arthrofibrosis following primary TKA. These patients are subsequently at a higher odds risk of undergoing the procedures necessary to treat arthrofibrosis, such as MUA and LOA. Future studies investigating confounding factors such as race, prior surgery, range of motion, and postoperative recovery are needed to confirm the association of keloid diagnosis and arthrofibrosis following primary TKA demonstrated in this study. LEVEL OF EVIDENCE: Level III retrospective comparative study.

Single-Cell Sequencing Analysis and Weighted Co-Expression Network Analysis Based on Public Databases Identified That TNC Is a Novel Biomarker for Keloid.

Background: The pathophysiology of keloid formation is not yet understood, so the identification of biomarkers for kelod can be one step towards designing new targeting therapies which will improve outcomes for patients with keloids or at risk of developing keloids. Methods: In this study, we performed single-cell RNA sequencing analysis, weighted co-expression network analysis, and differential expression analysis of keloids based on public databases. And 3 RNA sequencing data from keloid patients in our center were used for validation. Besides, we performed QRT-PCR on keloid tissue and adjacent normal tissues from 16 patients for further verification. Results: We identified the sensitive biomarker of keloid: Tenascin-C (TNC). Then, Pseudotime analysis found that the expression level of TNC decreased first, then stabilized and finally increased with fibroblast differentiation, suggesting that TNC may play an potential role in fibroblast differentiation. In addition, there were differences in the infiltration level of macrophages M0 between the TNC-high group and the TNC-low group. Macrophages M0 had a higher infiltration level in low TNC- group (P<0.05). Conclusion: Our results can provide a new idea for the diagnosis and treatment of keloid.

Cutaneous Leiomyoma Mimicking a Keloid.

Dear Editor, Cutaneous leiomyomas (CL) are rare, benign smooth muscle tumors of the skin (1). There are 3 subtypes with different origins and histopathologic features: piloleiomyoma, genital leiomyoma, and angioleiomyoma (2). Pilar leiomyoma is the most common subtype originating from arrector pili muscles of pilosebaceous unit. It presents as painful solitary or multiple papulonodules (2,3). A 30-year-old woman presented to our outpatient clinic with numerous painless, itchy papules on her gluteal region that had been present for 10 years. Dermatologic examination revealed red-brown, smooth, grouped papulonodules on bilateral gluteal regions (Figure 1). These lesions had appeared after intramuscular injections and had increased in number. Family history was unremarkable. A punch biopsy was performed with pre-diagnoses of keloid and tumoral infiltration. Histopathologic examination showed neoplastic infiltration with large bundles of spindle-like smooth muscle cells with acidophilic cytoplasm under epidermis (Figure 2). Neoplastic cells were stained by smooth muscle markers actin and caldesmon (Figure 3). Based on the clinical and histopathological findings the diagnosis of pilar leiomyoma was established. Pelvic and renal ultrasonographic examinations were normal. The patient's lesions were asymptomatic except for mild itching and she is currently in follow-up without any treatment. Pilar leiomyomas mostly manifest around the ages of 10 to 30 and are located on the trunk and extensor surfaces of the extremities. Lesions are firm, red-brown or skin-colored papulonodules with diameters varying from several mm to 2 cm (2). Differential diagnosis includes dermatofibroma, neurofibroma, smooth muscle hamartoma, neuroma, adnexal tumors, and painful papulonodular lesions such as glomus tumor (1,2). Our case clinically resembled keloid with red-brown, stiff nodules with epidermal thinning. In the literature, a patient with cutaneous pilar leiomyoma was diagnosed with eruptive keloid and treated with cryotherapy and intralesional steroid injections before histopathologic verification of pilar leiomyoma. He had multiple painless, red-purple papulonodules on the chest and arms (3). The case of a 53-year-old man with a history of multiple firm and painful lesions on the back showing segmental distribution and diagnosed with keloid-like leiomyoma was also reported (4). CL should be considered in the differential diagnosis of keloid-like lesions with atypical location and that are resistant to treatment. Cutaneous leiomyomas have different clinical presentations and many differential diagnoses, but CL can be diagnosed by histopathological examination. In all CLs, histopathologic examination shows bundles of spindle-shaped smooth muscle cells with eosinophilic cytoplasm, a cigarette-like nucleus, and a perinuclear halo. Smooth muscle markers actin and desmin are routinely positive. Histopathologic examination in our case also revealed bundles of spindle-like smooth muscle cells with large acidophilic cytoplasm; smooth muscle markers actin and caldesmon were positive. While solitary lesions are frequently sporadic cases, multiple lesions may be related to hereditary conditions such as Reed's syndrome (multiple cutaneous and uterine leiomyomatosis), hereditary leiomyomatosis, and renal cell cancer (2). These two hereditary conditions have been reported to be associated with a heterozygous germline mutation in fumarate hydratase gene (4). Our patient was considered a sporadic case due to lack of family history and uterine leiomyoma and normal renal ultrasonography. Treatment of CL depends on the number of lesions and presence of symptoms (1). Surgical excision is the gold standard in the treatment of solitary and self-limiting lesions (2). However, recurrence can be more commonly observed in patients with multiple lesions (1). Drugs targeting smooth muscle contraction such as nifedipine, nitroglycerin, and phenoxybenzamine are recommended for pain management. Methods such as cryotherapy and carbon dioxide laser ablation have been tested but their efficacy was found to be limited (1,2). In our patient, lesions were asymptomatic and few in number; we thus suggested follow-up without any treatment. CL are rare benign smooth muscle tumors of the skin. They are difficult to diagnose by clinical evaluation, but the diagnosis can be established by histopathologic examination. In patients with atypical keloid-like papulonodular lesions like our patient, pilar leiomyoma should be considered and histopathologic examination should be performed for the diagnosis.

Case for diagnosis. Keloidal cord-like lesion on the leg

Abstract We report a 74-year-old male presented to an outpatient dermatology clinic in Manaus, Amazonas, with a one-year history of pruritic, keloidal lesions on his left lower extremity. Histopathology showed round structures in reticular dermis. Grocott methenamine silver stain revealed numerous round yeasts with thick double walls, occurring singly or in chains connected by tubular projections. The diagnosis was lobomycosis. Although the keloidal lesions presented by this patient are typical of lobomycosis, their linear distribution along the left lower limb is unusual.

What is your diagnosis? Keloidal cord-like lesion on the leg.

We report a 74-year-old male presented to an outpatient dermatology clinic in Manaus, Amazonas, with a one-year history of pruritic, keloidal lesions on his left lower extremity. Histopathology showed round structures in reticular dermis. Grocott methenamine silver stain revealed numerous round yeasts with thick double walls, occurring singly or in chains connected by tubular projections. The diagnosis was lobomycosis. Although the keloidal lesions presented by this patient are typical of lobomycosis, their linear distribution along the left lower limb is unusual.