Derm Cases · Dermatology / Wound healing / Cosmetic
OSCE — post-ear-piercing scar: keloid vs hypertrophic scar and combined therapy
An 8-minute OSCE station distinguishing keloid from hypertrophic scar, risk factors in skin of colour, first-line multimodal therapy (intralesional steroid, silicone, pressure), surgery pitfalls, and sarcoma red flags.
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Target exams
NEET-PGINICETUSMLEPLABMRCP
Prompt
An 8-minute OSCE station distinguishing keloid from hypertrophic scar, risk factors in skin of colour, first-line multimodal therapy (intralesional steroid, silicone, pressure), surgery pitfalls, and sarcoma red flags.
Brief (to candidate)
A 22-year-old woman (Fitzpatrick V) has a firm, tender, pruritic scar on the earlobe 8 months after piercing. The scar has grown beyond the original piercing site into a dome-shaped mass. She wants “just cut it off.” You have 8 minutes to diagnose keloid vs hypertrophic scar, counsel risks, and outline multimodal management.
[2]Candidate instructions
- Distinguish keloid from hypertrophic scar.
- List risk factors (skin of colour, ear/chest/shoulder, tension, delayed healing).
- Outline first-line multimodal medical therapy.
- Explain why excision alone has high recurrence and what adjuvants are used.
- Mention prevention strategies for future procedures.
- Red flags that a “keloid” might be something else (DFSP, SCC).
Examiner checklist (mark each domain / 10)
| Domain | Key actions expected |
|---|---|
| Distinction | Keloid extends beyond original wound margins and does not spontaneously regress; hypertrophic scar stays within wound borders and may improve over 12–18 months; both are fibroproliferative remodelling disorders[1][4] |
| Risk factors | Fitzpatrick IV–VI; earlobes, presternal, deltoid, jawline; high-tension wounds; infection/delayed healing; family predisposition |
| Medical therapy | Intralesional corticosteroid (e.g. triamcinolone) first-line; silicone gel/sheets; pressure earrings for earlobe; consider 5-FU, cryotherapy, laser, or combination protocols in specialist care[2][3][6] |
| Surgery caution | Simple excision alone has high recurrence for keloids; if surgery used, plan adjuvant therapy (steroid, radiotherapy selected centres, pressure) and informed consent for recurrence risk[2][6] |
| Prevention | Avoid elective piercings/tattoos in high-risk sites; meticulous wound care; early silicone/pressure after surgery; counsel before chest/ear elective procedures |
| Red flags | Rapid growth, ulceration, fixation, atypical location without trauma → biopsy to exclude DFSP/sarcoma/SCC; keloids should not behave as aggressive tumours without alternative explanation |
| Communication | Empathic counselling on chronic course, multi-visit therapy, realistic expectations |
Model key actions
- Diagnose earlobe keloid (growth beyond piercing margins) rather than simple hypertrophic scar.[4]
- Start intralesional steroid ± silicone/pressure; avoid “excision only.”[2][3]
- Consent for recurrence and discuss adjuvant strategy if surgery is later required.[6]
Common errors
- Excising keloid without adjuvant plan.
- Confusing early hypertrophic scar with keloid and over-treating.
- Ignoring skin-of-colour risk and prevention counselling.
- Missing red-flag “keloid” that is actually DFSP/tumour.
- Single-modality therapy without combination thinking for recurrent disease.
References6ShowHide
- [1]Wang PH, Huang BS, Horng HC, et al. Wound healing. Journal of the Chinese Medical Association : JCMA, 2018.PMID 29169897
- [2]Ekstein SF, Wyles SP, Moran SL, et al. Keloids: a review of therapeutic management. International Journal of Dermatology, 2021.PMID 32905614
- [3]Walsh LA, Wu E, Pontes D, et al. Keloid treatments: an evidence-based systematic review of recent advances. Systematic reviews, 2023.PMID 36918908
- [4]Jeschke MG, Wood FM, Middelkoop E, et al. Scars. Nature Reviews Disease Primers, 2023.PMID 37973792
- [5]Zhou C, Zhang B, Yang Y, et al. Stem cell-derived exosomes: emerging therapeutic opportunities for wound healing. Stem cell research & therapy, 2023.PMID 37101197
- [6]Ogawa R, Dohi T, Tosa M, et al. The Latest Strategy for Keloid and Hypertrophic Scar Prevention and Treatment: The Nippon Medical School (NMS) Protocol. Journal of Nippon Medical School, 2021.PMID 32741903