Keloid and Hypertrophic Scar — SAQ

Questions

a) Give the most likely diagnosis and two defining clinical features. (2 marks)^[1][3]

b) State when you would biopsy a scar-like lesion and give two histological differences between a keloid and a hypertrophic scar. (3 marks)^[1][3][10]

c) Give a stepwise, evidence-bounded management plan, including the place of intralesional steroid, combination treatment and surgery/radiotherapy. (5 marks)^{[2][5][7][8][9]}

d) State two counselling or follow-up points that must be documented. (2 marks)^[1][2]

Model Answer

(a) Diagnosis and defining features — 2 marks

• Diagnosis: keloid. It extends beyond the original acne-scar boundary into adjacent skin and has persisted/progressed rather than flattening. The firm lobulated or pseudopodial morphology and itch/pain support the diagnosis.^[1][3]
• Award 1 mark for the diagnosis and 0.5 mark for each of two defining features. Family history and chest site support susceptibility but do not replace the boundary test.^[1][3]

(b) Biopsy and histology — 3 marks

Biopsy is not routine for a typical keloid. Biopsy when the diagnosis is uncertain or the lesion is ulcerated, fixed, destructive, unusually changing, unexplained by the clinical history, or otherwise suspicious for DFSP, scar-associated SCC, inflammatory disease or infection. A sufficiently deep sample and clinicopathological correlation are required.^[1][3]

Award 1 mark for an appropriate biopsy indication and 1 mark for each correctly contrasted histological feature. Histology cannot reconstruct the original wound boundary; that distinction remains clinical.^[3][10]

(c) Stepwise management — 5 marks

1. Agree the target and baseline (1 mark). Record pain, itch, function, lesion dimensions and photographs; explain that no treatment is a universal cure and comparative evidence is heterogeneous.^[1][2]
2. First-line treatment (1.5 marks). Silicone may be continued only on intact, epithelialised skin, with a low-certainty-benefit discussion. Offer intralesional triamcinolone for the symptomatic keloid. The 2024 KECORT e-Delphi preferred 40 mg/mL, four-week intervals and a maximum 80 mg per month, while finding no complete dosing consensus; individualise volume and counsel about pain, atrophy, telangiectasia and dyspigmentation.^[4][5]
3. Inadequate response (1 mark). Refer for an experienced scar service to consider combination intralesional therapy such as 5-fluorouracil, cryotherapy or another specialist option. Do not invent a universal mixture or interval. Laser is only an adjunct: a Cochrane review found low- or very-low-certainty evidence for most comparisons.^[2][6]
4. Surgery (0.75 mark). Excision alone has high recurrence because it creates a new wound. Operate only after agreeing the closure, adjuvant and follow-up plan; options include intralesional treatment, silicone/compression where feasible, or selected postoperative radiotherapy.^[1][2]
5. Radiotherapy (0.75 mark). This is a selected specialist option for recurrent/refractory adult keloids, not a universal “gold-standard” schedule. A meta-analysis reported 22% overall postoperative recurrence and heterogeneous modality subgroups; another meta-analysis did not show a significant timing advantage for immediate over delayed treatment. The radiation oncologist individualises modality, dose, fractionation, timing and shielding. Avoid during pregnancy and generally defer in children.^[7][8][9]

(d) Counselling and follow-up — 2 marks

Award 1 mark each for any two well-explained points:^[1][2][3]

• Treatment aims may be less pain/itch, improved function or flattening; complete eradication is not guaranteed.^[1][2]
• Recurrence is common and study follow-up is inconsistent; review according to the active protocol and continue surveillance long enough to detect clinically meaningful recurrence.^[2][7]
• Future optional trauma should be weighed against her personal scar history. If surgery is necessary, reduce wound tension and consider silicone only after complete epithelialisation.^[3][4]
• Ask what matters to her, acknowledge distress and include pain, itch, sleep, function and body image in follow-up.^[3]

Examiner's marking notes

• The defining phrase is “beyond the original wound boundary.”^[1][3]
• A biopsy answer must distinguish a typical clinical diagnosis from an atypical lesion; “biopsy every keloid” is incorrect.^[1][3]
• Full marks require a hierarchy, not an unranked treatment list.^[2]
• Exact intralesional-steroid numbers must be identified as 2024 expert consensus, not universal law.^[5]
• Do not award a fixed radiotherapy dose as the only correct regimen. The safe answer is specialist, individualized postoperative planning with explicit evidence uncertainty.^[7][8][9]