Acne and Rosacea Charity Training Manual

Types of scarring
Scarring in acne can be hypertrophic/ keloidal or atrophic.
Keloid scars
In surgical practice, keloid scars are most commonly seen in patients of Afro-Caribbean decent. In acne, however, the unique inflammatory response leads
to keloid formation in all ethnic groups involving the face, back, chest and upper arms.
Keloids are the result of overactive healing response leading to a raised lumpy scar that
goes beyond the boundary of the initial tissue injury. A 1mm inflammatory pustule can
result in a 5cm keloid. Keloids may be itchy or painful, red or pigmented but cause
major cosmetic problems. They are very visible and if large and on the trunk, will limit
the clothes that the patients can wear as anything tight will show the lumps in the skin.
Treatment of keloids involves the intralesional injection of a depot steroid. I generally use
depomedrome, 40mg/ml. Use a fixed-needle diabetic syringe as you often need to use a lot of
pressure to inject into the keloids and a detachable needle will often pop off. Make sure you are
within the body of the keloid – if you inject under the keloids all you get is atrophy of the lower
dermis and fat and the keloid sinks into a pit but is still present, painful and ugly. Inject until you see
blanching of the keloids. Repeat injections every 6-8 week. There is no way to predict how quickly
keloids will respond. Some respond quickly, others seem to do nothing for months and then
suddenly involute. Ablative pulsed dye laser treatment may accelerate response to intra-lesional
steroids. Very large keloids can be excised but only if followed by local radiotherapy. Excision alone
will lead to recurrence of an even bigger keloids.