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An adolescent female with ear lobe lesion
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A 12-year-old female presents for her well-child visit. She is concerned about a skin-colored protuberant lesion that developed on her right ear about a year ago and continues to enlarge. She had her ears pierced on her 10th birthday at a jewelry store. The lesion is occasionally pruritic and prevents her from wearing her favorite earrings.
Her mother had a similar problem with her own ears when piercing them several years ago. On physical examination, she has a 1-cm firm, round, mobile, skin-colored nodule on her right ear lobe. Her left earlobe is unaffected.
Can you spot the rash?
Diagnosis: Keloid
A keloid is a common aggressive scar overgrowth that occurs after trauma to the skin in predisposed patients. Keloids occur more often in teenagers and young adults but have been reported in children as young as 9 months of age. The pathophysiology of keloids is not fully understood but thought to be related to abnormal proliferation of collagen fibers in the dermis undergoing wound healing after trauma. Unlike hypertrophic scars, keloids present outside the original boundaries of the scar.
Marissa J. Perman
Keloids occur much more frequently in patients with darker skin types, including patients of African, Asian and Hispanic descent, and are presumed to have some genetic basis. Earlobe keloids secondary to ear piercing are commonly encountered in pediatric practice, although any trauma to the skin in a predisposed patient can lead to a keloid, including dermatologic conditions such as acne vulgaris. Other common locations of keloids include the pre-sternal area, upper back and shoulders.
Keloids are usually a clinical diagnosis, but histopathologic evaluation will show numerous haphazardly arranged collagen bundles within the dermis extending outside the original margins of the trauma. There is decreased vascularity and a hypocellular core. Keloids rarely regress, but rather tend to grow slowly for several years and can be disfiguring, painful and/or pruritic.
There are several treatments for keloids, in part because there is no single treatment that has proved to be superior among the rest. Steroid injections may be successful in softening the lesion but rarely help to completely eradicate a keloid. Steroids are often combined with local excision.
Local excision as monotherapy may lead to regrowth of the keloid, potentially larger than the original lesion excised. When combined with topical steroids immediately postoperatively, recurrence is less likely.
A smooth pink papule on the posterior earlobe.
Image: Section of Dermatology, CHOP
Compression in the form of earrings, dressings or support bandages, especially silicone-based bandages, work in some patients who are able to adhere to a daily protocol for several months. Compression also can be useful after excision.
Other treatment modalities, employed less commonly in pediatric practice, include cryotherapy, intralesional injection of chemotherapeutic agents such as bleomycin, or 5-fluorouracil, and adjuvant radiation therapy after excision.
Patients with a personal or family history of keloids should be counseled on preventive measures, including avoidance of body piercings, tattoo application and trauma in general. Treatment of keloids is challenging and variably successful, depending on the treatment modality used.
References:
Sidle DM. Facial Plast Surg Clin North Am. 2011;19:505-515.
Tirgan MH. Pediatrics. 2013;131:e313-317.
Williams CC. J Fam Pract. 2011;60:757-758.
For more information:
Marissa J. Perman, MD, is an attending physician at The Children’s Hospital of Philadelphia. She can be reached at permanm@email.chop.edu.
Disclosure: Perman reports no relevant financial disclosures.