Keloids are overgrowths of scar tissue that occur at the site of a skin injury. They are firm, rubbery lesions or shiny, fibrous nodules that can vary from pink to flesh-colored to red to dark brown in color. Keloids extend beyond the borders of the original wound and do not regress over time like normal scars do. While some keloids may appear to shrink slightly, a true keloid will never completely go away on its own without treatment. So do keloids ever fully fall off? The answer is no, keloids do not spontaneously fall off or disappear without some form of intervention. They are benign skin growths that are chronic and tend to persist and proliferate over time if left untreated.
What Causes Keloids?
Keloids develop due to an abnormal wound healing process involving excessive collagen deposition by skin fibroblasts. They can occur after any type of skin injury including cuts, burns, piercings, surgery, vaccinations, acne, insect bites, or more. Keloids form when there is an overabundant production of collagen that continues after the initial healing phase. This collagen overgrowth extends beyond the borders of the original wound and does not stop growing.
While the exact mechanisms are not fully understood, keloids tend to have a genetic component and occur more frequently in certain ethnic populations. Keloids occur more often in patients with darker pigmented skin. Additional risk factors for keloids include:
- Younger age at time of injury (10-30 years old)
- Hormonal changes like puberty or pregnancy
- Injuries that penetrate deep through the dermis layer of skin
- Wounds on the chest, shoulders, upper back and earlobes
- Prior trauma or injury sites
- Tension across a wound
- Genetic predisposition
Keloids arise due to an abnormality in the wound healing cascade where inflammation and fibrosis proceed without proper signals to cease tissue proliferation. The fibroblasts in keloids exhibit differences compared to normal wounds including continuing collagen synthesis for longer durations. In addition, they show alterations in various growth factors and cell signaling pathways that promote scar tissue accrual.
Do Keloids Shrink or Disappear Over Time?
Unlike normal scars which gradually flatten and fade over a period of months to years, keloids persist indefinitely if not treated. They do not tend to shrink significantly or disappear on their own without intervention.
The reasons keloids do not naturally regress include:
- Continued collagen production by fibroblast cells
- Alterations in apoptosis (natural cell death) allowing cell survival
- Abnormal regulation of various growth factors like TGF-beta
- Changes in MMP enzymes that break down scar tissue
- High tension on the wound edges
- Genetic predisposition and ethnic variability
These abnormal processes allow keloids to proliferate in an uncontrolled manner over months to years. Unlike normal scars, keloids do not have a finite endpoint to the healing process programmed in genetically.
While some keloids may appear to shrink slightly over time, this is often due to the lesion becoming softer or flatter rather than smaller. True reduction in keloid size rarely occurs without treatment. One study that followed untreated keloids over a 16 month period found that on average, the keloids enlarged in total surface area. Very few keloids underwent any amount of spontaneous partial regression during the follow-up period.
Do Small Keloids Disappear?
Even small or minor keloids are unlikely to disappear on their own without treatment. The abnormal fibroblast activity and collagen deposition occurs irrespective of keloid size and will persist unabated unless intervention is pursued. So while larger keloids often continue to expand over time, smaller lesions will also persist indefinitely.
Spontaneous flattening or lightening of discoloration may sometimes occur with smaller keloids, but the fibrotic core remains present. Thus keloids do not fully resolve regardless of size unless treated through methods like steroid injections, cryotherapy, radiation, laser removal, or surgical excision.
Can Keloids Fall Off Over Time?
Keloids do not fall off, detach, or slough off on their own over time. Unlike scabs or crusts from a healing wound, a keloid is firmly attached growth made up of fibrous scar tissue. Keloids are not loosely adherent lesions but rather are fused growths arising from and tethered to the underlying skin layers.
The bulk of a keloid is composed of tough, fibrous collagen-rich tissue fixed to the dermis and epidermis. This fibrotic core remains firmly in place and integrated with the surrounding skin. The outer surface may sometimes flake, peel or ulcerate due to trauma or friction, but the lesion itself does not spontaneously detach.
The only way a keloid can be fully removed from the skin is through deliberate removal by a doctor via:
- Surgical excision to cut out the entire lesion
- Cryosurgery to freeze it off
- Laser ablation to vaporize the scar tissue
If the keloid is not removed in its entirety, the abnormal fibroblast activity will persist causing recurrence and additional growth. So keloids do not randomly fall off or shed on their own. They require proactive treatment to be eliminated fully.
When Should Keloids Be Treated?
Since keloids do not disappear over time, treatment is often recommended. Especially once it is confirmed that a scar is not fading and flattening as expected, intervention should be considered. Reasons to treat keloids include:
- Prevent progression and growth of the lesion
- Improve cosmetic appearance
- Relieve painful or itchy symptoms
- Allow normal skin mobility if restricting movement
- Reduce psychosocial stress and embarrassment
In most cases treatment is pursued once a scar is confirmed to be a keloid, rather than a normal hypertrophic scar. This can often be determined 2-3 months post-injury when expected healing should complete but the lesion persists and enlarges. Early treatment provides the best results before keloids become too large or advanced.
Some general guidelines for when to treat keloids include:
- No longer actively healing or shrinking by 3-6 months post-injury
- Continued growth in size, height or width
- Symptoms like pain, itching or tenderness
- Restriction of joint mobility or tissue function
- Distress regarding cosmetic appearance
Providers may recommend periodically monitoring small, asymptomatic keloids to start. But most will warrant intervention if demonstrating clear keloidal characteristics that persist past normal scar maturation. Since keloids rarely regress spontaneously, proactive treatment is necessary.
Treatment Options for Keloids
There are variety of therapeutic options for improving keloids, although a gold standard treatment remains elusive. Some common interventions include:
Intralesional Steroid Injections
Steroid injections like triamcinolone or Kenalog are first-line for many keloids. The steroids help suppress inflammation and abnormal fibroblast function. Injections are repeated monthly.
Cryotherapy
Liquid nitrogen is used to freeze lesions with repeated cycles of freeze-thaw. Can help reduce collagen production.
Compression Therapy
Silicone sheets or other dressings applied with compression can flatten keloids and inhibit additional growth.
Radiation Therapy
Focused radiation exposure helps impede excessive fibrosis. Often combined with surgical excision.
Laser Therapy
Laser energy is used to destroy scar tissue and restore normal architecture. Vascular lasers may improve erythema.
Surgical Excision
Cutting out the entire lesion can be effective but recurrence rates are high if other adjuvant therapies like radiation are not added.
Interferon Injections
Interferons like alpha and gamma inhibit fibroblast proliferation and activity.
5-Fluorouracil (5-FU)
5-FU is a chemotherapy agent that can reduce collagen synthesis when injected into keloids.
Bleomycin
Bleomycin is a sclerosing agent shown to diminish keloids, especially in conjunction with triamcinolone.
Imiquimod Cream
Imiquimod stimulates the immune system and may help reduce keloid size and symptoms when applied topically.
Onion Extract
Onion extract gel applied regularly may minimize keloid formation, though more research is needed.
Preventing Keloid Recurrence
The biggest challenge with keloids is the high rate of recurrence after treatment, reported to be upwards of 80% or higher. Measures to help prevent keloids returning after removal include:
- Combination therapy using surgical excision plus another modality like radiation or steroid injections
- Avoiding tension or trauma to the area during healing
- Application of silicone sheets or other compression
- Laser therapy to the wound edges to prevent spread
- Careful wound closure and suture techniques to minimize scarring
- Intralesional cryotherapy immediately after keloid excision
- Long term use of steroid injections or topical treatments
- Keeping the area protected from sun exposure which can exacerbate keloids
Even with prophylactic measures, keloids may still return. Serial treatments are often required over long periods to keep recurring lesions at bay. Patients with a tendency for keloids need to be vigilant about preventing and treating them early on before they progress.
Conclusion
Keloids are unusual scars that grow abnormally beyond regular wound healing and do not naturally regress over time. The fibrotic lesions persist and proliferate indefinitely unless treated. Spontaneous shrinking, disappearance, falling off, or detachment of keloids does not occur without intervention. These benign skin tumors are chronic and require deliberate removal via steroid injections, cryotherapy, radiation, lasers or surgical excision. Keloids should be treated early before enlarging and recurring after treatment remains challenging. Patients prone to keloids need consistent monitoring and management to prevent expansion of these abnormal scars. While keloids do not disappear on their own, various therapeutic options are available to eliminate or reduce their size and symptoms.