Vulvar Keloid Following Friction Burns

Author Information

Parulekar SV
(Professor and Head, Department of Obstetrics and Gynecology, Seth G S Medical College & KEM Hospital, Mumbai, India.)

Abstract

A keloid is the result of an abnormal and excessive formation of scar tissue, usually following burns. It differs from a hypertrophic scar in that it extends beyond the limits of the original injury, tends to spread, and recur after excision. A case of keloid formation following friction burns on the vulva is presented. It is the first such case in the world literature.

Introduction

The word keloid originates from the Greek word ‘chele’, which means ‘crab claw’. It is the result of an aberrant healing process seen in some persons, characterized by formation of excessive scar tissue which extends beyond the limits of the original wound.[1] Both environmental and genetic factors are involved in formation of keloids.[2] A person predisposed to keloid formation may have keloids in multiple sites. It is more common in burns scars. Common sites of keloid formation include ear lobes, chest, upper back and shoulders. It has rarely been reported on the vulva.[3] A case of keloid formation following friction burns on the vulva is presented. It is the first such case in the world literature.

Case Report

A 21 year old single girl presented with a complaint of a mass of the right side of the vulva for 2.5 years. It had developed after she underwent an orthopedic operation on the neck of the right femur. She had intense burning pain on the right side of the vulva after the operation, and was told that she had developed burns there. It was at the site where the vertical rod of the operation table came in contact with the groin. Friction between the rod and her vulva resulted in those burns. The burns wound healed with conservative treatment using antiseptic dressings. However she developed a mass at that site over a period of 1.5 months. She was not sexually active. The mass caused discomfort while walking and sitting down to work. There was a history of pruritus over the mass off and on. She was also disturbed about the cosmetic disturbance of the appearance of the vulva. There was no family history of keloids. Local examination showed an irregular mass arising from the skin lateral to the right labium majus (figure 1). It measured 10x3x2 cm. It was pedunculated, had a base measuring 1.5 cm in diameter, and it was hanging down from its attachment. No trophic changes were found in the mass. A diagnosis of vulvar keloid following friction burns was made. General and systemic examination revealed no abnormality. There were no keloid at any other site on her body.
The patient desired surgical excision of the mass. After confirming fitness for anesthesia, the mass was excised by plastic surgery. The patient made an uneventful recovery. Histopathological examination showed epidermis of normal thickness showing regular and palliating basal cell organization, and vacuolar change in basal cells, keloid collagen, horizontal fibrous bands in collagen, moderate perivascular chronic inflammatory infiltrate, and prominent telangiectasia. The diagnosis of vulvar keloid was thus confirmed. There was no recurrence of the mass over a period of nine months after the excision.


Figure 1. Clinical appearance of the vulvar keloid.

Discussion

A keloid is the result of an abnormal and excessive formation of scar tissue after loss of tissue. It occurs more often in genetically predisposed individuals. It is 15 times more common in ethnic groups with deeply pigmented skin as compared to those with white skin. It needs to be differentiated from a hypertrophi scar. Both lesions are elevated. Keloids were differentiated from hypertrophic scars by Mancini and Peacock.[4] A comparison of the two conditions is shown in the following table.

Comparison of a Keloid and a Hypertrophic Scar

Feature
Keloid
Hypertrophic scar
Heredofamilial
Yes
No
Race
Black more than white
No effect
Sex
Female > Male
No effect
Growth beyond limits of wound
Yes
No
Regression
No
Possible
Irregular, spreading margin
Yes
No
Pruritus
Yes
No
Pain
Yes
No
Multiple sites on body
Yes
No
Recurrence
Yes
No
Histopathology
Epidermis of normal thickness showing regular and palliating basal cell organization, and vacuolar change in basal cells.
Papillary dermis shows scarring.
Epidermis flattened, showing disarray of basal cells,  and vacuolar change in a few cases.

Keloid collagen: large, broad, glassy, eosinophilic focally fragmented and haphazardly arranged collagen complexes with variable amounts of myxoid extracellular matrix. Location in full thickness of the reticular dermis. Positivity for α-SMA expressing myofibroblasts in 33% cases.
No keloid collagen.
Nodules containing fibrillar collagen of regular thickness arranged parallel to the epidermis, extracellular matrix with high density of cells, without myxoid change. Location in the upper one third of the reticular dermis. No positivity for α-SMA expressing myofibroblasts.

Horizontal fibrous bands in all cases, with an advancing edge under the epidermis in 66% cases.
Absent

Prominent telangiectasia: small blood vessels just below the epidermis appearing to grow from it.
Blood vessels arranged vertically around the nodules.

Moderate perivascular chronic inflammatory infiltrate;
mast cells seen in the reticular dermis in 70% cases.
mast cells seen in the reticular dermis in 20-30% cases.

Treatment of a keloid depends on its site, size and depth, the patient’s age and response to treatment in the past, if any. Conventional treatment options include intralesional injections of corticosteroids, surgical excision, cryosurgical ablation, laser ablation, radiation, and use of interferon, adriamycin, 5-fluorouracil, bleomycin, retinoic acid, verapamil, tamoxifen, imiquimod, tacrolimus, and botulinum toxin. Use of vascular endothelial growth factor inhibitors like bevacizumab, transforming growth factor–beta3, phototherapy, recombinant human epidermal growth factor, tumor necrosis factor-alpha inhibitors like etanercept and recombinant human interleukin shows promise.

Special care needs to be exercised during excision of a keloid to prevent its recurrence. Such measures include intrakeloidal excision, avoiding tension on the suture line, avoiding excessive inflammation in the operative site postoperatively. Steroids may be used locally, such as triamcenalone. The results may not always be very satisfactory. 

The case presented here was different from the usual cases of keloids in many ways. The patient did not have a genetic predisposition as evidenced by an absence of keloids at other sites of injuries, such as piercing of ears and injection sites. Its location in the vulva was unusual. It occurred after friction burns, which has not been reported in the literature so far. The fact that the friction burns were iatrogenic shows the importance of avoiding such an occurrence during orthopedic surgery on the hip joint area.

References
  1. Robles DT, Berg D. Abnormal wound healing: Keloids. Clin Dermatol. 2007;25:26–32.
  2. Moshref SS, Mufti ST. Keloid and hypertrophic scars: Comparative histopathological and immunohistochemical study. Med Sci. 2010;17:3–22.
  3. Gürünlüoglu R, Dogan T, Numanoglu A. A case of giant keloid in the female genitalia. Plast Reconstr Surg 1999;104:594.
  4. Gauglitz GG, Korting HC, Pavicic T, Ruzicka T, Jeschke MG. Hypertrophic scarring and keloids: Pathomechanisms and current and emerging treatment strategies. Mol Med. 2011;17:113–25.
Citation

Parulekar SV. Vulvar Keloid Following Friction Burns. JPGO 2016. Volume 3 No. 8. Available from: http://www.jpgo.org/2016/08/vulvar-keloid-following-friction-burns.html