Involvement of chest wall skin is by far the most common site for keloid development. The diverse and variable presentation of keloids on of chest wall, much like all other keloids, is most likely due to a very complex and highly variable genotype of the underlying disorder. On one end of spectrum, there are patients, white or black - Asian, Caucasian or Hispanic - who present with only one or very few small keloid lesions on their chest. On the other end of spectrum, there are patients who suffer from very severe form of the disorder, those with numerous and very large skin lesions that are scattered throughout their chest, and often elsewhere on their skin.
Much like scalp and neck keloids that are uniquely race specific, bulky and wide spread chest keloids, i.e. the most severe form of the disorder, is strikingly race specific and seen almost exclusively in Africans/African Americans The very most severe forms of chest keloids are not only race specific, but also gender specific and predominantly seen among Africans/African American females.
In addition to the appearance, the pace of growth of keloid lesions over time is also most likely genetically driven, with some patients having slow growing lesions, and others suffering from lesions that grow at a much faster rate.
In their early stages, chest wall keloids in all races present with three distinct patterns:
As time passes, keloid lesions grow in size and number. In great majority of patients, the existing small papules grow horizontally to form linear lesions which over rime can become larger and merge to form larger keloids. This growth pattern over time can lead to formation of unique skin lesions, whereby some patients develop very peculiar forms of keloids. Patients with mild form of the illness often present with one or few small papular or linear lesions and over time their skin involvement will be very limited to one or only few spots only. More severe form of the disorder leads to formation of large and often bulky keloidal lesions that cover a large portion of skin and grow and spread with a rapid pace to form large tumors or wide keloid patches.
Hyper-inflammatory, extremely painful chest wall keloid in a young Caucasian female. This large anterior chest wall keloid developed shortly after surgery for a prior smaller chest keloid at the same locations. Very soon after surgery, the wound transformed into keloid, in addition to its disturbing appearance, caused very severe pain, to a point that this patient seriously considered suicide as a way to end her pain. Treating such a keloid poses significant challenges. Best treatment results for this type of painful keloids is achieved by using chemotherapy injections inside the keloid tissue. This patient achieved tremendous pain control after one round of chemotherapy injections
Hyper-inflammatory, extremely painful chest wall keloid in a young Hispanic male. These large anterior chest wall keloid developed shortly after repeated surgeries to remove three smaller chest keloids. in addition to the disturbing appearance, all these keloid lesions were very painful to a point that wearing seat-belt while driving became impossible. The only method to control pain in such cases is by repeated intra-lesional chemotherapy injections. This patient achieved great pain control and flattening of his keloids with this treatment.
Surgical excision of chest keloids almost always results in worsening of these keloids, with the worst cases seen among those who have had several attempts at removing their keloids. Here again, contrary to the common belief and practice of some physicians, chest wall keloids should never be removed surgically. Primary chest wall keloids should only be treated with non-surgical, i.e. medical means, such as cryotherapy to remove the bulk of keloid tissue, as well as intra-lesional steroids or chemotherapy drugs for early stage keloids. Medical treatment of recurrent and secondary chest wall keloids can become quite complicated and rather challenging.
These keloids should also NOT be treated with radiation therapy, as radiation imposes an unacceptable risk of causing cancers or damage to the heart or thyroid gland.
The video below also shows the extent of the keloid that comfortably frozen in one session of cryotherapy. This patient required local anesthesia to allow for the procedure to be performed.