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Keloids in the hospital setting in northern Benin: Epidemiological, clinical and therapeutic aspects
Fabrice Akpadjan
1, Elie Ataїgba2, Claire Mouasso Dipita3, Laura Dotsop1,3, Nadège Agbessi3, Odile Houngbo3, Christiane Koudoukpo3
1Dermatology – Venerology Unit, Buruli Ulcer Diagnosis and Treatment Center (BUDTC), Allada, Faculty of Health Sciences, University of Abomey-Calavi, Benin, 2Adult Psychiatry Unit, Departmental University Hospital Center Borgou/Alibori, Faculty of Medicine of the University of Parakou, Benin, 3Dermatology -Venerology Unit, Departmental University Hospital Center Borgou/Alibori, Faculty of Medicine of the University of Parakou, Benin
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ABSTRACT
Background: Keloids are spontaneous or acquired benign fibroblastic tumors, corresponding to an inappropriate reaction of connective tissue to a sometimes minimal trauma, leading to an accumulation of type I collagen in the dermis, in predisposed individuals. The aim of this study was to describe the epidemiological, clinical, therapeutic and evolutionary aspects of keloids in a public dermatology department in northern Benin.
Methods: This was a descriptive cross-sectional study with retrospective data collection over a 13-year period from 2009 to 2021. Patients admitted to the unit with the diagnosis of keloids were included. All data was registered using Epi Data software and analyzed using Epi Info version 3.5 and IBM SPSS statistics 21.
Results: Of the 8342 patients seen over 13 years, 265 were included, representing a hospital frequency of 3.3%. Mean age was 29.96 ± 13.47 years. There was a female predominance (sex ratio = 0.9). Pruritus was the first cause for consultation and the most frequent symptom (74.3%). Keloids were secondary in 74.7% of patients. These keloids were mostly found on anterior trunk area (34%), face (14.3%), nape of the neck (14.3%) and scapular region (14%). Lesions were nodular in 44.5% of cases. Topical corticosteroids were used in the majority of patients (75.5%). Most patients were lost to follow-up after the start of treatment.
Conclusion: Management of keloids remains a current concern for dermatologists, as the therapeutic arsenal is limited in our practice context.
Key words: Keloids, Epidemiology, Clinic, Treatment, Parakou, Benin
INTRODUCTION
Keloids are pathological skin scars. It is a fibrous proliferation of the dermis due to an accumulation of collagen fibers, either spontaneously or secondary to a cutaneous wound [1]. They are very common, with an estimated 11 million cases worldwide every year [2]. In Europe, the prevalence of keloid scars ranges from 6 to 16%, with a clear predominance of black-skinned subjects [1,3]. In Africa, the existing data is essentially patchy and hospital-based. The following hospital frequencies have been noted: 2.5% in Congo [4], 3.5% in Burkina Faso [5], 1.2% in Senegal [6], 1.01% in Mali [7]. The treatment of keloids pertains to the specialist, and is complex and sometimes difficult due to the multiple interventions involved, which also add to the cost of treatment [8]. Moreover, results are unpredictable. According to the French study by Piérard-Franchimont et al. the evolution of a keloid depends on ethnicity, age, location and volume of the lesion, all of which should be considered when defining the best therapeutic options [9]. In Benin, Yédomon et al. carried out a descriptive study of keloids in a hospital setting in Cotonou, southern Benin, in 2012 [10]. In order to assess the situation of patients suffering from keloids in northern Benin, we carried out the present study in the Dermatology-Venerology Unit of the Departmental University Hospital Center Borgou/Alibori (DUHC-B/A).
MATERIALS AND METHODS
The study was conducted over a 13-year period from 2009 to 2021. It was a cross-sectional study with retrospective data collection, with a descriptive aim, which took place in the Dermatology-Venerology Unit of the DUHC-B/A. Patients admitted to the unit and diagnosed as having keloids on the basis of clinical arguments, and whose records were complete and usable, were included. All data was entered using Epi Data software and analyzed using Epi Info version 3.5 and IBM SPSS statistics 21. Patient confidentiality and anonymity were respected.
Ethics Statement
This work was carried out in accordance with current ethical standards. The research protocol was approved by the Local Ethics Committee for Biomedical Research of the University of Parakou (LECBR-UP).
RESULTS
Epidemiological Aspects
Of the 8342 patients seen in the Dermatology-Venerology Department from 2009 to 2021, 274 keloids were recorded, but 265 were retained in accordance with our inclusion criteria, representing a hospital frequency of 3.3%. A total of 618 keloids were identified in all the patients included; the same patient could present with several lesions at the same time (Table 1). The mean age was 29.96 ± 13.47 years, with extremes of 2 and 87 years; the age range 21 to 35 years was the most represented (Fig. 1). Female patients were the most represented (52.5%), with a sex ratio (M/F) of 0.9.
Clinical and Etiological Aspects
Pruritus was the most common reason for consultation, reported by 74.3% of patients (Table 2). The most frequent time lapse before consultation was less than 5 years in 78.9% of patients. In terms of etiology, keloids were secondary in 74.7% of patients (Table 3). Clinically, the most frequent locations of keloids were the anterior part of the trunk (34%), the face (14.3%), the nape (14.3%), the scapular region (14%) (Table 4). Lesions were nodular (Fig. 2) in 44.5% of cases, as shown in Table 5. The invasive form (Fig. 3) ranked second.
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Table 2: Distribution of patients treated for keloids in the Dermatology-Venerology Unit of the DUHC-B/A from 2009 to 2021, according to reason for consultation. |
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Table 3: Distribution of patients treated for keloids in the Dermatology-Venerology Unit of the DUHC-B/A from 2009 to 2021, according to etiology. |
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Table 4: Distribution of patients treated for keloids in the Dermatology-Venerology Unit of the DUHC-B/A from 2009 to 2021, according to location. |
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Figure 2: Nodular keloid of the left auricle in a 25-year-old man (Dermatology-Venerology Unit, CDTUB, Allada). |
Therapeutic Aspects
Therapeutically (Table 6), the most commonly used topical treatment was topical corticosteroids in 75.5% of cases. Systemic medical treatment was based on antihistamines (36.6%) and antibiotics (24.2%). Physical therapy was recommended for 17.73% of patients. Surgical excision alone or in combination with medical treatment was used in 9.4% of patients.
Discussion
Hospital Frequency
The hospital frequency of keloids in northern Benin referral center was 3.3%. Kouotou et al. in Cameroon found a similar frequency of 3.5% [11]. This relatively low frequency may be explained by the fact that the majority of patients suffering from keloids do not systematically consult specialists. A general population study would probably yield a higher frequency.
Socio-Demographic Characteristics
Age
The study population was young. The modal class was represented by the 21-35 age group, accounting for 47.5%. This result is similar to those of Olaitan et al. in Nigeria [12] and Traoré et al. in Mali [13], who found a predominance of the 21-40 age group in proportions of 47.3% and 40% respectively. Belie et al. in Nigeria [14] found a higher frequency of this age group in their cohort (73%). The mean age of patients was 29.96 ± 13.47 years. Belie et al. in Nigeria [14] and Furtado et al. in Brazil [15] reported comparable mean ages (30.19±10.7 and 27.2±10.7 years respectively). The predominance of young people in the majority of studies can be explained by the fact that young adults are the most exposed to the main classical risk factors for keloids, especially post-traumatic risk. Furthermore, young people are more concerned with their physical appearance in general, and tend to seek specialist care for their skin problems more frequently.
Gender
Our series was predominantly female (52.5%), with a sex ratio of 0.9. Yédomon et al. in Cotonou [10] and Traoré et al. in Mali [13] had noted a predominance of women in their cohorts, with sex ratios equal to 0.66 and 0.63 respectively. This female predominance was also observed by Rakotoarisoa et al. in Magadascar [16], Kibadi et al. in 2012 in Kinshasa [17] and Allah et al. in Côte d’Ivoire [18], with proportions of 92.30%, 60.5 and 65.3% respectively. On the other hand, Stahl et al. in Israel found a male predominance in 57% of cases [19]. Since keloid scars are unsightly, the predominance of women in most studies can be explained by the fact that most of these studies were conducted in hospital settings, and women are much more concerned about their appearance than men in general.
Clinical Aspects
Reason for consultation
Pruritus was the main reason for consultation in this study. Yédomon et al. [10] in Cotonou, as well as Kouotou et al. in Cameroon [11] and Traoré in Mali in 2013 [13] also found pruritus to be the main reason for consultation, with proportions of 72.23%, 66.7% and 73.3% respectively. The origin of pruritus is linked to the pathophysiology of keloids. Indeed, it is thought to be the consequence of the strong presence of mast cells in keloid tissue, whose degranulation leads to a high release of histamine [1].
Average consultation time interval
The average consultation time interval was 5 years. This average delay is close to those observed in the work of Olaitan et al. [12], Sendrasoa et al. [20] and Furtado et al. [15], who found average time intervals ranging from 5 to 10 years. These long intervals may be explained by the fact that the majority of patients suffering from keloids generally hope for scar involution, and do not seek medical advice until late in the process. In most cases, these patients turn first to traditional medicine, and only come to hospital after traditional treatment has failed.
Keloid onset mode
Around a quarter of patients (25.3%) had spontaneous keloids. Several studies have also reported spontaneous keloids. These include Traoré in Mali (13.3%) [13] and Andonaba et al. in Burkina Faso (4%) [21]. However, the reality of spontaneous keloids remains hotly debated by some authors, who believe that dermatoses could have pre-existed, been excoriated and subsequently disappeared, leaving room for the keloid process. This is the case of Salles et al. [22] and Pitche et al. [23].
Acquired keloids were observed in 74.9% of patients in our study. In comparison, Yédomon et al. [10], Traoré [13] and Kibadi et al. [3] found acquired keloids in 75%, 86.7% and 100% of patients respectively. Acquired forms are therefore the most frequent in general, and this is due to the multitude of dermatoses and other skin traumas that are incriminated in people predisposed to keloids. The areas at highest risk are the anterior part of the trunk and the face. The same observation was made in the study carried out by Yédomon et al. [10] in Cotonou, where these two sites came out on top with 39.57% and 10.65% respectively. As for the clinical form, nodular keloids were frequently observed in this study, followed by invasive keloids (32.8%). In the study by Yédomon et al. [10] in Cotonou, however, it was the invasive form (50.23%) that was most frequently observed.
Therapeutic Aspects
Therapeutically, intralesional corticosteroid infiltration came second to the use of topical corticosteroids, in contrast to the study carried out in Cotonou by Yédomon et al. [10], where intralesional corticosteroid infiltration was used predominantly.
CONCLUSION
Although keloids are relatively uncommon in the hospital setting, they remain a worrying health problem for both patients and dermatologists in sub-Saharan Africa. In addition to being unsightly, keloids frequently have an adverse effect on patients’ quality of life, due to the associated pruritus. On the other hand, the therapeutic arsenal is limited in our practice context. It would be advisable to raise public awareness on the risk factors for keloids, and to seek early advice from dermatologists to avoid long, costly and sometimes disappointing treatments. Other treatment protocols are currently being tested in our country.
Statement of Human and Animal Rights
All the procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the 2008 revision of the Declaration of Helsinki of 1975.
Statement of Informed Consent
Informed consent for participation in this study was obtained from all patients.
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