Pathophysiology

The pathogenesis of keloids is complex and involves both genetic and environmental factors.
It is widely accepted that keloids develop subsequent to injury or inflammation of the skin,
but the exact pathogenesis is still unknown. Inflammatory skin conditions such as acne
vulgaris, folliculitis, varicella infection, or vaccinations (particularly BCG vaccination) may
induce keloid formation. Keloids most often occur in the setting of surgical or non-surgical
wound healing (e.g., lacerations and earlobe piercing). Keloids often develop months after a
wound or inflammatory process, but may develop as far out as a year later [4]. Small needle
sticks such as those during local anesthetic injection seemingly do not evoke keloid
formation. However, the occurrence of a keloid or hypertrophic scar following BCG
vaccination is not uncommon and is likely more to the inflammatory nature of the injection
response rather than the size of the wound. In many cases, patients may not recall an inciting
traumatic event or inflammatory process. These "spontaneous keloids" are postulated to have
occurred in response to some form of inflammatory process perhaps forgotten or
unrecognized by the patient.