An improved classification of keloids based on morphology, topography, and heterogeneity for prognosis and treatment

Keloids are benign tumors resulting from pathological scarring and excessive collagen deposition with diverse clinical presentations. The treatment of keloids remains challenging, often leading to recurrences. In this study, we propose an enhanced morphological classification, derived from both previous research and a retrospective analysis of 95 keloids treated surgically in our department with a global recurrence rate of 41.1% over an average follow-up of 3.75 years. We have analyzed the clinical presentation, together with prognosis and recommendations of treatment for the several keloid phenotypes we identified. This analysis enables us to propose a keloid classification defining 5 categories: type I - Acne keloïdalis nuchae (AKN); type II - Nodular outside the ear; type III - Nodular of the ear; type IV - Superficial spreading; type V - Mixed shape. This new clinical classification of keloids was statistically predictive for the risk of recurrence after surgery (p = 0.0158). Of interest, this proposed classification not only captured all keloid presentations but also provided valuable insights for prognosis and treatment. Type I showed a favorable prognosis, with less than 20% recurrence after extralesional excision and wound healing. Types II, III, and IV had moderate recurrence rates (30-50%). Nodular keloids were treated with intralesional excision and suture, followed by corticosteroid injections. Type V, however, had a poor prognosis with a 75% recurrence rate post-surgery. This phenotype-based classification offers a better understanding of keloid pathophysiology and optimization of treatment strategies tailored to specific keloid types.