DR [Dermatology Reports 2011; 3:e15] [page 35] Eruptive keloids after chickenpox Nicolas Kluger,1,2 Antoine Mahé,3 Bernard Guillot1 1Université de Montpellier I, Service de Dermatologie, Hôpital Saint-Eloi, Montpellier, France; 2Departments of Dermatology, Allergology and Venereology, Institute of Clinical Medicine, University of Helsinki, Skin and Allergies Hospital, Helsinki University Central Hospital, Helsinki, Finland; 3Service de dermatologie, Hôpital Pasteur (HCC) Colmar Cedex, France Abstract Hypertrophic scars and keloids result from abnormal wound healing in predisposed indi- viduals. They occur within months of cuta- neous trauma (surgical wounds, piercing, lac- erations) or inflammation (acne, folliculitis, vaccination site). They have rarely been reported after chickenpox. Herein we report a dramatic case in a 4-year-old black girl and dis- cuss the issues related to the management of hypertrophic scars and keloids in this peculiar situation. Introduction Hypertrophic scars and keloids result from an abnormal wound healing process in predis- posed individuals. They occur within months of a cutaneous trauma or inflammation. We report a dramatic case in a young black girl after chickenpox. Case report A 4-year-old Congolese girl was referred for numerous raised skin lesions on chickenpox scars. Chickenpox occurred 4 months earlier, without complications and 3 weeks prior to consultation, new cutaneous lesions abruptly appeared. The patient had numerous (over 30) scattered, small, firm, pruritic, dark- skinned coloured nodules on the chest, shoul- ders, flanks and upper arms (Figures 1 and 2). Lesions were restricted to the chickenpox scars but infiltrated into surrounding normal tissue, favouring keloids rather than hyper- trophic scars. Examination was otherwise unremarkable. There was no similar familial history. The localisation, the number of lesions and her age, prompted to initiate pressure therapy with a custom-made com- pressive garment that had to be worn 23 hours a day for at least 6 months. Discussion Hypertrophic scars and keloids, which result from abnormal wound healing in pre- disposed individuals,1 occur within months of cutaneous trauma (surgical wounds, pierc- ing, lacerations) or inflammation (acne, folli- culitis, vaccination site). They are located mainly on the upper part of the body (ear- lobes, neck, shoulders, back), may be pruritic or painful, and do not regress spontaneously.1 Chickenpox is a rare cause of keloids described since the 1960s: the lesions occur as either small eruptive keloids or gigantic and monstrous ones on the chickenpox scars.2-4 Numerous treatments have been pro- posed with varying degrees of efficacy: surgi- cal excision, intralesional corticosteroid injections, cryotherapy, topical silicone gel, laser therapy, and 5-fluorouracil and bleomycin injections,1 among others. Our case illustrates the issues related to the man- agement of a young dark-skinned pre-puber- tal girl. The high number of lesions, the young age, and the skin phototype were con- traindications for a wide range of treatments, including highly potent local corticosteroid ointments, intralesional corticosteroid injec- tions and cryotherapy. All are efficient but painful and expose to transitory hypopigmen- tation. Repeated steroid injections can lead to adverse systemic effects. Laser must be used with caution in dark-skinned patients. Therefore, we proposed pressure therapy as it is widely used for burn scar patients.5 Its pre- cise mechanism of action is not understood but pressure appears clinically to enhance the scar maturation process.1 However, the effica- cy has never been proven in scientific or clin- ical trial and the optimum pressure for treat- ment is not known.5 The vest must be worn by the patient almost 24 hours a day and success is related to compliance as pressure garment therapy exposes to overheating, pruritus, cutaneous rash and abnormal bone growth.5 In our case, garment can be changed every three months to follow the growth of the child. Our case is a reminder of the burden of dark- skinned individuals exposed to the risk of keloids and their cosmetic consequences. It illustrates the difficulties in the management of young children when the lesions are scat- tered over the body. Dermatology Reports 2011; volume 3:e15 Correspondence: Nicolas Kluger, Departments of Dermatology, Allergology and Venereology,, Skin and Allergies Hospital, Helsinki University Central Hospital, Meilahdentie 2, P.O. Box 160, FI-00029 HUS, Finland. E-mail: nicolaskluger@yahoo.fr Key words: keloid, chickenpox, scar, cicatrix, child. The mother of the patient gave consent for publi- cation of the pictures. Received for publication: 15 July 2011. Accepted for publication: 20 July 2011. This work is licensed under a Creative Commons Attribution NonCommercial 3.0 License (CC BY- NC 3.0). ©Copyright N. Kluger et al., 2011 Licensee PAGEPress, Italy Dermatology Reports 2011; 3:e15 doi:10.4081/dr.2011.e15 Figure 1. Eruptive keloids of the trunk on chickenpox scars. Figure 2. Close up view of the lesions. No n- co mm er cia l u se on ly [page 36] [Dermatology Reports 2011; 3:e15] References 1. Wolfram D, Tzankov A, Pülzl P, et al. Hypertrophic scars and keloids--a review of their pathophysiology, risk factors, and therapeutic management. Dermatol Surg 2009;35:171-81. 2. Scheinfeld N, Cohen SR. Varicella causes skin pits and keloids--more reasons for the varicella vaccine. Pediatrics 2000;106:160. 3. Duperrat B, Puissant A, Goetschel GE, et al. Monstrous keloid. Bull Soc Fr Dermatol Syphiligr 1972;79:210-11. 4. Matheis H. Keloid eruption following chickenpox. Dermatologica 1971;143:319- 27. 5. Macintyre L, Baird M. Pressure garments for use in the treatment of hypertrophic scars - a review of the problems associated with their use. Burns 2006;32:10-15. Case Report No n- co mm er cia l u se on ly