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Keloid co-existing with epidermoid cyst in a black elderly patient: A case report

1 Plastic and Reconstructive Surgery Unit, Department of Surgery, College of Health Sciences, Ladoke Akintola University of Technology, Ogbomoso, Nigeria
2 Department of Morbid Anatomy and Histopathology, Ladoke Akintola University of Technology, Ogbomoso, Nigeria
3 Department of Surgery, LAUTECH Teaching Hospital, Ogbomoso, Nigeria

Date of Submission30-Nov-2022
Date of Decision29-Jan-2023
Date of Acceptance30-Jan-2023
Date of Web Publication10-Apr-2023

Correspondence Address:
Oluwatosin S Ilori,
PMB 4007, LAUTECH Teaching Hospital, Ogbomoso
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njbcs.njbcs_60_22


Keloid is an abnormal scar that can be due to tissue trauma or occur spontaneously. It commonly occurs in dark pigmented individuals with positive family history. Epidermoid cyst (EC) on the other hand is an adnexal cysts that contain keratin and stratified epithelium. The co-existence of both keloid and EC is rare and very few have been reported in the literature especially among the Negroids. The objective is to report a keloid mass co-existing with an EC in a Negroid elderly patient. A 76-year-old man presented with right sided upper back swelling of a year duration with no prior trauma or family history of keloid. Physical examination showed a 2 × 7 cm raised keloid scar with an intraoperative incidental finding of a 1 × 1 cm hemispheric epidermoidcyst. The significance of this case is in the rarity of co-existing keloid and EC especially in the elderly and Negroids.

Keywords: Elderly, epidermoid cyst, keloid tissue

How to cite this URL:
Ilori OS, Adekunle AA, Amao AA, Nnara SO. Keloid co-existing with epidermoid cyst in a black elderly patient: A case report. Niger J Basic Clin Sci [Epub ahead of print] [cited 2023 Jun 10]. Available from: https://www.njbcs.net/preprintarticle.asp?id=374002

  Introduction Top

Keloid is a benign fibroblastic mass that is most often secondary to tissue injury.[1],[2] It can also occur without prior trauma in patients with black pigmented skin or in those with positive family history.[3] The incidence of keloids in the literature especially among the black population ranges between 4.5% and 16%, with higher female preponderance.[4] Clinically, keloid is characterized as a hard, fibrous, and hyperpigmented tissue, which can be pruritic or painful. It extends beyond the margins of the initial wound and it seldom resolves spontaneously. Also, its response to treatment is often poor and sometimes unsatisfactory.[3]

Epidermoid cysts (ECs) on the other hand are benign dermal or hypodermal adnexal cysts that are lined by simple squamous epithelium.[5] The cysts contain keratinaceous substances that are made up of proteins, cell membrane lipids, and cholesterol. They are commonly found in the head, neck, and anterior trunk. The clinical presentation is variable, with slow-growth. Remnants of inflammatory follicular tissues, traumatic or non-traumatic, can be trapped in scar tissues, providing a source for the inflammation resulting in the formation of ECs in scar tissue (keloid).[6] The co-existence of both keloid and EC is rare and very few have been reported in the literature.[3],[7] At the time of the literature search no such pathology has been reported in any Negroid elderly patient. The aim of this study is to describe the case of an elderly Negroid patient with keloid scar and coexisting EC.

  Case Presentation Top

The patient is a 76-year-old man who presented in the surgical outpatient clinic with right sided upper back swelling of a year duration. The swelling which was noticed incidentally was initially the size of a small ground nut but gradually increased to three times the initial size before presentation. It was occasionally painful but not pruritic and there was no associated ulceration. There was no similar swelling in any other part of the body. There was no antecedent trauma to the site and he has no family history of keloid. He neither smokes nor takes alcohol and the past medical history was uneventful. There was no known drug allergy and he has no co-morbidities.

On examination at presentation, he was healthy looking, not pale, and well hydrated. There was no significant lymph node enlargement. The vital signs were within normal range. There was a 2 × 5 cm fusiform mass on the right parascapular area with rough surface. It was firm in consistency, not tender with no differential warmth. The mass was not mobile but it was attached to the overlying skin. There were multiple hyperpigmented skin tags on the upper back [Figure 1].
Figure 1: Fusiform firm mass on the upper back of the patient

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The packed cell volume was 40% and the retroviral screening was negative for HIV-I and II. A diagnosis of upper back keloid was made and the patient had intralesional keloid excision under local anesthesia. The intraoperative findings revealed a 1.5 × 1.5 cm spherical soft mass deep within the keloid scar containing brownish gel like substance [Figure 2]. The wound was sutured with prolene 3-0 after excising the mass [Figure 3]. Histopathological examination of the excised tissues showed a cyst containing keratin flakes and lined by stratified squamous epithelium with prominent granular layer. Sections of the tissue also showed haphazardly arranged dense and hyalinized fibrocollagenous tissue within which are seen scattered fibroblasts. The overlying epidermis was acanthotic with a focal area of hyperplasia. Thus, a histopathological diagnosis of keloid with epidermal inclusion cyst was made.
Figure 2: Spherical mass in the center of the wound during intralesional excision of the keloid tissue

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Figure 3: Immediate post-operative wound

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The patient was commenced on scar modulation with topical silicone gel and shea butter after the sutures were removed. He is currently being followed up at the surgical outpatient clinic though he has not been regular with his visit.

  Discussion Top

ECs found in normal skin are relatively common but those that coexist with abnormal scars like keloids and hypertrophic scars are rare and have a different line of management because the keloid scar have a high tendency for recurrence.[7] In our patient, the co-existing EC was an incidental finding discovered at surgery when he was planned for an intralesional excision. There was no known history of any preceding trauma in the patient. There may however possibly be a very trivial trauma that went unnoticed by the patient because ECs arising from keloids are believed to be due to excessive inflammation from abnormal wound healing.[8]

According to Lee et al.,[7] there are no epidermal appendages in scar tissues; therefore, ECs arising from abnormal scars are most likely resulting from traumatic causes. That notwithstanding, ECs from non-traumatic causes are commonly located in hair-bearing areas of the head, neck, and upper trunk.[9] That may possibly be the case in our patient where the lesion was located on the hair bearing part of the back. In our patient we were unable to prove clinically which of the lesions started first or possibly if they occurred at the same time because there was no punctum located on the scar and no ultrasound scan was done prior to the excision. On the contrary, Wilson et al.[3] made the diagnosis of coexisting EC sonographically. Their patient was sent for ultrasound because he presented with an ulcerated keloid mass with associated fever.

In a similar study by Lee et al.[7] among the Asians, keloid scars were found in four of their patients while the remaining two patients presented with hypertrophic scars. Our patient presented with keloid, an abnormal scar which is also common among Africans. The sizes of their patients' scars ranged from 2 × 1 cm to 9 × 7 cm, and those of the ECs ranged from 0.2 × 0.2 cm to 2 × 1.5 cm. These are also comparable to the sizes found in our patient which were 2 × 5 cm and 1 × 1 cm, respectively. Following the surgery, our patient was commenced on local silicone gel and shea butter application. He however has not been regular on follow-up visit unlike the good follow-up adherence that was reported by Lee et al.[7]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Moshref SS. Topical zinc oxide adhesive tape for keloid management. Egypt J Surg 2006;25:169-77.  Back to cited text no. 1
Kim S, Choi TH, Liu W. Update on scar management: Guidelines for treating Asian patients. Plast Reconstr Surg 2013;132:1580-9.  Back to cited text no. 2
Wilson JP, Whittle C, García V, Norris F, Castro A, Hitschfeld F. Ulcerated keloid secondary to a coexisting complicated epidermal inclusion cyst: A sonographic diagnosi. J Diagn Med Sonogr 2020;36:365-8.  Back to cited text no. 3
Ogawa R. Keloid and hypertrophic scars are the result of chronic inflammation in the reticular dermis. Int J Mol Sci 2017;18:E606.  Back to cited text no. 4
Hoang VT, Trinh CT, Nguyen CH. Overview of epidermoid cyst. Eur J Radiol Open 2019;6:291-301.  Back to cited text no. 5
Wollina U, Langner D, Tchernev G. Epidermoid cysts—A wide spectrum of clinical presentation and successful treatment by surgery: A retrospective 10-year analysis and literature review. J Med Sci 2018;6:28-30.  Back to cited text no. 6
Lee HW, Kim CG, Song JS, Koh IC, Kim H KK. Management of epidermal cysts arising from scar tissues: A retrospective clinical study. Medicine (Baltimore). 2018;97:12188.  Back to cited text no. 7
Chike-Obi CJ, Cole PD, Brissett AE. Keloids: Pathogenesis, clinical features and management. Semin Plast Surg 2009;23:178-84.  Back to cited text no. 8
Tollefson TT, Kamangar F, Aminpour S, Lee A, Durbin-Johnson B. Comparison of effectiveness of silicone gel sheeting with microporous paper tape in the prevention of hypertrophic scarring in a rabbit model. Arch Facial Plast Surg 2012;14:45-51.  Back to cited text no. 9


  [Figure 1], [Figure 2], [Figure 3]


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