The Dynamic Sequential Comprehensive Treatment for Labia Majora Keloids: A Case Report and Literature Review

Keloids are overgrown pathological scar tissues that typically develop following skin trauma in susceptible individuals. Clinically, keloids are characterized by their elevation above the surrounding skin, extension beyond the original wound boundaries, and continuous growth with a congested and tough texture [1]. Common sites for keloid formation include the anterior chest, upper back, and upper arm. The incidence of keloids is influenced by factors such as genetics, ethnicity, age, inflammation, and anatomical location. Although the exact pathogenesis of keloid formation remains unclear, regions of high tension and hyperactive sebaceous glands are known to be associated with their development.

Keloids in the female genital region are particularly rare compared to other high-tension, sebaceous gland-rich areas. The perineal region, characterized by dense pubic hair, a moist environment, and challenges in maintaining hygiene, is prone to skin inflammation, which can complicate keloid management. This area poses unique challenges due to its anatomical and physiological peculiarities, which can significantly affect treatment outcomes and recurrence rates. Keloids are notoriously resistant to treatment and have high recurrence rates, with studies indicating that surgical excision alone can result in recurrence rates ranging from 45% to 100%, often with scars that are larger than the original [2].

Given the significant impact of perineal keloids on fertility and psychological well-being in women, it is crucial to approach their treatment with comprehensive and effective strategies. Here, we present a case of bilateral labia majora keloids treated with a dynamic, sequential comprehensive approach centered on surgery. The patient reported satisfaction with the surgical outcome, and no recurrence was observed after 1 year. By reviewing relevant literature and retrospectively analyzing the diagnosis and treatment process, we aim to evaluate the clinical manifestations, etiology, diagnosis, and treatment options for labia majora keloids, and highlight the value of comprehensive treatment in managing this condition.

A 35-year-old woman presented with bilateral labia majora keloids that had progressively worsened over the past 20 years. The patient initially developed scattered keloids on her labia majora during puberty. As she grew, these keloids enlarged and coalesced. Notably, following her pregnancy and childbirth 2 years ago, the keloids became significantly larger, causing recurrent perineal epifolliculitis, vaginal inflammation, discomfort due to friction, and difficulty in sexual intercourse (Fig. 1).

After comprehensive examinations and ruling out surgical contraindications, we proceeded with surgical intervention under local anesthesia. Design surgical incision placed 5 mm from the edge of keloids, and make sure to cover the resulting wound after complete excision. The operative region was infiltrated with a solution of 2% lidocaine, saline, and epinephrine for anesthesia. After allowing the anesthetic to take effect, the skin was incised down to the superficial fascia along the marked lines, and then resected the keloids along the adipose layer. After achieving hemostasis, 5–0 PDSII interrupted subcutaneous suture and 6–0 absorbable suture were used for skin closure. Postoperative radiation therapy commenced within 24 h of surgery, consisting of five daily sessions with a single irradiation dose of 4 Gy. Given the peculiarities of the labia majora area, the patient used potassium permanganate sitz baths daily until suture removal and did not apply topical silicone gel postoperatively.

At the 1-year follow-up, the patient was highly satisfied with the outcome. Her clinical symptoms, including pain and itching, had resolved, and the skin lesions had softened with no signs of recurrence such as induration or thickening. The Vancouver Scar Scale score improved significantly, changing from an initial score of 14 to a score of 3 (Fig. 2). This case highlights the effectiveness of a dynamic, sequential comprehensive treatment approach considering the aesthetic requirements in managing labia majora keloids, offering promising results for similar cases. The CARE Checklist has been completed by the authors for this case report, attached as online supplementary material (for all online suppl. material, see https://doi.org/10.1159/000543932).

To gather relevant literature on the treatment of labia majora keloids, we conducted a comprehensive search using databases including PubMed, Cochrane Library, Embase, Web of Science, and Wanfang. Keywords included “labia majora keloids” and/or “surgical treatment.” This search yielded 6 case reports on the treatment of labia majora keloids, as detailed in Table 1 [3‒8].

The 6 reports encompassed 6 patients who underwent combination treatments centered on surgical intervention. Four articles were in English and two in Chinese. The patients’ ages ranged from 2 to 59 years, with two being minor children who suffered trauma-induced keloids [3, 4], and four adult women who reported recurrent ulceration and purulence in the keloid-affected areas [5‒8]. Among these patients, two had multiple keloids in other body regions [5, 6].

In all cases, a combination of two or more treatment modalities was employed, including surgical excision followed by adjunct therapies such as corticosteroid injections, radiation therapy, or silicone gel application. The follow-up periods ranged from 6 months to 2 years, during which none of the patients experienced recurrence. All patients expressed satisfaction with their treatment outcomes.

This review highlights the necessity and effectiveness of a comprehensive treatment strategy for labia majora keloids. The consistent use of combination therapies demographics underscores the potential of such approaches in managing this challenging condition. However, these articles did not address the aesthetic requirements specific to the labia majora. As advancements in keloid treatment continue, it is important to consider postoperative aesthetic outcomes alongside the primary goal of disease management. Tailored, dynamic, sequential comprehensive treatment regimens that also focus on aesthetic considerations can significantly improve patient satisfaction and overall quality of life, reinforcing the need for further research, and clinical application in this area.

Keloids are characterized by the abnormal deposition of collagen fibers and excessive proliferation of fibroblasts, resulting from an imbalance in extracellular matrix remodeling, with decreased levels of select matrix metalloproteinases and increased collagen production. These pathological scars persistently grow beyond the original lesion, leading to cosmetic and functional impairment, pain, itching, ulceration, and other discomforts that significantly reduce the quality of life for affected individuals [1]. The precise pathogenesis of keloids remains unclear, but both genetic and local factors are thought to disrupt normal wound healing processes. Normal wound healing involves a local inflammatory response followed by neovascularization and fibroblast activation, resulting in collagen deposition that provides structural integrity. However, in keloid tissues, growth factors such as transforming growth factor-β, vascular endothelial growth factor, and connective tissue growth factor are overexpressed, significantly increasing fibroblast proliferation and collagen synthesis. Genetic factors also contribute, with evidence suggesting an autosomal dominant inheritance pattern with incomplete penetrance and variable expression.

Current treatments for keloids include local injections of glucocorticoids and 5-FU, topical silicone application, compression therapy, surgical excision, postoperative radiotherapy, laser therapy, and cryotherapy. Other treatments, such as local injections of botulinum toxin type A, bleomycin, or mitomycin-C, and topical imiquimod cream, have shown efficacy in some clinical trials but are not widely recommended [2]. High recurrence rates are often associated with these treatments when used alone, making the combined application of multiple treatments essential. In this case report, a surgery-based dynamic sequential comprehensive treatment was adopted. Dynamic therapy involves a set of decision rules that guide the sequence of treatment interventions, each corresponding to a critical point in the disease’s treatment, requiring decisions about the next therapeutic action [9]. Known as adaptive therapeutic strategies or adaptive interventions, dynamic therapy emphasizes that each treatment constitutes new trauma to the keloid site and should be managed dynamically and cyclically to minimize recurrence risks. Sequential therapy for keloids is based on the premise that some treatments are more effective in removing lesions, while others are better at preventing relapse and maintaining treatment efficacy. Sequential therapy aims to optimize outcomes over time by using specific strategies to address different stages of the treatment process.

Most perineal keloids occur in the mons pubis, with few studies reporting on labia majora keloids and none on labia minora keloids. Treating keloids in the perineal area is challenging due to the intimate location, persistent local inflammation, and cleansing difficulties. The comprehensive treatment in this case report advocated a dynamic sequential approach and emphasized co-developing treatment options and goals with the patient. Treatment goals include symptom relief (itching and pain), reducing scar size, improving appearance and function, and preventing recurrence [1]. The comprehensive treatment is divided into three phases: the initial phase involves diagnosis, patient communication, and preoperative preparation; the second phase focuses on lesion removal and wound healing; and the third phase aims at recurrence prevention.

As for preoperative cleaning, a recent meta-analysis study clarified that hair removal with a razor was associated with higher rates of surgical site infection compared to hair removal with clippers, a depilatory cream, or no hair removal [10]. To reduce the rate of surgical site infections, avoiding razors for hair removal, controlling for perioperative glucose concentrations, combined application of chlorhexidine gluconate and alcohol-based skin preparation agents, and using negative pressure wound therapy are recommended [11].

Before treatment, clinicians should accurately diagnose keloids based on history and clinical manifestations. Considering factors like patient age, keloid location, size, type, functional impairment, and patient expectations to formulate an appropriate treatment plan with patient’s full cooperation. In addition, patients should be fully informed about the high recurrence risk associated with all current treatments. During surgery, tension reduced operations help reduce skin tension-related keloid recurrence. Proper separation of subcutaneous tissues and using absorbable sutures for closing deep and superficial fascial layers help distribute tension. Sequential irrigation of the operative area with glucocorticoids, 5-FU, and saline before wound closure can effectively reduce recurrence rates [12]. Postoperative radiotherapy should be administered within 24 h, with close monitoring of adverse reactions for surrounding normal tissues [13]. Patients should use potassium permanganate diluted solution for sitz baths until suture removal, keeping the area clean and dry to reduce inflammation risk. Due to the proximity of the labia majora to the urethral and vaginal orifices, external silicone gel application is not recommended; instead, Mepilex should be cut to fit and changed regularly. Regular follow-ups are crucial, and any signs of recurrence should prompt immediate glucocorticoid injections at the incision edges.

The labia majora, located on the outer side of the female vulva, are soft structures rich in fat and connective tissue, providing protective functions. On the one hand, their elasticity can be used to offset the impact from below the perineum and reduce damage; on the other hand, their full volume of tissues will push the labia minora inward, covering the vaginal vestibule and protecting both the urethra and the vagina. Their aesthetic criteria include a hemispherical curved appearance, fullness, firm texture, few skin folds, and a slightly higher position than the vulvar groove plane [14]. Smaller keloids can be directly excised and sutured, but larger ones often require flap or graft repair due to significant defects post-excision. Although skin grafting is straightforward and donor site availability is not a limitation, the graft area is prone to contamination by feces or urine [15].

The perineal area, with dense body hair, rich sebaceous glands, a moist environment, and poor hygiene, is prone to skin inflammation, contributing to keloid formation. Hormonal fluctuations during puberty, pregnancy, menstrual periods, and hygiene conditions also exacerbate keloids. In addition, the perineal area is private, and patients often hesitate to seek medical treatment, so there are fewer reports on the treatment of keloid in the perineal area. Despite the low incidence of vulvar keloids, their profound impact on women’s conception and psychological well-being warrants full attention.

Although keloids in the perineal region have a low prevalence, their impact on female reproductive health and psychological well-being necessitates careful consideration. Early diagnosis and appropriate management can alleviate symptoms and improve the overall quality of life for affected individuals. The dynamic sequential comprehensive treatment based on surgery is recommended for labia majora keloid. Moreover, we emphasize the importance of paying attention to the aesthetic requirements of the labia majora to achieve optimal patient satisfaction. Further research and increased awareness are essential for a comprehensive understanding and management of this rare but impactful condition.

The authors state that the patient’s parents gave written informed consent to publish this case and any accompanying images. Any information revealing the patient’s identity is avoided. The study has been done according to the Declaration of Helsinki. Ethical approval was not required for this study according to the national guidelines.

The authors have no conflicts of interest to declare.

This study was not supported by any sponsor or funder.

Kun Yang: conceptualization; methodology; and writing – original draft. Jiayi Fu: investigation. Qiang Li: writing – review and editing; supervision; and project administration.

All necessary data from the study have been included in the manuscript. However, if required, additional findings are available from Dr. Qiang Li upon request.