HX03 From pharaohs to fluorouracil: the enduring mystery of keloids

Abstract The history of wound healing intertwines with human civilization. A clay tablet from 2200 Bce describes early wound care techniques, including the ‘three healing gestures’ of cleansing the wounds, preparing the plasters and applying the bandage. Keloids, an exaggerated fibroproliferative response to cutaneous wound healing, have been recognized across cultures throughout history. Ancient civilizations, including Egyptians, Greeks and Romans, utilized keloids for identification, punishment and cultural practices. Keloid scars were recognized as early as 3000 Bce, when the Edwin Smith papyrus, the earliest known surgical treatise detailing ancient Egyptian medical practice, depicted a ‘swelling on his breast, large, spreading, and hard’, that felt like ‘touching a ball of wrappings’. Keloids uniquely affect Homo sapiens, with Black African populations being particularly susceptible. It is not surprising that the narrative of keloids is based in African folklore, recounted in African proverbs and folk medicine. The East Nigerian Yoruba tribe documented keloids as early as the 10th century. In 1790, Retz mistakenly referred to keloids as ‘fatty hernias’ or ‘darter de graisse’ in his book Treatise on Skin Diseases and Things of Mind. The term ‘keloid’ was introduced by Baron Jean-Louis Alibert (1768–1837), a French pioneer in dermatology, in 1806. He identified the keloid as a specific entity, describing it as tumour-like scars that he initially referred to as ‘les cancroïdes de la peau’. By 1817, when it became clear that these cicatricial tumours were in fact noncancerous, Alibert changed the name to ‘cheloïde’ or ‘keloïde’. The term is derived from the Greek word ‘$\chi\eta \lambda\overset{\prime}{\eta}$’ ($\rm kh\hat{\bar e} |\bar e$) for crab’s claw and the suffix -oid meaning ‘like’. This represented their horizontal invasive expansion beyond the initial wound edges into the surrounding skin. The 1863 photograph ‘Whipped Peter’ vividly illustrated the severe keloid scarring resulting from brutal beatings of an escaped slave, bringing wider attention to the condition. Treatment approaches have evolved with time. Cosman et al. conducted the first systematic study of keloids in 1961 (Cosman B, Crikelair GF, Ju DMC et al. The surgical treatment of keloids. Plast Reconstr Surg 1961; 27: 335–58). Intralesional corticosteroid injections, introduced in the mid-1960s, remain a popular treatment. Pressure therapy emerged in the 1970s, followed by topical silicone gel sheeting in the early 1980s. In 1999, Fitzpatrick demonstrated the efficacy of 5-fluorouracil in reducing keloid size. Despite significant advancements, keloids continue to present a challenging clinical problem. Their unique occurrence in humans, particularly in those of African descent, and their relentless invasion into healthy skin make them a persistent enigma in modern medicine.