Assessing the Readability of Online Keloid Resources

BACKGROUND: Keloids are fibroproliferative scars that can disproportionately affect individuals with skin of color. Given the complexity of treatment options, many patients seek guidance through online health resources. However, these materials may not be written at a level accessible to the general public, particularly those with limited health literacy. OBJECTIVE: To evaluate the readability of the top 100 Google search results for "keloid scar" and determine whether these online patient education materials (PEMs) meet the readability standards recommended by the American Medical Association (AMA). METHODS: A Google search was conducted on April 29, 2025, using incognito mode with cleared cookies to minimize bias. The first 100 websites were screened, with exclusions for duplicate content, insufficient text (<250 words), scientific articles, clinician-targeted pages, and non-educational material. A total of 40 websites met the inclusion criteria. Readability was assessed using six validated formulas: Flesch-Kincaid Grade Level, Simple Measure of Gobbledygook (SMOG), Gunning Fog, Coleman-Liau, Automated Readability Index, and Linsear Grade Level. Mean grade-level scores were calculated and stratified by source type. RESULTS: Only 12.5% (5/40) of keloid-related PEMs had an average grade-level score at or below the AMA's recommended sixth-grade threshold. The average readability across all materials was at the 10th-grade level (mean=9.54; range 6.00-12.84). When considering individual formulas, the highest reading level assigned per resource ranged from grade 11.09 to 15.02. Government websites had the lowest mean readability (sixth-grade level), while "Other" sources scored highest (mean=10.38). Academic/hospital-based sites (mean=9.26), commercial (mean=9.79), and non-profit sources (mean=9.53) also exceeded recommended levels. A one-way analysis of variance (ANOVA) showed no significant difference in readability across source types (p=0.122). LIMITATIONS: Only English-language, text-based materials were analyzed; multimedia content and regional search variations were not assessed. CONCLUSIONS: Online PEMs related to keloid scars exceed recommended readability levels, potentially limiting their utility for patients with low health literacy. These findings underscore the need for more accessible, culturally inclusive materials, especially for populations disproportionately affected by keloids.