Patient, Lesion, and Surgical Predictors of Keloid Recurrence After Excision: A Systematic Review
DOI:
https://doi.org/10.59890/mjst.v4i9.338Keywords:
Keloid Recurrence; Surgical Excision; Prognostic Factors; Risk Stratification; Wound Healing; Systematic ReviewAbstract
Keloid recurrence after surgical excision remains a significant clinical challenge due to its multifactorial nature involving patient susceptibility, lesion characteristics, and perioperative factors. This systematic review aimed to identify and synthesize prognostic factors associated with keloid recurrence following surgical excision. The review was conducted according to the PRISMA 2020 guidelines, including primary human studies published from January 2020 to September 2026. Relevant studies were retrieved from Scopus, PubMed/MEDLINE, Embase, Web of Science, and CENTRAL. Eligible studies included observational cohorts, case-control studies, and clinical studies reporting postoperative recurrence and prognostic factors. Risk of bias was assessed using the Quality In Prognosis Studies (QUIPS) tool, and findings were synthesized across patient, lesion, and surgical domains. The evidence indicates that recurrence risk is associated with multiple factors, including family history, age, lesion size, clinical activity, anatomical location, mechanical tension, postoperative infection, and wound-related complications. Lesion-related and perioperative factors demonstrated more consistent prognostic relevance than isolated systemic biomarkers. Postoperative therapies appeared mainly as treatment modifiers rather than intrinsic predictors of recurrence. This review provides an integrated prognostic framework by combining individual susceptibility, lesion characteristics, and modifiable surgical factors
References
Bai, R., Hao, L., Zhou, G., Fu, Q., Zhang, P., Lin, P., & Chen, M. (2024). The mechanism of TGF-beta mediating BRD4/STAT3 signaling pathway to promote fibroblast proliferation and thus promote keloid progression. Heliyon, 10(19), e38188. https://doi.org/10.1016/j.heliyon.2024.e38188
Campbell, M., McKenzie, J. E., Sowden, A., Katikireddi, S. V., Brennan, S. E., Ellis, S., Hartmann-Boyce, J., Ryan, R., Shepperd, S., Thomas, J., Welch, V., & Thomson, H. (2020). Synthesis without meta-analysis (SWiM) in systematic reviews: Reporting guideline. BMJ, 368, l6890. https://doi.org/10.1136/bmj.l6890
Chen, B., Ding, J., Jin, J., Song, N., & Liu, Y. (2020). Continuous tension reduction to prevent keloid recurrence after surgical excision: Preliminary experience in Asian patients. Dermatologic Therapy, 33(4), e13553. https://doi.org/10.1111/dth.13553
Cheng, X., Gao, Z., Shan, S., Shen, H., Zheng, H., Jin, L., Li, Q., & Zhou, J. (2024). Single cell transcriptomics reveals the cellular heterogeneity of keloids and the mechanism of their aggressiveness. Communications Biology, 7, 1647. https://doi.org/10.1038/s42003-024-07311-1
Dirand, Z., Maraux, M., Tissot, M., Chatelain, B., Supp, D., Viennet, C., Perruche, S., & Rolin, G. (2024). Macrophage phenotype is determinant for fibrosis development in keloid disease. Matrix Biology, 128, 79-92. https://doi.org/10.1016/j.matbio.2024.03.001
Fernandes, J., Liao, D., Dasgupta, A., Tsao, M. N., & Barnes, E. A. (2024). A single-institution review of the use of radiation in the adjuvant and definitive management of keloids. Clinical Oncology, 36(6), e163–e167. https://doi.org/10.1016/j.clon.2024.03.018
Foroutan, F., Guyatt, G., Zuk, V., Vandvik, P. O., Alba, A. C., Mustafa, R., Vernooij, R., Arevalo-Rodriguez, I., Munn, Z., Roshanov, P., Riley, R., Schandelmaier, S., Kuijpers, T., Siemieniuk, R., Canelo-Aybar, C., Schünemann, H., & Iorio, A. (2020). GRADE Guidelines 28: Use of GRADE for the assessment of evidence about prognostic factors: Rating certainty in identification of groups of patients with different absolute risks. Journal of Clinical Epidemiology, 121, 62-70. https://doi.org/10.1016/j.jclinepi.2019.12.023
Fu, S., Duan, L., Zhong, Y., & Zeng, Y. (2024). Comparison of surgical excision followed by adjuvant radiotherapy and laser combined with steroids for the treatment of keloids: A systematic review and meta-analysis. International Wound Journal, 21(3), e14449. https://doi.org/10.1111/iwj.14449
Gao, N., Lu, L., Ma, X., Liu, Z., Yang, S., & Han, G. (2022). Targeted inhibition of YAP/TAZ alters the biological behaviours of keloid fibroblasts. Experimental Dermatology, 31(3), 320-329. https://doi.org/10.1111/exd.14466
Hao, Y., Liang, Z., Liu, H., Shan, M., Xia, Y., Song, K., & Wang, Y. (2023). A nomogram with the Keloid Activity Assessment Scale for predicting the recurrence of chest keloid after surgery and radiotherapy. Aesthetic Plastic Surgery, 47(2), 872–879. https://doi.org/10.1007/s00266-022-03187-w
Hao, Y., Shan, M., Liu, H., Xia, Y., Kuang, X., Song, K., & Wang, Y. (2025). Comparison of predictive models for keloid recurrence based on machine learning. Journal of Cosmetic Dermatology, 24(2), e70008. https://doi.org/10.1111/jocd.70008
Hayden, J. A., van der Windt, D. A., Cartwright, J. L., Côté, P., & Bombardier, C. (2013). Assessing bias in studies of prognostic factors. Annals of Internal Medicine, 158(4), 280-286. https://doi.org/10.7326/0003-4819-158-4-201302190-00009
Hu, X., & Qiu, T. (2024). Logistic regression analysis of risk factors influencing postoperative keloid scar recurrence. American Journal of Translational Research, 16(9), 4849-4857. https://doi.org/10.62347/CZYH2768
Hwang, N.-H., Chang, J. H., Lee, N. K., & Yang, K.-S. (2022). Effect of the biologically effective dose of electron beam radiation therapy on recurrence rate after keloid excision: A meta-analysis. Radiotherapy and Oncology, 173, 146–153. https://doi.org/10.1016/j.radonc.2022.06.003
James, A. J., Torres-Guzman, R. A., Chaker, S. C., Sigel, M. E., Perdikis, G., Supp, D. M., & Dale Slater, E. L. (2024). Global insights into keloid formation: An international systematic review of regional genetic risk factors and commonalities. Wound Repair and Regeneration, 32(5), 746-757. https://doi.org/10.1111/wrr.13203
Katano, A., Minamitani, M., & Yamashita, H. (2024). Risk factors for local recurrence of keloids and hypertrophic scars after postoperative electron beam radiotherapy. Journal of Cancer Research and Therapeutics, 20(1), 163-166. https://doi.org/10.4103/jcrt.jcrt_1861_22
Kim, J., Won, C., Ham, S., Han, H., Shin, S., Jang, J., Lee, S., Kwon, C., Cho, S., Park, H., Lee, D., Lee, W. J., Lee, T., & Lee, J. H. (2024). Increased susceptibility to mechanical stretch drives the persistence of keloid fibroblasts: An investigation using a stretchable PDMS platform. Biomedicines, 12(10), 2169. https://doi.org/10.3390/biomedicines12102169
Lawera, N. G., Madzia, J., Casey, L. C., Guyton, R. L., Woodyard De Brito, K. C., Kinzer, A., Ulma, R. M., Pan, B. S., Schwentker, A. R., & Leto Barone, A. A. (2024). Keloid intralesional excision reduces recurrence: A meta-analytic study of the available literature on 608 keloids. Plastic and Reconstructive Surgery Global Open, 12(3), e5652. https://doi.org/10.1097/GOX.0000000000005652
Lee, D. W., Kang, D., Ha, B., Kim, D. H., Chang, C. H., & Park, T. H. (2025). The relationship between preoperative vitamin D levels and keloid recurrence. Journal of Cosmetic Dermatology, 24(2), e16687. https://doi.org/10.1111/jocd.16687
Li, D., Li, Z., Liu, S., Chen, X., Che, X., Deng, G., Chen, J., Li, H., Wang, R., Chen, X., Su, W., & Su, J. (2025). Single-cell RNA sequencing highlights the role of proinflammatory fibroblasts, vascular endothelial cells, and immune cells in the keloid immune microenvironment. International Journal of Dermatology, 64(5), 890-900. https://doi.org/10.1111/ijd.17516
Li, Q., Chen, Z., Zou, X., Sha, X., Wei, Z., Chen, M., Liu, Q., Cai, Z., & Jiang, Z. (2024). Effectiveness of postoperative superficial radiotherapy following the keloid-cross-flap surgery for auricular keloid: A prospective cohort study. Radiotherapy and Oncology, 199, 110425. https://doi.org/10.1016/j.radonc.2024.110425
Lin, D., Duan, L., Xu, Y., Liu, Y., & Wang, L. (2026). Anatomical location overrides biologically effective dose as a predictor of keloid recurrence after adjuvant radiotherapy: A systematic review and meta-regression. Strahlentherapie und Onkologie. Advance online publication. https://doi.org/10.1007/s00066-026-02548-7
Liu, C. (2023). Risk factors for recurrence after keloid surgery with electron radiotherapy. Medicine, 102(43), e35683. https://doi.org/10.1097/MD.0000000000035683
Liu, S., Yang, H., Song, J., Zhang, Y., Abualhssain, A. T. H., & Yang, B. (2022). Keloid: Genetic susceptibility and contributions of genetics and epigenetics to its pathogenesis. Experimental Dermatology, 31(11), 1665-1675. https://doi.org/10.1111/exd.14671
Liu, X., Chen, W., Zeng, Q., Ma, B., Li, Z., Meng, T., Chen, J., Yu, N., Zhou, Z., & Long, X. (2022). Single-cell RNA-sequencing reveals lineage-specific regulatory changes of fibroblasts and vascular endothelial cells in keloids. Journal of Investigative Dermatology, 142(1), 124-135.e11. https://doi.org/10.1016/j.jid.2021.06.010
Mao, J., Chen, L., Qian, S., Wang, Y., Zhao, B., Zhao, Q., Lu, B., Mao, X., Zhai, P., Zhang, Y., Zhang, L., & Sun, X. (2024). Transcriptome network analysis of inflammation and fibrosis in keloids. Journal of Dermatological Science, 113(2), 62-73. https://doi.org/10.1016/j.jdermsci.2023.12.007
McGowan, J., Sampson, M., Salzwedel, D. M., Cogo, E., Foerster, V., & Lefebvre, C. (2016). PRESS peer review of electronic search strategies: 2015 guideline statement. Journal of Clinical Epidemiology, 75, 40-46. https://doi.org/10.1016/j.jclinepi.2016.01.021
Mohamed, R., Elawadi, A. A., Al-Gendi, R., Al-Mohsen, S., Wani, S., & Wafa, A. (2022). The outcome of postoperative radiation therapy following plastic surgical resection of recurrent ear keloid: A single institution experience. Journal of the Egyptian National Cancer Institute, 34(1), 4. https://doi.org/10.1186/s43046-022-00105-8
Nangole, F. W., Omu, A., Ogeng'o, J., & Agak, G. W. (2023). Determinants of keloid recurrence: The Nairobi keloid recurrence scoring system; A cohort, prospective study. International Journal of Surgery Open, 52, 100596. https://doi.org/10.1016/j.ijso.2023.100596
Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Chou, R., Glanville, J., Grimshaw, J. M., Hróbjartsson, A., Lalu, M. M., Li, T., Loder, E. W., Mayo-Wilson, E., McDonald, S., ... Moher, D. (2021a). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ, 372, n71. https://doi.org/10.1136/bmj.n71
Page, M. J., Moher, D., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Chou, R., Glanville, J., Grimshaw, J. M., Hróbjartsson, A., Lalu, M. M., Li, T., Loder, E. W., Mayo-Wilson, E., McDonald, S., ... McKenzie, J. E. (2021b). PRISMA 2020 explanation and elaboration: Updated guidance and exemplars for reporting systematic reviews. BMJ, 372, n160. https://doi.org/10.1136/bmj.n160
Peng, Q., Lu, Y., Huang, R., & Chen, R. (2025). Should we do postoperative radiotherapy after keloid excision as soon as possible? A systematic review and meta-analysis. Aesthetic Plastic Surgery, 49(16), 4671–4682. https://doi.org/10.1007/s00266-025-04869-x
Ramelyte, E., Welti, M., Gardin, F., Maul, J. T., Dummer, R., & Imhof, L. (2024). Post-excision soft X-ray radiotherapy for keloids: Experience in a tertiary referral center. Dermatology, 240(4), 572-580. https://doi.org/10.1159/000539782
Ran, X., Guo, X., Liu, Y., Zhu, S., Li, S., Chen, Z., Han, T., Jin, S., Zhou, M., & Zang, M. (2025). Effectiveness of core excision technique for keloids: A systematic review. Plastic and Reconstructive Surgery, 155(4), 801e–808e. https://doi.org/10.1097/PRS.0000000000011733
Riley, R. D., Moons, K. G. M., Snell, K. I. E., Ensor, J., Hooft, L., Altman, D. G., Hayden, J. A., Collins, G. S., & Debray, T. P. A. (2019). A guide to systematic review and meta-analysis of prognostic factor studies. BMJ, 364, k4597. https://doi.org/10.1136/bmj.k4597
Seth, I., Gibson, D., Marcaccini, G., Pentangelo, P., Xie, Y., Lim, B., Cuomo, R., Khor, R., Rozen, W. M., & Ng, S. K.-H. (2026). Post-excisional radiotherapy for keloid treatment: A systematic review and meta-analysis. Journal of Plastic, Reconstructive & Aesthetic Surgery, 113, 459–531. https://doi.org/10.1016/j.bjps.2025.11.016
Vorstandlechner, V., Neid, K., & Fochtmann-Frana, A. (2026). Clinical and therapeutic predictors of keloid recurrence: Outcomes in a European cohort of 206 patients. Journal of Clinical Medicine, 15(6), 2150. https://doi.org/10.3390/jcm15062150
Xie, R., Li, C., Zhao, T., Zhang, S., Zhong, A., Chen, N., Li, Z., & Chen, J. (2026). Integration of flow cytometry and single-cell RNA sequencing analysis to explore the fibroblast subpopulations in keloid that correlate with recurrence. Advances in Wound Care, 15(6), 381-398. https://doi.org/10.1089/wound.2024.0262
Zhang, J., Li, S., Kuang, C., Shen, Y., Yu, H., Chen, F., Tang, R., Mao, S., Lv, L., Qi, M., Zhang, J., & Yuan, K. (2024). CD74+ fibroblasts proliferate upon mechanical stretching to promote angiogenesis in keloids. The FASEB Journal, 38(20), e70103. https://doi.org/10.1096/fj.202401302R
Zhang, Y., Wang, C., Lyu, D., Wang, D., & Zhou, R. (2025). Long-term outcome of anterior chest keloid excision using intercostal artery perforator propeller flaps. Aesthetic Plastic Surgery, 49(7), 2097–2103. https://doi.org/10.1007/s00266-024-04574-1
