Keloids: When scar tissue thickens the skin

Skin Findings Demystified: Keloids and Friends in the ATI Physical Assessment Guide

Let’s spend a moment on something you’ll bump into again and again on the front lines of care: the skin. It’s not just a protective cover; it’s a map of how the body’s healing, inflammation, and tissue work together. If you’ve scanned through ATI physical assessment materials, you’ll know that recognizing different skin findings isn’t just about naming them. It’s about understanding what they mean for a patient’s comfort, risk, and treatment. Today we’ll zero in on one particular finding—thickened, hardened skin—and then compare it to a few similar-sounding yet very different lesions.

What’s the big idea here?

When skin healing goes into overdrive, scar tissue can pile up and harden the surface. In medical shorthand, that’s a keloid. A keloid isn’t just a bigger scar; it’s tissue that has proliferated beyond the edges of the original wound. It can feel firm or rubbery to the touch and sit above the level of surrounding skin. Keloids can be flat and pale or dark and shiny, and they may itch or tingle for some people. The key feature is the thickened, raised texture that stretches beyond the boundary of the initial injury.

Now, let’s put that in contrast with a few other skin findings that often show up in patient history and physical exams. If you’re listening for the same heartbeat—raised or nonraised, flat or crackly—you’d group them as follows:

• Macules: flat patches of color. Think freckle or a light patch of vitiligo. They’re color changes on the surface, but they’re not raised or thickened.

• Papules: small, solid bumps that sit on the skin. They’re raised, but they’re not the same thickened, scar-like texture you’d see with a keloid.

• Fissures: linear cracks in the skin, often at the corners of the mouth or on callused areas. They’re breaks in the surface, not a growth or thickening.

If you’re drawing a quick mental map, it looks like this: keloids = thickened, raised tissue; macules = flat color changes; papules = small bumps that project a bit; fissures = cracks in the surface. Simple, right? Yet the nuance matters because it changes how we describe findings, flag potential causes, and plan care.

A closer look at keloids: why they form and what they feel like

Keloids are a curious product of the healing process. After an injury, the body starts laying down collagen to mend the skin. In some people, this process overshoots. Collagen keeps accumulating, and the scar tissue grows beyond the original wound. The result is a lump that’s rigid, often smooth but sometimes uneven, and clearly raised above surrounding skin.

What does that feel like when you’re examining someone? Here are some practical cues to rely on during palpation:

• Elevation: The lesion rises above the skin level. It doesn’t disappear back into the surface when you press lightly.

• Texture: It’s firmer than the surrounding skin; you might describe it as rubbery or dense.

• Borders: The edges often extend beyond the initial scar, with a clearly defined, sometimes irregular outline.

• Color: It can be pink, red, brown, or match the person’s natural skin tone, depending on age and skin color.

• Symptoms: Some people notice itching or tenderness, especially in areas of tension or recent injury.

These tactile hints are what help you separate a keloid from a flat discoloration or a tiny bump that might be a papule or mole.

Why the distinction matters in real-world care

Understanding the difference isn’t just about labeling. It informs risk assessment, patient education, and, when appropriate, management decisions. Here’s why this matters:

• Healing trajectory: Keloids tell a story about how someone’s skin heals. If a patient tends to form thick scars, you might flag the need for cautious wound care in future injuries or surgeries.

• Cosmetic and functional impact: Keloids can cause social or comfort concerns, especially when they appear on visible areas like the chest, shoulders, or earlobes, or in areas prone to rubbing from clothing.

• Differential diagnosis: Other skin findings that look raised or thickened can point to different conditions. For example, a papule could be a wart or an inflammatory lesion, while a fissure signals skin breakdown in a crack rather than scar formation. Getting the category right helps you avoid confusion and pursue appropriate care.

If you’ve ever watched a patient describe a scar that seems to keep growing beyond the initial wound, you’ve seen one of the telltale signs of a keloid in action. It’s a reminder that the body sometimes writes its own script when it comes to healing—and that script isn’t always neat.

A quick side chat about a few related skin findings

You don’t have to memorize these for a pop quiz and then forget them. They’re useful anchors for clinical conversations and chart notes:

• Hypertrophic scars: These are often mistaken for keloids. They’re raised as well, but they stay within the original wound borders. They tend to improve or flatten over time, whereas keloids can continue to grow.

• Planar scars and atrophic patches: Not all thickened skin is raised. Some scars become indented or pale, which changes how you feel and look at them during exam maneuvers.

• Lesion color changes: Color helps you categorize. A flat, pigmented macule differs from a raised, scar-like lesion. The color plus texture tells a story about tissue changes and blood flow.

Adapting your eye for clinical reality

The best way to get comfortable with these distinctions is to pair eyes with hands. Here are a few practical habits you can fold into daily rounds:

• Start with a careful inspection: Observe the size, color, and location. Note whether the lesion sits on the skin’s surface or lifts off it.

• Palpation becomes your truth-teller: Gently press and feel for hardness, elevation, and edge quality. Is it soft and flat, or firm and expanding?

• Look for boundary behavior: Does it stay within a wound’s original footprint, or does it spill over? That boundary can be the clue that you’re dealing with a keloid.

• Ask about symptoms and history: Has the area changed recently after an injury or surgery? Do they have a history of thick scarring? Family history can also be a helpful hint.

• Correlate with the whole picture: Skin findings rarely exist in isolation. Consider the patient’s overall health, any autoimmune concerns, and their skin color, which can influence how lesions appear.

A few practical tips for students and practitioners

• Build a mental checklist: When you see a raised lesion, run through “raised? beyond original wound? firm texture? color?” to guide your thinking.

• Use visuals to reinforce memory: Pair descriptions with quick sketch notes or a trusted atlas image. The visual cue helps you recall details during a busy shift.

• Practice with real-world examples: Look at patient photos (with consent) or case studies to train your eye for differences between keloids, hypertrophic scars, macules, and papules.

• Keep it simple in notes: A concise, precise description helps you communicate clearly with teammates and chart accurately for future care.

• Stay curious about variants: Skin is diverse. What looks like a straightforward keloid in one patient might appear a bit different in another due to skin color, age, or location.

Misconceptions worth clearing up

• “All raised scars are keloids.” Not true. Hypertrophic scars rise but stay within the original wound edges; keloids extend beyond.

• “A keloid is just a big pimple.” No—the texture and boundary behavior are different, and the etiology involves an exaggerated healing response, not an infectious or inflammatory bump.

• “Macules are flat; papules are raised.” That’s the essence, but remember the context: macules are flat color changes; papules are small, solid bumps. They’re cousins, not twins.

What this means for your broader clinical toolkit

The ability to distinguish between these skin findings strengthens your clinical reasoning. You’ll be better at building accurate differential diagnoses, communicating clearly with patients (who often worry about what they see in the mirror), and collaborating with colleagues on thoughtful care plans. In the end, the goal isn’t only to name a finding; it’s to understand what it means for that person’s comfort, health, and daily life.

Let me explain it this way: skin is the body’s storytelling surface. When you read a lesion as a keloid, you’re hearing a story about healing gone a bit exuberant. When you recognize a macule, you’re noting a quiet color shift. Papules tell you about small, raised bumps that aren’t the same thick hero as a keloid. Fissures show a crack in the surface that calls for moisture and protection, not an overgrowth of tissue.

A final nudge for your practice

If you’re studying or working with ATI physical assessment materials, remember that the ultimate aim is clear, precise observation. Use the textures, the borders, the elevation, and the direction each lesion points you toward. And yes, it’s perfectly fine to pause and breathe—sketch a quick picture in your mind or jot a note. In a busy clinical environment, these small habits add up.

Keloids are a classic example of how the body’s healing response can cross lines. They remind us that thickened, hardened skin isn’t just a cosmetic issue—it’s a signal about tissue dynamics, patient experience, and the care decisions we make next. By keeping the distinction between keloids, macules, papules, and fissures in mind, you’re equipping yourself with a sharper eye for skin—one that serves patients with empathy, accuracy, and steady clinical judgment. And that’s a skill that translates across exams, rounds, and real life, one patient at a time.