When should I consider referring a patient with keloid scars to a specialist for further management?

Consider referring a patient with keloid scars to a specialist when:

• There is diagnostic uncertainty about the nature of the scar, especially if it is atypical or difficult to distinguish from other types of scars or skin lesions.
• The keloid scar is causing significant symptoms such as pain, pruritus, or functional impairment that are not controlled by primary care management.
• The scar is extensive, disfiguring, or located in cosmetically sensitive areas where specialist interventions such as surgery, laser therapy, or intralesional treatments may be required.
• Previous treatments in primary care have failed to improve the scar or have led to adverse effects.
• The patient experiences significant psychological distress or social impact related to the keloid scar.

Referral is typically to dermatology or plastic surgery specialists who can offer advanced management options including intralesional corticosteroids, laser therapy, surgical excision with adjunctive therapies, or other emerging treatments.

This approach aligns with general principles for managing problematic scars, where specialist input is sought for complex, symptomatic, or refractory cases to optimise outcomes and minimise complications (Pym, 2006). Although UK guidelines do not provide explicit referral criteria for keloid scars, extrapolating from guidance on other complex skin conditions and scars suggests referral when primary care management is insufficient or the scar significantly impacts quality of life ¹.