How to manage a keloid on the foot of a patient with a history of keloid formation and impaired renal function?

Management of Keloid on the Foot in a Patient with History of Keloid Formation and Impaired Renal Function

For a patient with a history of keloid formation and impaired renal function, conservative management with proper foot care and comfortable shoes is the most appropriate approach, avoiding surgical intervention which carries a high risk of recurrence.

Assessment of the Keloid

The patient presents with:

• 0.4 cm diameter hard mass on the right foot
• History of keloid formation
• Single kidney (impaired renal function)

Management Approach

Primary Recommendations

1. Avoid Surgical Intervention

   • Surgical removal is contraindicated due to high probability of keloid recurrence
   • Patients with history of keloid formation have significantly higher risk of developing new keloids after surgical intervention

2. Footwear Modifications

   • Use comfortable, properly fitted shoes that reduce pressure on the keloid area
   • Shoes should be 1-2 cm longer than the foot and wide enough at the metatarsal phalangeal joints 1
   • Avoid shoes with rough edges or uneven seams that could irritate the keloid 1

3. Foot Care Regimen

   • Continue with Epsom salt soaks at bedtime as recommended
   • Daily foot inspection to monitor the keloid and surrounding skin 2
   • Regular moisturizing to prevent dryness and fissuring 2
   • Avoid prolonged soaking in soapy water without protection 2

Monitoring

• Regular follow-up visits to assess:
  • Changes in size or symptoms of the keloid
  • Development of pain or itching (strongest indicators of quality of life impairment in keloid patients) 3
  • Signs of infection or ulceration

Special Considerations for Renal Impairment

• Patients with renal impairment require special attention to foot care due to potential vascular complications
• Proper foot care is essential as recommended in guidelines for patients with impaired renal function 2
• Meticulous attention to foot care helps reduce the risk of skin ulceration and necrosis 2

Patient Education

Educate the patient about:

• Importance of proper footwear
• Daily foot inspection
• Avoiding trauma to the affected area
• Reporting any changes in the keloid (increased size, pain, itching)
• Continuing recommended foot care with Epsom salts

Rationale for Conservative Management

1. High Recurrence Risk: Keloids have a high tendency to recur after surgical excision, especially in patients with history of keloid formation

2. Renal Considerations: The patient's single kidney status requires caution regarding any interventions that might impact renal function

3. Quality of Life Impact: Pain and itching are the strongest indicators of quality of life impairment in keloid patients 3, so management should focus on preventing these symptoms

4. Evidence-Based Approach: Studies show that appropriate foot care and footwear can significantly reduce foot problems 4

When to Consider Further Intervention

• If the keloid becomes painful or itchy (significant impact on quality of life) 3
• If there are signs of infection
• If the keloid significantly increases in size affecting mobility

Conservative management with proper foot care and appropriate footwear is the most prudent approach for this patient with a history of keloid formation and impaired renal function, focusing on preventing complications while avoiding interventions that carry high risk of recurrence.