Four months after commencing the initial treatment, the patient presented again, and a 15% improvement was observed with a reduction in the size of the keloid scar tissue to a diameter of 11 mm. Again, the patient received another local injection of methylprednisolone acetate, but at a reduced dose of 20 mg. At 5 months follow-up, the base of the keloid was unchanged and remained at 11 mm. However, the overall volume of the keloid had a flattened appearance as a result of the pressure earing. Again, the patient was administered another injection (locally) at the original dose of 40 mg methylprednisolone acetate. A further 10 weeks on, the base of the keloid scar measured 10 mm and its height was reduced, with the total thickness of the right helix of the involved area measuring 8 mm as opposed to 7 mm in the opposite ear. Of significance, it was noted that part of the normal tissue in the involved area was replaced by the keloid over 1 mm thickness. The dose of 40 mg methylprednisolone acetate was once again injected locally, in conjunction with the pressure earring (Figure 3).

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A further 2 months on, the base of the keloid remained unchanged at 10 mm; however, the total thickness of the helix reduced to 7 mm. The posterior region of the helix remained a small flat patch, while the anterior of the helix presented with only minimal keloid content. At this time, another injection of 40 mg methylprednisolone acetate was administered. After completing a year’s treatment with methylprednisolone acetate and 3 years after the original piercing, the keloid scar became active again, appearing red and telangiectasic. A final local injection of 60 mg methylprednisolone acetate was administered, resulting in no improvement with a further rapid growth in size (Figure 4).

It was decided to surgically excise the keloid lesion using wide margins, and subsequently, the growth was sent for histological examination. Histological examination determined that the lesion was consistent with keloid and had tiny foci of BCC arising from within. The patient provided informed written consent for the described procedures and the use of digital photography for the purposes of treatment, teaching and use in academic publications.