Keloids as a rare complication of voluntary medical male circumcision: findings from PEPFAR’s notifiable adverse events reporting system

TL;DR

Keloids are rare complications of male circumcision, especially in boys aged 10–14, according to a study of PEPFAR's adverse event reports.

Contribution

This study identifies a strong age-related risk for keloids after circumcision in a large-scale HIV prevention program.

Findings

11 keloid cases were reported, with 10 occurring in clients under 15 years old.

Clients aged 10–14 had significantly higher risk for keloids compared to those 15 and older (p = 0.0004).

Silicone gels or sheeting were not used in management, suggesting a potential conservative treatment option.

Abstract

Keloids are rare but challenging complications in penile surgeries, including circumcision. The President’s Emergency Plan for AIDS Relief (PEPFAR) supports voluntary medical male circumcisions (VMMC) for HIV prevention in sub-Saharan Africa, and has monitored major adverse events through its Notifiable Adverse Event Reporting system (NAER) since 2015, providing unique opportunities to understand keloid epidemiology and risk factors.

All 2015–2023 NAER keloid cases were reviewed. Variables abstracted included age at VMMC, time course, and case characteristics. Descriptive analysis and Fisher’s exact test of the association between client age (< 15 years vs. ≥ 15 years) and keloids were performed. Systematic literature searches were also conducted on case reports, outcomes and management guidelines, to produce a narrative summary and comparisons between the NAER cases and prior literature.

Eleven cases were reported. Clients were < 15 years old in 10/11, with median age 12 years and mean time to diagnosis 1.8 years. Clients aged 10–14 years had a significantly higher risk for keloids compared to those aged 15 and older (p = 0.0004). Case characteristics were similar to those in prior case series, as was management, except that silicone gels or sheeting were not used. Follow-up was too brief to assess outcomes.

Keloids were a rare complication of PEPFAR-supported VMMCs. Keloids were strongly associated with age 10–14 years at circumcision as compared to older age. Programs can remind clients to return to VMMC sites even for late complications, and develop expert referral networks. Silicone gels or sheeting could represent an additional conservative management option.

The online version contains supplementary material available at 10.1186/s12894-025-01949-7.