Treating Keloids and Hypertrophic Scars: What Actually Works

Expert Evaluation and Evidence-Based Management

Keloids and hypertrophic scars can be raised, firm, and sometimes itchy or painful. They appear after skin injuries of many kinds, including surgical incisions, acne breakouts, ear piercings, burns, and even minor cuts that heal with an overactive response. Beyond the physical discomfort, their size and prominence can make patients self-conscious about the areas of their body where the scars have formed.

Fortunately, keloids and hypertrophic scars are treatable, and while complete elimination is not always achievable, significant flattening, softening, and improvement in color, texture, and symptoms is realistic with the right plan. Whether you are dealing with a fresh hypertrophic scar or a long-standing keloid that has resisted prior treatment, understanding your options is the first step toward meaningful improvement.

In this guide, we break down how keloids and hypertrophic scars are treated: what works best for different scar types and presentations, what results look like over time, and what a dermatologist can do to build a plan that addresses your specific scar and reduces the risk of recurrence.

What Are Keloids and Hypertrophic Scars and Why Are They So Stubborn?

Both keloids and hypertrophic scars are the result of an overactive wound-healing response in which the body produces excess collagen during the repair process. However, they differ in important ways that affect how they behave and how they are treated.

A hypertrophic scar is a raised, firm, often red or pink scar that remains within the boundaries of the original wound. It develops within weeks of an injury and may gradually improve on its own over 1 to 2 years, though treatment can accelerate and enhance that improvement.

A keloid is a more aggressive form of abnormal scarring in which the scar tissue grows beyond the original wound boundaries, sometimes extending significantly into surrounding normal skin. Keloids do not self-resolve and may continue to grow slowly over time. They are more common in individuals with darker skin tones and have a strong genetic component.

Both types can be uncomfortable, itchy, or tender, and both can occur anywhere on the body, though certain areas carry higher risk. You are more likely to develop keloids or significant hypertrophic scars if you experience any of the following:

• Skin Tone: Keloids are significantly more common in individuals with darker skin tones, including those of African, Hispanic, Asian, and South Asian descent. The underlying mechanism is not fully understood but has a strong genetic basis.
• Family History: A personal or family history of keloid formation is one of the strongest predictors of whether a new wound will produce a keloid.
• High-Risk Body Locations: The chest, shoulders, upper back, earlobes, and jawline are particularly prone to keloid and hypertrophic scar formation, regardless of the type of injury that caused the wound.
• Type of Skin Injury: Burns, piercings, surgical incisions, acne (especially inflammatory or cystic acne), vaccinations, and insect bite reactions can all trigger abnormal scar formation in predisposed individuals.
• Age: Younger individuals, particularly those between the ages of 10 and 30, are at higher risk for keloid formation than older adults.
• Prior Keloid History: Having formed one keloid is a strong indicator that future wounds in predisposed areas may also develop keloids.

Why Keloids and Hypertrophic Scars Are Hard To Treat

Keloids and hypertrophic scars are notoriously resistant to treatment for two key reasons:

• They represent an overactive, dysregulated healing response. The underlying biology involves fibroblasts that continue producing excess collagen long after normal healing would have stopped. Reversing this process requires targeted interventions that directly suppress collagen overproduction within the scar tissue.
• Keloids carry a high recurrence risk. Even after successful flattening or surgical removal, keloids frequently recur unless treatment is followed by appropriate adjuvant therapy. This means that managing keloids is often an ongoing process rather than a single procedure.

This is why treatment plans for keloids in particular require persistence, realistic expectations, and close follow-up with a dermatologist who is experienced in scar management.

Assess Your Scar Before Treating Keloids and Hypertrophic Scars

Distinguishing a keloid from a hypertrophic scar before starting treatment is essential, because the two conditions differ in recurrence risk, treatment response, and how aggressively they need to be managed. Your dermatologist will evaluate the following before recommending a treatment plan:

• Scar Type (Hypertrophic vs. Keloid): Hypertrophic scars stay within the wound margins and may improve on their own. Keloids extend beyond the wound and require more aggressive intervention to achieve meaningful, lasting improvement.
• Scar Age: Newer scars that are still in an active, red phase tend to respond better to treatment than older, more established scars. Starting treatment early, particularly for known keloid-prone patients, produces better outcomes.
• Scar Location: Scars on the chest, shoulders, and upper back are at particularly high recurrence risk after treatment. Location affects which techniques are safest and most effective.
• Symptoms: Pruritus (itching), pain, and tenderness within the scar tissue are signs of active collagen remodeling and indicate that the scar may respond well to injection-based therapy.
• Prior Treatment History: Understanding which treatments have already been attempted, and with what results, helps the dermatologist avoid repeating ineffective approaches and build a plan tailored to the specific scar.

A thorough evaluation at Connolly Dermatology ensures that the right treatment is selected for your specific scar type, location, and history before any procedure begins.

Treating Keloids and Hypertrophic Scars: Treatment Options Compared

The right treatment depends on whether the scar is a keloid or hypertrophic scar, how old it is, where it is located, and how it has responded to any prior treatment. In many cases, a combination approach produces significantly better results than any single treatment alone.

Corticosteroid Injections

Corticosteroid injections, most commonly triamcinolone acetonide, are the most widely used and well-established first-line treatment for both keloids and hypertrophic scars. The steroid is injected directly into the scar tissue at regular intervals, typically every 4 to 6 weeks. This reduces inflammation, suppresses the overactive fibroblasts driving excess collagen production, and progressively flattens and softens the scar over a series of sessions. Most patients see meaningful improvement after 3 to 6 injections, though the number of sessions needed varies by scar size and type.

Tips to improve outcomes with corticosteroid injections:

• Do not skip scheduled injection appointments, as consistent treatment intervals are important for sustained response
• Report any skin thinning or pigment changes at the injection site promptly
• Consider pairing injections with silicone sheeting between sessions for added benefit
• Begin treatment as early as possible after a keloid or hypertrophic scar forms

Silicone Gel Sheets and Topical Silicone

Silicone sheeting and topical silicone gel are well-supported, non-invasive first-line options for hypertrophic scars and as adjuvant therapy for keloids. Applied consistently over the scar for 12 or more hours per day, silicone hydrates the scar tissue, regulates collagen production, and helps flatten and fade the scar over time. Silicone is most effective for newer, active hypertrophic scars and as a complementary treatment alongside injections or laser therapy for keloids.

Laser Treatments

Laser therapy is most effective as part of a combination treatment plan for keloids and hypertrophic scars. Pulsed dye laser (PDL) targets the abnormal blood vessels within active, red scars, reducing redness and helping to flatten the scar over a series of sessions. Fractional laser resurfacing can improve the surface texture and overall appearance of the scar. Laser treatments alone are generally insufficient for keloids, but when combined with corticosteroid injections, they can produce significantly better outcomes than either treatment used alone.

Cryotherapy

Cryotherapy applies liquid nitrogen to freeze scar tissue from the inside out, destroying the excess collagen within the lesion. It is most effective for smaller keloids and hypertrophic scars and is often combined with corticosteroid injections for a synergistic effect. Cryotherapy can cause temporary or permanent pigment lightening at the treated site, which is an important consideration for patients with darker skin tones.

Intralesional Treatments (5-FU and Bleomycin)

For keloids that have not responded adequately to corticosteroid injections alone, intralesional injection of 5-fluorouracil (5-FU) or bleomycin can be used to directly inhibit the fibroblast activity driving excess collagen production. These agents are typically used in combination with corticosteroid injections for resistant or recurrent keloids and are reserved for cases where standard first-line approaches have not produced sufficient improvement.

Surgical Excision With Adjuvant Therapy

Surgical removal of a keloid or hypertrophic scar alone carries a very high recurrence rate, particularly for keloids, which frequently return larger than the original scar after excision without additional treatment. When surgery is indicated, it must be combined with adjuvant therapy, typically corticosteroid injections beginning shortly after excision, silicone sheeting, or in selected cases, postoperative radiation therapy. Surgical excision is better suited to hypertrophic scars with lower baseline recurrence risk, and to keloids in patients who commit to rigorous postoperative follow-up.

Combination Plans

Combination therapy consistently produces better outcomes than monotherapy for both keloids and significant hypertrophic scars. Commonly used combinations include corticosteroid injections plus pulsed dye laser, cryotherapy followed by steroid injections, and surgical excision followed by steroid injections and silicone sheeting. The specific combination is tailored to the scar type, size, location, and prior treatment history.

Quick Comparison Table

Timeline And Expectations: How Long Treatment Takes

When treating keloids and hypertrophic scars, the most common question is: how much improvement is realistic, and how long will it take? Setting accurate expectations requires understanding that scar remodeling is a gradual biological process, and that the goal of treatment is significant reduction in scar volume, firmness, redness, and symptoms rather than complete elimination.

The extent and speed of improvement depend on the scar type, its age, the treatments used, and how consistently the treatment plan is followed. A realistic timeline often looks like:

Weeks 1 to 4: Following the first corticosteroid injection or cryotherapy session, some initial softening and flattening of the scar may become perceptible within 2 to 4 weeks. Symptoms such as itching and tenderness often improve before visible changes in scar size are apparent.

Months 1 to 3: With continued injection sessions every 4 to 6 weeks, progressive flattening, reduction in firmness, and fading of redness become increasingly visible. Most patients notice meaningful improvement after 3 treatment sessions.

Months 3 to 6: Patients who respond well to treatment typically show significant improvement at this stage. The scar is flatter, softer, less symptomatic, and closer in color to the surrounding skin. Additional sessions may be continued depending on the remaining scar volume.

Months 6 to 12+: Long-term monitoring continues, particularly for keloids, to identify early signs of recurrence while the scar is still small and most responsive to retreatment. Maintenance injections may be recommended for keloid-prone patients at high-risk locations.

Preventing Recurrence After Treatment

Because keloids in particular carry a significant recurrence risk, prevention and monitoring after treatment are as important as the treatment itself. Here are key steps to protect your results and catch any early recurrence before it progresses:

• Protect healing wounds and surgical incisions from tension by minimizing movement in the area during the early healing phase
• Apply silicone sheeting to healing scars for at least 12 hours per day for a minimum of 3 to 6 months after a wound closes
• Inform your dermatologist, surgeon, or any provider performing skin procedures about your history of keloid formation before any procedure is performed
• Avoid elective procedures (such as piercings) in body areas where you have previously formed keloids
• Return for a follow-up evaluation at the first sign of scar regrowth, as smaller recurrences respond much better to retreatment than larger established keloids
• Continue using any prescribed topical therapies or silicone products as directed after your injection series is complete

How Connolly Dermatology Helps With Treating Keloids and Hypertrophic Scars

At Connolly Dermatology, we take a clinical, comprehensive approach to scar management. We do not guess. We begin with a thorough evaluation of your scar, its type, age, location, and prior treatment history before recommending any procedure. Once we have a complete picture, our team will build a personalized combination treatment plan designed to flatten, soften, and reduce your scar as effectively as possible while minimizing the risk of recurrence.

If you are ready to take the first step toward flatter, more comfortable skin, let us begin your journey. Book an appointment with Connolly Dermatology today.