Here is the classic scenario during a consultation.
I’m discussing a procedur, let’s say a tummy tuck, where a longer scar is part of the outcome. As we go over incision placement and healing, the patient will pause and say:
“I’m worried… I tend to form keloids.”
The word keloid comes up frequently. It has almost become a catch-all term for “bad scarring.”
But in reality, true keloids are relatively uncommon—and often confused with something else entirely.
So what is the difference?
What is a Keloid?
A keloid is a benign overgrowth of scar tissue—essentially a form of excessive healing that behaves almost like a benign tumor.
Key characteristics:
- Grows beyond the boundaries of the original wound
- Can continue to expand over time
- Often appears thick, raised, shiny, and rubbery
- May be associated with itching or discomfort
- Has a high recurrence rate, even after treatment
- Keloids are not simply “worse scars.” They are a different biological process.
Keloids are not simply “worse scars.” They are a different biological process altogether.
What Is a Hypertrophic Scar?
A hypertrophic scar is much more common—and is often what patients are actually referring to.
Key characteristics:
- Raised, thickened scar
- May appear red or firm early on
- Confined to the original incision or wound
- Often improves over time
- Responds well to conservative treatments
In other words, a hypertrophic scar is an exaggerated but still controlled healing response.
Look, it’s confusing. At the end of the day just looking at the scar it can be confusing even for us physicians or experts who deal with this frequently. They both can look raised, firm, or even “fleshy”. What it ultimately boils down to is this
- Keloid → grows beyond the original scar
- Hypertrophic scar → stays within the original scar
Now you could argue and say “well if they look the same, does it matter that I call them one or the other?” Yes, here is why it matters.
Why This Distinction Matters
This is not just semantics—it directly impacts treatment and expectations.
Hypertrophic scars
- Often improve over time
- Respond very well to:
- Silicone therapy
- Steroid injections
- Laser treatments
- Surgical revision can be highly effective in improving the appearance
Keloids
- More unpredictable
- High recurrence rate after excision alone (often quoted up to 50–80%!!!)
- Always requires multimodal treatment, such as:
- Steroid injections
- 5 FU Injections (
- Pressure therapy
- Silicone sheeting
- Chemotherapeutic agent injection (5-FU) and/or low-dose radiation therapy after removal in difficult cases
As you can see, one get’s treated very conservatively and only in selected cases with revision surgery which yields great results. The other (Keloids) has a very high recurrence rate and might need to be treated with chemo medication or radiation – big difference. Because of this, identifying a true keloid tendency is important before elective surgery.
Who Is More Likely to Develop Keloids?
Keloids are more commonly seen in:
- Individuals with darker skin tones (particularly African, Afro-Caribbean, and some Asian populations)
- Patients with a family history of keloids
- Certain anatomical areas:
- Chest
- Shoulders
- Earlobes
- Upper back
They are relatively uncommon in fair-skinned individuals, although not impossible.
How Do You Know If You’re Prone to Keloids?
Two simple indicators:
- You already have a keloid from a previous injury, piercing, or surgery
- A close family member has developed keloids
If neither is present, the likelihood of true keloid formation is generally low.
Putting It Into Perspective
Most patients who worry about “keloids” are actually describing hypertrophic scarring—which is far more manageable and often improves with time and simple interventions.
This is an important distinction, especially when considering elective procedures.
Scarring is part of surgery. But not all scars behave the same way—and understanding that difference allows for better planning, better treatment, and ultimately more predictable outcomes.
What Can Be Done If You’re Concerned About a Scar?
If you’ve read this far, it’s likely because you’re wondering whether a scar you have—current or anticipated—might be a keloid or a hypertrophic scar, and more importantly, what you can do about it.
The answer depends, in part, on what type of scar you’re dealing with. But the good news is that there are several simple, low-risk measures that can be helpful in both cases—especially early on.
What You Can Try at Home
For both hypertrophic scars and early keloid formation, the following are commonly recommended:
- Silicone therapy (gel or sheets)
One of the most evidence-supported treatments. Helps regulate collagen production and can flatten and soften scars over time. - Gentle scar massage
Improves pliability and may help remodel scar tissue when performed consistently. - Sun protection (SPF 30 or higher)
Prevents discoloration and helps scars mature more favorably. - Topical hydration (petrolatum-based or scar creams)
Keeps the skin barrier healthy during the remodeling phase. - Pressure therapy (in selected areas)
More commonly used in certain locations like earlobes, but can be effective in reducing scar thickness.
These measures are most effective when started early in the healing process, typically within the first few weeks after wound closure.
A Note on Timing
Scar biology changes over time.
If you’ve had a scar for a long time and haven’t noticed any significant growth—particularly beyond its original boundaries—it is less likely to be a keloid. It also means that topical or conservative measures may have limited impact at that stage.
That doesn’t mean nothing can be done—but it does shift the conversation.
When to Consider Further Treatment
If a scar remains:
- Raised
- Symptomatic (itching, discomfort)
- Aesthetically bothersome
…there are more advanced options available.
These may include:
- Steroid injections
- Laser therapy
- Surgical scar revision
- Combination treatments (especially for keloids)
Because treatment strategies differ significantly between keloids and hypertrophic scars, it’s important to establish the correct diagnosis first.
When to Seek Evaluation
If you’re considering more definitive treatment—particularly procedures like scar revision or excision—it’s best to consult with a:
- Board-certified plastic surgeon, or
- Board-certified dermatologist
They can assess the scar, guide expectations, and tailor a treatment plan that minimizes recurrence and optimizes outcome.
Final Thought
Not every prominent scar is a keloid—and not every scar requires intervention.
But understanding what you’re dealing with is the first step toward managing it effectively and, when appropriate, improving both its appearance and behavior.
