Keloid and Hypertrophic Scar

What is a keloid?

A keloid is a fibrotic scar that forms during wound healing due to excessive production of connective tissue and collagen, and can extend beyond the original wound area.

It can develop after the following:

surgical incision,

piercing,

acne,

burn,

trauma,

Vaccine,

small cuts,

Sometimes very minor injuries that go unnoticed by the patient.

Keloids can develop within months and continue to grow over time. The AAD notes that some keloids can develop months after injury and slowly grow over months to years.

What is hypertrophic scarring?

A hypertrophic scar is also a raised scar, but it usually remains within the boundaries of the original wound.

It can develop after surgery, trauma, or burns.

Unlike keloids, hypertrophic scars develop over time:

may soften,

can be flattened,

It may become less noticeable.

The AAD states that hypertrophic scars mostly develop within the first few months after injury and may become less noticeable over time.

How to differentiate between keloids and hypertrophic scars?

The most practical distinction:

Hypertrophic scar

It remains at the edge of the wound.

Keloid

It goes beyond the boundaries of the wound.

However, not every lesion may be so clearly defined in the clinic. The boundaries can vary, especially in scars from previous surgeries or injections.

In differential diagnosis:

dermatofibroma,

dermatofibrosarcoma protuberans,

some benign tumors,

rare skin cancers

This should also be considered.

If the diagnosis is uncertain, a biopsy may be necessary. AAD also states that in some cases, a biopsy may be performed to rule out other conditions that resemble keloids.

What causes keloids?

There isn't just one reason.

In keloid development:

genetic predisposition,

fibroblast activity,

excessive collagen production,

mechanical stress,

inflammation,

some growth factors

plays a role.

Family history is important. AAD reports that approximately one-third to one-half of individuals who develop keloids have a similar family history.

Who is more likely to develop keloids?

Keloids can appear on any skin tone.

However, the risk may be higher:

in darker phototypes,

In those with a family history of keloids,

in those who have previously developed keloids,

in young adults.

The AAD reports that the risk is higher in people of Black, Asian, Latin American, or Mediterranean descent.

This does not mean that keloids will necessarily develop in a particular ethnic group.

In which areas do keloids occur more frequently?

Especially:

chest,

shoulder,

upper back,

jawline,

earlobe,

around the ear

These are high-risk areas.

Ear keloids, especially those resulting from piercings, are a common clinical example.

Can keloids form on the face?

It could be.

Especially:

jawline,

mandibular region,

beard area

They may be more prone to keloid formation.

Keloids can also develop after acne.

Therefore, in patients prone to keloid formation:

early control of acne,

avoiding unnecessary trauma,

Careful planning of cosmetic procedures

It is important.

Why do keloids itch or hurt?

Keloids are not just a cosmetic problem.

In some patients:

itching,

pain,

sensibility,

tension,

combustion

it could be.

Large keloids, or keloids near joints, can also lead to restricted movement. The AAD states that keloids can cause pain and itching and may restrict movement in some areas.

Will keloids disappear on their own?

Usually not.

While hypertrophic scars may regress significantly over time, keloids usually do not disappear completely without treatment.

Therefore, the expectation that "it will completely go away if I wait a few years" may not be realistic.

Is there a single best method for treating keloids?

No.

This is an important point.

In keloid treatment, a combination approach is often more successful.

The AAD also notes that no single treatment provides the best results for all keloids, and that a combination of multiple methods is often preferred.

Treatment:

size of the scar,

place,

thickness,

duration,

previous treatments,

history of relapse,

skin type

It should be planned accordingly.

What is the purpose of a cortisone injection?

Intralesional corticosteroids are one of the most commonly used methods for treating keloids and hypertrophic scars.

Aim:

soften the scar,

to reduce its height,

to reduce itching and pain,

suppress collagen production

it could be.

Usually, a series of injections are needed instead of a single session.

The AAD states that a significant proportion of keloids can shrink after corticosteroid injections; however, recurrence is still possible.

Are there any side effects of cortisone injections?

It could be.

Especially:

skin thinning,

telangiectasia,

depression,

pigment release

visible.

Therefore, dose, concentration, and depth of injection are important.

Combination therapies may help reduce steroid dosage in some cases.

Is 5-FU usable?

Yes.

5-fluorouracil (5-FU) can be used intralesionally in keloid and hypertrophic scars.

It can be used alone or in combination with corticosteroids.

AAD also lists 5-FU injections as one of the options used in the treatment of raised scars and keloids.

A combination approach may be considered, especially in resistant lesions.

Can bleomycin be used?

Intralesional bleomycin can also be used in selected resistant keloids.

The AAD's scar treatment guidelines list bleomycin as one of the intralesional options that can be used.

However, it is not the first choice for every patient and requires careful patient selection due to its side effect profile.

Does silicone gel work?

Yes.

Silicone gel or silicone sheet specifically:

in newly developing hypertrophic scars,

In scars at risk of keloid formation,

in the post-surgical conservative approach

available.

The AAD states that silicone sheets can be used to reduce the development of new keloids or lower the risk of recurrence after treatment.

Consistent use is important; using it for a few days and then stopping is usually not enough.

What is the purpose of compression therapy?

Especially:

ear keloids,

hypertrophic scars after burns

Pressure therapy can be used in some areas, such as those mentioned.

Special pressure earrings can be used for ear keloids.

The goal is to reduce the formation of new, excessive scarring by altering the mechanical and vascular conditions of the scar tissue.

The AAD states that compression therapy may help reduce the risk of recurrence after surgery.

Does cryotherapy work?

Yes.

Cryotherapy for small and prominent raised keloids:

scar height,

hardness,

itching

It can reduce.

It is sometimes combined with intralesional injections.

However, the risk of permanent hypopigmentation is significant, especially in darker phototypes. For this reason, the AAD also states that cryotherapy should be carefully selected for dark-pigmented skin.

Can laser treatment completely eliminate keloids?

Not always alone.

Lasers can be used for different purposes.

Pulsed Dye Laser (PDL)

Especially:

redness,

vascular density,

itching,

some raised scars

It can be used for.

Fractional lasers

It can be used for the regeneration of scar tissue.

Lasers are often used:

corticosteroid,

5-FU,

other treatments

It is combined with.

AAD also states that laser treatment can reduce keloid height and color, and is often used in combination with other treatments.

Can keloids be removed surgically?

Yes, but surgical excision alone is not the ideal approach for keloids.

Because removing the keloid itself creates a new scar, and that new scar can lead to the development of another keloid.

The AAD's patient guidelines state that recurrence rates after keloid surgery alone can be very high.

Therefore, surgery is usually:

steroid injection,

printing,

silicon,

radiotherapy,

other adjuvant methods

It is combined with.

“"Is it true that cutting off a keloid will definitely make it bigger?"

Such a definitive statement is not accurate.

More accurately:

Surgical excision alone carries a high risk of keloid recurrence.

With the right adjuvant therapy, the recurrence rate can be reduced.

Therefore, surgery should not be viewed as a "ban," but rather as part of a combined treatment approach.

Is radiotherapy used for keloids?

In selected resistant or large keloids, adjuvant radiotherapy may be used, especially after surgical excision.

The goal is to reduce the risk of recurrence.

However:

dose,

anatomical region,

patient's age,

proximity to radiation-sensitive organs

It is important.

The AAD states that superficial radiotherapy can be used to reduce postoperative recurrence with appropriate safety precautions; however, potential long-term risks should be considered.

Therefore, it is usually not the first step.

Will the keloid recur?

Yes.

One of the biggest problems in keloid treatment is recurrence.

Risk of recurrence:

method,

to the region,

depending on the size of the lesion,

to the person's predisposition,

previous keloid history

It may vary depending on the situation.

Therefore, follow-up after the initial treatment is important.

How is ear keloid treated?

Keloids in the earlobe or helix area can develop especially after piercings.

In treatment:

Intralesional corticosteroid,

surgical excision,

headband earring,

silicon,

cryotherapy,

radiotherapy in selected cases

They can be combined.

Pressure earrings, especially after surgery, can help reduce the risk of recurrence.

Why is chest keloid treatment so difficult?

The chest and preternal region are subjected to high mechanical stress.

Because:

repeat,

expansion,

treatment resistance

It may happen more often.

In this field, a long-term and combined approach may be more realistic than single-session treatments.

Can acne cause keloids?

Yes.

Especially:

chest,

shoulder,

jawline,

upper back

Keloids can develop in these areas after inflammatory acne.

Therefore, controlling active acne is important for individuals prone to keloid formation.

Should I get a piercing?

In someone who has previously developed keloids, a new piercing may pose a risk for developing new keloids.

The Association of Dental Associations (AAD) states that avoiding piercings, tattoos, and unnecessary cosmetic skin trauma is one of the most effective preventive approaches for individuals prone to keloids.

The decision to get a new ear piercing should be made carefully, especially if you have developed a keloid from a previous ear piercing.

Is it possible to have cosmetic surgery if there is a tendency towards keloid formation?

Not every procedure is an absolute contraindication.

However:

surgical,

piercing,

deep ablation,

some traumatic procedures

A prior history of keloid formation should definitely be evaluated.

The decision should be made based on the risk zone, the depth of the process, and alternative methods.

Is it possible to prevent keloid formation?

It cannot be completely guaranteed.

However, in high-risk patients:

to avoid unnecessary trauma,

managing the wound correctly,

to prevent infection,

Appropriate silicone application after the wound has closed,

pressure in high-risk areas,

Dermatological intervention when early thickening begins

It can reduce the risk.

The AAD states that moist healing in wound care, followed by silicone and sun protection, can be beneficial, especially in individuals prone to keloids.

Does vitamin E prevent keloids?

Vitamin E, onion extract, and similar over-the-counter "scar creams" are frequently used.

However, the evidence regarding their effectiveness is not as strong as that of silicon. The AAD also notes that data on the effectiveness of products containing vitamin E and onion extract is limited.

Therefore, new scar treatment options with a higher level of evidence should be prioritized.

When should you consult a dermatologist?

Especially:

If the scar grows beyond the wound boundary,

if it is getting thicker,

if it causes itching and pain,

If it swells up quickly after surgery/piercing,

if there is a history of keloids,

if a new surgical procedure is planned,

if it recurs after treatment

Dermatological evaluation is appropriate.

Dermatologist's Note

The fundamental mistake in keloid treatment is thinking, "if we just cut out this tissue, the problem will be solved.".

In keloids, the problem is not just the existing tissue; it's the individual's wound healing response.

Therefore, we try not only to eliminate the scar but also to control the possibility of its recurrence.

My approach to keloids:

Height + redness + hardness + itching/pain + anatomical location + risk of recurrence

to evaluate in this way and in patients where necessary:

injection + laser + silicone/pressure + selected surgical techniques

It is about planning the combinations.

The goal isn't always "complete elimination in a single session"; it's about achieving a flatter, smoother, less symptomatic, and less noticeable scar, and reducing the risk of recurrence.

Frequently Asked Questions

Are keloids and hypertrophic scars the same thing?

No. While hypertrophic scarring remains within the wound boundaries, keloids can extend beyond those boundaries.

Will keloids disappear on their own?

Generally no. However, hypertrophic scars may regress further over time.

Will cortisone injections work?

Yes. It can soften and flatten keloids and reduce itching/pain; usually, a series of treatments are required.

Can keloids be completely resolved with surgery?

Surgery alone carries a high risk of recurrence; therefore, additional treatment is often necessary.

Is it possible to create a laser?

Yes. It can be used, especially in combination with other treatments, to reduce redness, thickness, and symptoms.

Does silicone gel work?

It can be particularly useful in cases of new scars and in patients at risk of keloid formation.

Can keloids recur after piercing?

The risk is higher after a new piercing in people who have previously developed keloids.