Keloid Scars: Why Do They Keep Growing? Key Care Tips to Prevent Recurrence

A keloid is not a scar that remains 'strictly within' the injured area. It is a collagen hyperplastic scar that grows and spreads beyond the boundaries of the original wound into the surrounding normal skin. While ordinary scars subside over time, keloids often harden and grow larger. Therefore, the mindset of "it will get better if left alone" is the most dangerous.

First, let's cover the key points. Keloids do not resolve on their own, and if merely removed surgically, the recurrence rate is as high as 45% to 100%. Rather than 'complete elimination,' the goals of treatment are to reduce size, relieve symptoms such as itching and pain, suppress recurrence, and manage the condition over the long term. If you merely apply ointment on your own or leave it untreated, the tissue can continue to grow.

🔍 Keloids vs. Hypertrophic Scars: What's the Difference?

The two scars look similar on the surface as raised lesions, often causing confusion. However, differentiation is clinically essential because the treatment approaches are entirely different.

The biggest differences are the 'boundary' and 'time.' Hypertrophic scars remain confined within the boundaries of the original wound and tend to gradually flatten as redness fades after 6 to 18 months. In contrast, keloids grow beyond the wound boundaries and do not subside on their own over time. A height typically exceeding 4 mm is also used as one of the distinguishing criteria.

For reference, keloids are benign scars, are not contagious, and generally do not develop into cancer. Even if they appear severe in shape, keep in mind that they are fundamentally different from cancer.

📌 Key Takeaway: If it grows beyond the wound boundaries and does not subside on its own, it is likely a keloid; if it stays within the boundary and flattens over time, it is more likely a hypertrophic scar.

🧬 Why Do Keloids Form?

When the skin is injured, **fibroblasts** become active and produce **collagen** to heal the wound. Under normal conditions, they produce just the amount needed and then stop. In keloids, these cells become abnormally hyperactive and continuously pour out collagen without stopping. This excessive accumulation of collagen is the direct cause of keloids.

Therefore, almost all treatments ultimately aim toward a single goal: suppressing excessive fibroblast activity and inhibiting collagen production.

Constitutional predisposition plays a major role in its development. Known risk factors include the following:

• Darker skin tones: The prevalence is up to 16% in Black populations, 4.5–16% in Hispanic populations, and around 10% in Asian populations, whereas it is less than 0.1% in Caucasian populations.

• Younger age: Most commonly occurs between the ages of 10 and 30.

• Family history: About one-third of patients have a family history.

• Sex: Approximately twice as common in females than in males, with piercing frequency and hormonal influences cited as contributing factors.

• Specific anatomic sites: Among Asians, the occurrence sites rank in the order of the anterior chest (48.9%), shoulders (26.9%), lower jaw/neck (12.1%), and upper arms (4.8%).

In addition, lifestyle habits that support skin healing, such as quitting smoking and abstaining from alcohol, cannot be overlooked. Smoking and drinking hinder wound recovery and work toward increasing the risk of scarring.

📌 Key Takeaway: Keloids are constitutional scars caused by fibroblasts overproducing collagen, with darker skin tones, young age, family history, and predilection sites like the chest being major risk factors.

💉 How Are Keloids Treated and Managed?

Remember this one core principle: Combination therapy is more effective than monotherapy for keloids, and long-term follow-up management is essential. This means it is not a condition resolved with a single procedure.

First-Line Treatment: Intralesional Steroid Injections

The most widely used first-line treatment is intralesional steroid injection, such as triamcinolone. The medication is injected directly into the scar to suppress fibroblast activity. **Scar flattening efficacy is reported at 50% to 100%**, but since the recurrence rate is non-negligible at 9% to 50%, it is usually repeated at intervals of 3 to 6 weeks. When the response to steroids is slow, antimetabolite drugs such as 5-fluorouracil (5-FU) may be combined.

Non-Invasive Management: Silicone and Compression

Silicone gel and silicone sheets are the non-invasive gold standard, used for prevention and early-stage management. However, to see results, they must be applied consistently for at least 12 to 24 hours a day for a minimum of 2 to 3 months to over 3 to 6 months. Using them briefly and stopping will not produce the expected benefits.

In particular, for areas with frequent postoperative recurrence, such as ear keloids, **compression therapy (pressure earrings, compression garments)** is combined. By suppressing collagen synthesis to prevent recurrence, wearing them for 12 to 24 hours a day for at least 4 to 6 months is frequently recommended.

Laser and Physical Therapies

Different types of lasers serve different roles:

• Pulsed Dye Laser (PDL): A representative vascular laser used to alleviate keloid redness, vascular reactions, and itching.

• Fractional CO₂ Laser: Used in combination to assist scar tissue remodeling and drug penetration.

• Cryotherapy: A therapy that destroys tissue with liquid nitrogen, effective for small keloids and combinable with steroids.

In addition, botulinum toxin is being studied as an adjuvant therapy to reduce tension and inhibit fibroblasts.

Proceeding with Surgery Cautiously

**Surgical excision** alone carries a very high recurrence rate of 45% to 100%. Therefore, if surgery is performed, it must be combined with adjuvant therapies such as radiation therapy or steroid injections. In fact, it is reported that starting radiation therapy within 24 to 72 hours after surgery lowers the recurrence rate to about 10% to 30% or less. However, radiation requires caution in children, pregnant women, and areas adjacent to the thyroid, breasts, or gonads, necessitating interdisciplinary collaboration with radiation oncology.

In summary, going under the knife is not the ultimate answer. Greater caution is needed especially for high-tension areas like the anterior chest and shoulders. Many keloids can be managed through non-surgical care combining lasers, drug injections, and compression to suppress their activity. Gangnam Onlif Clinic also approaches treatment by first diagnosing the scar's activity, then alleviating tissue adhesion with lasers and formulating a plan that combines intralesional drug injections and compression therapy. Initially, management for 3 to 6 or more sessions at 3 to 4-week intervals is typically recommended.

📌 Key Takeaway: Steroid injections are first-line, while silicone, compression, and lasers are adjuvant; surgery alone carries a high recurrence rate and must be combined with adjuvant therapy.

🛡️ Why Keloid Prevention Is Even More Important

Once formed, keloids are challenging to manage. Therefore, if you have a predisposition, preventing wounds in the first place is the best form of management.

Prevention boils down to four key elements: suppressing wound occurrence, early interception of inflammation, reducing skin tension, and sun protection. In particular, if you have a family history of keloids or past experience with them, it is much safer to strictly avoid intentional skin trauma such as piercings, tattoos, and unnecessary cosmetic procedures.

Let's clear up one misconception here. It is not true that "every wound turns into a keloid if you have a keloid predisposition." Even with a predisposition, outcomes vary depending on the anatomic site, wound depth, and tension. It simply means taking extra care because the risk is higher. Another point: itching is not necessarily 'a good sign of healing.' In keloids, itching can be a signal that the lesion is actively progressing.

If you have upcoming surgery, simply informing the team in advance that "I have a keloid predisposition" can alter the suture techniques and post-care strategies.

📌 Key Takeaway: Prevention centered on minimizing wounds and managing tension, inflammation, and UV exposure is crucial for keloids; those predisposed must avoid unnecessary skin trauma.

❓ Frequently Asked Questions (FAQ)

Do keloids require lifelong management?

Yes. The goal of keloid scar treatment is to reduce size, relieve symptoms, and suppress recurrence. Due to constitutional factors, it is practical to monitor progress and manage them over the long term even after treatment.

Will a keloid recur if removed surgically?

If surgery alone is performed, the recurrence rate is exceptionally high at 45% to 100%. Therefore, when undergoing surgery, adjuvant therapies such as radiation or steroid injections must be combined. In many cases, non-surgical management combining lasers, drug injections, and compression is considered first instead of surgery.

How many steroid injections are needed?

They are usually repeated at intervals of 3 to 6 weeks, and the number of sessions varies depending on the scar's activity and extent. While scar flattening efficacy is good, the potential for recurrence means it rarely ends with a single session. The exact number of sessions is customized after diagnosis.

How long should I keep silicone sheets on?

To expect visible effects, they must be applied consistently for 12 to 24 hours a day for at least 2 to 3 months to over 3 to 6 months. They are used for early scar management and prevention, and their efficacy drops if stopped after brief use.

Are treatments effective on old keloids?

Yes. Current activity—that is, whether it is currently expanding or stable—is a more important criterion than when it first occurred. Even for old keloids, a treatment direction can be established through clinical evaluation.

Are lasers effective for keloids? Which type is suitable?

Different types of lasers serve different roles. Pulsed dye lasers (PDL) are used for redness and itching, while fractional CO₂ lasers assist tissue remodeling and drug penetration. Better results are usually expected when combined with drug injections and compression rather than used alone.

It is difficult to self-diagnose whether a lesion is a keloid or a hypertrophic scar based solely on appearance or symptoms. Because management strategies differ depending on activity and extent, we recommend confirming an accurate diagnosis and treatment plan through a specialist consultation.

What to Check Before Choosing a Clinic for Keloids

Even for the same procedure, results and recovery courses vary depending on where, by whom, and how it is performed. Asking the following questions during your consultation will help you make an informed decision.

• Is this a procedure performed frequently at the clinic? — Main focus procedures vary by clinic. Check whether the clinic regularly treats keloids.

• Can you verify the products and equipment used? — Inquire during the consultation whether product names and authenticity (approved import status, unsealing verification procedures) can be confirmed.

• Is the cost breakdown clearly explained? — Rather than just hearing a lump sum, you need an explanation of which products are used, in what amounts, and across what areas to make an informed choice.

• Is the design planned with the whole face in mind? — Even for the exact same treatment, injection sites and dosages vary depending on facial shape, skin condition, and bilateral asymmetry.

• Are adverse reactions and the recovery process explained beforehand? — Rather than a consultation that only promises expected improvements, a clinic that explains potential adverse reactions and how to handle them is much better for making a sound decision.

• Is there a clear follow-up channel after the procedure? — Check whether follow-up check-in timelines, emergency contact methods, and criteria for return visits are clearly defined.

How Onlif Clinic Approaches Keloids

• We divide responsibilities — Based on the principle that a single doctor cannot master every single procedure, Onlif assigns dedicated physicians by specialty area.

• We review products and equipment together during consultation — We guide you through the products used and the unboxing/unsealing verification process during your consultation.

• Costs are presented with breakdown details after diagnosis — Because target areas, dosages, and coverage vary per person, we explain what costs apply to each aspect.

• We design while considering overall facial balance — Viewing the face across the three pillars of texture, balance, and youthfulness signals, we plan treatments to refine features that obscure your natural expression rather than altering your underlying shape.

• We explain adverse reactions and recovery beforehand — Along with expected improvements, individual differences, potential adverse reactions, and countermeasures are guided prior to treatment.

• We follow up on progress after treatment — If follow-up evaluation is needed during recovery, we provide return visit guidelines and contact channels.

If you are concerned about a keloid, it is best to first evaluate what is feasible and what is challenging in your current state. Accurate diagnosis and treatment planning can only be established through an in-person consultation. Find out more through a consultation at Gangnam Onlif Clinic.