How much do you know about keloid scar treatment? Principles of management to reduce recurrence

The goal of keloid scar treatment is not 'complete removal', but rather reducing its size, soothing symptoms like itching and pain, and improving its appearance while suppressing recurrence. Since a keloid is an abnormal scar that grows beyond the boundaries of the original wound into normal skin, it is rarely cleared up nicely with a single treatment. Therefore, in most cases, a 'combination therapy' approach is used, combining methods such as intralesional steroid injections, silicone, compression, and lasers to suit the condition.

In particular, it is important to note that keloids do not disappear on their own over time. If left untreated, they may actually grow or spread. Therefore, accurately diagnosing the 'activity' of the scar and establishing a treatment plan based on that state is the very first step. Gangnam Onlif Clinic views keloids from this perspective—directing non-surgical procedures from a dermatological standpoint to control tissue activity.

🔍 What exactly is a keloid?

A keloid is a raised scar that occurs when excess collagen is produced during the wound healing process. The core causative cells are **fibroblasts (Fibroblast)**, which are abnormally active and continue to build up collagen.

The biggest risk factor is **genetic predisposition, the so-called 'keloid constitution'**. About 1 to 2% of the total population has this constitution, with a high incidence in African, Asian, and Hispanic populations. The most common age of onset is between 10 and 30. It easily occurs in areas with high skin tension, such as the anterior sternum, earlobes, shoulders, upper arms, and jawline.

One reassuring point: Keloids are benign lesions, they are not contagious, and they do not turn into cancer. However, if they suddenly grow or are accompanied by ulceration or bleeding, they need to be differentiated from other diseases, so it is best to seek medical attention.

📌 Key Summary: Keloids are caused by the overproduction of collagen by fibroblasts, have a strong constitutional factor, and are benign scars that do not disappear on their own.

⚖️ How do keloids and hypertrophic scars differ?

The two types of scars are often confused, but their management directions are different. The most reliable points of differentiation are **'whether they cross the boundaries of the wound' and 'whether they improve naturally'**.

While time can be the cure for hypertrophic scars, this is not the case for keloids. If it grows beyond boundaries and does not shrink on its own, it is highly likely to be a keloid, and is approached as a subject for active management.

📌 Key Summary: If it grows beyond the boundary of the wound and does not improve naturally, it is a keloid; if it stays within the boundary and has the potential to improve, it is a hypertrophic scar.

💉 What keloid treatments are available?

For keloids, combination therapy is better than a single treatment for both suppressing recurrence and improving symptoms. Here is a summary of the representative methods.

Intralesional Steroid Injection (First-line Treatment)

The most common first-line treatment is drug intralesional injection. It is used to suppress the activity of hyperplastic tissue and reduce its size. It is usually repeated at intervals of 3 to 6 weeks, with response rates reported to be around 50 to 100% and recurrence rates around 9 to 50% in literature.

If the response is insufficient, it is used in combination with steroids. If there is no response even to anticancer drugs that suppress fibroblast proliferation, other drugs are sequentially reviewed to observe the response.

Silicone Gel/Sheet (Prevention/Adjuvant)

Silicone gels and sheets are the primary non-invasive choice for scar prevention and early management. They must be used consistently for more than 12 hours a day, for at least 2 to 3 months, to be meaningful. However, it is difficult to eliminate already mature keloids with these alone.

Compression Therapy

Applies continuous pressure to the tissue to suppress hyperproliferation. It is recommended to maintain a pressure of approximately 20 to 30 mmHg for several months to over a year. For earlobe keloids, **pressure earrings** are sometimes used, and studies have shown that when compression is combined, the recurrence rate is reduced to about 5%.

Laser Treatment

**Laser treatment is used to improve vascular symptoms such as redness and itching, improve surface texture, or assist in drug delivery. It is not realistic to completely eliminate keloids with laser alone; instead, it creates synergy when used alongside injections and compression.

📌 Key Summary: Steroid injections are primary, and combination therapy that combines silicone, compression, and lasers to match the condition is the standard.

⚠️ Won't they recur if cut out surgically?

This is a point of misunderstanding for many people. The recurrence rate for surgical excision alone is reported to be 45 to 100%, meaning that they almost always recur. This is because keloids create a vicious cycle where a new wound forms where it was cut, and that wound turns into a keloid again.

Therefore, even if surgery is unavoidable, adjuvant therapy must be combined. For example, if radiation therapy is started within 24 to 48 hours after surgery, the recurrence rate can be reduced to below 10%, and some studies report a recurrence suppression effect of over 90%. A fractionated treatment with a total dose in the range of approximately 12 to 20 Gy is used. However, radiation therapy must be approached with extreme caution in children and adolescents, as well as in areas adjacent to the thyroid, breasts, and gonads.

The direction in which Onlif Clinic views keloids is slightly different. Rather than surgical excision, we prioritize non-surgical management that diagnoses the activity of the scar and combines intralesional drug injections, lasers, and compression therapy. Instead of stimulating the tissue to create new wounds, this approach focuses on suppressing and stabilizing hyperplastic tissue activity.

📌 Key Summary: Surgery alone has a very high recurrence rate, so adjuvant therapy is absolutely necessary, and Onlif prioritizes non-surgical management of the lesion.

📈 How do you check the progress of the treatment?

Keloid treatment is not completed in a single session, but should be viewed as a long-term maintenance concept. Depending on the activity, treatments are often continued over multiple sessions at 3 to 4-week intervals initially.

Standardized scar assessment scales like the Vancouver Scar Scale (VSS) or POSAS are used to judge progress. These tools score changes in color, thickness, flexibility, and subjective symptoms to objectively check trends. After treatment, regular observation for usually 1 to 2 years is required to determine whether there is a recurrence.

For reference, evidence that topical agents such as onion extract gel alone significantly reduce keloids is limited. There are also adjuvant topical agents being researched for the purpose of suppression through immune regulation, such as imiquimod, but it is accurate to understand them strictly as playing an auxiliary role.

📌 Key Summary: Keloids require long-term management, and it is recommended to evaluate progress with VSS and POSAS and observe regularly for 1 to 2 years.

🛡️ How do you prevent keloids?

If you have a keloid constitution, prevention is the most reliable strategy. The key is to avoid creating new wounds.

• Carefully decide on unnecessary piercings, tattoos, and cosmetic procedures

• If a wound occurs, manage it with silicone gel or sheets from an early stage

• Avoid irritation on high-risk areas for recurrence, such as the ears, chest (sternum), shoulders, upper back, and jawline

• If there is a family history, consult in advance before a procedure to check the risks

When dealing with skin concerns, there are also points of intersection with other aspects like texture, elasticity, and volume. The way Onlif addresses skin texture and elasticity through non-surgical procedures such as ultrasound HIFU, high-frequency RF, and skin boosters follows the same vein—a direction of lifting away the concerns that have been overshadowing the skin, without harming its natural state.

📌 Key Summary: For those with a keloid constitution, avoiding unnecessary wounds and managing wounds with silicone from an early stage is the best prevention.

❓ Frequently Asked Questions (FAQ)

Do keloids disappear on their own?

No. Unlike hypertrophic scars, keloids rarely undergo natural regression, and tend to maintain their size or even grow larger over time. Rather than waiting for it to get better on its own, it is better to have its activity diagnosed and managed.

What is the most effective treatment for keloids?

Combination therapy is more effective than a single treatment. The best results for recurrence suppression and symptom improvement are achieved when intralesional steroid injections are used as a base and combined with silicone, compression, laser, or 5-FU depending on the condition.

How often should steroid injections be administered?

They are usually repeated at intervals of 3 to 6 weeks at a concentration of 10 to 40 mg/mL. Depending on the activity and response of the keloid, they are often continued for 3 to 6 times or more initially, and the exact number of times is determined after diagnosis.

Can lasers completely remove keloids?

It is difficult to completely eliminate them with laser alone. PDL plays a supporting role in helping with redness and itching, while fractional CO₂ helps with surface texture improvement and drug delivery, and they create synergy when combined with injection and compression therapies.

Is health insurance applicable to keloid treatment?

If accompanied by functional symptoms such as pain, itching, or contracture, partial benefits may be applied. However, as it varies depending on the state of the scar and the purpose of treatment, it is most accurate to check individually during your consultation.

How do you treat a keloid that formed after an ear piercing?

In many cases, compression therapy, such as pressure earrings, is combined with intralesional drug injections. Studies have shown that when magnetic compression is used after excision, the recurrence rate is reduced to about 5%, making recurrence prevention management particularly important.

Can a keloid turn into cancer?

No. Keloids are benign lesions, are not contagious, and do not turn into cancer. However, if it grows rapidly or if ulceration or bleeding appears, differentiation from other diseases is required, so please seek medical attention.

Can I receive keloid treatment during pregnancy?

During pregnancy, certain drug injections or radiation therapy may be restricted. Since non-invasive management like silicone and compression is often considered first, you must inform your doctor of your pregnancy and decide on a safe method through consultation.

Keloids are scars whose course varies greatly depending on individual constitution and condition. Therefore, rather than a standardized answer, accurately diagnosing the activity and type of your scar and then establishing a direction is more important than anything else. We recommend checking through a consultation for an accurate diagnosis and a management plan tailored to you. Gangnam Onlif Clinic aims for a direction that helps stabilization without excessive irritation, through personalized designs matched to the scar type and tissue condition.