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Dec 2024
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Management of Keloids and Hypertrophic Scars

Justin Bailey, MD
Megan Schwehr, MD
Alexandra Beattie, MD, MS

American Family Physician. 2024;110(6):605-611.

Author disclosure: No relevant financial relationships.

This clinical content conforms to AAFP criteria for CME.

Keloid and hypertrophic scars are a result of aberrant wound healing responses within the reticular dermis. They are thought to be secondary to the formation of a disorganized extracellular matrix due to excessive fibroproliferative collagen response. Prevention of these scars focuses on avoiding elective or cosmetic procedures such as piercings in patients at high risk, reducing tension across the lesion, and decreasing the inflammatory response. Topical treatments, including tension reduction with gel sheets, inflammatory reduction with corticosteroid ointments, and combined treatment with corticosteroid-infused tapes and plasters, can reduce scarring. Liquid nitrogen is beneficial, especially when injected into the scar through intralesional cryotherapy. Corticosteroid injection is effective for prevention and treatment. OnabotulinumtoxinA appears to be superior to both fluorouracil and corticosteroid injections for treating keloids and hypertrophic scars. Advanced treatment includes laser therapies (direct ablation, postsurgical, or laser-assisted drug delivery). Surgical revisions can be successful when tension-reducing techniques are used and when combined with other treatments such as postoperative steroid injection, laser ablation, and radiation therapy. For keloid prevention, corticosteroid injections administered 10 to 14 days postsurgery is superior to injections administered before or during surgery. Radiation therapy is considered safe with low cancer risk and can be used alone or in combination with other therapies.

Keloid and hypertrophic scars are formed through an aberrant response to the normal wound healing process. These scars are thought to occur when a disorganized extracellular matrix forms due to an excessive fibroproliferative collagen response.1 These prominent scars can be cosmetically and emotionally troubling for patients.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating Comments
Counseling patients with previous keloid and hypertrophic scarring to avoid elective procedures should be considered.10 C Expert opinion
Use of pressure dressings is first-line treatment for burn injuries and can reduce keloid thickness, erythema, and hardness.13 B Systematic review and meta-analysis of small trials
Cryotherapy effectively promotes keloid regression with multiple sessions, and intralesional cryotherapy appears more effective than spray cryotherapy.25 C Single randomized controlled trial of 50 patients with disease-oriented outcomes
Intralesional corticosteroids are effective for treatment of keloids and hypertrophic scars.27 C Expert opinion and very low-quality evidence of benefit in a systematic review
OnabotulinumtoxinA injection is an effective first-line treatment for keloids and hypertrophic scars, with clear benefit over placebo and improved pain and patient-reported effectiveness compared with corticosteroid injection.35,36 B Meta-analysis of clinical trials, case series, and case reports

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

Keloids are firm, raised, thick scars that occur in areas of previous skin trauma, extend beyond the border of the original wound, and progress over time (Figure 1). In comparison, hypertrophic scars do not extend beyond the original wound borders (Figure 2). Hypertrophic scars generally develop soon after an injury, whereas keloids may develop months or years later. Hypertrophic scars and keloids are compared in Table 1.2,3

JUSTIN BAILEY, MD, FAAFP, is an associate professor in the Department of Family Medicine at the University of Washington, Seattle, and director of the Procedure Institute at Full Circle Health, Boise, Idaho.

MEGAN SCHWEHR, MD, is a staff physician at the Terry Reilly Health Services, Caldwell, Idaho. At the time this article was written, she was a resident physician at the Full Circle Health Family Medicine Residency Program.

ALEXANDRA BEATTIE, MD, MS, is a faculty development fellow at Full Circle Health. At the time this article was written, he was a resident physician at the Full Circle Health Family Medicine Residency Program.

Address correspondence to Justin Bailey, MD, at justinbailey@fullcircleidaho.org.

Author disclosure: No relevant financial relationships.

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