Yes, and that history is common. Recurrence after simple excision is one of the defining features of keloid scarring, which is why the approach here is to reduce the drive to the scar rather than to remove tissue and hope.
Overview
The opposite problem to a depressed scar
A raised scar and a depressed scar are opposite problems. Treating them the same way is how keloids get worse.
This page covers scars that were made by something other than acne: surgery, accidents, burns, bites and piercings — and the raised, thickened scars that some of them turn into. What they share is that the tissue healed under tension, or healed too enthusiastically, or both.
Hypertrophic and keloid scars are the result of an over-enthusiastic healing response. Collagen keeps being laid down after the wound has closed, producing tissue that is thick, red, often itchy, and — in the case of a true keloid — extends beyond the boundary of the original injury. Keloids rarely resolve on their own and frequently recur after simple surgical excision, which is why cutting one out is seldom the first answer.
The logic here is the reverse of atrophic scar work. Rather than stimulating collagen, the aim is to calm an overactive process: reduce the vascular drive, soften the collagen already deposited, and control the itch and tension that keep the cycle running.
Treatment is almost always a combination rather than one thing, and the evidence is unusually clear about which combination. Intralesional corticosteroid on its own is the familiar first step and is not the best one: in a double-blind randomised trial, adding 5-fluorouracil to the steroid produced good-to-excellent improvement in 55 per cent of patients against 20 per cent with steroid alone, and the skin thinning and visible thread veins that follow steroid were less frequent. The trial was small and followed patients for twelve weeks. Vascular laser is added where the scar is red and active. That triad is the backbone of what we do here.
At a glance
- Treatment timeMinutes for a small scar; about 10 for a palm-sized area
- AnaestheticUsually none; topical if required
- DowntimeMild redness for up to an hour; possible bruising for 7–10 days
- SessionsInjections every 3–4 weeks; laser every 4–6 weeks, over months
- ResultsGradual over weeks to months by scar type
- Combines withIntralesional therapy, CO2 laser, silicone and pressure
How it works
Take the drive out of the scar
First, the distinction that governs everything else. A hypertrophic scar stays within the borders of the original wound and may settle on its own over a year or two. A keloid grows beyond those borders, does not regress spontaneously, and recurs readily. They look similar and behave completely differently, which is why an active hypertrophic scar less than a year old is usually left alone and supported rather than operated on.
The pulsed dye laser targets the blood vessels inside a red, active scar. Destroying that microvasculature reduces the supply to the fibroblasts driving the scar, and laser-treated keloid tissue shows reduced TGF-β1 signalling in the laboratory. We describe that as the proposed mechanism because that is what it is — guideline bodies recommend this laser specifically for reducing the erythema of recent, strongly vascularised scars, not for flattening them.
Thickened and established scars need the injectable work. Corticosteroid softens collagen already deposited; 5-fluorouracil suppresses the fibroblasts still laying it down; the two together outperform either alone. Silicone and pressure are reasonable, cheap and guideline-endorsed adjuncts — and their evidence is weaker than their ubiquity suggests, which we would rather say than imply otherwise.
Smoking meaningfully reduces the response and may mean more sessions are needed. That is worth knowing before you start.
Indications
Suited to
- Post-surgical scars, from fresh and red to old and tethered
- Traumatic scars after accidents, lacerations, burns and bites
- Keloid scars extending beyond the original wound
- Hypertrophic scars — raised but within the wound boundary
- Itchy or tender scars
- Scars after burns, trauma or piercings
- Post-surgical scars on the chest, shoulders and earlobes
- Excision of a keloid without a planned adjuvant protocol agreed in advance — we will not do it
- Ablative fractional laser on an active keloid, which guidelines specifically advise against
- Surgery on a hypertrophic scar under a year old that is neither restricting movement nor disfiguring
- Active infection in the field
- An expectation of removal rather than control
In the clinic
Step by step
Assessment
Whether the scar is still active matters more than how old it is. Active, growing scars are calmed before anything is resurfaced.
Vascular laser
The pulsed dye laser is passed over the scar. Small scars take minutes; a palm-sized scar takes around ten.
Intralesional therapy where needed
Corticosteroid, sometimes combined with other agents, softens established collagen in thick or keloid scars.
Repeat at two-week intervals
A minimum of three sessions is recommended, and thicker scars will need more.
Maintenance
Silicone, pressure and sun protection support the result and reduce recurrence risk.
Recovery
What to expect afterwards
Mild redness and a tingling sensation may last up to an hour. Where the scar is red because of vessel growth, a temporary violet to dark discolouration can appear as those vessels break down, lasting seven to ten days. This is expected and resolves.
Timing matters with new scars. A fresh surgical scar treated early often ends up far better than the same scar treated two years later. If you have a planned operation, ask us about treating the scar from around the time the sutures come out.
After vascular laser
Redness and tingling for up to an hour at low settings. Where the scar is strongly vascular, a violet discolouration appears as the vessels break down and lasts seven to ten days.
After intralesional injection
Soreness at the site for a day or two. The scar softens over the following weeks rather than immediately.
Between sessions
Injections are repeated at three- to four-week intervals; laser at four to six weeks. Most courses run for several months.
Months three to twelve
Flattening, fading and — usually first — relief of itch and tension. The itch going is often the earliest sign that the scar is becoming inactive.
Afterwards
Keloids are followed up long term, not discharged. Recurrence is part of the natural history of the condition and is easier to deal with early.
Risks
What can go wrong
Expected
Soreness after injection; bruising after vascular laser at vessel-destroying settings.
Uncommon
From corticosteroid: thinning of the skin at the injection site, visible thread veins and pigment change — in the randomised trials, atrophy and thread veins affected roughly a third of patients given steroid alone, and were less frequent where 5-fluorouracil was combined with it. Pigment loss is particularly conspicuous in darker skin.
Rare but serious
Ulceration at an injection site. With high cumulative steroid doses, systemic effects including menstrual disturbance. Recurrence after excision — which is not rare at all: between 45 and 100 per cent after excision alone, and the recurrence is often larger than the original.
Those recurrence figures are the reason the sequence here is conservative treatment first, surgery only when conservative treatment has failed, and never surgery without the adjuvant plan already agreed. Where excision is unavoidable, adjuvant radiotherapy brings recurrence down to around a tenth — that is a shared decision, taken with its own risks on the table.
Evidence
What the evidence shows
Strong for injectables, weak elsewhereThe best single piece of evidence in this area is the randomised double-blind trial of corticosteroid against corticosteroid plus 5-fluorouracil, and it points one way: more complete flattening, with less atrophy and fewer thread veins, from the combination. It was a small trial with twelve weeks of follow-up. A network meta-analysis of twenty-two trials agrees, ranking combinations above steroid alone — and finding that steroid monotherapy did not reach even a fifty per cent probability of being among the treatments that prevent recurrence.
For lasers, the Cochrane review concluded there is insufficient evidence to support or refute laser therapy for hypertrophic and keloid scars, and could not distinguish it from steroid or 5-fluorouracil. Guideline bodies still recommend the pulsed dye laser for the erythema of a recent vascular scar, which is the narrower claim we make here.
For silicone, Cochrane found improvements in thickness and colour but described the trials as poor quality and highly susceptible to bias. For pressure garments, one meta-analysis found small benefits and a separate Cochrane review found the evidence insufficient to recommend them. Both are safe, cheap and reasonable. Neither is proven, and the British Association of Dermatologists states plainly that there is no cure for keloids and no evidence that any one treatment is better than another. We start from that, and then tell you what the combination data adds.
If you are travelling
Neither injection nor low-setting laser prevents flying. A vessel-destroying laser setting means roughly ten days of bruising to plan around.
This is, however, the treatment on this site that least suits a single visit. Injections at three- to four-week intervals over several months is the protocol that works, and for an international patient it usually means we set the plan and a local dermatologist delivers part of it, with review here.
If you have surgery planned, the most valuable thing we can do is see you before it. A scar treated from around the time the sutures come out generally ends up far better than the same scar treated two years later — and in a patient known to form keloids, the preventive plan agreed before the operation matters more than anything available afterwards.
Questions
Good to know
If your question is not here, ask it in the enquiry form — Dr. Henningsen answers these personally.
Ask a question- My keloid was cut out and came back bigger. Can anything be done?
- How soon after surgery can a scar be treated?
Often from around the time sutures are removed. Early intervention on a red, active scar generally produces a better final result than treating a mature one.
- Does smoking really matter?
It does. Laser scar treatment is less effective in smokers, and more sessions are typically required.
- Will the scar disappear?
No. The realistic goal is a scar that is flat, pale, comfortable and no longer the first thing you or anyone else notices.
Consultation
Ready to talk about your skin?
Consultations with Dr. Henningsen are arranged individually. Tell us what you would like to change and we will come back to you with the options, the honest downtime and the realistic result.