Raised Scars, Explained (Keloids vs Thick Scars)

Most scars settle. They start red and raised, then over a year or so they soften, flatten and pale into something you stop noticing. When a scar doesn't do that — when it stays thick, or keeps growing — there are two possibilities, and telling them apart is genuinely the most useful thing you can do, because they behave differently, respond differently, and carry very different odds.

The line that decides everything: does it stay inside the wound?

Hypertrophic scars are raised, firm scars that stay contained within the site of the original injury, and they may regress over time. Under a microscope their collagen runs in a wavy but regular pattern. Their prognosis is described as good, with a real tendency to settle on their own and to respond to a single course of treatment.

Keloids spread beyond the borders of the initial injury into skin that was never damaged, and they do not regress. Their collagen has no distinct pattern. Their prognosis is worse, with a high rate of recurrence after treatment.

So find the original injury. If the raised tissue traces the line of the cut, the burn or the spot — that's the hypertrophic pattern, and time is on your side. If it has pushed out past it, often with claw-like extensions into normal skin, you're looking at a keloid, and waiting it out isn't a plan.

Who gets them

Raised scarring after wounding is not rare. Hypertrophic scars are reported in 39% to 68% after a surgical procedure and 33% to 91% after burns, and they occur across all skin tones. The most affected age group is 11 to 30 years old.

Keloids skew differently, and it's worth being plain about it because the risk is unevenly distributed:

• Skin tone. Keloids occur more often in people with darker skin complexions, with the highest prevalence reported in the African population, followed by Asian and Hispanic populations. The AAD notes that in the United States, Black people between the ages of 10 and 30 have the greatest risk, and that ethnic Chinese have the highest risk in Asia.
• Family history. About one-third of people who get keloids have a first-degree blood relative who also gets them.
• Pregnancy. Hormonal changes in pregnancy raise the risk.

What sets them off: surgery, cuts, burns, piercings, tattoos, insect bites, vaccinations, chickenpox, shingles, shaving, folliculitis and acne — anything that injures skin. Spontaneous keloids on uninjured skin exist but are rare.

Where: earlobes, shoulders, chest, upper back, cheeks and knees are the classic keloid sites; hypertrophic scars favour areas under tension. A keloid is far more likely to form on the chest than on the palm of a hand.

What a keloid looks and feels like

They're slower and stranger than people expect. The first signs typically take 3 to 12 months or longer after the injury, and about 20% appear more than a year later. Once one appears it often keeps growing for weeks or months.

They can be round, oval or oblong, and range from the size of a pimple to larger than a football. To the touch they're either hard and rubbery or soft and doughy. Colour usually starts red, pink or slightly darker than your natural tone, and often darkens as it grows. They may itch, burn, feel tender or hurt — symptoms that generally ease once growth stops, though not always.

And critically: once a keloid stops growing it tends to stay that size. Unlike other scars, it rarely fades without treatment.

Prevention is the part you actually control

Since treatment of an established keloid is difficult and recurrence is common, the highest-value moves all happen before or just after the injury.

Think hard before optional wounds. The AAD's guidance for keloid-prone people is that the best way to prevent an ear keloid is to skip the piercing altogether. If you proceed, watch for thickening and switch to a pressure earring at the first sign, worn 12 to 20 hours daily for 4 to 6 months. For tattoos and cosmetic procedures, start with a small test area and watch how it heals.

Tell your surgeon. If you or your relatives form keloids, say so before any planned operation, and watch the scar closely afterwards.

Care for small wounds properly. Clean promptly with soap and water, keep the wound moist with a hydrogel dressing, and avoid hydrogen peroxide and rubbing alcohol — both are harsher on healing tissue than people assume.

Silicone, once the scab is gone. Applying silicone gel sheets or gel daily for around six months after a wound heals is the standard preventive measure. Here's the honest version of the evidence, though: a Cochrane review of silicone gel sheeting found trials reporting improvements in scar thickness and colour, but judged them poor quality and highly susceptible to bias. Silicone stays first-line largely because it's cheap, low-risk and easy — not because the evidence behind it is strong. Worth doing; not worth expecting miracles from.

Protect the healing scar from sun. Broad-spectrum SPF 30 or higher, water-resistant, applied about 15 minutes before going out; tinted formulas are often a better cosmetic match on deeper skin tones. This won't prevent the keloid, but it reduces the pigment change that makes any scar more noticeable — see sunscreen, explained.

Shaving-related bumps count as injuries. Recurrent ingrown hairs and bumps along the hairline can seed raised scarring at the nape and jawline, so getting on top of those is prevention too.

What treatment actually looks like

This is where honest expectations matter most. The AAD's own numbers tell the story:

• Corticosteroid injections — usually triamcinolone, repeated every four to six weeks. Between 50% and 80% of keloids shrink after being injected — but many regrow within five years. On darker skin tones, injections can leave light spots at the injection sites.
• Surgery alone is the trap. Nearly 100% of keloids return after surgical removal on its own, which is why excision is almost always paired with something else — pressure garments, cryosurgery, injections or radiation at the time of closure.
• Pressure garments and pressure earrings — reduce blood flow after surgery to discourage regrowth. Effective but demanding: 12 to 20 hours a day for months.
• Cryotherapy — freezing; works best on small keloids, generally needs three or more treatments, and can cause permanent light spots on darker skin. It performs better on hypertrophic scars than on keloids.
• Laser — reduces height and fades colour, typically as part of a combination rather than alone.
• Radiation therapy — used to prevent regrowth after other treatments, at doses around 20–25 Gy split into about three fractions. It carries real trade-offs: peeling, itching, permanent colour change and a potential cancer risk.

The pattern across all of it: keloid treatment is combination treatment, it takes months, and "improved and stable" is a good result. Anyone offering a one-visit cure is not describing this condition.

Don't try to remove one yourself

Keloids form in response to injury, so injuring one is the reliable way to make it bigger. Tying off, cutting, freezing or burning a keloid at home risks infection and a larger scar than you started with. There's no over-the-counter product that removes an established keloid — the OTC aisle's real contribution is silicone, used early.

See a doctor if

• The raised scar is growing beyond the original wound, or is still enlarging months later
• It's painful, intensely itchy, or restricting movement across a joint
• It's on your earlobe after a piercing and thickening — early pressure treatment works far better than late treatment
• You keloid and have surgery coming up — this is a pre-operative conversation, not a post-operative one
• A scar-like patch appeared where you never had an injury, or an existing scar starts to change, grow, ulcerate, bleed or refuses to heal. The morpheaform subtype of basal cell carcinoma classically appears as a white or flesh-coloured, indurated plaque with poorly defined borders "often resembling a scar", and it's the subtype most often reported arising within scar tissue — any alteration in a scar deserves a proper look. See skin cancer warning signs and how to do a skin self-exam
• The scar becomes hot, swollen, or starts draining pus — that's infection, not scarring; see when is a rash an emergency?
• You have recurring deep lumps and tunnels in the armpits, groin or under the breasts — that may be hidradenitis suppurativa, which scars heavily and needs its own treatment

The short version

A raised scar that stays inside the original wound is usually hypertrophic, and it will often flatten with time and simple measures. One that creeps beyond the wound is a keloid: it won't fade on its own, it comes back after surgery almost every time, and its treatment is a repeated in-office process rather than a product. If you're keloid-prone, the biggest wins are decisions made before the injury — about piercings, tattoos and telling your surgeon — plus silicone and sun protection while the wound heals. And any scar that appears without an injury, or changes after years of sitting still, is worth showing to a doctor.

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Raised scars are one of the things that photograph reasonably well, since the giveaway is shape and border rather than subtle colour. dermatrix.life offers a private, automated skin assessment that reads the photos you upload and returns a plain-language write-up you can use to describe what you're seeing. It is informational, not a diagnosis, no clinician reviews it, and it cannot tell you whether a lump is a keloid, a cyst or something that needs a biopsy — that takes an in-person exam. If you're dealing with depressed acne scarring instead, acne scars, explained covers the other half of this topic.