A Physician’s Guide to Scar Types: Surgical, Keloid, Hypertrophic and Atrophic Scars and How Each Is Treated

Every scar is the visible record of a repair job. Skin cannot regenerate perfectly once the deeper layer is injured, so it patches the wound with collagen. When that patch is laid down in just the right amount, the scar fades into a fine line. When the body produces too much or too little collagen, we get scars that are raised, sunken, discolored or tight.

Because scars can be too much tissue or too little, the right treatment for one type can be exactly wrong for another. In this guide I’ll help you identify the major categories, explain the evidence-based options for each, and point out when a scar needs medical evaluation rather than cosmetic treatment.

How scars mature

Scars evolve for a long time. A new scar is usually pink or red and may be slightly raised. Over roughly 12 to 18 months, most scars flatten, soften and fade toward a paler color. This matters for two reasons: some early scars will improve considerably on their own, and the first several months are also the window when certain treatments can guide healing most effectively.

The four main scar types

Surgical and traumatic scars (fine-line scars)

These follow a surgical incision or a cut. Most heal as a flat line that may be pink at first and fade over time. Some widen, stay red, pull slightly, or heal lighter or darker than the surrounding skin.

Hypertrophic scars

These are raised, firm and often red, but they stay within the borders of the original wound. They are common after burns, in areas under tension such as the chest and shoulders, and after wound infections. They often improve gradually over time.

Keloids

Keloids are also raised, but they grow beyond the original wound, sometimes forming large, shiny, rubbery nodules. They may itch or hurt. They are more common in people with deeper skin tones and in those with a family history, and they favor the earlobes, chest, shoulders and upper back. Even a piercing or a pimple can trigger one. Keloids tend not to regress on their own and can recur after treatment.

Atrophic scars

These are sunken scars caused by a loss of collagen. Acne and chickenpox scars are the classic examples.

Matching treatments to scar type

For fresh surgical scars, the first steps are simple and well supported: keep the scar protected from the sun, and use silicone gel or silicone sheeting once the wound has fully closed. International scar-management recommendations list silicone as a first-line option for preventing and treating raised scars. Laser and light treatment may help reduce redness and improve texture in selected scars, and our laser skin team can advise on timing.

For hypertrophic scars and keloids, the goal is to flatten excess tissue and reduce symptoms:

• Silicone gel or sheets worn consistently for months.
• Corticosteroid injections. Triamcinolone acetonide, known by the brand name Kenalog, can be injected directly into the scar to soften and flatten it and relieve itching. Its FDA labeling includes intralesional use for keloids. It is usually given as a series of injections several weeks apart. You can learn more on our Kenalog page.
• Pressure therapy, such as pressure earrings after earlobe keloid treatment.
• Surgical removal combined with other therapy for selected keloids. Because keloids frequently return after excision alone, surgery is typically paired with injections or other measures, and it is something to discuss with a dermatologist or plastic surgeon.

For atrophic scars, the aim is to rebuild collagen or lift depressed areas. Options include microneedling, radiofrequency microneedling, fractional or ablative laser resurfacing, and in some cases dermal fillers.

Risks and limits of Kenalog injections

Steroid injections are effective for many raised scars, but they are not risk-free. Possible side effects include thinning of the skin, a sunken area if too much steroid is placed or it spreads, lightening of the skin color (particularly noticeable in deeper skin tones), and small visible blood vessels. For that reason we use conservative doses, precise placement and spacing between sessions. Steroid injections should never be used on a sunken scar, since they would make it worse.

When a scar needs a doctor first

Please see a physician before any cosmetic treatment if a scar:

• is growing quickly or changing in color or shape years after the injury
• bleeds, ulcerates or forms an open sore that does not heal
• limits movement, such as a tight scar across a joint
• appeared without any known injury

Rarely, skin cancers can arise within longstanding scars or mimic them, and tight burn scars may need surgical release. Patients who are pregnant, have active infection, or have poorly controlled diabetes may also need to delay treatment.

Frequently asked questions

How can I tell a keloid from a hypertrophic scar?

A hypertrophic scar stays within the borders of the original wound and often improves over time. A keloid grows beyond those borders and usually does not regress on its own.

Do Kenalog injections work for keloids?

Triamcinolone injections are a standard treatment and often flatten keloids and relieve itching over a series of sessions. Keloids can recur, so ongoing monitoring and combined therapy are common.

When should I start treating a new surgical scar?

Silicone and sun protection can usually begin once the wound has fully closed and your surgeon agrees. Procedures are timed based on how the scar is healing.

Can laser treatment remove a scar?

Lasers can improve redness, texture and contour, but they cannot erase a scar. The realistic goal is a scar that blends better with the surrounding skin.

Get a clear plan for your scar

At Serene Med Spa, injections and laser treatments are performed or supervised by trained medical professionals under my oversight. Book a complimentary, no-commitment consultation and we will identify your scar type and the options most likely to help.

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References: Mustoe TA, Cooter RD, Gold MH, et al. International clinical recommendations on scar management. Plastic and Reconstructive Surgery. 2002. · Gold MH, Berman B, Clementoni MT, et al. Updated international clinical recommendations on scar management: part 1. Dermatologic Surgery. 2014. · U.S. Food and Drug Administration. Prescribing information for Kenalog-10 (triamcinolone acetonide injectable suspension). · American Academy of Dermatology. Keloids: diagnosis and treatment. aad.org.

This article is for general information only and is not medical advice. Treatments are provided only after consultation and evaluation by a licensed provider. Individual results vary.