Raised scars can be flattened, softened, and made less noticeable with treatments that range from over-the-counter silicone sheets to steroid injections, laser therapy, and surgery. The right approach depends on whether your scar is a hypertrophic scar or a keloid, how old it is, and how much it bothers you. No single treatment works perfectly for everyone, and the most effective strategies often combine two or more methods. Here is what the research actually supports.
Hypertrophic Scars and Keloids Are Not the Same Problem
Both types of raised scar involve excess collagen buildup during healing, but they behave differently and respond differently to treatment. A hypertrophic scar stays within the boundaries of the original wound and often improves on its own over one to two years. A keloid grows beyond the original wound edges and almost never shrinks without intervention. Under a microscope, keloids have thick, tightly packed collagen bundles, while hypertrophic scars contain smaller nodular structures with fine, loosely organized collagen fibers and cells called myofibroblasts that contribute to scar contraction.1PubMed Central. Morphological and immunochemical differences between keloid and hypertrophic scar Despite these structural differences, the two conditions share many of the same abnormalities, and the distinctions between them are often a matter of degree rather than kind.2PubMed Central. Hypertrophic scars and keloids: Overview of the evidence and practical guide for differentiating between these abnormal scars
This matters for treatment because a method that resolves a hypertrophic scar may only partially reduce a keloid, and keloids have a much higher chance of coming back after treatment. Knowing which type you have, ideally confirmed by a dermatologist, shapes every treatment decision from there.
Who Gets Raised Scars and Why
Anyone can develop a raised scar, but the risk is not evenly distributed. Black and African American individuals have a higher likelihood of developing hypertrophic scars and keloids compared to white and Hispanic populations, likely linked to differences in how melanocytes interact with the cells that produce collagen.3PubMed. Insights Into Demographics, Comorbidities, and Risk Factors in Keloids and Hypertrophic Scars: A Retrospective Study Genetics play a role too, with research identifying multiple chromosomal regions and gene variants associated with keloid development.4PubMed Central. Keloid: Genetic susceptibility and contributions of genetics and epigenetics to its pathogenesis
Beyond genetics, wound infection, repeated irritation of the scar, and having keloids at multiple body sites all increase the risk of a keloid becoming severe. One study found that excessive scrubbing of keloids carried a particularly high risk of worsening the condition, and scars that had been present for more than fifteen years were also more likely to progress.5PubMed Central. Risk factors associated with the progression from keloids to severe keloids The practical takeaway: handle raised scars gently, keep them clean, and treat infections promptly.
Silicone Products Are the Standard First Step
Silicone gel sheets and silicone-based gels are the most widely recommended first-line treatment for both hypertrophic scars and keloids. They work by hydrating the outer skin layer, which dampens the overactivity of the cells that produce scar tissue and reduces collagen buildup.6PubMed Central. The Use of Silicone Adhesives for Scar Reduction In one animal study, two weeks of silicone gel application at the earliest stage of scarring reduced scar thickness by roughly 70 percent compared to untreated scars, and total occlusion brought that figure closer to 80 percent. Epidermal thickness dropped by more than 30 percent.7PubMed. The role of the epidermis in the control of scarring: evidence for mechanism of action for silicone gel
Silicone sheets also help with two symptoms that make raised scars especially annoying: pain and itching. In one clinical study, pain and itching clearly decreased after four weeks of wearing silicone gel sheets and disappeared entirely after twelve weeks.8PubMed. Silicone gel sheets relieve pain and pruritus with clinical improvement of keloid: possible target of mast cells Over-the-counter silicone sheets are inexpensive, widely available, and carry virtually no risk. The main challenge is compliance: you need to wear them consistently, ideally for twelve or more hours per day, over several months to see meaningful results.
Steroid Injections Are the Workhorse for Stubborn Scars
When silicone alone is not enough, steroid injections into the scar, most commonly triamcinolone acetonide, are the next standard option. The steroid reduces inflammation, slows collagen production, and can flatten a raised scar considerably. Response rates vary widely, with studies reporting anywhere from 50 to 100 percent regression of the scar. The catch is that recurrence is common, happening in about a third of cases within a year and roughly half within five years.9PubMed Central. Triamcinolone acetonide intralesional injection for the treatment of keloid scars: patient selection and perspectives
Steroid injections also come with side effects. Higher concentrations are more likely to cause skin thinning at the injection site and visible small blood vessels called telangiectasias.10PubMed. The safety and efficacy of intralesional triamcinolone acetonide for keloids and hypertrophic scars: A systematic review and meta-analysis This is one reason dermatologists have increasingly moved toward combination therapies rather than relying on steroids alone.
5-Fluorouracil and Combination Injectables
5-fluorouracil (5-FU) is a chemotherapy drug that, in small doses injected directly into a scar, slows the growth of the fibroblast cells responsible for excess collagen. Used on its own, 5-FU monotherapy has shown solid results, with about two-thirds of treated keloids achieving more than 50 percent improvement and a relapse rate of around 16 percent at roughly six months.11PubMed Central. Intralesional 5-Fluorouracil for Keloids: A Systematic Review
Where 5-FU really shines is in combination with steroids. Combining triamcinolone with 5-FU has been shown to produce better long-term improvements in scar height, pliability, and pigmentation than either drug used alone, with fewer side effects than steroid monotherapy.10PubMed. The safety and efficacy of intralesional triamcinolone acetonide for keloids and hypertrophic scars: A systematic review and meta-analysis The combination approach has also shown statistically significant improvements over single-agent treatment in separate reviews, with combined recurrence rates that tend to be lower than steroid injections alone.12PubMed Central. The Use of Chemotherapeutics for the Treatment of Keloid Scars If your dermatologist suggests adding 5-FU to your steroid injections, the evidence supports that move.
Laser Therapy for Redness, Thickness, and Texture
Laser treatments tackle raised scars through two main approaches, each suited to different scar features.
Pulsed Dye Laser for Red, Vascular Scars
A pulsed dye laser (PDL) targets the blood vessels feeding a scar. The laser energy is absorbed by hemoglobin in those vessels, which heats and collapses them. This cuts off the blood supply that fuels scar growth and triggers a remodeling process that breaks down excess collagen.13Medical Lasers. Scar Treatment Using 585-nm Pulsed Dye Laser PDL is especially useful early in a scar’s life, when it is red or purple and actively growing. One study found that PDL treatment over three months significantly reduced scar vascularity, redness, blood perfusion, and pigmentation, while untreated scars continued to thicken. Treated scars held steady at their original thickness, while untreated ones grew by nearly 50 percent over the same period.14PubMed. Vascularity and Thickness Changes in Immature Hypertrophic Scars Treated With a Pulsed Dye Laser
PDL also showed significant improvements in erythema, height, pliability, and pigmentation in hypertrophic sternotomy scars when evaluated a year after the last treatment session.15PubMed Central. Early dye laser treatment of hypertrophic sternotomy scars with prominent vascular component The treatment is generally well tolerated with minimal downtime, making it a good option for people who want visible improvement without a long recovery.
Fractional CO2 Laser for Thicker, More Mature Scars
Fractional carbon dioxide lasers drill tiny columns of damage into the scar tissue, prompting the body to replace stiff scar collagen with more normal tissue during healing. This approach is particularly effective for improving texture, thickness, and pliability. One prospective study on post-burn scars found statistically significant improvements in pigment, thickness, and pliability after even the first treatment, and those improvements held through subsequent sessions.16PubMed Central. Efficacy of fractional carbon dioxide laser-assisted drug delivery in the management of post-burn scars – A prospective study
A growing technique pairs the fractional CO2 laser with immediate drug delivery. After the laser creates microscopic channels in the scar, a topical steroid or other agent is applied and absorbed directly into the deeper layers of the scar tissue. This laser-assisted drug delivery has shown significant clinical improvements with low recurrence rates in treating hypertrophic scars.17PubMed Central. Manual Fractional Technology with CO(2) Laser Combined with Transdermal Drug Delivery for Hypertrophic Scar: A Retrospective Study A typical protocol involves three to six sessions spaced about four weeks apart, with topical triamcinolone applied immediately after lasing.18Journal of Cutaneous and Aesthetic Surgery. Combination of fractional CO2 laser with laser-assisted drug delivery in the treatment of hypertrophic and atrophic scars
When to Start Treatment Matters
There is a common assumption that you should wait for a scar to fully mature before treating it. The evidence is more nuanced. A systematic review and meta-analysis of laser treatment timing found that both early treatment (within twelve months of injury) and later treatment (after twelve months) improved scar outcomes. However, later treatment was actually more beneficial for reducing vascularity and scar height.19PLOS ONE. Influence of scar age, laser type and laser treatment intervals on adult burn scars: A systematic review and meta-analysis
That said, the picture differs by treatment type. PDL therapy seems to work best when started early, before excess vascularity has had time to drive collagen overproduction. Silicone products work best when applied as soon as a wound has fully closed. Steroid injections can be effective at almost any stage. The general principle: start with noninvasive options early, add targeted treatments as the scar’s behavior becomes clearer, and do not assume a scar is “too old” to treat.
Cryotherapy Can Flatten Keloids
Freezing a keloid with liquid nitrogen destroys scar tissue from the inside and can produce dramatic flattening. The technique comes in two forms: surface contact freezing and intralesional cryotherapy, where a needle-like probe delivers the freeze deep inside the scar. The intralesional approach outperforms surface contact, with one study reporting an excellent response in 87 percent of intralesionally treated scars compared to 60 percent for surface contact. The intralesional method also achieved faster flattening and caused fewer side effects.20PubMed. Intralesional vs. contact cryosurgery in treatment of keloids: a clinical and immunohistochemical study Cryotherapy can cause temporary or permanent lightening of the skin, which makes it less appealing for people with darker skin tones.
Surgery Plus Radiation for Severe Keloids
Cutting a keloid out surgically and then hitting the site with radiation therapy sounds like a definitive solution, but the results are inconsistent. Surgical excision alone has recurrence rates as high as 45 to 100 percent for keloids because the surgery itself creates a new wound that can trigger another keloid. Adding radiation immediately after excision is meant to prevent that regrowth. One study using superficial radiation therapy reported a long-term cure rate of about 86 percent from two years onward, with temporary darkening of the skin being the most common side effect and no skin cancers observed during follow-up.21PubMed Central. A Retrospective Registry Study Evaluating the Long-Term Efficacy and Safety of Superficial Radiation Therapy Following Excision of Keloid Scars
However, other research tells a less optimistic story. A single-center cohort study found that 65 percent of patients experienced keloid recurrence within two years after surgical excision followed by radiation, leading the authors to conclude their regimen had an unacceptably high recurrence rate.22PubMed Central. Frequency of keloid recurrence post-surgical excision and radiation therapy on a 2-year follow-up: A single center cohort study The wide gap between these results likely reflects differences in radiation dose, timing, and technique. Surgery combined with radiation remains an option for large or disfiguring keloids that have not responded to less aggressive treatments, but it is not the slam-dunk that some clinics market it as.
Pressure Garments After Burns
Custom-fitted pressure garments are a mainstay of burn scar management. They work by applying sustained mechanical force that disrupts collagen alignment and reduces scar thickness. An animal study found that all levels of garment wear reduced scar thickness and contraction compared to no treatment, but garments worn around the clock produced significantly better results than those worn for only eight or sixteen hours. For maximum benefit, the garments should be worn 23 to 24 hours per day.23PubMed Central. Improved Scar Outcomes with Increased Daily Duration of Pressure Garment Therapy
The practical reality is harder. Pressure garments are uncomfortable, hot, and socially conspicuous. A Cochrane systematic review noted that the evidence for pressure garments improving scar appearance in burn patients is very uncertain, partly because adherence in studies is inconsistent and partly because well-designed trials are scarce.24PubMed Central. Pressure-garment therapy for preventing hypertrophic scarring after burn injury Even with imperfect evidence, most burn centers still prescribe them because the available alternatives for widespread burn scarring are limited.
Over-the-Counter Onion Extract Gels
Products containing onion extract (the active ingredient in brands like Mederma) are among the most widely purchased scar treatments. The evidence for them is modest but real, particularly for newer scars. In a randomized controlled trial, an onion extract gel applied to fresh surgical scars produced scars that were significantly softer at two weeks and showed greater improvement in overall appearance by eight weeks compared to untreated control scars.25PubMed Central. A New Proprietary Onion Extract Gel Improves the Appearance of New Scars: A Randomized, Controlled, Blinded-Investigator Study A separate study on cesarean section scars in Asian patients found that 12 percent onion extract gel improved scar height and symptoms, though it did not significantly change redness, pliability, or overall cosmetic appearance.26PubMed Central. Effectiveness of Onion Extract Gel on Surgical Scars in Asians
Onion extract gels are unlikely to flatten a well-established keloid, but they are cheap, safe, and may provide incremental improvement for mild hypertrophic scars and fresh surgical scars. Think of them as a complement to silicone, not a replacement for it.
Microneedling and Drug Delivery
Microneedling uses tiny needles to create controlled micro-injuries in scar tissue, which stimulates the body’s wound-healing process and prompts collagen remodeling. More recently, microneedle technology has been used as a drug delivery system, allowing therapeutic agents to be released directly into scar tissue in a controlled and sustained way.27PubMed Central. Leveraging Microneedles for Raised Scar Management Radiofrequency microneedling, which adds heat energy to the needling, has shown promise in case reports for improving both color and texture of hypertrophic scars, particularly in darker skin types that are more prone to complications from laser therapy.28PubMed Central. Combination Therapy Using Radiofrequency Microneedling and Corticosteroids for Hypertrophic Scars: A Case Report The evidence is still early-stage, but microneedling is increasingly being incorporated into multimodal scar treatment plans.
Botulinum Toxin for Prevention and Remodeling
Botulinum toxin (commonly known by brand names for wrinkle treatments) has an unexpected role in scar management. When injected around a fresh wound, it relaxes the surrounding muscles, reducing the mechanical tension on healing tissue that can trigger excessive scarring. A systematic review with meta-analysis found that botulinum toxin injection was both safe and effective for preventing scar formation at wound sites and for remodeling scars that had already formed, compared to placebo or no treatment.29PubMed. The safety and efficacy of botulinum toxin for management of scars: A systematic review with meta-analysis and trial sequential analysis This treatment is most relevant for surgical scars in high-tension areas like the forehead, chest, and shoulders, where muscle pull on the wound edges can worsen scarring.30PubMed Central. Botulinum toxin type A: implications in wound healing, facial cutaneous scarring, and cleft lip repair
Fat Grafting as an Emerging Approach
Injecting a person’s own fat into a scar may sound cosmetic, but the science behind it goes deeper than filling a defect. Adipose tissue contains stem cells that appear to reduce fibrosis through several biological pathways, including suppressing the growth signals that drive excessive collagen production and inhibiting the contraction of scar-forming cells. Animal and laboratory studies have demonstrated that fat-derived stem cells can reduce collagen deposition and promote architectural remodeling of scar tissue, along with new blood vessel formation and improved hydration.31PubMed Central. Autologous fat grafting in keloids and hypertrophic scars: a review Clinical evidence in humans is still limited, but early results are encouraging enough that fat grafting is being used in some specialized centers for burn scars and recalcitrant keloids.
The Emotional Weight of Raised Scars
Raised scars are not just a cosmetic concern. Research on the quality-of-life impact of keloids has found that the condition is associated with considerable impairment of emotional wellbeing, with the greatest burden showing up on emotional and mental health measures rather than physical ones.32PubMed. Burden of Keloid Disease: A Cross-sectional Health-related Quality of Life Assessment In a qualitative interview study, patients with visible scars most frequently discussed psychological themes like how often they thought about the scar and how they felt talking about it with others. Some reported discomfort with physical intimacy and, less commonly, negative effects on their professional lives.33PubMed Central. Daily Quality-of-life Impact of Scars: An Interview-based Foundational Study of Patient-reported Themes If a scar is affecting your mental health or daily functioning, that is a legitimate medical reason to pursue treatment, and it is worth communicating to your doctor so they can help build a treatment plan that matches the real impact the scar has on your life.