Why Keloids Keep Coming Back After Removal

Keloids often come back because removing the visible lump does not change the skin's tendency to over-heal, and cutting one out creates a fresh wound that can form a new keloid. The American Academy of Dermatology (AAD) says nearly 100% return after surgery alone [1]. Combining treatments can lower the chance of return, but cannot remove it entirely.

Keloids are more common in people of African and Asian heritage, the Japan Scar Workshop consensus notes [2]. At Fluid Medical in Cape Town, a doctor examines the scar first and may then recommend doctor-led keloid treatment that combines injections into the scar with controlled freezing to flatten and soften it.

At a glance

• Surgery alone carries a high chance of a keloid returning, so treatments are usually combined.
• Among injected options, current evidence favours a corticosteroid combined with 5-fluorouracil (5-FU), although response varies.
• On brown or black skin, injections and freezing can leave a lighter patch, so discuss this before you start.

How Is a Keloid Different From a Hypertrophic Scar?

A keloid is a raised scar that grows sideways beyond the border of the original wound, while a hypertrophic scar is also raised but stays within the wound, according to the Japan Scar Workshop consensus [2]. Unlike hypertrophic scars, keloids do not usually settle on their own [3].

Who Is More Prone to Keloids?

Risk factors include a personal or family history of keloids, darker skin, puberty and pregnancy, and triggers include surgery, burns, piercings, insect bites, chickenpox and acne, a review in the International Journal of Dermatology notes [3].

In a small South African Medical Journal study at one Durban public hospital, keloids were the most common reason for dermatological surgery (57.9%), and 20 of 21 people with keloids were black African [4].

Keloids can also worsen with high blood pressure [2], which can be checked during an unhurried general consultation that reviews your blood pressure and medicines in detail.

Keloids vs Acne Scars

Many acne scars are the opposite: depressed rather than raised. A separate guide explains how depressed acne scars form when fibrous bands tether the skin downwards, and why they need a different approach. Another covers how many microneedling sessions indented acne scars usually need, and why scar type changes the plan.

If you form keloids, mention it before any procedure that breaks the skin, including acne-scar treatment.

Why Do Keloids Come Back After Surgery or Injections?

Keloids often return because treatment leaves behind skin that is prone to over-heal, and cutting one out makes a new wound in that skin [2]. Estimates of recurrence after surgery alone range from 50% to 80% in the Japan Scar Workshop consensus [2] to nearly 100% according to the AAD [1].

Wound Tension and Body Site

Tension on a surgical wound can strain the reticular dermis, the deeper, collagen-rich layer of skin, and keep it inflamed, which is thought to drive recurrence [2]. After removal, keloids on the front of the chest, shoulder blade and upper pubic area return more often than earlobe keloids [2].

How Long After Removal Can a Keloid Grow Back?

A keloid can grow back months or years after treatment. The AAD says 50% to 80% of keloids shrink after injection, but many regrow within five years [1]. A Japanese follow-up study of 52 patients found recurrence was high in the first two years after treatment [5].

Keep follow-up going beyond the first year, and see your doctor early if the scar thickens, itches or feels tender again.

Can a Keloid Be Removed Permanently?

A keloid cannot reliably be removed for good: the AAD states that no treatment can consistently get rid of one or always stop it returning [1]. The realistic aim is a flatter, softer, more comfortable scar with a lower chance of regrowth.

On Fluid Medical's service page, "keloid removal" means reducing the keloid with injections and freezing, not cutting it out.

What Lowers the Risk of a Keloid Coming Back?

Combining two or more keloid treatments often improves results, the AAD notes [1].

Combination Injections Into the Keloid

A 2026 analysis in the Aesthetic Surgery Journal, comparing injection treatments across 24 randomised trials, found that triamcinolone (a corticosteroid) combined with 5-FU offered the most favourable balance between response and recurrence reduction [6]. The analysis also included hypertrophic scars, and the combination may lower the chance of return rather than prevent it; response varies.

At Fluid Medical, 5-FU, which slows the cells that make excess scar collagen, is combined with an anti-inflammatory corticosteroid and injected directly into the keloid. Controlled freezing (cryotherapy) follows to reduce bulk and firmness, with sessions spaced to limit skin thinning, ulceration and pigment change.

Contact your doctor if a treated area becomes a sore that isn't healing, or increasingly red, hot or painful.

Surgery With Follow-On Treatment

For a large or bulky keloid, your doctor may discuss referral to a surgeon. The Japan Scar Workshop reports that adequate-dose radiotherapy completed within a week of surgery can lower recurrence to 10% or less [2], though results vary between studies.

Radiotherapy can permanently change skin colour, and there have been reports of cancer many years later [1], so the consensus advises against it over the thyroid or breast, or in children [2].

Silicone Gel Sheets After Healing

Once the skin has healed, your doctor may suggest silicone gel sheets, which the AAD says can help stop a keloid returning [1], although meta-analyses cited in the International Journal of Dermatology review found silicone ineffective for prevention [3].

How Many Keloid Injections Will You Need?

There is no fixed number of keloid injections. They are usually given as a series [1], and an international expert consensus in the American Journal of Clinical Dermatology suggests about four weeks between corticosteroid sessions, without setting a total [7].

The Japan Scar Workshop instead spaces injections two weeks apart and notes that small keloids can improve markedly after one or two [2]. With no South African keloid guideline, doctors here draw on these sources.

Your doctor tailors the schedule to size, site and response, as shorter intervals can raise side-effect risk [7].

Tell your doctor if you are pregnant, breastfeeding or planning a pregnancy, or have diabetes, glaucoma or cataracts; the Japan Scar Workshop advises against triamcinolone injections in pregnancy and with these conditions [2].

Do Keloid Injections Lighten Dark Skin?

Keloid injections and freezing can leave lighter patches on brown or black skin. The AAD notes that corticosteroid injections can cause light spots, and that freezing can leave a permanent one, so it may not be recommended for darkly pigmented skin [1].

Pigment can also darken. In one trial described in the Clinical, Cosmetic and Investigational Dermatology review, 5-FU injections given alone darkened the skin in 90% of patients, against 12.5% with triamcinolone [8]. Across other studies, the review concludes that combining the two causes fewer unwanted effects than either alone [8].

Fluid Medical's service page describes the usual result as a softer, flatter scar, often with a paler but stable patch. Ask how that might look on your skin tone, and whether freezing suits you.

How Are Keloids From Ear Piercings Treated?

Corticosteroid injections can be especially helpful for an ear keloid, the AAD notes, and a pressure earring, worn 12 to 20 hours a day for several months, can help prevent its return [1]. Many earlobe keloids start at earring holes [2].

An allergic reaction to earring metal can look similar, so have new earlobe swelling checked [1], and speak to a doctor before re-piercing.

When Should a Raised Scar Be Checked by a Doctor?

Have a raised scar or lump checked by a doctor if it appeared without any injury, grows quickly, bleeds or breaks down. Keloids themselves are benign (non-cancerous) growths, even when they return [3], but occasionally other growths, including some skin cancers, can resemble a keloid and need a small tissue sample (biopsy) to be sure [2].

If in doubt, book a doctor's assessment of skin lumps and growths, with tissue sent for testing where it is clinically indicated.

Book a Doctor-Led Keloid Assessment in Cape Town

A doctor can confirm whether your scar is a keloid and plan treatment to flatten it and lower the chance of return.

Your scar, blood pressure and any new lump can be looked at in one place: Fluid Medical is a multidisciplinary medical centre, doctor-led from consultation to treatment.

Start with a free 30-minute aesthetic consultation with a doctor, where your options for managing a keloid or hypertrophic scar are assessed. It is an assessment rather than a treatment appointment, ending with a written plan and costs. If your scar needs medical rather than aesthetic care, your doctor will say so, and normal consultation fees apply.

You can book a keloid assessment online with a doctor at Fluid Medical in Gardens, Cape Town, call 021 200 2121 or WhatsApp 076 577 9287. All treatment is subject to individual clinical assessment, and results vary.

This article is general health information and does not replace a consultation with a doctor.

References

[1] American Academy of Dermatology Association. Keloid scars: diagnosis and treatment [Internet]. Rosemont (IL): American Academy of Dermatology Association; [updated 2023 Jan 26; cited 2026 Oct 11]. Available from: https://www.aad.org/public/diseases/a-z/keloids-treatment

[2] Ogawa R, Akita S, Akaishi S, Aramaki-Hattori N, Dohi T, Hayashi T, et al. Diagnosis and treatment of keloids and hypertrophic scars: Japan Scar Workshop consensus document 2018. Burns Trauma. 2019;7:39. doi:10.1186/s41038-019-0175-y. Available from: https://pubmed.ncbi.nlm.nih.gov/31890718/

[3] Ekstein SF, Wyles SP, Moran SL, Meves A. Keloids: a review of therapeutic management. Int J Dermatol. 2021;60(6):661-71. doi:10.1111/ijd.15159. Available from: https://pubmed.ncbi.nlm.nih.gov/32905614/

[4] Peer M, Hoosen K, Mosam A. A descriptive study of the spectrum of dermatological surgery services provided by the University of KwaZulu-Natal Department of Dermatology at Inkosi Albert Luthuli Central Hospital. S Afr Med J. 2022;112(10):784-5. doi:10.7196/SAMJ.2022.v112i10.16769. Available from: https://doi.org/10.7196/SAMJ.2022.v112i10.16769

[5] Maeda T, Funayama E, Yamamoto Y, Murao N, Osawa M, Ishikawa K, et al. Long-term outcomes and recurrence-free interval after the treatment of keloids with a standardized protocol. J Tissue Viability. 2021;30(1):128-32. doi:10.1016/j.jtv.2020.11.003. Available from: https://pubmed.ncbi.nlm.nih.gov/33288386/

[6] Lai IC, Huang GL, Lee KC, Wu PY. Comparative efficacy and recurrence risk of intralesional therapies for hypertrophic scars and keloids: a network meta-analysis. Aesthet Surg J. 2026;46(2):202-12. doi:10.1093/asj/sjaf182. Available from: https://pubmed.ncbi.nlm.nih.gov/40972598/

[7] Yin Q, Wolkerstorfer A, Lapid O, Qayumi K, Alam M, Al-Niaimi F, et al. KECORT study: an international e-Delphi study on the treatment of keloids using intralesional corticosteroids in clinical practice. Am J Clin Dermatol. 2024;25(6):1009-17. doi:10.1007/s40257-024-00888-7. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11511692/

[8] Morelli Coppola M, Salzillo R, Segreto F, Persichetti P. Triamcinolone acetonide intralesional injection for the treatment of keloid scars: patient selection and perspectives. Clin Cosmet Investig Dermatol. 2018;11:387-96. doi:10.2147/CCID.S133672. Available from: https://pubmed.ncbi.nlm.nih.gov/30087573/