Hypertrophic vs. Keloid Scars — and How They Look on Darker Skin

Two great questions in one comment section:

1. What's the difference between a hypertrophic scar and a keloid?
2. Do they look the same on darker skin as they do on lighter skin?

Let's break them down.

Hypertrophic scars and keloids are relatives of each other — both are examples of the body overproducing scar tissue in response to an injury or incision. But they behave a little differently.

A hypertrophic scar is:

• Thick
• Pink
• Often rope-like in appearance
• Contained within the boundaries of the original incision

So if your incision was 6 cm long, a hypertrophic scar stays within those 6 cm — it's raised and angry looking, but it hasn't grown out past the edges.

A keloid is:

• Also thick and raised
• But spills over the boundaries of the original incision
• Often continues to grow over time, well beyond where the cut was

A keloid from a small gallbladder incision, for example, can end up much larger than the original cut ever was.

In my experience:

• Hypertrophic scars are more common.
• Hypertrophic scars are also easier to treat than true keloids.

So the distinction matters — it affects expectations for how responsive the scar will be to injection-based treatments like Kenalog and 5-FU, and how aggressive the treatment plan needs to be.

The simple answer: they usually start out looking the same.

In the early phase, both hypertrophic scars and keloids tend to be:

• Pink
• Thick
• Angry-looking and inflamed

This is true across skin tones.

Where things often change in patients with darker skin tones is pigmentation. Skin with more melanin has a stronger tendency to produce pigment in response to inflammation — also known as post-inflammatory hyperpigmentation (PIH).

So in darker skin patients, hypertrophic scars and keloids often:

• Start out pink and inflamed
• Then darken over time as the inflammation drives pigment production
• End up brown, dark brown, or purplish rather than pink

Interestingly, this doesn't happen to every patient with darker skin. I see plenty of patients with darker skin tones whose hypertrophic scars stay pink and never pigment. Skin biology is individual, and you can't predict exactly which patients will pigment and which won't.

If a scar does pigment, we add treatments targeted at the pigmentation — on top of the inflammation-targeted injections.

A typical layered approach in a darker skin patient with both hypertrophic scarring and hyperpigmentation might include:

• Injection therapy (Kenalog or 5-FU) to turn off the inflammation
• Topical pigment correctors (TXA, hydroquinone) to fade the dark color
• Strict sun protection to prevent the pigment from getting worse
• Occasionally laser or microneedling as an adjunct

Treating the inflammation alone isn't enough if the pigment is already established. You need to address both.

• Hypertrophic scars stay within the boundaries of the original incision; keloids grow beyond them.
• Both start out looking similar across skin tones — pink, thick, and inflamed.
• Patients with darker skin have a higher tendency to develop pigmentation on top of the raised scarring, though not always.
• When pigment is present, the treatment plan should address both the inflammation and the pigmentation to actually improve the scar's appearance.

If you have a raised, darkening scar, it's worth seeing someone who can actually distinguish between these scar types and treat the layers appropriately — they each respond to a slightly different plan.