Learning Center: SCAR TREATMENT

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SCAR BIOLOGY

Last reviewed: October 1, 2026

Summary

Any injury that reaches the deeper layer of the skin (the dermis) heals with a scar. A scar cannot be erased, but its final appearance can often be improved, and many problem scars can be prevented or made less noticeable. Most scars keep changing for a year or more, becoming flatter, softer and paler with time. The best-supported steps for a new scar are careful wound closure, protecting the scar from tension, keeping it moist with silicone, and protecting it from the sun. Raised scars (hypertrophic scars and keloids) respond to steroid injections, often combined with 5-fluorouracil, and keloids that are cut out usually need an added treatment such as radiation to keep them from returning. Lasers, dermabrasion, microneedling and surgical scar revision can improve color, texture, width and position. Many popular creams, such as vitamin E and onion extract, have not proven better than plain petroleum jelly.

The sections below explain each of these points in more detail, with the studies behind them. A numbered reference list is at the end of the page. The evidence for many scar treatments comes from small trials, and this page says so where it matters.

Scar biology

Wound healing follows three overlapping phases [1].

Inflammation (the first few days). Bleeding stops, and white blood cells clear debris and bacteria.
Proliferation (roughly days 4 to 21). New blood vessels grow into the wound, and cells called fibroblasts lay down new collagen. The skin surface closes over the wound.
Remodeling (weeks to more than a year). The early, disorganized collagen is gradually broken down and replaced with stronger, better-organized collagen. Blood vessels regress, so the scar fades from red or pink toward the surrounding skin color.

A mature scar is never identical to normal skin. It lacks hair follicles and sweat glands, its collagen runs in parallel bundles rather than a basket-weave pattern, and it never fully regains the strength of uninjured skin [1]. Because remodeling continues for so long, a scar at six weeks often looks much worse than it will at a year. This is the main reason most surgical scar revisions are delayed.

Types of scars

Mature (normal) scar. Flat, pale and soft. It may be wider than the original wound.
Immature scar. Red, sometimes itchy, and slightly raised. This is a normal stage of healing, not a problem in itself.
Widened (stretched) scar. Flat but broad, usually caused by tension across the wound in the months after the stitches come out.
Atrophic (depressed) scar. Sunken below the surrounding skin, as with acne or chickenpox scars.
Hypertrophic scar. Raised, firm and red, but it stays within the borders of the original wound. It usually appears within weeks of the injury and often improves on its own over a year or two.
Keloid. Raised scar tissue that grows beyond the borders of the original wound, often months after the injury. Keloids rarely regress on their own and commonly return after they are cut out [2, 3].
Scar contracture. A scar that tightens and shortens, pulling on nearby structures such as the eyelid, lip, or the skin of the neck. Contractures are most common after burns.

Why some people scar more than others

Hypertrophic scars and keloids are now understood as a problem of prolonged inflammation in the dermis, which drives fibroblasts to keep producing collagen [4]. Several factors increase the risk:

Tension. Skin under constant stretch, such as the chest, shoulders, upper back and areas over joints, forms thicker scars. Wounds that run across the natural skin creases are under more tension than wounds that run along them [4].
Genetics and skin type. Keloids are more common in people with darker skin and often run in families [3, 4].
Location. The earlobes, jawline, chest and shoulders are common keloid sites. Scars on the eyelids and most of the face usually heal well.
Delayed healing. Infection and slow wound healing, as with many burns, lead to more scarring [4].
Smoking. In a meta-analysis of 140 studies of nearly 480,000 surgical patients, smokers had about twice the odds of wound complications and higher rates of wound infection than nonsmokers. Stopping smoking around the time of surgery reduced wound infections [5].

Assessing a scar

An evaluation of a scar covers its age, cause, location and direction relative to the natural skin creases, along with its color, height, width, firmness, and any itching, pain or tightness. Whether the scar limits movement (of an eyelid, the mouth, or the neck) is as important as how it looks. Photographs are taken to follow change over time. Research studies use standard scoring systems, such as the Patient and Observer Scar Assessment Scale (POSAS), which asks both the patient and the examiner to rate the scar [6]. The patient's own view of the scar matters, because a scar that bothers one person may not bother another.

The first question is usually timing. A scar under about a year old is often best managed with measures that help it mature. A mature scar that still bothers the patient is a candidate for the procedures described further down this page.

COSMETIC SCAR IMPROVEMENT

Preventing a poor scar

International consensus guidelines, published by panels of plastic surgeons and dermatologists, recommend the same core steps for every new scar: good surgical technique, reducing tension, taping, keeping the scar hydrated (usually with silicone), and protecting it from ultraviolet light [7, 8]. Additional measures are added for people at high risk of a raised scar.

At the time of surgery or repair

The surgeon has the greatest influence on the final scar. Incisions are placed in natural skin creases or along the borders between facial features where possible. Deep stitches take the tension off the skin surface, and the skin edges are brought together precisely and slightly raised (everted), so that the scar flattens as it matures rather than sinking. Dead tissue is removed, and the wound is closed when it is clean. Reviews of the evidence rate tension reduction and wound-edge eversion among the most effective ways to prevent a raised scar [9].

Wound care in the first weeks

A clean wound kept moist heals faster than one allowed to dry and crust. Plain white petrolatum (petroleum jelly) is a safe choice. In a randomized trial of 922 patients after skin surgery, wounds treated with white petrolatum had an infection rate that was not significantly different from wounds treated with bacitracin, an antibiotic ointment. No one in the petrolatum group developed an allergic skin reaction, compared with 0.9% in the bacitracin group [10].

Taping and tension offloading

A healing scar is weak for months after the stitches are removed, and tension during this time can widen or thicken it. Paper tape applied along the scar supports it. In a randomized trial of 70 women after cesarean section (39 of whom completed the study), 41% of scars without tape had become hypertrophic at 12 weeks, compared with none of the taped scars [11]. Specialized adhesive devices that pull the skin edges toward each other have also improved scar appearance in a small randomized trial of 12 patients having scar revision [12]. Both studies were small, but they support a consistent principle: less tension, less scar.

Silicone gel and silicone sheeting

Silicone is applied as a thin, self-adhesive sheet or as a gel that dries to a film. It is started once the skin has fully closed, usually around two weeks after surgery, and used for at least 12 hours a day for two months or longer. Gel is easier to use on the face and neck, where sheets do not stay on well. Silicone is thought to work by keeping the scar hydrated, which calms the signals that drive collagen production.

Consensus guidelines consider silicone the first-line option for preventing and treating hypertrophic scars and keloids [7]. The quality of the supporting research is debated. A Cochrane review of 20 trials found that silicone sheeting reduced the risk of a hypertrophic scar by about half in people prone to abnormal scarring, and it reduced the thickness and redness of existing scars. The reviewers concluded the evidence was weak, because most trials were at high risk of bias [13]. A later systematic review of 34 trials of topical scar products found the most consistent support for silicone, with only limited support for other products [14]. Silicone is inexpensive and has few side effects other than occasional skin irritation, so it is a reasonable choice for most new scars despite the uncertainty.

Sun protection

Ultraviolet light darkens new scars. In a randomized trial, small wounds that were exposed to sunlight after healing were judged more disfiguring at 12 weeks than wounds kept out of the sun, with more color and more pigmentation [15]. A new scar is protected with clothing, a hat or tape, and with broad-spectrum sunscreen once the skin has closed, for at least the first year. This matters more for people with darker skin, who are more prone to lasting darkening of scars.

Massage

Firm massage of a healing scar, usually started a few weeks after surgery, is widely recommended. A review of 10 studies including 144 patients found that about 46% improved overall, with better results in surgical scars than in burn or injury scars. The authors concluded that the evidence is weak and the studies are not standardized [16]. Massage is harmless and may help with tightness and itching, but it should not be expected to change a scar dramatically.

Vitamin E, onion extract and other creams

Many products sold for scars have not held up in controlled trials.

Vitamin E. In a double-blind trial in which half of each surgical scar was treated with vitamin E and half with a plain ointment, vitamin E had no benefit or made the scar look worse in 90% of cases, and a third of patients developed an itchy skin rash (contact dermatitis) from it [17].
Onion extract. In a double-blind trial of 24 patients, onion extract gel applied to one half of a new surgical scar did no better than petrolatum on the other half for appearance, redness, thickness, itching or pain [18].

A systematic review found only limited evidence supporting onion extract, vitamin E and similar topical products [14].

Botulinum toxin at the time of repair

Muscles beneath the skin of the face pull on a healing wound with every expression. Botulinum toxin (such as Botox), injected into these muscles near the time of repair, relaxes them for several months while the scar matures. This approach is most often considered for wounds on the forehead, between the eyebrows, and around the mouth.

In a blinded, placebo-controlled trial of 31 patients with forehead wounds, scars treated with botulinum toxin were rated better by facial plastic surgeons who reviewed photographs without knowing which treatment each patient received (median score 8.9 versus 7.2 on a 10-point scale) [19]. A second randomized trial of 30 patients with facial wounds found a similar improvement on photograph ratings, but no difference on the scar scales completed by the patients and an independent examiner [20]. A meta-analysis of 20 studies of face, head and neck scars found better appearance and narrower scars with botulinum toxin, with the largest effects on the upper lip and forehead [21]. A 2026 meta-analysis of 19 studies reached a similar conclusion [22]. However, a meta-analysis limited to injection immediately after wound closure found improved photograph ratings and slightly narrower scars, but no difference on a standard scar scale [23]. Overall, botulinum toxin appears to give a modest improvement in selected facial wounds. The studies are small, and the best timing and dose are not settled.

Cosmetic scar improvement

Treatment of a scar that is already present depends on what is wrong with it. A red scar, a raised scar, a depressed scar, a wide scar and a scar in the wrong place each call for a different approach. Many people do best with a combination of treatments over several months [8].

Steroid injections and 5-fluorouracil (raised scars)

Injection of a corticosteroid, usually triamcinolone, directly into a hypertrophic scar or keloid is a standard treatment. It reduces inflammation and collagen production and flattens and softens the scar. Injections are usually repeated at intervals of several weeks. A meta-analysis of 15 randomized trials found that triamcinolone improved redness and pliability in the short term. Over longer follow-up, 5-fluorouracil (5-FU, a medication that slows fibroblast growth) or the combination of 5-FU with triamcinolone produced better results than triamcinolone alone. Triamcinolone at higher strengths (20 to 40 mg/mL) caused more thinning of the skin (atrophy) and small visible blood vessels (telangiectasia) than the alternatives [24]. In a small trial comparing treatments on different parts of the same chest scars, half of the segments treated with steroid alone developed lightening of the skin, telangiectasia or atrophy [25].

A 2024 meta-analysis of 13 studies, 12 of them randomized trials, found that combined triamcinolone and 5-FU had three to four times the odds of a good response compared with either medication alone, with less telangiectasia than triamcinolone alone [26]. An earlier meta-analysis reached the same conclusion [27]. International guidelines now favor earlier use of 5-FU for keloids [8].

Keloids: excision with added treatment

Cutting out a keloid without any other treatment is followed by a high rate of recurrence, sometimes with a larger keloid than before. Excision is therefore combined with another treatment, such as steroid injections into the wound in the weeks after surgery, pressure (for example, pressure earrings after earlobe keloid surgery), or radiation [3, 9].

Radiation after surgery lowers the recurrence rate. A meta-analysis of 72 studies covering more than 9,000 keloids found a recurrence rate of 22% when radiation was given after excision, compared with 37% for radiation alone [28]. A larger meta-analysis of 106 studies and 10,745 keloids found recurrence rates of 14 to 18% after excision and radiation, with no significant difference between types of radiation or between radiation given within 24 hours of surgery and later [29]. The American Radium Society's 2026 appropriate use criteria concluded that radiation after surgery is effective and safe for reducing recurrence of keloids and hypertrophic scars in appropriately selected patients [30]. Radiation is generally reserved for adults with keloids that have recurred or are at high risk of recurrence, and the decision is made with a radiation oncologist [30].

Lasers

Lasers are chosen according to the problem.

Pulsed dye laser targets blood vessels and is used mainly for red scars and for raised scars that are still red. In a study of chest scars after heart surgery, the treated half of each scar improved in redness, height, texture and itching compared with the untreated half [31]. A 2022 Cochrane review of 15 randomized trials of lasers for hypertrophic scars and keloids found the evidence low in certainty, because all trials were at high risk of bias [32].
Fractional lasers make a grid of microscopic columns of injury in the skin, separated by untouched skin that speeds healing. Ablative fractional lasers (such as fractional carbon dioxide laser) remove tissue and remodel thick, stiff or uneven scars. An international expert consensus panel recommends them for traumatic and burn scars, including scars that limit movement, and supports starting them early, once the skin has closed [33].
Early laser treatment. A systematic review of 25 studies of laser started within three months of injury or surgery found that laser-treated scars generally looked better than untreated scars, but not always significantly so, and called for higher-quality studies [34].

Lasers usually need several sessions spaced weeks apart. Side effects include temporary redness and swelling and, particularly in darker skin, temporary or lasting darkening or lightening of the skin [33].

Dermabrasion and microneedling (texture)

Dermabrasion uses a rotating instrument to sand the top layers of the skin, smoothing the edges of a scar and blending it with the surrounding skin. In a controlled study of 48 patients in which one half of each surgical scar was abraded, the abraded half improved more, with the most consistent improvement when abrasion was done about eight weeks after surgery [35].

Microneedling uses fine needles to create many small punctures that stimulate new collagen, and it is used mainly for depressed scars such as acne scars. A 2026 systematic review of 27 studies comparing needling-based treatments with ablative fractional lasers found that both improved scars. The lasers often gave more improvement, while needling had less downtime and fewer pigment changes, which matters for darker skin [36].

Surgical scar revision

Surgery cannot remove a scar. It replaces one scar with another that is intended to be narrower, flatter, better positioned or less noticeable. The common techniques are [37]:

Excision and layered closure. A wide or depressed scar is cut out and the skin is closed carefully in layers, with less tension than the original wound.
Z-plasty. Two triangular flaps are transposed, which lengthens a scar and changes its direction. It is used to release a tight scar and to turn a scar so that it lies in a natural skin crease.
W-plasty and geometric broken-line closure. A long straight scar is converted into a zig-zag or an irregular pattern of small segments. The eye follows a straight line easily but has trouble following an irregular one, so the scar becomes harder to see. These techniques work best on flat areas of the face, such as the cheek and forehead.

Surgical revision is usually combined with the preventive measures described above, and often followed by dermabrasion or laser to blend the new scar. A surgical revision is usually delayed until the scar has matured, often 6 to 12 months or longer, because many scars improve substantially on their own during that time [1, 37]. Exceptions include a scar that pulls on the eyelid or lip, or that limits function, which may be treated sooner.

FUNCTIONAL SCAR IMPROVEMENT

Functional scar improvement

Some scars cause problems beyond appearance. A scar contracture can pull the lower eyelid down so that the eye does not close completely, distort the lip, or tighten the skin of the neck so that it limits head movement. Burn scars and scars from wounds that healed slowly are the most common causes. Raised scars can also itch or hurt.

Release and lengthening. Z-plasty and related flaps lengthen a tight band of scar [37]. A larger contracture may need the scar released and the gap filled with a skin graft or flap. See the skin graft page for more on grafts.
Laser. Ablative fractional laser can soften and loosen tight scars and is recommended by expert consensus for contractures after injury and burns, sometimes in place of surgery and sometimes alongside it [33].
Pressure garments. Pressure garments are widely used after extensive burns. A meta-analysis of six trials with 316 patients found no difference in overall scar scores with pressure garments and only a small reduction in scar height, so their benefit remains unproven [38].
Itching and pain. Silicone, steroid injection and pulsed dye laser can each reduce itching and discomfort in raised scars [31, 9].
Therapy. Stretching, splinting and massage, often guided by a hand or occupational therapist, help keep a healing scar from tightening across a joint or around the mouth and neck.

Scars after skin cancer surgery and facial injury

Many facial scars follow removal of a skin cancer or repair of an injury. The closure is planned at the time of surgery to place the scar along natural creases and the borders between facial features, using local flaps or skin grafts when a wound cannot be closed in a straight line. Most of these scars improve steadily through the first year. The preventive measures above apply, and dermabrasion, laser or minor revision can refine the result later if needed. See the skin cancer pages for more on these operations.

What to expect

A scar is permanent. The goal of treatment is a scar that is less noticeable and causes no symptoms, not normal skin [9].
Scars change for a year or longer, and it is often worth waiting before judging the result.
More than one treatment is often needed, and the treatments are often combined [8].
Keloids are a long-term condition. Even with good treatment, some return, and follow-up continues after treatment ends.
The evidence for many scar treatments comes from small studies, and the strongest evidence supports tension reduction, silicone, sun protection, and steroid injections with or without 5-FU.

Choosing a treatment

New surgical scar. First treatments: petrolatum, taping, silicone, sun protection. Other options: botulinum toxin for selected facial wounds; early laser.
Red scar. First treatments: time, silicone, sun protection. Other options: pulsed dye laser.
Hypertrophic (raised) scar. First treatments: silicone, steroid injection. Other options: steroid with 5-FU; laser.
Keloid. First treatments: steroid with or without 5-FU. Other options: excision with injections, pressure or radiation.
Depressed or uneven scar. First treatments: dermabrasion, fractional laser, microneedling. Other options: excision and revision.
Wide or poorly placed scar. First treatments: surgical revision (after maturation). Other options: Z-plasty, W-plasty, geometric broken-line closure.
Tight scar (contracture). First treatments: therapy, Z-plasty or release. Other options: skin graft or flap; fractional laser.

COST OF SCAR TREATMENT

Cost of scar treatment

Insurance coverage depends on the reason for treatment. Treatment that restores function, such as releasing a scar that keeps the eyelid from closing or limits movement of the neck, is more often covered by insurance. Treatment to improve appearance alone is usually considered cosmetic and paid for by the patient. Coverage varies by plan, and a pre-authorization may be needed before surgery. See the surgical fees page and the financial information page for more.

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