Current Algorithms for Non-Surgical Management of Hypertrophic Scars and Keloids: An Updated Narrative Review

Abstract

Pathological scarring, encompassing hypertrophic scars and keloids, results from dysregulated wound healing characterised by persistent fibroblast activation, excessive collagen deposition, and abnormal profibrotic signalling pathways, leading to high recurrence rates and significant functional, cosmetic, and psychosocial burden. This narrative review evaluates current evidence-based non-surgical management strategies and emerging regenerative approaches, with emphasis on stepwise escalation and multimodal treatment algorithms. Silicone-based therapies remain the preferred first-line intervention due to their favourable safety profile and preventive efficacy, while intralesional corticosteroids continue to represent the cornerstone of second-line management, with botulinum toxin type A emerging as a steroid-sparing alternative through antifibrotic and neuromodulatory effects. For refractory lesions, intralesional 5-fluorouracil provides effective second-line escalation by directly inhibiting fibroblast proliferation, particularly when combined with corticosteroids. Laser-based modalities further enhance non-surgical management, with pulsed dye laser targeting vascular components and fractional CO₂ laser promoting dermal remodelling and improved drug delivery, with superior outcomes consistently reported in combination protocols compared to monotherapy. Across network meta-analyses, combination regimens incorporating corticosteroids, antimetabolites, lasers, and adjunctive modalities demonstrate improved scar appearance, symptom control, and recurrence prevention, supporting a multifactorial disease model. Long-term outcomes are strongly influenced by adjuvant strategies such as pressure therapy, tension reduction techniques, and structured postoperative surveillance, alongside patient-specific factors including age, ethnicity, anatomical location, and psychosocial burden, reinforcing the need for individualised treatment planning. Emerging regenerative therapies, including platelet-rich plasma, mesenchymal stem cells, and extracellular vesicle-based approaches, demonstrate promising antifibrotic and immunomodulatory effects in preclinical and early clinical studies, but remain limited by heterogeneity, small sample sizes, and lack of standardised protocols. Overall, current evidence supports a paradigm shift toward risk-stratified, combination-based, and biologically targeted management strategies aimed not only at scar reduction but also at durable long-term control and recurrence minimisation.