How do atrophic (pitted) scars differ from keloids and hypertrophic scars? Are their treatments the same?

This article has been compiled and clinically reviewed by the Dermatology Specialists at BonBoz Clinic.

Scars come in many forms, and they are not all the same in nature or treatment. Atrophic scars, keloids, and hypertrophic scars are three groups that are frequently confused, yet their formation and treatment approaches are entirely different. Correctly identifying your scar type is the crucial first step, as the wrong treatment direction is not only ineffective but can sometimes worsen the condition. Understanding these differences helps you communicate more effectively with your doctor.

What are atrophic scars?

Atrophic scars (depressed scars) are characterized by a loss of tissue, creating indentations below the skin surface, commonly occurring after severe inflammatory acne or chickenpox. This is the result of skin tissue being destroyed and not fully repaired during the healing process. Atrophic scars present in various forms, such as icepick, boxcar, and rolling scars. Because the underlying issue is "tissue loss," treatment focuses on stimulating collagen regeneration to raise and fill the scar bed.

What is the difference between keloids and hypertrophic scars?

In contrast to atrophic scars, keloids and hypertrophic scars are caused by an overgrowth of scar tissue, creating raised bumps above the skin surface. Hypertrophic scars typically remain within the boundaries of the original wound and may subside over time; keloids grow beyond the original wound boundaries, rarely regress on their own, and are highly prone to recurrence. Both are linked to genetic predisposition and the healing process, which is entirely different from the "tissue loss" mechanism of atrophic scars.

Why is distinguishing scar types so important?

Because of their opposing mechanisms, their treatments also go in completely different directions: atrophic scars require regenerative stimulation to fill them in, whereas keloids and hypertrophic scars require flattening and tissue reduction. Applying the method of one type to another is ineffective and can be harmful; for example, aggressive, improper intervention on a keloid-prone individual can stimulate further scar growth. This is why a proper clinical examination and classification by a doctor before treatment is mandatory.

Can a person have multiple types of scars at the same time?

Yes. Many people can have atrophic acne scars in one area and keloids or hyperpigmentation in another, or different types of atrophic scars on the same face. Additionally, atrophic scars are often accompanied by post-inflammatory hyperpigmentation. Therefore, an effective treatment plan typically requires a comprehensive assessment of all scar types and accompanying skin concerns, combining the appropriate methods for each rather than applying a single approach.

How do you know which type of scar you have?

The most reliable way is to have a dermatologist perform a physical examination and skin analysis, as distinguishing scar types requires evaluating the structure, elevation/depression, and individual skin predisposition. Self-diagnosing through photos is highly prone to error, especially when multiple types coexist. Once the correct type is identified, the doctor will recommend the appropriate treatment plan. This is a step that should not be skipped to avoid incorrect and wasteful treatments.

Frequently Asked Questions

Can an atrophic scar turn into a keloid?

No. Atrophic scars (tissue loss) and keloids (excess tissue) result from two different mechanisms and do not convert into one another. However, an individual can have both types in different areas depending on their genetics and how each wound heals.

Is the treatment for atrophic scars and keloids the same?

No. Atrophic scars require regenerative stimulation to fill them in, while keloids/hypertrophic scars require flattening and tissue reduction—two opposite approaches. Therefore, correct classification is essential before choosing a treatment method.

How do I know what type of scar I have?

You should seek a clinical examination so a doctor can evaluate the structure and elevation/depression of the scar, as self-diagnosis is highly prone to error. Identifying the correct type ensures the right treatment path and prevents worsening the condition.

If you are unsure what type of scar you have and how it should be treated, let a dermatologist analyze your skin, classify your scars, and advise you on the proper approach before starting any treatment.