Keloid scars are thought to involve an impaired balance between fibroblastic proliferation and apoptosis as well as possible endothelial dysfunction. Management options can be divided into those aiming to decrease the bulk of the scar and improve symptoms or replace the bulky keloidal mass with a fine and symptom-free surgical scar. Historical literature reports suggest that isolated intralesional excision of keloid scars is associated with a very high rate of recurrence of up to 80–100%. Early reports dating back to 1953 have identified obstacles and proposed a set of intralesional excision principles such as removal of the most proliferative fibroblast group within the scar, more specifically the centre of the lesion. More recent studies have shown that extralesional excision has lower recurrence rates. Histological analysis from these studies however demonstrate that keloids have multiple separate components, namely a central proliferative core as well as an area of surrounding superficial dermis with prominent lymphocytic infiltration. This suggests that while the centre of the lesion is the most proliferative, it is in fact the peripheral rim of active fibroblasts that initiates this growth. This also supports findings from earlier reports and justifies the use of adjuvant therapy. The historical evolution of keloid management demonstrates our increasing understanding the different components of a keloid scar. This informs principles that take into account clinical factors, including severity and location of keloids, to guide treatment options whether that be intralesional excision, extralesional excision, adjuvant therapy or a combination approach.