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The assessment of activity in keloids may be critical for defining their management. There is a lack of clinical scorings designed for the evaluation of keloids and biopsies may be contraindicated.To assess the sonographic activity of keloids in comparison with clinical scoring.A retrospective study of the clinical and color Doppler ultrasound (CDU) images of patients medically derived to CDU with the diagnosis of keloid was performed. Activity was evaluated clinically (modified Seattle Scar Scale) and CDU. Keloids were considered active when CDU detected vascularity within the lesion. Statistical analysis was performed (Wilcoxon–Mann–Whitney, Student t-test, and interobserver agreement).Thirty-five patients with 42 keloids were evaluated. Color Doppler ultrasound provided the diameters, including depth, and vascularity. On CDU, 76% were active and 24% inactive. Clinically, Observer 1 found 55% and Observer 2 found 88% of active keloids. Interobserver agreement between clinical observers was moderate (k = 0.42). Subclinical fistulous tracts, involvement of the hypodermis, muscle, and calcifications were also found on CDU.Color Doppler ultrasound can support the assessment of activity in keloids. Clinical evaluation alone can underestimate the activity in keloids. Relevant anatomical and subclinical features can be detected by CDU.