4. Effects of keloid properties on treatment efficacy 103 4. DISCUSSION This systematic review aimed to identify clinically relevant keloid properties that may impact treatment efficacy. In total, only 16 RCTs performed a separate analysis for specific keloid properties. In these 16 studies, keloid duration prior to treatment and location were the most frequently analyzed properties followed by size, Fitzpatrick skin type, baseline POSAS score, baseline VSS score, keloid thickness, ethnicity, etiology, number of keloids, and history of recurrence. Our findings suggest a lower treatment efficacy in keloids with a longer duration prior to treatment, location on the chest, extremities, pinna, or shoulder, a larger size, history of recurrence, and a lower baseline VSS score of keloids. However, we cannot exclude clinical relevance of the other keloid properties because the number, sample size, and quality of the studies is insufficient to draw firm conclusions. Hence, more research is needed with a focus on these keloid properties. Some keloid properties were found to be relevant for specific treatments only, suggesting that the influence of keloid properties depends on the treatment used. In line with this finding, some experts proposed treatment algorithms addressing specific keloid properties.19,20 Although size and number of keloids were mentioned in these algorithms as important properties to take into account, other potentially clinically relevant properties such as duration prior to treatment and location of keloids were not mentioned. Moreover, these algorithms were not based on a systematic review. Importantly, a diversity of outcome instruments and scales were used in the included studies. For instance, some studies used the Swada and Sone,7 POSAS,4,6 or VSS scale8,9 to evaluate keloid treatment outcomes, while others used reduction in keloid size3,5,18 as the primary outcome. This variation in outcome measures makes it challenging to compare results between studies, decreasing the value of these studies and contributing to waste in research. Therefore, it is imperative that a consensus-based Core Outcome Set will be implemented in future research and reporting in this field.
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