4. Effects of keloid properties on treatment efficacy 104 The strengths of this systematic review include the use of a comprehensive database search, inclusion of RCTs with no limitation of publication date, and a critical methodological quality assessment using the ROB 2.0. Limitations of this review include the low number of eligible studies and the heterogeneity of outcome measures and scales which precludes a meta-analysis. Moreover, the study populations were generally small which makes it difficult to detect differences in efficacy between keloid properties. In conclusion, only a minority of studies performed sub-analyses for specific keloid properties and even fewer studies found clinically relevant keloid properties. Our results suggest that keloid duration prior to treatment, -location, -size, -history of recurrence, and -severity influence treatment efficacy. Nonetheless, more high quality head-to-head RCTs using validated outcome measures should report on the potentially relevant keloid properties. These further investigations are crucial to corroborate our findings, establish a clinically relevant keloid classification, and ultimately develop an evidence-based treatment algorithm for clinical practice that takes these properties into account.
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