6. Needle-free electronically-controlled jet injector treatment with bleomycin and lidocaine is effective and welltolerated in patients with recalcitrant keloids. 148 intralesionally (Figure 1). In contrast to needle-free spring-driven jet injectors, EPI allow the adjustment of settings such as volume and pressure.15 A recent study demonstrated the high effectiveness, good tolerability, and patient satisfaction of intralesional EPIassisted triamcinolone acetonide (TCA) treatment in keloids.16 A. B. C. Figure 1 Illustration of an electronically-controlled pneumatic jet injector-assisted treatment with bleomycin and lidocaine in a keloid scar. (A) Before administering treatment, the electronically-controlled pneumatic jet injector (EPI) hand piece with the injector tip is placed perpendicularly on the keloid scar. (B) A crosssectioned illustration of the injector tip and nozzle of an EPI-device. The liquid container within the EPI contains a solution with the combination of bleomycin and lidocaine (depicted in blue). (C) Illustration during injection. The EPI device generates a high-velocity jet stream that punctures the epidermis of the keloid, disperses the combination of bleomycin and lidocaine in the mid-deep dermis and creates visible skin papule or blanching. Bleomycin could potentially be used as an alternative drug for the intralesional treatment of recalcitrant keloids. It is an antineoplastic antibiotic that has been used off-label for various dermatological indications (e.g., hemangiomas, hypertrophic scars, Kaposi sarcoma, and warts) with satisfactory results.17 The therapeutic effect of bleomycin is attributed to its ability to induce DNA destruction, apoptosis of the cell and inhibition of the collagen synthesis by decreasing a.o. TGF- β1, an important cytokine in immunoregulation, wound healing, angiogenesis and cancer.18 Previous studies have 0.5 mm
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