6. Needle-free electronically-controlled jet injector treatment with bleomycin and lidocaine is effective and welltolerated in patients with recalcitrant keloids. 151 6. of a scar compared to pretreatment, which consists of five degrees: exceptional improvement, very improved patient, improved patient, unaltered patient, and worsened patient.23 An online questionnaire to measure patient satisfaction was conducted at follow-up and was created with LimeSurvey version 2.06 (LimeSurvey GmbH, Hamburg, Germany).24 Treatment During a regular outpatient visit, a test treatment with intralesional bleomycin combined with lidocaine was administered using respectively an EPI (Enerjet 2.0, Perfaction, Rehovot, Israel) and a CNI (27 gauge) in two similar keloids according to a local SOP. Treatment related pain scores on a numerical rating scale (NRS; range 0−10) during EPI and needle injections and patient preferences were recorded by the treating physician after the test treatment. Depending on pain scores and patient preferences, treatment with either EPI or CNI was chosen as delivery method for the consecutive treatments. All patients who received a test treatment with EPI and CNI, were included in this study. Needle injections with 0.5–3 mL bleomycin mixed with lidocaine (1 USP/mL bleomycin in 5 mg/mL lidocaine and NaCl 0.9%) were used for the intradermal treatment. For EPI an injection volume of 100 µL (device range: 50–130 moL) and pressure level of 3.2 Bar (device range: 2–6 Bar) were pre-selected for each treatment. In firmer keloids, the pressure was increased with 10% per injection until a consistent papule or blanching (clinical endpoint) was visible after injection (Figure 2). Each EPI-assisted injection was administered in a 1 cm2 surface area. Clinical photographs of all keloid scars were taken at each visit.
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