6. Needle-free electronically-controlled jet injector treatment with bleomycin and lidocaine is effective and welltolerated in patients with recalcitrant keloids. 159 6. more resistant to any type of treatment. However, this observation remains a hypothesis, and further research is necessary to investigate the effect of morphological features on treatment outcomes. A common adverse effect of intralesional bleomycin injections is local hyperpigmentation at the injection site. This was also observed in our study; six out of 15 patients developed hyperpigmentation (Table S4). Interestingly, only three patients noticed the hyperpigmentation (Table S5). This may be due to the location of the keloids, as those on the shoulders or back may be harder to detect. Furthermore, physicians may be more aware of adverse effects than patients. This study represents the first evaluation of the effectiveness of EPI-assisted intralesional bleomycin combined with lidocaine treatment in recalcitrant keloid scars. The patients included in our analysis, represent a severely affected patient population who suffer from recalcitrant keloids and, although the sample size is limited, the study findings provide important insight into the effectiveness of this treatment approach in recalcitrant keloids. A strength of our study is the real world setting and patient-oriented approach. As previously noted, patients with keloids often experience a reduced QoL due to the various symptoms that are associated with this disease.4, 29 By analyzing the patient's perspective on their treatment experiences and outcomes, optimal treatment modalities can be identified that align with the individual patient's needs and preferences. Limitations of our study are the lack of a control group, and the short follow-up time which precluded the assessment of the recurrence rate of keloids after EPI-assisted bleomycin treatment. Furthermore, the limited sample size of 15 patients may restrict the generalizability of our findings. Although our results are promising, the administration of intralesional bleomycin might be limited in general practice because the off-label status with limited availability. Moreover, jet-injector assisted administration of chemotherapeutics such as bleomycin can cause the formation of potentially harmful aerosols. Therefore, adequate protective safety measures are required, including the use of goggles, gloves, and mechanical room ventilation with FFP-2/FFP-3/N95 masks or
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