7. Needle-free jet Injector-assisted triamcinolone treatment of keloids and hypertrophic scars is effective and well tolerated in children. 179 7. INTRODUCTION Keloids and hypertrophic scars are pathological scars that can cause considerable pain, pruritus, impairment of movement, as well as severe psychological distress. These types of scars are often extremely difficult to treat, especially in children with needle phobia.1 Although keloids and hypertrophic scars (HTS) are considered distinct entities, they have some similarities with regard to their pathophysiology.2 These excessively growing scars result from chronic inflammation in which several interleukins (ILs, e.g. IL-6, IL-8, and IL10) and transforming growth factor B1 and B2 play an important role.3 Moreover, these scars are characterized by abnormal fibroblast proliferation, collagen deposition, and increased angiogenesis.4 However, differences lie in the fact that keloids extend beyond the boundaries of the original wound, whereas HTS do not.5 Keloids and HTS occur very commonly in children or young people aged between 10 and 30 years.6, 7 Overall, keloids and HTS develop in respectively 0.1–10% and 32–72% of all scars.8,9,10,11 First-line treatment includes the application of silicone sheets and intralesional triamcinolone acetonide (TCA) administered with conventional hypodermic needles (CN).12 Although this can be effective, long-treatment regimens with multiple painful injections are usually needed to reach the desired results. In clinical practice, many children discontinue treatment prematurely because of the painful injections, or refuse treatment entirely because of fear of needles.13 It is well known that painful and stressful medical procedures can cause a serious burden for children and their parents. Therefore, to prevent traumatic experiences, child-friendly procedures that do not cause pain and stress are highly needed. In a previous study, children aged between 1 and 14 years with keloids were treated with two to five sessions of intralesional TCA needle injections.14 This resulted in a mean scar volume reduction of 82.7% compared with baseline (p < 0.001). However, the injections
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