8. General discussion 201 8. MAIN FINDINGS OF THIS THESIS Keloidal scars Keloidal scars belong to one of the most common chronic inflammatory skin disorders, especially in darker Fitzpatrick skin types 4 through 6. Impairment in quality of life seems to be higher in severely affected patients, which are described in the literature as patients with keloids larger than 10 cm2 or when multiple keIoids are present. In chapter 4, we investigated which keloid properties may result in keloids being categorized as ‘severe’. We found that the efficacy of certain treatments for keloids may be negatively influenced by keloids that are larger in size, located on the chest and extremities, or have a lower Vancouver Scar Scale (VSS) score, longer duration of the keloid prior to treatment, and a more extensive treatment history. Although keloids form a serious burden, yet no effective, safe and minimally painful treatment for this group of difficult to treat keloids is available. In this thesis we sought to find an efficacious, safe and patient-friendly treatment for patients that suffer from (severe) keloidal scars. Currently, needle injections with triamcinolone acetonide (TCA) are the standard treatment for keloids. However, this therapy with TCA is often suboptimal due to adverse effects like skin atrophy, hypo- and hyper pigmentation and a high risk of recurrences because of the temporary effects of TCA.4 Therefore, treatments with a safer profile, that offer longer term effects are warranted. Bleomycin is an antibiotic chemotherapeutic agent that causes apoptosis of keratinocytes and fibroblasts and has an antiangiogenic effect.5 This mechanism of action also results in less recurrences in keloids. However, needle-injections with bleomycin in keloids are painful, making patients reluctant to undergo treatment. Therefore, needle-free drug delivery devices such as needle-free jet-injectors (NFI) represent an attractive option for treating keloids.
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