8. General discussion 202 Needle-free jet injectors in dermatology A needle-free jet injector (NFI) is a drug delivery device that enables intradermal drug delivery of liquid therapeutics.6 NFI have been used for several indications as alternative to conventional hypodermic needle injections (CNI), including needle-free mass vaccination and self-administration of insulin by patients with Diabetes.7 NFI may overcome several limitations associated with CNI. For example, NFI can be used for patients with (extreme) needle-phobia, cause less injection-related pain and do not harbor a risk of needle-stick injuries. In the past decades, NFI have also been used for dermatological indications. In this thesis we first performed a systematic review (chapter 2) that summarizes and critically evaluates the available evidence for the efficacy and tolerability of intralesional treatment using NFI to treat several dermatological indications.8 Thirty-seven articles, involving 1911 participants were finally included in the review. Two types of jet-injectors were used to treat dermatological indications: spring-loaded jet-injectors (SLI) that act with pressure generated by a mechanical spring, and electronically controlled pneumatic jet-injectors (EPI) that generate pressure by compressed gasses (e.g. CO2 or air). Several drugs, with varying characteristics (e.g. different viscosities and molecular masses) including triamcinolone acetonide (TCA), bleomycin and 5-fluorouracil (5-FU) were successfully delivered intralesionally. The most evidence was found for NFI-assisted treatment of keloids and other types of scars (hypertrophic, atrophic and burn scars) using various drugs. Other indications in which NFI were used were alopecia areata, hyperhidrosis, nail diseases, non-melanoma skin cancer, common warts, local anesthesia, and aesthetic indications. However, the quality of the included studies was generally low. Only two high quality RCTs were identified in our review. These studies showed that jet injections with a combination of 5-FU and TCA and jet injections with saline are efficacious, safe, and well-tolerated in respectively hypertrophic scars and atrophic acne scars.9,10 Additionally, our review suggested that jet injector treatment might result in less injection related pain than CNI for certain indications.
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