8. General discussion 206 The clinical application of needle-free jet injections to treat children with keloids and hypertrophic scars In general, extra caution with regards to new therapies is warranted when treating children. However, at the same time there is an urgent need for innovative child-friendly therapies to treat children with painful hypertrophic- and keloid scars. First-line treatment of children with keloids and hypertrophic children includes the application of silicone gel or sheets and intralesional TCA administered with conventional needles.19 However, many children refuse needle-injections because of needle-phobia or discontinue treatment prematurely because of the painful needle injections.20 Previous results show that EPI-assisted treatment with EPI and TCA in keloids was effective on short term, and well tolerated in adult patients with recalcitrant keloids. In chapter 7 we therefore performed a retrospective study to evaluate the effectiveness, tolerability and patient satisfaction of needle-free EPI-assisted TCA treatment in children with keloids and hypertrophic scars.21 Eleven patients aged 5-17 years, with a total of >118 keloids or hypertrophic scars were included in this study. We observed a significant reduction of 28.9% and 23.8% in respectively the POSAS-observer and POSAS-patient scores, respectively. Adverse events in our study were limited to mild adverse reactions (hyperpigmentation: n = 1, hypopigmentation: n = 1, and white macules: n = 1) were observed. No moderate or adverse events such as subcutaneous atrophy, telangiectasia, and local infection occurred. Due to a limited sample size, we could not perform sub analysis for keloids and hypertrophic scars. EPI caused significantly lower injection-related pain scores compared to needle-injections (3 (IQR: 3–4) vs 7 (IQR: 6–8), respectively (p = 0.027)). This difference clearly surpasses the minimal clinical important difference (MID) of one point.22 Moreover, all children preferred EPI-injections over needle-injections. In a previous study of Acosta et al., children between 1 and 14 years old with keloidal scars were treated with intralesional TCA administered using conventional needles.23 In this study two to five treatments resulted in a mean scar volume reduction of 82.7% compared to baseline. However, the needle injections were (very) painful in all cases. Another study by Hamrick et al., found that TCA injections before and after excision is effective and well-tolerated in children.24 However, in this study procedure related pain
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