8. General discussion 207 8. scores were not reported. It is well established that painful and stressful procedures can cause serious burden in the pediatric population, and should be avoided if possible. With our study, we showed that EPI-assisted intralesional TCA treatment can be an effective, and child-friendly alternative treatment for minors with keloids or hypertrophic scars. Biodistribution of electronic pneumatic jet-injections in severe keloids The biodistribution of a drug refers to how a therapeutic is distributed in the skin after it is administered. This distribution of therapeutics in the skin is directly related to the efficacy of a certain treatment. Key factors that influence the biodistribution of a drug include fluid specific properties (e.g. size and molecular mass), skin characteristics, and the drug delivery technique. A previous ex-vivo study in human skin, and an in-vivo study in pigs showed promising results with regards to the biodistribution of intralesional EPI-assisted jet injections.25 The EPI-assisted injections resulted in more consistent, standardized and equally distribution of injections into the dermis, compared to SLI-assisted and CNI-assisted injections. However, no previous studies investigated the biodistribution of EPI-assisted jet injections in keloidal skin. We hypothesized that the biodistribution of EPI-assisted jet injections in rigid keloidal scars may differ from the distribution in normal skin due to differences in skin characteristics (e.g. rigidity, elasticity, and porosity). Therefore, we performed an ex vivo study that evaluated the biodistribution of EPI-assisted jet-injections and CNIassisted jet-injections in severe keloids. Our results showed that the biodistribution of drugs in keloids demonstrated a high variability, compared to normal skin using both EPI and CNI. In summary, we observed large heterogeneity with regards to the biodistribution in severe keloids with both needles and an EPI. This may partly explain why there is a large variability in treatment efficacy among severe keloids.
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