8. General discussion 208 PERSPECTIVES In this thesis the clinical application of intralesional treatment with bleomycin and triamcinolone acetonide using an EPI was explored. In the last paragraphs of this chapter an outline of current challenges in research, current developments in keloid treatment and emerging needle-free technologies will be discussed. Challenges in research on keloid treatment According to the Dutch guidelines for keloidal scars, mild keloids should be treated with silicon plasters, non-ablative laser therapy (e.g. Pulsed Dye Laser or Nd-Yag laser) or intralesional triamcinolone administered by conventional needle injections.26 However, up to date there is no (inter)national evidence-based guideline for the treatment of severe keloidal scars. Due to the lack of standardization, patients that are referred to a dermatologist are likely to receive a different treatment compared to a plastic surgeon or general practitioner. This may be the result of the lack of strong evidence for one particular treatment modality. Ideally, future research should be multidisciplinary organized in order to achieve a standardized algorithm for (severe) keloid treatment. Moreover, current research is varying with regards to the outcome assessment measures. Some studies use volume reduction as outcome measure, while others report on scar assessment scales, such as POSAS, VSS or JSW.27 Ideally, there should come consensus on which scar assessment tool to use for keloids. This uniformity could contribute to easier comparisons between treatments used among different studies. Another challenge is the high heterogeneity among keloid patients. Keloid characteristics such as size, duration of keloids and location of keloids can play an important role on treatment efficacy, and should therefore be properly mentioned in studies, while this is a point that is frequently lacking in clinical studies.
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