8. General discussion 209 8. Research gaps in current literature concerning EPI-assisted treatment In the previous studies we investigated the efficacy and safety of EPI-assisted jetinjections in keloids with different research methodologies. Firstly, we evaluated the literature to identify the current evidence with regards to EPI-assisted injections to treat dermatological indications. Hereafter, we performed both explorative ex-vivo and in vivo studies with small groups of patients with keloids. However, to improve treatment options for patients with recalcitrant keloids and make real impact in clinical practice more high-quality research is needed. Future research should focus on studies with larger sample sizes and longer follow-up. This may attribute to evidence for an international treatment guideline. Collaborations The need for a high quality RCT with a large sample size and sufficient follow-up time after EPI-assisted bleomycin in recalcitrant keloids faces some difficulties. Firstly, exact numbers concerning the prevalence of patients with severe keloids are lacking. However, it is known that the prevalence of all keloids including mild to severe keloids is around 0.1% in European countries. Therefore, to perform large trials it is necessary to collaborate with other expert centers with sufficient experience of keloid treatment with EPI. Moreover, EPI are currently relatively expensive, and are particularly used in countries with a high socio-economic status. Therefore, there is a need for the development of tailor-able, handheld jet-injectors that are more affordable for hospitals in countries with lower socio-economic status. In order to develop these jet-injectors, physicians need to collaborate with engineers to design and develop more efficient tunable jet-injector. The future of intralesional treatment administered with EPI for keloid scars In our research, we explored EPI-assisted drug delivery in ex vivo keloids and we evaluated clinical endpoint in keloids patients in vivo. Additionally, an in vivo keloid study could be performed to explore the spatiotemporal profile of bleomycin administered with an EPI, to closely investigate EPI-assisted injections of keloids in clinical practice.30 Next, an ex-vivo study which compares fluids with different characteristics (e.g.
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