8. General discussion 210 bleomycin, triamcinolone, lidocaine, and 5-Fluorouracil) could provide more insight in differences in biodistribution and splash back in keloids. Ideally, a high-speed camera may be used to compare the jet stream backflow and splatter in slow motion when injected on ex vivo keloid skin and to in vivo keloid tissue. In future clinical studies bleomycin should preferably be administered in combination with lidocaine. In our real-world data study, we observed much lower pain scores, compared to the RCT in which we treated patients solely with bleomycin. Moreover, lidocaine increases the intracellular uptake of bleomycin.28 Eventually, to change clinical practice and make EPI-assisted bleomycin a serious alternative to treat recalcitrant keloids, larger high quality randomized controlled trials are needed. Ideally, this will be a RCT with a long-term follow-up and parallel design including multiple arms: 1) CNI and triamcinolone, 2) CNI and bleomycin with lidocaine and 3) EPI with bleomycin and lidocaine. This would allow to compare the efficacy in terms of recurrence with i.l. bleomycin versus triamcinolone, and compare the addition of an EPI compared to CNI. A parallel design in contrast to a split-lesion design will be more appropriate for patients to score patient reported outcome measures such as NRS pain-, and POSAS tool. Significant differences in efficacy, safety and patient satisfaction will eventually lead to more efficacious, safe and patient-friendly treatment for recalcitrant keloids according to international guidelines. Also, EPI treatment with 5-Fluorouracil (and TCA) should be explored in patients with recalcitrant keloids, since high efficacy and safety was found in patients with hypertrophic scars.9 Other applications to be explored for EPI Previous work demonstrated satisfactory effectiveness, tolerability and treatment satisfaction with EPI-assisted corticosteroids in adult patients with keloids.18 Therefore, EPI-asisted treatment with TCA was offered to children who would normally receive intralesional corticosteroid treatment using conventional needles for their keloids or hypertrophic scars. We concluded that EPI-assisted TCA is an effective and child-friendly treatment for keloids and hypertrophic scars. Therefore, we would suggest to perform
RkJQdWJsaXNoZXIy MTk4NDMw