9. English and Dutch summaries 226 as keloid-related symptoms and injection-related pain, were examined. In the bleomycin treated lesions a reduction in keloid volume and keloid related symptoms was found, which was not seen in the lesions treated with saline. No significant difference in blood flow was seen between the bleomycin and placebo treated lesions. Side effects that occurred were temporary necrosis, hematoma and hyperpigmentation. Interestingly, the procedure-related pain with an NRS of 5 was relatively high. However, this pain score was not significantly different compared to lesions treated with saline. Chapter 6 shows the results of a real-world data study, in which intralesional EPI treatment with bleomycin was evaluated in clinical practice. This study included patients with recalcitrant keloids who received three treatments with bleomycin and lidocaine administered with an EPI. Clinical improvement was seen in this difficult-to-treat population, which was objectified with the Patient and Observer Scar Assessment Scale (POSAS). The side effects observed also included necrosis, hematoma and hyperpigmentation. Furthermore, the injection was associated with minimal pain, which was rated significantly lower by patients than needle injection with bleomycin and lidocaine. The questionnaire survey showed that all patients preferred treatment with EPI over treatment with needles. Chapter 7 shows the results of a real-world data study with a questionnaire in children with keloids or hypertrophic scars treated with an EPI and TCA. In this study we found that clinical improvement occurred with this needle-free treatment and that the treatment was well tolerated. The needle-free treatment resulted in significantly lower injection-related pain scores compared to needle injections. All included patients preferred needle-free EPI treatment over treatment with needles. Given that the majority of patients under the age of eighteen suffer from a fear of needles or needle phobia, this needle-free treatment is specifically of added value in this population. Chapter 8 is the general discussion of this thesis, which places our findings in a larger perspective. It addresses current challenges in the treatment of recalcitrant keloid and discusses the advantages and disadvantages of treatment with intralesional bleomycin
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