2. Efficacy and safety of needle free jet injector assisted intralesional treatments in dermatology—a systematic review. 48 DISCUSSION In this systematic review, we summarized and critically appraised the current evidence on the efficacy and safety of jet injector-assisted intralesional treatments for dermatological indications. We selected 37 studies including 12 (randomized) controlled trials. The majority of studies had a “high risk of bias” or “some concerns” and only five studies (investigating acne scars, hypertrophic scars, keloids, and non-melanoma skin cancer) had “low risk of bias”. Furthermore, 19 of 37 studies lacked statistical analysis for the reported outcomes. Due to large heterogeneity among studies with respect to a.o. study design, indication, type of jet injector, therapeutics, and outcome measures, a meta-analysis could not be performed. Significant favorable effectiveness was reported in 13 of 15 studies, in which statistical analyses were reported. These studies investigated intralesional jet injections in scars, hyperhidrosis, nail psoriasis, non-melanoma skin cancer, seborrheic dermatitis, local anesthesia, and aesthetic indications. Most studies investigated keloids and other types of scars (hypertrophic, atrophic, and burn scars) and showed good efficacy and high tolerability.21–26 Additionally, our review shows that despite differences in viscosity, several fluids have been successfully administered with jet injectors. None of the included studies compared the use of spring-loaded vs. pneumatic jet injectors. In studies published before 2000, only spring-loaded jet injectors were used because pneumatic jet injectors were not yet introduced. Importantly, spring-loaded jet injectors were associated with a number of severe adverse reactions, including fluctuating cortisol levels and arteria temporalis damage in alopecia areata treated with TCA. Cellulitis, large hematomas, and lymphangitis occurred in patients with warts treated with spring-loaded devices and bleomycin or interferon alfa-n3.30, 32, 42, 43 In contrast, no severe adverse reactions were reported in studies that investigated pneumatic jet injectors. Possibly, this could be related to the tunable settings for pneumatic jet injectors enabling safer and more effective treatment settings based on clinical endpoints, which are not available for spring-loaded injectors.57
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