2. Efficacy and safety of needle free jet injector assisted intralesional treatments in dermatology—a systematic review. 49 2. 2. Only five of the included studies compared patient-reported pain between needle-free jet injectors and conventional needle injections.33, 34, 41, 48, 49 Jet injections with lidocaine caused significantly less injection-related pain, and less procedure-related pain with 5ALA and PDT treatment in non-melanoma skin cancer compared to needle injections with 5-ALA and PDT.34, 41, 48 Jet injections with botulinum toxin for palmar and axillar hyperhidrosis and with xylocaine for local anesthesia in children were better tolerated than conventional needle injections; however, no statistical analyses were performed.34, 49 On the other hand, two studies investigating local anesthesia with lidocaine and palmar hyperhidrosis with onabotulinumtoxinA reported no significant difference in procedurerelated pain between jet injections and conventional needle injections.33, 48 Risk of bias assessment resulted in two high-quality RCTs. The results of these studies suggest that jet injections with 5-FU and TCA and jet injections with saline in atrophic acne scars (boxcar and rolling) are efficacious, safe, and well-tolerated.20, 22 Also, favorable efficacy and safety were found in cohort studies with low risk of bias for intralesional jet injections with 5-FU combined with corticosteroids in keloids and with hyaluronic acid in atrophic acne scars. To our knowledge, this is the first systematic review that evaluated the efficacy and safety of intralesional treatment with jet injectors for dermatological indications. The strengths of this study include the use of a comprehensive database search, reporting of outcome measures as efficacy and adverse reactions, addressing jet injector settings, critical methodological quality assessment, and inclusion of all study designs with no limitation to publication date. Limitations of this systematic review include a majority of studies in cohorts or case series, noncomparative studies, poor methodological quality of the included studies, and missing of important clinical data such as skin type. At our tertiary outpatient clinic, patients with keloids, hypertrophic scars, and recalcitrant warts are commonly treated with spring-loaded or pneumatic injectors to administer TCA, bleomycin or a mixture of both. Moreover, we believe there is a significant clinical benefit of jet injector treatment in children (e.g., for keloids and hypertrophic scars), because in our experience they tolerate
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