Next Article in Journal
Community Response to Burn Injuries: Examples from Dhading District of Nepal
Previous Article in Journal
No Change in Fireworks-Related Burn Center Admissions: A 10-Year Analysis of the Admission Rates, Treatment, and Costs
 
 
Review
Peer-Review Record

Corticosteroid Injection Alone or Combined with Surgical Excision of Keloids versus Other Therapies Including Ionising Radiotherapy: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

by Ru Wang 1, Patricia L. Danielsen 2,3, Magnus S. Ågren 2,4,5,*, Janine Duke 3, Fiona Wood 6, Xiao-Xi Zeng 7, Yu Mao 8 and Ying Cen 1
Reviewer 1: Anonymous
Reviewer 2: Anonymous
Reviewer 3: Anonymous
Reviewer 4: Anonymous
Submission received: 13 March 2021 / Revised: 29 April 2021 / Accepted: 7 May 2021 / Published: 14 May 2021

Round 1

Reviewer 1 Report

The review is well structured, organized and the choice of studies to include was meticulous.

I move some important notes to colleagues in order to improve this work:

  • the choice of studies was too selective: this leads, on the one hand, to consider only highly reliable studies, but, on the other hand, it causes an intrinsic bias in comparing the types of treatment, linked to the small number of cases present in the few studies considered.

For example you said that "the effectiveness of Botulinum Toxin A Is the same as TAC injection", but in licterature there are some studies supporting the superiority of Botulinum Toxin against the Tac inj.

-"Bi M, Sun P, Li D, Dong Z, Chen Z. Intralesional Injection of Botulinum Toxin Type A Compared with Intralesional Injection of Corticosteroid for the Treatment of Hypertrophic Scar and Keloid: A Systematic Review and Meta-Analysis. Med Sci Monit. 2019 Apr 22;25:2950-2958."

Please review this part and consider other reserches for each treatment, widening the number studies included.

  • the conclusion of the study is completely misleading, and misleads the reader: corticosteroid therapy cannot be considered as the "Gold Standard" for the treatment of keloid scars, because, unfortunately, there isn't, so far, a Gold Standard treatment for keloids. Furthermore, even if TAC injection as "first line monotreatment" can be considered the most effective, surgical excision followed by RT or HDR BT Is the best association in order to prevent recurrences and many studies and reviews support this thesis

i.e:

-"Ekstein SF, Wyles SP, Moran SL, Meves A. Keloids: a review of therapeutic management. Int J Dermatol. 2020 Sep"

-"Berman B, Maderal A, Raphael B. Keloids and Hypertrophic Scars: Pathophysiology, Classification, and Treatment. Dermatol Surg. 2017 Jan;43 Suppl 1:S3-S18."

-"Ojeh N, Bharatha A, Gaur U, Forde AL. Keloids: Current and emerging therapies. Scars Burn Heal. 2020 Aug 10".

This part has to be reviewed.

I recommend re-evaluating the studies selection method, broadening the review and substantially revising the conclusions.

Author Response

We are very grateful for the comments and useful references. Accordingly, we have now included the suggested work on botulinum toxin (Bi et al. 2019). Furthermore, the notion that corticosteroid therapy is gold standard has been deleted throughout the manuscript and the Conclusion reworded according the suggestions of the Reviewer. However, we do not agree with him/her on performing a broader search profile which will yield distorting non-informative publications that will not contribute significantly to evidence-based medicine. This has been high-lighted in the 4th paragraph of the Discussion

Reviewer 2 Report

An excellent summary of the evidence.

Author Response

Thank you.

Reviewer 3 Report

Thank you for the opportunity to review this article.  I believe this is a valuable addition to the literature. It is well structured and written, and the methodology is sound. I would like to see a greater emphasis on the follow-up time for the studies included, given their importance, especially in the context of comparing excised (keloid is removed and recurs) versus medical therapy.  It seems an unfair comparison and is only relevant given that there is such a high recurrence rate.

The authors do emphasize that keloids and hypertrophic scars are both included in these studies. Given this, and the small size of these samples, it is hard to see how these studies are principally high and moderate ‘quality’, rather than low if the inclusion criteria and follow-up are dificient.

My only other comment might be that rather than repeat the core results of the studies in the discussion, it might be of value for the authors to interpret these more and propose a rational approach based on these findings.  In other words, what is written in the conclusions might be expanded upon in the discussion. Which cases would the authors consider excising and which ones not, and which adjuvant therapies would be recommended?

Author Response

Thank you for very valuable comments. 

Regarding quality assessments (GRADE) of the studies we agree about the possible confusion this may have caused. We agree that follow-up periods should be standardised in future trials and keloids separated from hypertrophic scars. Therefore, we have reconsidered our assessment of the study by Darzi and graded it as of moderate quality.

The second comment is very relevant. However, we are awaiting consensus guidelines determined by many experts based on results of RCTs rather than presenting our subjective view on preferable treatment. Ideally, we should aim as a community to develop a general treatment algorithm.

The Discussion has been revised and expanded to improve the balance between our results and the present literature.

Reviewer 4 Report

Thank you for allowing me to review the manuscript entitled:

Corticosteroid Injection Alone or Combined with Surgical Excision of Keloids versus Other Therapies including Ionising Radiotherapy: A Systematic Review and Meta-Analysis of Randomised Controlled Trials.

This is an interesting and well written review that addresses a problematic area. The review process and search strategy are comprehensive and is well defined. The data in the tables are clear, correctly formatted and presented.  

 

Author Response

Thank you for reviewing our paper. 

Back to TopTop