We thank Drs. Annacontini et al. for reviewing our work. In addition to our article, valuable considerations are made in their letter.
A distinction is made between the early and late effects of radiation therapy on skin. Indeed, the patient follow-up in our study only allowed for evaluation of the acute deterministic effects of radiation and its sequelae after a minimum period of 12 months with respect to its effect on keloid formation. We did not claim or intend to study long-term effects. Evaluation of either long-term deterministic effects or the stochastic risk of malignancy formation will require a much longer follow-up. Irradiation-induced malignancy is a theoretical and probably small risk, but it should never be disregarded, and we agree with Drs. Annacontini et al. that youth, pregnant women, and susceptible organs should not be exposed to irradiation therapy for a benign lesion. As stated in our inclusion criteria, our protocol did not allow radiation treatment for patients younger than 16 years old, pregnant patients, or patients with a keloid located close to the thyroid gland or the female breast.
With regard to the discussion about the lack of consensus on dosage and fractionation, we need to emphasize that the dosage unit in our study was erroneously printed as Gray (Gy), whereas it should have been printed in centiGrays (cGy).
As concluded in our article, we subscribe to the recommendations of Dr. Annacontini and colleagues with regard to using irradiation treatment for keloids as a last resort and only in strictly selected cases.
Mick Kreulen, M.D., Ph.D.
Annekatrien van de Kar, M.D.
Department of Plastic Surgery
Academic Medical Center
Amsterdam, The Netherlands
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