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The higher the tier is, the more rare they are to randomly show up for you.
Mr. I'm-selling-you-the-good-stuff-if-you-take-some-curses always presents you kind of rare stuff that's usually pretty hard to get.
What he has in store for you and how useful it ends up varies heavily of course.
It's not like Isaac where the Demon gives you straight up OP stuff.
Also, remember:
You can leave one Relic of your choice on that Altar thingy for another run. Use it wisely.
Especially if you top your HP pool up before a particular annoying boss fight.
If you manage to get a Ham Shank in that sucka, it will essentially rise your maximum HP by 95+.
I mean, the possibility of that is there. It's just not very practical in your everyday dungeon-exploring unless you're playing really careful.
Not to mention, if you're able to get item doubling potions before opening the stache, you are able to constantly get between 60-99 keys and bombs. 99 bombs is worthless, but 99 keys with Keyblade gives you 198 damage just from that one relic.
I think I average around 20-30 curses a run, maybe more xD. I've gotten the stache at Hall 4 before, and by the end up the next dungeon (Den I think) I had it completed, plus 2 item multipliers, allowing me to remove all curses I had gotten too.
I know the uses of the lunchbox, but, the only time I don't get food a lot is when I'm fighting bosses, and I've beaten them all 100's of times, so I know how to beat them all xD. My main save is at SS10 at the moment, so I'm aiming for higher with this other save, since I've limited down the relics, potions and blessings :D.
Then, it's on to another attempt at the Othermine with this setup!
You don't need to have 10 curses at the same time to trigger Kurtz' Stache, if that's what you were thinking.
I have already done that, and it has changed the game for me when it comes to getting relics you want. So far, I have about 30 relics that are in the shop. Did the same for potions and familiars too, just to try and make Othermine a lot easier as well.
It defo makes a difference though, at the end of every run I'm always hitting about the same amount, if not more. My usual damage is around 900+ crits, but I've gone up to 2,700 crit damage when I did a crit strike and crit chance altar run for fun, but I've never hit for less than 300 on ALL runs I've done since unlocking my Sylph, so a good 20 runs where my damage has always been high.
That's why they do it. I and others use the altar for removing one of the useless relics that we'll never use, giving us 1 less rubbish one to get each run basically.
You'd be better off selling a garbage relic instead.