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Needle Dermabrasion
Abstract
In this article we describe a technique of needle dermabrasion (tattoo without pigment) used to improve achromic, hypertrophic, and unsightly scars. It is simple, safe (no complications), and it gives us consistently good results.
... In 1997, a technique similar to tattooing but without pigment was introduced, based on a similar underlying theoretical basis. 3 Further along the timeline, the technique of PCI was popularised with the use of a 200 drumshaped needling device, offering a more practical and faster needling modality for large scars. 4 The basic principle of needling is the repetitive application of the device on the stretched scar in multiple directions (horizontally, vertically and obliquely) until uniform pinpoint bleeding is reached as an endpoint; the procedure is then repeated as necessary at variable intervals. ...
... Non-atrophic scars.at an average follow-up of 17 months (range 6-36).One patient from the MN alone group had mild hyperpigmentation that responded well to3 months of treatment with vitamin A and tyrosine inhibitors. (P ⩽ 0.005) was noted, whereas the VSS showed an improvement of 2.7 points and POSAS of 8 points (both results significant with P ⩽ 0.005). ...
Introduction
Percutaneous collagen induction (PCI) or needling techniques are increasingly popular in the reconstructive and aesthetic arena. The underlying mechanisms of action rest on producing a pattern of non-ablative and non-confluent puncture wound pattern to the dermis with a resulting regenerative effect to the skin.
Methods
A detailed English literature review was conducted using PubMed Medline, Embase and Web of Science; the manuscripts were appraised and classified according to level of evidence as well risk of bias. Results are presented in descending order of evidence for non-atrophic scars.
Discussion
On the basis of level 1 evidence currently available, the combination of needling and silicone gel can improve the short-term pliability, height and vascularity of hypertrophic and keloid scars. According to level 2 evidence, needling alongside spray keratinocytes can produce a statistically significant improvement to patient/observer scar ratings and improve pigmentation in hypopigmented burn scars at 12-month follow-up. Results from mixed cohort studies also point towards needling having a beneficial effect on fat graft retention. Level 3 data suggest that needling can render significant resurfacing effects to both mature and actively hypertrophic burn scars at 12-month follow-up based on objective scar scales; furthermore, favourable histological changes are seen, including better collagen alignment in the dermis and increased epidermal thickness.
Conclusion
Needling techniques are promising adjuncts to non-atrophic scar management. Further research with long-term follow-up and comparative design protocols incorporating other resurfacing modalities is warranted before the exact value of needling is delineated in scar management protocols.
Microneedling, also referred to as percutaneous collagen induction therapy, uses small needles to create mechanical injury to the skin, stimulating the wound-healing cascade and new collagen formation. Compared with other skin resurfacing techniques, microneedling preserves the epidermis and is nonablative, therefore reducing inflammation, downtime, and risk of dyspigmentation. In addition to increasing collagen production in fibroblasts, microneedling also helps normalize cell function of keratinocytes and melanocytes and can be used to increase absorption of topical medications, growth factors, or deliver radiofrequency directly to the dermis. The benefits of microneedling, associated procedures, indications for use, technical considerations, and potential complications are discussed.
Introduction
Transdermal drug delivery is limited by the stratum corneum, inhibiting the therapeutic potential of the permeants. Microneedles (MN) have opened new frontiers in transdermal drug delivery systems. These micro-sized needles offer painless and accentuated delivery of drugs even with high molecular weights.
Areas covered
The review embodies drug delivery strategies with microneedles with a description of MN types and fabrication techniques using various materials. The application of MN is not limited to drug delivery, but it also encompasses in vaccine delivery, diagnosis, phlebotomy and even in the cosmetic industry. The review also tabulates microneedle-based marketed formulations. In a nutshell, we aim to present a panoramic view of microneedles including the design, applications, and regulatory aspects of MN.
Expert opinion
With the availability of numerous materials at the disposal of pharmaceutical scientists; the microneedle-based drug delivery technology has offered significant interventions towards the management of chronic maladies including cardiovascular disorders, diabetes, asthma, mental depression, etc. As happens with any new technology there are concerns with MN also such as biocompatibility issues with the material used for the fabrication. Nevertheless, the pharmaceutical industry must strive for preparing harmless, efficient, and cost-effective MN based delivery systems for wider acceptance and patient compliance.
Microneedling has several indications and can significantly improve certain skin concerns and conditions. Gemma Fromage explains the basics of the treatment
Medical aesthetics is the use of a procedure or product for a therapeutic indication which is conventionally used for aesthetics. Several medical conditions are now being treated with products, procedures or equipment that are conventionally used for aesthetic indications. This has widened the scope of treatment modalities available for dermatologists to treat various indications that fall outside the purview of aesthetic dermatology. The authors present aesthetic treatment modalities and procedures which can be used for medical aesthetics, their present‐day status and usefulness in field of therapeutics with a review of published literature from “Medline” (via “PubMed”), “Cochrane,” the Virtual Health Library, and Google Scholar.
Microneedling, also referred to as percutaneous collagen induction therapy, uses small needles to create mechanical injury to the skin, stimulating the wound-healing cascade and new collagen formation. Compared with other skin resurfacing techniques, microneedling preserves the epidermis and is nonablative, therefore reducing inflammation, downtime, and risk of dyspigmentation. In addition to increasing collagen production in fibroblasts, microneedling also helps normalize cell function of keratinocytes and melanocytes and can be used to increase absorption of topical medications, growth factors, or deliver radiofrequency directly to the dermis. The benefits of microneedling, associated procedures, indications for use, technical considerations, and potential complications are discussed.
Human skin is a multilayered physiochemical barrier protecting the human body. The stratum corneum (SC) is the outermost keratinized layer of skin through which only molecules with less or equal to 500 Da (Dalton) in size can freely move through the skin. Unfortunately, the conventional use of a hypothermic needle for large therapeutic agents is susceptible to needle phobia and the risk of acquiring infectious diseases. As a new approach, a microneedle (MN) can deliver therapeutically significant molecules without apparent limitations associated with its molecular size. Microneedles can create microchannels through the skin’s SC without stimulating the proprioceptive pain nerves. With recent technological advancements in both fabrication and drug loading, MN has become a versatile platform that improves the efficacy of transdermally applied therapeutic agents (TAs) and associated treatments for various indications. This review summarizes advanced fabrication techniques for MN and addresses numerous TA coating and TA elution strategies from MN, offering a comprehensive perspective on the current microneedle technology. Lastly, we discuss how microneedling and microneedle technologies can improve the clinical efficacy of a variety of skin diseases.
Background: Collagen induction therapy is a form of microneedling. It is cheap and effective and has less side effects than other alternative therapies. Purpose: It is done using dermaroller for the treatment of scars, wrinkles, stretch marks, hair growth, and transdermal delivery of substances like lipopeptides and antiaging products. Methods: It acts by stimulating collagen production, produces microwounds and thus release of various inflammatory mediators. It also increases electric potential, thus inducing cellular activity with release of cytokines and growth factors leading to wound healing with collagen induction. Results: There are various new modified instruments, and combination with other modalities of treatment increases its utility in different dermatological and cosmetic conditions. Conclusions: Microneedling is a simple, inexpensive procedure with no down time and good results in acne scars, hair loss and wrinkles.
Facial rejuvenation treatments include any injectables or skin interventions that make the face appear younger. This article aims to improve treatment outcomes by assisting practitioners in selecting optimum treatment for patients depending on their individual needs, whether that is wrinkle reduction, long-term improvement of skin elasticity, reduction in pigmentation, tightening or all of these. This review includes clinical analyses of botulinum toxin, microneedling, hyaluronic acid dermal filler and intense pulsed light, including evidence and arguments for the benefits and limitations in each case.
Radiofrequency application obtained enhanced precision with the combination of a microneedle where the microneedle penetrates the skin in order to target a specific skin layer. Radiofrequency microneedling (RFMN) became a staple within cosmetic dermatology with its use of treating wrinkles, acne vulgaris, primary axillary hyperhidrosis, and cellulite. RFMN uses bipolar radiofrequency through an array of microneedles to produce a controlled coagulation at a specified dermal depth to induce neoelastogenesis and neocollagenesis. Radiofrequency is delivered in two modalities: monopolar and bipolar. A paucity of literature is available for the treatment of acne vulgaris using radiofrequency. For radiofrequency delivery into the skin, the operator has to adjust power level, radiofrequency conduction time, and frequency. RFMN devices are shown to be safe and effective for the treatment of wrinkles, acne scars, acne vulgaris, primary axillary hyperhidrosis, and standard cosmetic benefit such as texture, pore size, skin tone, and smoothness.
Microneedling can accelerate skin repair through numerous complex processes triggered by micro-injuries it produces on the skin surface with very thin needles. The current growth in the application of microneedling in the treatment of cutaneous diseases can be explained by its numerous effects on the skin as reported in the literature. Despite the numerous studies conducted on the application of microneedling in the treatment of skin lesions, its effects on pigmented skin lesions have remained relatively unexplored. The present review comprises an examination of the evidence for the application of microneedling in skin diseases in general and a comprehensive review of the applications of microneedling in pigmentation disorders. The review involved a search of all clinical studies, including trials, case reports, and case series, in the databases MEDLINE/PubMed and Google Scholar using the following keywords: “microneedling”, “dermal needling”, “percutaneous collagen induction”, “skin needling”, “dermaroller”, and “dermatology disorder”. Pertinent data were extracted from all relevant articles published from 1990 to April 2021, and focused on the application of microneedling in the treatment of pigmented skin lesions. Despite the limited number of available studies, evidence suggests the effectiveness and safety of microneedling in treating vitiligo, melasma, and periorbitalhypermelanosis. It is noteworthy that the combination of any type of non-aggressive needing technique with other effective therapies (especially topical agents and mesotherapy) yields more promising therapeutic results than single therapy for melasma, dark cycles and vitiligo as the prototype of pigmentary disorders. However, single needling therapy is significantly effective, too.
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A microneedle (MN) is a painless and minimally invasive drug delivery device initially developed in 1976. As microneedle technology evolves, microneedles with different shapes (cone and pyramid) and forms (solid, drug-coated, hollow, dissolvable and hydrogel-based microneedles) have been developed. The main objective of this review is the applications of microneedles in biomedical areas. Firstly, the classifications and manufacturing of microneedle are briefly introduced so that we can learn the advantages and fabrications of different MNs. Secondly, research of microneedles in biomedical therapy such as drug delivery systems, diagnoses of disease, as well as wound repair and cancer therapy are overviewed. Finally, the safety and the vision of the future of MNs are discussed.
Microneedling, a minimally invasive technique utilized to induce neocollagenesis, is frequently combined with platelet-rich plasma (PRP) to enhance results for a variety of medical and cosmetic dermatological conditions. It is generally well-tolerated and effective with preliminary data demonstrating improved outcomes for the treatment of acne scarring, striae distensae, melasma, and photoaging.
Context:
There are several modalities of treating acne scars. The combination of microneedling and platelet-rich plasma (PRP) is a synergistic approach to treat acne scars.
Aims:
The aim was to compare the efficacy of microneedling alone versus microneedling with PRP in acne scars.
Materials and methods:
This was a split face study conducted on 36 patients with acne scars who underwent four sessions of microneedling with PRP on right side and microneedling alone on left side at monthly interval. The total scars with subtypes and Ecchelle D'Evaluation Cliniques des Cicatrices D'Acne (ECCA) score were assessed at baseline and second, fourth, and sixth visits. Visual analog score (VAS) was evaluated by both physicians and patients.
Statistical analysis:
The statistical analysis was carried out using Statistical Package for Social Sciences. Paired-t test and Wilcoxon signed rank test were used to compare the results.
Results:
Mean age was 23.7±3.2 years with 17 male and 19 female patients. The mean total scars on right and left sides declined from 42.14±21.15 to 25.08±14.14 and 43.28+23.08 to 27.17±15.68, respectively, with insignificant differences (P-value = 0.094). ECCA score on right and left sides declined from 88.31±32.78 to 62.92±23.68 and 89.58±32.43 to 66.25±23.89, respectively (P-value = 0.058). VAS evaluated by patient and physician showed maximum improvement at second and third visits, respectively.
Conclusions:
This study showed no added advantage of topical application of PRP over microneedling in acne scars.
An overview of various forms of noninvasive facial rejuvenation procedures is presented including toxins for muscle relaxation and fillers for repair or enhancement of facial features. In addition, energy-based devices to induce facial remodeling are introduced including light-based systems, ultrasound or radiofrequency devices as well as mechanical needling devices.
This chapter focuses on the history of skin needling and includes a substantial autobiographical focus due to the author's role in bringing skin needling to the attention of the medical profession. The roller is the safest and most effective way to needle the whole face, stretch marks, deep acne scars, or burn scars. The author believed the results he achieved validated the necessity to use vitamin A before and after skin needling. We know vitamin A hastens healing, normalizes skin cells, and promotes normal collagen in a lattice pattern. Vitamin C is essential for the production of normal collagen and even activates genes related to collagen production, and since we were stimulating the system to produce more collagen, that automatically means that one needs more vitamin C. Cosmetic peptides have in recent years become very effective – ever since the introduction of the pioneering Matrixyl about 20 years ago.
Microneedling is a minimally invasive procedure that uses fine needles to puncture the epidermis. Microneedling, or percutaneous collagen induction therapy, was introduced in the 1990s for the treatment of scars, striae, and laxity. The mechanism of action is thought to be a disruption of the epidermis and dermis. Micropunctures are created using microneedles, which produce a controlled skin injury without damaging the epidermis. Modern microneedling devices consist of rollers, stamps, and pens. Physicians and providers need to consider important factors like needle length, needle material, and clinical indications in selecting which device to utilize. DermaFrac treatment is a newer modification of microneedling combining microdermabrasion, microneedling, simultaneous deep tissue serum infusion, and light emitting diode therapy. Microneedling is an effective modality of treatment, especially in patients with Fitzpatrick's IV and V skin types because it overcomes the side effects of scarring and hyperpigmentation resulting from other procedures in which the epidermis is compromised.
In recent years, microneedling has been combined with platelet‐rich plasma (PRP) with the aim of augmenting cosmetic outcomes. This chapter discusses PRP and its use in combination therapies with microneedling. PRP is an autologous high concentration of platelets derived from blood plasma. Microneedling provides accelerated neocollagenesis. Collagen induction therapy, in combination with the additional growth factors and cytokines from PRP, may act synergistically with the microneedling cascade to provide enhanced collagen remodeling and patient outcomes. PRP has been utilized for many years in dentistry, orthopedics, endodentistry, and other surgical fields. PRP as monotherapy has demonstrated significant improvements in hair growth when treating androgenic alopecia. PRP and microneedling continue to evolve as therapeutic tools in dermatology and aesthetic medicine. Top evidence‐based dermatologic indications for microneedling and PRP include hair restoration and skin rejuvenation, as well as improvements in acne scars.
Acne vulgaris is a chronic inflammatory condition of the pilosebaceous unit. It can be seen as open or closed comedones or both, and as inflammatory lesions – including papules, pustules, or nodules. Scarring, as a physical disfigurement, is a frequent complication of acne. Acne scars have always been challenging to treat. Different factors, for example. color, texture, and morphology, can affect the treatment choice for each individual scar. Microneedling (MN), also known as collagen induction therapy, is a new option for treatment of acne scars. The reported high efficacy, safety, and minimal post‐treatment recovery rates associated with microneedling have increased its popularity among patients and clinicians. Light emitting microneedling device incorporate titanium microneedles. Microneedle delivery systems offer a minimally invasive and painless method of transdermal drug administration. Microneedle radio frequency systems deliver energy directly to the dermis via a number of microneedle electrodes and create a microthermal zone (MTZ), providing untouched areas between MTZs.
Medical needling offers a new alternative treatment for burn scars by changing pathological scar collagen with thousands of micro punctures into a scar with normal collagen. When we prick skin, we puncture blood vessels and the release of platelets signals the release of growth factors which then improve dermal collagen, vascularization, and epidermal thickening. The scars after medical needling tend to be smoother, softer, less itchy, and much less obvious. The skin becomes altogether more elastic and as a result contractures are also softened. Skin needling relieves tensions in tissues and minimizes the need for Z‐plasty and major flaps. Early skin needling could help avoid scar contractures, which is one of the most crippling feature of burns. Repigmentation offers the ideal pretreatment for non‐cultured autologous skin cell transplantation. Both treatments preserve the epidermis, which results in a reduced risk of new scarring or dyspigmentation.
Background:
While ablative techniques have been standard of care for the treatment of fine lines and wrinkles, microneedling is a minimally invasive alternative.
Objectives:
The purpose of this study was to assess the efficacy of microneedling on facial and neck fine lines and wrinkles.
Methods:
35 subjects between 44 and 65 years old with Fitzpatrick skin types I-IV received four monthly microneedling treatments over the face and neck. Subjects returned one and three months post-treatment. At every visit, high-resolution ultrasonography, optical coherence tomography, transepidermal water loss and BTC-2000 were performed. 0.33mm microbiopsies were collected pre-treatment, before the fourth treatment and three months post-treatment.
Results:
32 subjects (93.75% female, 6.25% male) completed all seven visits. Facial dermal and epidermal density increased 101.86% and 19.28%, respectively from baseline at three months post-treatment. Facial elasticity increased 28.2% from baseline three months post-treatment. Facial attenuation coefficient increased 15.65% and 17.33% one and three months post-treatment. At study completion, blood flow 300µm deep decreased 25.8% in the face and 42.3% in the neck. Relative collagen type III and elastin gene expression was statistically higher three months post-treatment. However, total elastin protein levels unchanged compared to baseline. 58% of biopsies extracted three months post-treatment showed dermal muscle formation, compared to baseline 15.3%.
Conclusions:
The results illustrate the effects of microneedling treatments. Non-invasive measurements and biopsy data showed changes in skin architecture and collagen/elastin gene expression suggesting skin rejuvenation, with new extracellular matrix production and muscle formation.
To date, treatment of atrophic acne scars remains a therapeutic challenge for dermatologists, yet there is no standard option on the most effective treatment. Microneedling (MN) is a minimally invasive technology that involves repetitive skin puncture using sterile microneedles to disrupt dermal collagen that connects the scar tissue. Recent studies have demonstrated the potency of MN, such as dermaroller and fractionated microneedle radiofrequency, in the treatment of atrophic scars. The objective of this review is to evaluate systematically the current literature on MN for atrophic acne scars. A systematic search of literature was performed from PubMed, Medline, Cochrane Central, and Google Scholar databases for articles published during the last 20 years. Only randomised controlled trials (RCTs) with full-text version of the manuscript available were included in our study. Nine RCTs were included in this review. All treatment modalities demonstrated consistent results that MN was efficacious in treating atrophic acne scars as a monotherapy or in combination with other treatments. Moreover, no serious adverse effects were reported in all studies after MN treatment. MN is a well-tolerated and effective therapeutic modality in treating atrophic acne scars. Further research is required to validate the efficacy of MN with a larger sample size and lengthy follow-up.
Background:
Microneedling (MN) is used for the treatment of scars, amongst other indications. Although used in Asia and the Middle East for decades, related to the supposed lack of post-procedure pigmentary alterations even in darker skin types, MN only recently gained attention in the United States as an effective, well-tolerated aesthetic treatment.
Materials and methods:
A systematic review of the Medline database was completed using search terms "microneedle" or "microneedling" or "micro needle" or "micro needling" and "scar". Included articles were written in English and discussed the use of MN for the treatment of scars in human subjects.
Results:
Fifty-eight studies were included for review, with a total of 1845 patients treated for acne scarring, hypertrophic or keloid scars, and those resulting from surgery, trauma, varicella or smallpox. MN and its counterpart fractional radiofrequency MN (FRF-MN) were used as monotherapy or in combination with topical, surgical or systemic modalities. MN and FRF-MN treatment resulted in clinical improvement of scar appearance from baseline. No serious adverse events occurred.
Conclusion:
MN is a well-tolerated, minimally invasive procedure that can be used for the treatment of scars with a high level of patient satisfaction. Further clinical studies are needed to develop standardized treatment protocols.
OBJECTIVE: To assess the effectiveness of the amiea med (amiea med, MT.DERM GmbH, Berlin, Germany) automated microneedling device in reducing facial atrophic acne scars. STUDY DESIGN: Open label, single center. PARTICIPANTS: Healthy males and females, aged 18 to 65 years, with signs of facial atrophic acne scarring were selected. After consenting and satisfying inclusion criteria, each subject underwent four microneedling sessions 30 days apart. Subjects were assessed at baseline and three months after the last treatment. MEASUREMENTS: Acne scars were classified according to Jacob classification. Physician assessment of acne scarring severity was carried out using the Goodman and Baron grading scale. Subjects graded their redness, pain and discomfort on the evening of the treatment and up to seven days posttreatment using a subject diary. RESULTS: Three months after the last treatment, facial acne scars had improved by 0.91 of a grade [CI. 0.78-1.05] according to Goodman and Baron Grading Scale (p<0.001). Improvement in acne scarring was not restricted to severity of grade,with no difference seen in Fitzpatrick skin types. According to Jacob classification, rolling scars showed the greatest improvement, with a mean improvement of 1.06 of a grade at the final assessment (p<0.001). CONCLUSION: This study demonstrates that four microneedling treatments of facial skin, spaced four weeks apart, significantly improves the appearance of facial acne scarring. The treatment is well tolerated with minimal pain, discomfort, and downtime. Side effects appear minor and easily managed compared to other more aggressive technologies. STUDY REGISTRATION: German Register for Clinical studies (DRKS) No [DRKS00013187].
Several treatments have been proposed that offer better results in reddish striations when compared to alba striations. Topical tretinoin in cream in high concentrations, applied as home therapy, improves the appearance of these lesions; however, it may not be well tolerated by the patient, considering climatic conditions and maintenance of her average activities. Interventions such as chemical peelings, microdermabrasion, fractionated lasers, and intense pulsed light, alone or in association, are some of the therapeutic options used by dermatology for the management of these lesions. However, there is no treatment considered ideal, and the results many times modest signal its challenge. PCI, regarding treatments with microneedles that induce collagen production, offers a stimulus in the production of this protein, without causing the deepithelialization observed in ablative techniques. The epidermis and dermis are perforated but not removed. Thus, the penetration of its needles in the skin causes micropunctures in the stretch marks, modifying their surface, destructuring the abnormal collagen and favoring neovascularization and neoangiogenesis. Both violent and white stretch marks respond to PCI, but the former commonly present satisfactory results with a smaller number of sessions, while the former need a longer time to achieve such results.
During treatment, needles pierce the stratum corneum and create the microchannels without damaging the epidermis, making it possible to create an accessible means of transporting macromolecules and other hydrophilic substances to the skin. The microchannels facilitate drug delivery efficiently and can increase the absorption of larger molecules by up to 80%. The application of drugs by the transdermal drug delivery system has been used as an alternative to the oral or parenteral administration of various substances. Transdermal patches can, for example, be useful for the application of vaccines and medications that require slow and controlled release into the skin. However, the transdermal route of drug absorption faces a major challenge, which is the barrier function of the skin, mainly exercised by the stratum corneum, which limits the absorption of many actives. PCI is a simple, safe method with low incidence of side effects. The association with drug delivery has the advantage of being a safe, low cost, and effective procedure that enhances the results of dermatological treatments.
The use of needles for cosmetic interventions is increasingly gaining ground and consolidating within the dermatologist’s therapeutic arsenal. Orentreich and Orentreich were the first to report the use of needles with the objective of stimulating the production of collagen in the treatment of depressed scars and wrinkles, a technique widespread under the name of Subcision™, followed by other authors who presented adaptations to the technique, with needle variation and approach. As already mentioned in previous chapters, dermal tunneling (DT) was inspired by this detachment technique and guided by its principles of fibrotic beam rupture and collagen production stimulus. For this, the methodology and instruments themselves required the DT denomination to characterize this new approach. Post-acne inflammatory scars are a frequent complaint, which presents itself as a great challenge, even in the face of all the therapeutic options offered by qualified dermatologists. The technique offers its own methodology to be followed, seeking standardization, with the objective of presenting results, as far as possible, predictable. It is indicated for facial lipodystrophy, often observed in patients after cystic acne. The typical flaccidity of the genian region and the wrinkles resulting from this excess skin are improved by the technique.
Scleroderma is a connective tissue disease of unknown etiology, characterized essentially by progressive fibrosis of the skin. An inflammatory response triggered by the destruction of the epidermis causes the production of parallel oriented thick bundles of collagen, unlike the interlacing network of collagen found in normal skin. Studies have shown that TGF-COPY3 plays a significant role: TGF-COPY16 and TGF-COPY2 promote the formation of scar tissue collagen, while TGF-COPY4 promotes wound regeneration and healing at the expense of collagen closer to physiological. When a parallel is made with the pathogenesis of scleroderma, it is observed that the GFR-β1 and the TGF-β2 are considered the main regulatory factors of both physiological fibrogenesis and pathological fibrosis with pleiotropic activities on several cell types. Thus, it was possible to suggest that the action of PCI on this sclerotic collagen, due to the modification of the inflammatory cascade triggered mostly by TGF-α1 and TGF-α3, would result in skin that looks closer to the physiological.
The modification of the skin after burn accident, established by the destruction of sebaceous and sweat glands, hair follicles, nerves, and vessels, results in impairment of its homeostasis, with dramatic alteration of physiological functions. Complaints, such as neuropathic pain, itching, eczema, and exulcerations, are frequent over areas of late scarring and always translate into a therapeutic challenge before the modest arsenal of possibilities available. Compared to the “light needles” of fractionated lasers, microneedles act by producing micropunctures and hematic columns at epidermal-dermal depth, causing the rupture of collagen and elastic fibers altered by burning, which favors their replacement by a new tissue. This technique can act in the different formats of scars, in any area of the body, in any type of skin, and at all ages. Even in areas with decreased concentration of sebaceous glands, the percutaneous induction of collagen with needles (PCI) is a possibility of treatment. PCI in post-burn scars produces changes in color, texture, depth, relief, and flexibility.
PCI performs thousands of controlled microperforations in the papillary and reticular dermis. The objective is to execute a mechanical stimulation of the dermis with minimal damage to the epidermis, thus promoting the formation of collagen and increasing angiogenesis. Dermal vasodilatation and migration of keratinocytes occur immediately, resulting in the release of cytokines such as interleukin-1, interleukin-8, interleukin-6, TNF-α, and GM-CSF. Several studies have demonstrated the importance of PCI in cell stimulation and growth factor production, showing an increased expression of genes related to hair growth stimulation. The mechanisms proposed for the growth of new hair shafts using the PCI technique are the release of platelet-derived growth factors (PDGF), elevation of growth factor levels as epidermal growth factors (EGF), activation of regeneration mechanisms, activation of stem cells in the bulge area of the dermal papilla, overexpression of genes related to hair growth, vascular endothelial growth factors, β-catenin, and increased expression of Wnt proteins, especially Wnt3a and Wnt10b.
The keloids initiated in the reticular dermis project to the skin and do not regress spontaneously. They are erythematous-violaceous, skin-colored, or hyperchromic and are distinguished from elevated scars by exceeding the limits of initial injury. It is believed that there are no spontaneous keloids. Lesions without apparent causes were probably the result of a mild injury, not perceived by the patient. Techniques for keloid management have been used with variable responses, such as intralesional injections with bleomycin and corticosteroids alone or in association, cryosurgery, use of silicone plates, lasers, intense pulsed light, in addition to topical assets such as 5-fluorouracil, interferone, retinoids, 5% imiquimode, tacrolimus, verapamil. Botulinum toxin has shown good results in specific cases. Corticosteroids present side effects such as risk of secondary infection, atrophy, telangiectasis, and hypopigmentation. Cryosurgery, when performed by not very experienced professionals, can lead to atrophy and hypochromia, and bleomycin can trigger hyperpigmentation. PCI proposes to destructure fibrosis and abnormal collagen, creating hematic columns with production of a new collagen, without causing the deepithelialization observed in ablative techniques.
The use of needles for cosmetic interventions is increasingly gaining ground and consolidating within the dermatologist’s therapeutic arsenal. Orentreich and Orentreich were the first to report the use of needles with the objective of stimulating the production of collagen in the treatment of depressed scars and wrinkles, a technique widespread under the name of Subcision™. Their studies were confirmed by other authors, who were based on the same precept: rupture and removal of the damaged subepidermal collagen, followed by substitution by new collagen and elastin fibers. The change in color, texture, elasticity, and uniformity of the skin surface in the presence of scars is secondary to inflammatory changes affecting the epidermis, dermis, and hypodermis en bloc or alone, and these sites are targeted by techniques that use needles. Needles with particular characteristics have been used by different authors in their procedures, among them 19 G, 20 G, 21 G, and 18 G 1.5 Nokor, presenting particular technical advantages in their experiments. Dermal tunneling (DT) proposes the release of fibrotic beams in the dermis into depressed scars, with the use of a new instrument and guided by an easy to perform methodology.
The use of needles in order to stimulate the production of good quality collagen in the treatment of scars was initially described by Orentreich and Orentreich in 1995, who successfully reported the use of the Subcision™ technique. Shortly after, Camirand and Doucet (Aesthetic Plast Surg 21(1):48–51, 1997) reported cases of scar improvement after performing scar scarification using the needles of a tattoo machine. It is already well established that the perforation caused by needles triggers the cascade of wound healing, and in this process, through the release of growth factors, collagen production occurs. The origin of the instruments used is also important with respect to the quality of the needles. Different materials used in the manufacture of the needles interfere with the resistance, the characteristic of the injury caused, and, consequently, the results. The needles are diagonally arranged in some instruments, seeking optimization of results. The scanning microscopy shows the difference in length of the needles, which directly interferes in the intensity of the lesion caused in the skin. The microneedles attached to the device are made of stainless steel and generally pre-sterilized with gamma radiation. The rollers used for medical treatment are for single use. They should not be re-sterilized, as they lose their cut and buckle the needles, compromising the result and the safety of the procedure (Aust MC. Plast Reconstr Surg. 121(4):1421–9, 2008; Bal SM et al. Eur J Pharm Sci. 35(3):193–202, 2008; Brody HJ. Plast Reconstr Surg. 2(2):127–8, 1995).
An electrosurgery device is composed of a current generating unit and two electrodes: one active and one dispersive. By using an electrode consisting of a series of eight needles 0.1 mm thick and 2.0 mm long, we will equally divide by eight the energy selected for contact. With the proper configuration of the device, we can realize eight columns of 0.1 mm per shot, with a depth of 2.0 mm. Thus it is plausible the epidermal restitution is in an integral form and mechanical and thermal dermal stimulus, producing tissue retraction and synthesis of collagen. The multi-needle radiofrequency (MNR) technique has its applicability on periorbital skin excess and flaccidity, periorbital hyperpigmentation, static facial wrinkles, acne scars, superficial skin flaccidity, xanthelasma, syringoma, surgical scars, and stretch marks, among others. The use of high-frequency randomized fractional energy triggered on the skin results in dermal regeneration at the papillary-reticular interface through the stimulation of fibroblasts with consequent synthesis of collagen and elastic fibers, as well as epidermal regeneration produced by the migration of keratinocytes.
Accidents that result in unaesthetic scars happen more and more frequently in our environment; they are a relatively common cause of visits to specialist offices. The sources and causes that cause these scars are diverse; for this reason there is almost always an injurious polymorphism that can be distinguished from normotrophic to hypertrophic and atrophic injuries, with variation in color and shape, which often requires the association of techniques aiming at the best therapeutic gain. Besides cosmetic improvement, functional correction of the area should be considered. With a certain frequency there is impairment of the elasticity of the affected region, with function deficit. Techniques using needles described in this work have the advantage of addressing scars without excision and synthesis, which could favor situations such as enlargement or dystrophy in the postoperative period. These are techniques that perforate, without cutting, cause punctures without deepithelialization of the area, and, therefore, offer more safety regarding the cosmetic results and reduction of complications. Whether isolated or in association, the proposals presented here have shown, in author’s experience, good options in the approach to scars after accidents and can be included in the therapeutic arsenal of challenging injuries.
Scarring lesions can result from inflammatory processes, accidents, surgeries, and present varied characteristics, which contemplate both changes in color and change in skin texture, as well as compromising the revelation and distortion by retraction. Multineedle radiofrequency (MNR) proposes a neocollagenesis with preservation of this noble structure. Even the widest and deepest scars will respond to microneedles, considering that the more superficial and narrower they are, the better the therapeutic result obtained. MNR is a promising therapeutic proposal for the treatment of various forms of scarring. A thorough knowledge of these lesions is essential so that the indication alone or in association with the technique offers good cosmetic results. In the author’s conception, the results achieved can be reproduced using the methodology and the electrodes presented here with precision. The procedure requires training and is technical-dependent. The operator must be properly enabled and have all the basic knowledge necessary to guarantee the excellence of the results.
Current interventions seek to promote fractional skin damage, which allows the integrity of the microregion adjacent to the trauma to be maintained intact, favoring a shorter recovery time and reduced risk of complications. The fractionated CO2 laser is an example of this proposal, as is the PCI. It is important to note that, even when the patient is submitted to surgeries that remove skin leftovers, attenuating flaccidity and wrinkles, the resulting skin must offer a good quality. This is the PCI proposal, offering a good quality of skin based on neocollagenosis and neoangiogenesis. The needles, initially idealized for the treatment of scars, also demonstrated valuable therapeutic response in aged skin. The studies of Orentreich and Orentreich (Dermatol Surg 21(6):543–549, 1995) were the first to report their use with the objective of stimulating the production of collagen in depressed scars and wrinkles, a technique widespread under the name of Subcision™. Other authors confirmed the rupture and removal of the damaged subepidermal collagen followed by the substitution of new collagen and elastin fibers by the intervention of needles. More recently, it has been proposed the use of a system of microneedles applied to the skin in order to generate multiple micropunctures, long enough to reach the dermis and trigger, with bleeding, inflammatory stimulus and activation of an inflammatory cascade that would result in the production of collagen and, subsequently, its maturation.
Some treatments are proposed to correct the scars that occur after the surgeries. Among them we can mention the surgical removal of the scar, generating a new incision, the use of ablative techniques such as peelings and dermabrasion, besides the use of fillers, botulinum toxin, and technologies with light, which seek from the improvement of color to the treatment of relief and texture. Although they constitute a surgical procedure, the techniques with needles have the differential of not causing cuts, which are subject to enlargement. Instead, they cause multiple micropunctures that aim to break micro and macro fibrotic beams, restructuring and renewing the scar tissue. PCI provides good results in acne scars and, according to author’s experience, is a useful technique for the treatment of all forms of scars, regardless of their presentation. In shallower, normochromic, and elastic lesions, the gains are substantial, and in those deep, dyschromic, and rigid, they are more modest, but always happen. The use of dermal tunneling may be indicated when facing thick, rigid, and deep fibrotic beams that need loosening and release of the skin surface. Multi-needles associated with radiofrequency are a good option when a more delicate surgical approach is required. Not infrequently, the author’s experience demonstrates the optimization of results when associating these last three proposals. There is not necessarily a mandatory sequence to be followed, and the peculiarity of each case will determine how this association should be performed. Considering the linear characteristic of post-surgical scars, the instrument with motorized needles can be effective to perform the treatment with great practicality.
The ability to induce epidermal changes in the upper dermis and promote the migration of melanocytes forms the basis for our hypothesis that in the case of vitiligo, microneedling can act not only as an agent in the promotion of drug delivery but also as a therapeutic agent. However, thus far, microneedling has been neither reported nor investigated as an exclusive treatment for vitiligo. Lima et al. (Dermatol Surg 46(13):434–5, 2020) describe the satisfactory results for cutaneous microneedling tests as a clinical treatment in 12 patients with stable localized refractory vitiligo. There was pigmentation induction in ten (83%) of the treated patients. All 12 patients completed the 4 sessions. There were no adverse effects associated with the treatment that were considered to be of good tolerability. Those who observed some pigmentation reported greater satisfaction with the treatment. The pigmentary response was sustained for 12 months after treatment. The pathophysiology of vitiligo is complex, involving oxidative damage in the upper dermis, changes in melanocyte adhesion, loss of autophagy, and fibroblast senescence.
The deeper the scar, the greater the challenge. Scars in which the epidermis has been completely destroyed with melanin loss and result in atrophic scarring are also more difficult to treat. The lesions on the face are more responsive to PCI when compared to those found on the chest or back; the latter need more interventions to offer the same result as the former. Scars located in more oily areas, in the author’s experience, offer a better response to treatment, when compared to those arranged in regions with fewer seborrheic glands. This characterizes a differential of PCI, a technique that only needle the skin, in relation to the incision. In the latter, the enlargement and often the worsening of the scar is evidenced, most commonly in oily skin. Cystic acne usually results in scars that are difficult to treat. The consumption of the dermis and hypodermis, as well as the deterioration of the epidermis resulting from the destructive action of inflammatory cytokines, gives rise to depressed, elevated, dystrophic lesions, in addition to loss of pigment, hyperpigmentation, flaccidity, and development of superficial and deep rhytides. This polymorphism, commonly observed in patients after severe and prolonged inflammatory acne, presents itself as a therapeutic challenge. For this reason, it is necessary to evaluate these lesions in a particular way, examining their architecture and directing the option of more specific intervention to the correction of each cicatricial unit.
Studies have shown that the beta tissue growth factor (TGF-β) plays a significant role in the first 48 hours of scar formation. So, as TGF-β1 and TGF-β2 promote the formation of scar collagen, TGF-β3 appears to promote wound regeneration and healing at the expense of normal collagen, virtually without the characteristics of scar tissue. Percutaneous collagen induction (PCI) with microneedling proposes a stimulus in the production of collagen without causing the total deepithelialization observed in ablative techniques. This intervention starts with the loss of the cutaneous barrier integrity, targeting the dissociation of keratinocytes, which results in the release of cytokines such as IL-1 alpha (predominantly), besides IL-8, IL-6, tumor necrosis factor alpha (TNF-α), and granulocyte-macrophage colony-stimulating factor (GM-CSF). This results in dermal vasodilatation and migration of keratinocytes to restore epidermal damage. Three phases of the healing process, consequent to needle trauma, can be didactically delineated for better understanding: injury, healing, and maturation.
Cellulitis is a metabolic disorder located in subcutaneous cell tissue that causes changes in body contour. There are several treatments proposed to attenuate the waviness aspect observed in the skin affected by cellulite such as endermology, liposuction, use of topics with potential to thicken the epidermis and dermis such as retinoids, and the use of peelings, which also act for this purpose. The use of needles with the intention of breaking the fibrous septum and releasing the imprisoned skin and the incarcerated adipocytes has been recommended. Orentreich and Orentreich (Dermatol Surg 21(6):543–9, 1995) were the first to report the use of needles with the purpose of stimulating the production of collagen in the treatment of depressed scars and wrinkles, a technique spread with the name of Subcision™. Hexsel and Mazzuco (An Bras Dermatol 72(1):27–32, 1997) studied 46 patients with different degrees of cellulitis treated with Nokor 18 G needle. PCI offers the proposal to improve texture, coloring, waving, and relief of the area with cellulite by means of microneedles. It is considered a safe therapeutic approach with interesting cosmetic results in the treatment of modest cellulite conditions or as a complementary technique in association with dermal tunneling or Subcision™. To this end, it is essential that the operator is skilled and safe in the proposal and ensures its suitability for the individual to be treated.
Percutaneous collagen induction (PCI) with needling is a technical-dependent intervention. The use of different needle lengths alone provides a versatility that requires direction between the lesion to be treated and the proposed level of injury. Therefore, it is necessary to establish a relationship between the depth of damage produced by the needles and the response to this trauma to better define the indications. Once the characteristics of the skin and the region to be treated have been evaluated, it is important to establish the objective of the treatment, which can be to break fibrotic beams, to uniform skin color, to improve its texture and brightness, to treat superficial wrinkles, to approach recent or old stretch marks, to stimulate collagen in a region of flaccid skin, or to restructure an abnormal collagen in a rigid skin area. All of this will influence the choice of the length of needles and the planning of the injury to be provoked. Emerson Lima et al. (Surg Cosmet Dermatol 5(2):1104, 2013) proposed, in an experimental study, a relationship between the length of the needle and the depth of damage achieved, using live pigskin because they consider it a model that approximates human skin. The interventions were performed by the same operator and at the same surgical time, establishing the same pattern of strength and number of needle roll passes. Macroscopically, it was possible to identify the difference in damage caused by needles with lengths of 0.5, 1.0, 1.5, 2.0, and 2.5 mm. It is essential to understand the relationship between needle length and degree of injury when indicating the PCI technique for each specific situation.
The muscle activity on the skin deepens depressions, the laxity of structures compromises, and the support and the redistribution of fat adds more weight to the excess skin, whether in aging or in the process of consuming an inflammatory acne. The use of needles and microneedles in procedures seeks the remodeling of collagen degraded by aging or scarring after the inflammatory process. Percutaneous needle collagen induction PCI remodels the epidermis and dermis, without deepithelializing them, with a short recovery period. It acts releasing static wrinkles and replacing damaged skin with one closer to the physiological. This transformation of collagen has been able to correct wrinkles, furrows, flaccidity, and scars. There is a tendency, supported by literature and medical experience, for the association of techniques seeking the optimization of results. The reflection proposed in this chapter is to improve the quality of the affected tissue, before planning the application of an asset with volumerizing potential or even with the potential to relax the adjacent musculature.
When an intervention is made in Afrodescendant patients, the most significant difference in relation to Caucasians, for example, corresponds to the amount of melanin. This peculiarity of ethnic skin requires special attention from the dermatologist when choosing a treatment for scars, stretch marks, cellulite, wrinkles, flaccidity, and bleaching of spots, as well as extra care in the preparation, during treatment and post-procedure, in order to avoid complications. It is worth noting that in a mixed country like Brazil, where the majority of the population is ethnically diverse, interventions will always be subject to unexpected effects, even on skins considered less susceptible to complications. The percutaneous induction of collagen with needles presents a proposal to stimulate the production of collagen, without causing the deepithelialization observed in ablative techniques and without the heating of lights. The epidermis and dermis are perforated but not removed. The procedure is safe even when there is so much melanin.
Derma roller, a device rolled onto the skin to form micropores, is extensively used for cosmetic purposes. The pores thus created are utilized to either result in the induction of collagen production, leading to glowing and wrinkle-free skin or for permeating the applied formulations to the site of action within the skin. Recent studies have shown the benefits of using derma rollers for transdermal delivery of drugs. In the nascent stage, this approach paves a way to successfully breach the stratum corneum and aid in the movement of medications directed towards the dermis and the hair follicles. The review essentially summarizes the evidence of the use of derma rollers in cosmetic setup, their designing, and the preclinical and clinical reports of efficacy, safety, and concerns when translated for pharmaceutical purposes and transdermal drug delivery.
Demand for safe, less aggressive and cost-efficient treatment modality to improve skin quality and appearance following scarring or photoaging is increasing steadily. A treatment modality that preserves the epidermis while promoting regeneration rather than cicatrization would be ideal. Percutaneous collagen induction (PCI) therapy or microneedling is claimed to approach this ideal objective. The current comprehensive literature review is intended to analyze the scientific basis supporting this therapeutic modality and to evaluate the efficacy of PCI microneedling therapy versus no treatment of patients with photoaged skin and scars of various etiologies on aesthetic skin rejuvenation, skin tightening and scar quality in prospective, retrospective and experimental studies. Twenty-five published studies were identified and included in this review. Four publications are experimental animal studies; most clinical reports are case series or small cohort non-randomized studies or trials lacking methodological unity with a heterogenous mix of scars, wrinkles and skin laxity being treated. The majority are studies about management of scars of various etiologies while only 4 specifically investigated the effect of PCI on wrinkles and aging skin. One study compared burn scar erythema in the treated area to the untreated area, and 5 studies included histologic evaluation of biopsies. Despite PCI promising therapeutic benefits and its increasing cosmetic applications, the current literature review unfortunately revealed a limited number of high-quality studies mostly experimental. Data and conclusions of clinical studies must be carefully interpreted before translating the evidence presented into clinical recommendations. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
This is a brief history of the skin needling treatment (collagen induction therapy), and it covers the original clinical work that was validated by research of Matthias Aust and the team at Hanover Medical School, Germany. Skin needling became the very first medical procedure to induce regeneration instead of scar formation, as it employs TGFB3 and IL10. The methods to optimise the effects of skin needling are examined. The depth of penetration into the skin will depend upon the condition treated. Wrinkles, stretch marks and so forth only require 1.0 mm, whereas burn scars, acne scars and so on require a deeper penetration, that is, about 3.0 mm. The use of topicals both before and after skin needling also needs to be considered. Vitamins A and C are scientifically proven to almost quadruple the effects of needling. Selected peptides seem to further enhance the results. Hyaluronic acid is best induced naturally, but it may be used topically for comfort. Finally, the rationale of the intervals between needling is examined. To take advantage of the increased titres of TGFB3 and IL10, the best clinical results seem to come from treatments at 4‐ to 10‐day intervals. For better results, other modalities such as red and infrared LED, platelet rich plasma and mild peeling are receiving attention. Skin needling is the safest and the most effective method to treat photoageing, lax skin, stretch marks, acne scars and burn scars.
Background:
In recent years, microneedling has been increasingly used to treat a number of dermatologic conditions, including scars. Microneedling has been shown to promote neocollagenesis via mechanical disruption of the epidermis and dermis. The creation of multiple microchannels by needle penetration physically disrupts the compact collagen bundles while inducing new collagen and elastin synthesis and deposition within the fibrotic dermis. The latest microneedling devices are motorized and have improved the ability to more precisely and effectively treat scars. While initial studies have demonstrated improvement of (mostly) atrophic scars with microneedling, the number of patients evaluated have been relatively small and the devices and treatment protocols utilized as well as post-treatment follow-up have varied widely. Through this prospective observational study, we describe the results of microneedling on a consecutive series of 120 patients with a variety of scars. Clinical outcomes and adverse effects were evaluated over a 12 month period after treatment.
Materials & methods:
One hundred twenty consecutive patients (SPT I-VI) with facial and non-facial scars from a variety of etiologic sources (acne, trauma, surgery) were treated using a mechanical microneedling device. Treatments were delivered at monthly intervals by the same operator using a motorized microneedling device with 2.5-3mm needle depths. No additional treatments (topical or intralesional) were applied. Representative clinical photographs were obtained at baseline, prior to each treatment, and 1, 3, 6, and 12 months after treatment. Two assessors blinded to treatment protocol rated clinical improvement of scars on a 5-point scale (0= no change, 1= 1-25% improvement, 2= 26-50% improvement, 3=51-75% improvement, 4= 76-100% improvement). Side effects were monitored and tabulated.
Results:
Patients received 1 to 6 consecutive monthly microneedling treatments. All scars improved at least 50% after an average of 2.5 treatments. Over 80% of patients had 50-75% improvement and 65% of patients demonstrated over 75% improvement. No significant clinical differences were observed in treatment responses of facial scars versus non-facial scars. Similarly, no significant clinical differences were seen between responses of atrophic acne scars and traumatic or surgical scars. Side effects were limited to transient erythema and edema. Rare purpura formation and herpes simplex reactivation were experienced. No scar worsening nor long-term adverse sequelae were observed.
Conclusion:
The clinical results obtained in this study support the use of microneedling for various facial and non-facial scars across a broad range of skin phototypes with minimal risk of adverse effects. Further studies will help to establish standardized protocols to optimize treatment outcomes for different scar types.
ResearchGate has not been able to resolve any references for this publication.