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Skin needling as a treatment for acne scarring: An up-to-date review of the literature

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Background: Skin needling is a technique used to improve the appearance of acne scarring. Objective: To comprehensively review the medical literature regarding skin needling as a treatment for acne scarring. Methods: A literature search was performed using the PubMed, Medline, and Embase databases, in addition to reviewing the bibliographies of relevant articles. Results: Ten studies presented patients treated with skin needling alone, while eight studies discussed skin needling in combination with other treatments for acne scarring. All studies showed improvements in scarring after needling, with 12 reporting statistical significance. The median number of treatments when needling was used alone was three, the median duration between treatments was 4 weeks, and the median needle length used was 1.5 mm. Reported adverse events were infrequent and included post-inflammatory hyperpigmentation, “tram track” scarring, acne, and milia. There were no reports of bacterial infections. Limitations: The studies reviewed were heterogeneous in design and of variable validity, with some not reporting statistical significance. Conclusion: There is moderate evidence to suggest that skin needling is beneficial and safe for the treatment of acne scarring. However, double-blinded, randomized controlled trials are required to make more definitive conclusions.
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Skin needling as a treatment for acne scarring: An up-to-date review of
the literature
Adam G. Harris, MBChB, Catherine Naidoo, MBBS, Dedee F. Murrell, MA, BMBCh, MD, FACD, FRCP
Department of Dermatology, St George Hospital, Sydney, Australia
University of New South Wales, Sydney, Australia
abstractarticle info
Article history:
Received 28 January 2015
Received in revised form 9 March 2015
Accepted 18 March 2015
Keywords:
Acne scarring
Dermaroller
Microneedling
Micro-needling
Percutaneous collagen induction
Skin needling
Background: Skin needling is a technique used to improve the appearance of acne scarring.
Objective: To comprehensively review the medical literature regarding skin needling as a treatment for acne scarring.
Methods: A literature search was performed using the PubMed, Medline, and Embase databases, in addition to
reviewing the bibliographies of relevant articles.
Results: Ten studies presented patients treated with skin needling alone, while eight studies discussed skin needling in
combination with other treatments for acne scarring. All studies showed improvements in scarring after needling,
with 12 reporting statistical signicance. The median number of treatments when needling was used alone was
three, the median duration between treatments was 4 weeks, and the median needle length used was 1.5 mm.
Reported adverse events were infrequent and included post-inammatory hyperpigmentation, tram trackscarring,
acne, and milia. There were no reports of bacterial infections.
Limitations: The studies reviewed were heterogeneous in design and of variable validity, with some not reporting
statistical signicance.
Conclusion: There is moderate evidence to suggest that skin needling is benecial and safe for the treatment of
acne scarring. However, double-blinded, randomized controlled trials are required to make more denitive
conclusions.
© 2015 The Authors. Published by Elsevier Inc. on behalf of Women's Dermatologic Society. This is an open access
article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
Introduction
Skin needling is a technique predominantly used to improve the ap-
pearance of cutaneous scarring and photodamage (Fig. 1). Fine needles
puncture the skin, resulting in increased dermal elastin and collagen,
collagen remodeling, and thickening of the epidermis and dermis
(Aust et al., 2008a, 2010a, 2010b, 2011; Fabbrocini et al., 2011a;
Fernandes, 2005; Fernandes and Signorini, 2008; Kim et al., 2011; Park
et al., 2012; Schwarz and Laaff, 2011). Additionally, skin needling cre-
ates small channels, which increase the absorption of topically applied
preparations (Badran et al., 2009; Kalluri et al., 2011), a property
which has been used in various dermatological treatments (Bencini
et al., 2012; Budamakuntla et al., 2013; Clementoni et al., 2010;
Fabbrocini et al., 2011b, 2014a; Kang et al., 2008; Torezan et al., 2013;
Yoon et al., 2008, 2010).
Skin needling for cutaneous scarring was introduced into the medi-
cal literature in 1997, when tattooing without pigment was used to
abrade facial scars, improving their quality and color (Camirand and
Doucet, 1997). In 1998, Desmond Fernandes, a plastic surgeon from
South Africa, designed a hand-held device composed of a rolling barrel
with multiple protruding needles and used it for a technique he termed
percutaneous collagen induction.He later published his experience
using this technique for various dermatological conditions, including
acne scarring (Fernandes, 2005; Fernandes and Signorini, 2008).
Both manual and electronic hand-held skin needling devices are
now widely available as low-cost therapies for the treatment of acne
scarring (Doddaballapur, 2009; Dogra et al., 2014), yet, to our knowl-
edge, there has been no dedicated review of the medical literature re-
garding this topic.
Objective
The objective of this study was to comprehensively review the med-
ical literature regarding skin needling as a treatment for acne scarring.
Material and methods
A literature search was performed using the PubMed, Medline 1946-
to-present, and Embase classic plus Embase 1947-to-present databases.
Search terms included skin needling,microneedling,needle derma-
brasion,tattooing without pigment,dry tattooing,percutaneous col-
lagen induction therapy, and dermaroller. All terms are used in the
medical literature to describe skin needling and were combined with
the term acne. The search was performed without limitations or
International Journal of Women's Dermatology 1 (2015) 7781
Conicts of interest: The authors state no conicts of interest.
Corresponding author.
E-mail address: d.murrell@unsw.edu.au (D.F. Murrell).
http://dx.doi.org/10.1016/j.ijwd.2015.03.004
2352-6475/© 2015 The Authors. Published by Elsevier Inc. on behalf of Women's Dermatologic Society. This is an open access article under the CC BY license (http://creativecommons.org/
licenses/by/4.0/).
Contents lists available at ScienceDirect
International Journal of Women's Dermatology
language restrictions. All bibliographies within the relevant articles
were reviewed for their relevance.
Results
Nineteen articles included patients with acne scarring treated with
skin needling. Included were nine prospective observational studies
(Beretta et al., 2008; Dogra et al., 2014; Fabbrocini et al., 2009, 2014b;
Garg and Baveja, 2014; Kang et al., 2009; Kim, 2008; Majid, 2009;
Schwarz and Laaff, 2011), nine prospective controlled studies
(Alam et al., 2014; Fabbrocini et al., 2011c; Gadkari and Nayak, 2014;
Nofal et al., 2014; Leheta et al., 2011, 2014a, 2014b; Mohammed,
2013; Sharad, 2011), and one case report (Pahwa et al., 2012). Additionally,
one prospective observational study likely contained patients with acne
scarring (Aust et al., 2008a), but the method was unclear. Eighteen
articles were in English and one was in Italian, which was translated.
All studies were critically evaluated and are summarized in tables that
can be found in the Supplementary Material.
Efcacy
The majority of the studies reviewed included an objective scar scoring
system to measure efcacy, most commonly the grading systems
designedbyGoodmanandBaron(Goodman and Baron, 2006a, 2006b).
Others used subjective scar scoring scales, subjective improvement scales,
and patient satisfaction scales. For the purpose of this review, if an objec-
tive scar scoring scale was not used, the results of a subjective scale were
used to evaluate efcacy.
Studies evaluating the efcacy of skin needling alone as a treatment for
acne scarring
Six studies measured the efcacy of skin needling alone as a treat-
ment for acne scarring (Alam et al., 2014; Beretta et al., 2008; Camirand
and Doucet, 1997; Fabbrocini et al., 2009, 2014b; Majid, 2009). All studies
showed improvements in scar severity scores compared to baseline, with
statistical signicance reported in all except one. One study was a
randomized placebo controlled trial (Alam et al., 2014); the remaining
ve were prospective observational trials, which are subject to a high
risk of selection bias and inherently lower validity.
The rst study published included 20 patients assessed before and
after treatment by two physicians, blinded to pretreatment scores
using the Goodman and Baron grading systems (Beretta et al., 2008).
After treatment, there was a statistically signicant improvement in
scores, but it was unclear how this was calculated.
A similar study included 37 patients with facial scarring, 32 of whom
had acne scarring (Majid, 2009). A single dermatologist consecutively
graded patients using the qualitative Goodman and Baron grading
system. Twenty-seven of the 31 patients with acne scarring who com-
pleted the study had improved scar grades, but there was no statistical
analysis of the results.
An Italian group published two further observational studies
(Fabbrocini et al., 2009, 2014b). The rst (2009) included 32 patients
consecutively graded by the same dermatologist using the qualitative
Goodman andBaron grading system. After treatment, there was a statis-
tically signicant reduction in the mean severity grading. A second, lar-
ger study (2014b) included 60 patients whose scar severity was
evaluated from photographs using the Global Aesthetic Improvement
Scale. After treatment, there was also a statistically signicant reduction
in severity grading.
A recent uncontrolled study form India (Dogra et al., 2014) included
36 patients assessed with the acne scar assessment tool described by
Peterson et al. (2011). After treatment, there was a statistically signi-
cant improvement in the mean scar grading from 11.73 to 6.5, although
six patients did not complete the study, ve because of treatment-
related complications including severe post-inammatory hyperpig-
mentation and tram-trek scarring.
The most rigorous study was a placebo-controlled, split-face trial
from the United States, which included 20 participants randomized to
receive either skin needling with topical anesthetic or topical anesthetic
Fig. 1. An improvement in acne scarring and photodamage in a patient treated with one session of skin needling.
Fig. 2. Development of erythema, crusting,and pustules in a patient one day after skin needling.
78 A.G. Harris et al. / International Journal of Women's Dermatology 1 (2015) 7781
alone to either side of the face (Alam et al., 2014). Two dermatologists
blinded to the intervention graded standardized photographs with the
quantitative Goodman and Baron grading system. At 6 months post-
treatment, there was a statistically signicant decrease in the mean
grade of the skin-needled side compared to the placebo side, with a
mean difference in scores of 3.4 compared to 0.4. Five patients dropped
out before the study protocol was initiated. There was no blinding of
the patients.
An additional study included a prospective sub-analysis of 15 pa-
tients with scars and stretch marks,but it was not clear if the group
contained patients with acne scarring (Aust et al., 2008a). Patients
were a part of a larger group included in a retrospective analysis of
skin needling used for a variety of conditions including acne scarring.
The subgroup demonstrated a statistically signicant improvement
based on the Vancouver Scar Scale (Baryza, 1995) and Observer Scar
Assessment Scale as assessed by two independent observers.
Studies evaluating the efcacy of skin needling compared to other methods
of treatment for acne scarring
A total of three studies compared skin needling to other methods of
treatment for acne scarring.
An Egyptian group (Leheta et al., 2011) randomized 30 participants
to receive either skin needlingor the focal application of 100% trichloro-
acetic acid (TCA) using the CROSS (chemical reconstruction of skin
scars) method (Lee et al., 2002). A blinded dermatologist scored a 68%
mean improvement in the needling group and a 75% improvement in
the TCA group, with no statistically signicant difference between
groups. Participants were not blinded and three participants in the
TCA group dropped out and were not included in the analysis on an
intention-to-treat basis.
An Italian group compared skin needling to skin needling combined
with the topical application of platelet-rich plasma (PRP) in a split-face
trial of 12 patients (Fabbrocini et al., 2011c). After treatment, all scores
were reduced but the PRP group had an overall mean lower severity
score. The statistical signicance of this result was not reported. There
was also no mention of blinding,either of the investigator or the patient,
or randomization to which side received each treatment.
A study from India sequentially enrolled 30 patients and compared
skin needling to the combination of skin needling alternating with 35%
glycolic acid (GA) peels (Sharad, 2011). Scars were graded by the treating
dermatologist using the Echelle dEvaluation clinique des Cicatrices
dacne classication (Dreno et al., 2007). The combination treatment re-
sulted in a statistically signicant greater mean improvement of 63%
comparedto31%.Thepatientsandtheassessorswerenotblinded.
Studies evaluating the efcacy of skin needling in conjunction with other
treatments for acne scarring
Skin needling was used in eight studies to increase the penetration
of topically applied preparations and alongside other treatments to
synergistically improve efcacy.
An Egyptian group randomly assigned 24 patients to receive skin
needling and 20% TCA or deep skin peeling using 60% phenol (Leheta
et al., 2014a). Live assessment by a dermatologist blinded to the inter-
vention gave statistically signicant mean improvements in scores of
70% in the combination group and 75% in the deep phenol peel group
with no statistically signicant difference between two. A second
study by the group randomly assigned 39 patients to skin needling
and 20% TCA (group I), fractional thermolysis (group II), or a combina-
tion of both treatments (group III) (Leheta et al., 2014b). The same
blinded dermatologist scored patients and gave an improvement in
mean severity scores of 60%, 62%, and 78%, respectively. There was no
statistically signicant difference between groups I and II, but there
was between groups I and II versus group III. One patient from group I
was lost to follow-up and was included in the analysis on an
intention-to-treat basis. Two patients from each group in the rst
study dropped out and were not included in the analysis. In both studies
the patients were not blinded.
Another study combined skin needling, subcision, and 15% TCA in 50
patients (Garg and Baveja, 2014). Photographs were graded by the same
nontreating physician using the qualitative Goodman and Baron gra-
ding system. Scar grades improved in all patients and although the
process of statistical analysis was mentioned, it did not appear to be
performed and presented.
A Korean study (Kang et al., 2009) assessed the combination of the
focal application of 100% TCA, skin needling using a 29-gauge needle,
subcision (Orentreich and Orentreich, 1995), and fractional thermolysis
in 35 patients. An independent physician scoredpatients using the acne
severity scale described by Lipper and Perez (2006). Ten patients
completed the study, with scores improving in all patients. Statistical
signicance of the results was not reported and there was a large loss
to follow-up.
An Indian study compared skin needling combined with subcision to
subcision combined with cryorolling (Gadkari and Nayak, 2014).
Cryorolling consisted of dipping the needling device into liquid nitrogen
immediately before the procedure. Thirty-seven patients were randomized
to have both procedures to either side of their face and a blinded observer
scored standardized photographs using the qualitative and quantitative
Goodman and Baron grading systems. Both treatments resulted in statisti-
cally signicant improvements in mean quantitative gradings of 57% in the
cryoroller group and 40% in the needling group. The difference between
the two was statistically signicant. Seven patients dropped out of the
study and it was unclear which group they were from and whether they
were included with intention to treat.
Another Egyptian study compared 45 patients equally randomized
into three groups to receive either skinneedling combinedwith the top-
ical application of PRP, the focal application of 100% TCA, or intralesional
dermal injections of PRP (Nofal et al., 2014). Photographs were assessed
by two blinded dermatologists using the qualitative Goodman and
Baron grading system. All three treatments resulted in statistically sig-
nicant improvements in scar grades with nodifference between them.
Finally, two separate studies looked at the combination CO
2
laser and
skin needling using a 26-gauge needle. The rst included 35 patients
who all had improvements in a 4-point improvement scale. There was
no statistical analysis of the results (Kim, 2008). The second randomized
60 patients to compare laser and skin needling to laser alone
(Mohammed, 2013). Patients were assessed by three independent
observers blinded to the treatment using the quantitative Goodman
and Baron grading system. After treatment there was a statistically
signicant improvement in scores in both groups with no statistically
signicant difference between them.
Histological changes
One study published histological sections before and after skin nee-
dling treatment of 10 patients with posttraumatic and acne scarring
(Schwarz and Laaff, 2011). A blinded dermatologist and pathologist
concluded that, in seven patients, there was a noticeable increase in
elastin correlating with the depth of needle penetration. Increases in
collagen and dermal thickness, but no change in epidermal thickness,
were also noted. These results are similar to studies treating patients
for other scarring conditions. An increase in collagen and elastin was
seen in two studies treating patients with striae distensae (Aust et al.,
2010b; Park et al., 2012), with one additionally showing an increase in
epidermal thickness (Park et al., 2012). A study treating burn scars
showed an increase in collagen (Aust et al., 2010a). Increases in colla-
gen, elastin, and epidermal and dermal thickness have also been seen
with skin needling in nonscarring conditions such as photodamage
and skin laxity (Aust et al., 2008a, 2011; Fabbrocini et al., 2011a;
Fernandes, 2005; Fernandes and Signorini, 2008; Kim et al., 2011).
79A.G. Harris et al. / International Journal of Women's Dermatology 1 (2015) 7781
Optimal number of treatments, duration between treatments, and
needle length
There have been no studies directly evaluating the optimal number
of treatments, time between treatments, or needle length. The median
number of treatments in studies using skin needling alone was three
(Alam et al., 2014; Beretta et al., 2008; Dogra et al., 2014; Fabbrocini
et al., 2009, 2011c, 2014b; Leheta et al., 2011; Majid, 2009; Schwarz
and Laaff, 2011; Sharad, 2011), with a range of one to ve treatments.
The median duration between treatments was 4 weeks, with a range
of 2 to 8 weeks. The median needle length used was 1.5 mm, ranging
from 1 mm to 3 mm. No studies compared needle thickness or degree
of pressure applied.
Adverse events
Eighteen patients out of 246, over 10 studies (Alam et al., 2014;
Beretta et al., 2008; Dogra et al., 2014; Fabbrocini et al., 2009, 2011c,
2014b; Leheta et al., 2011; Majid, 2009; Schwarz & Laaff, 2011; Sharad,
2011) treating patients with skin needling alone, had adverse events re-
ported. Skin needling is expected to cause temporary erythema, pain, a
burning sensation, edema, bleeding, or a serous ooze resolving with
crusting or scabbing (Alam et al., 2014; Beretta et al., 2008; Dogra
et al., 2014; Fabbrocini et al., 2009, 2011c, 2014b; Leheta et al., 2011;
Majid, 2009; Sharad, 2011). Bruising and hematomas are also expected,
particularly over bonyprominences (Dogra et al., 2014; Fabbrocini et al.,
2014b; Schwarz and Laaff, 2011), The development of tram trekscar-
ring was reported with 2-mm needles in one case report (Pahwa et al.,
2012). This phenomenon also occurred in a study using 1.5-mmneedles
(Dogra et al., 2014), but not in a study using 2.5-mm needles (Gadkari
and Nayak, 2014). It is therefore unclear if this phenomenon is related
to needle length. There were no other reports of scarring. Other adverse
events included the development of acne and the formation of milia
(Beretta et al., 2008; Leheta et al., 2011; Sharad, 2011) (see Fig. 2).
Serious adverse events worth noting when skin needling was used for
other dermatological conditions included facial allergic granuloma and
systemic hypersensitivity reactions, possibly related to topical products
put on the skin before needling or to the needles themselves (Patsou,
2013; Soltani-Arabshahi et al., 2014).
Infection as an adverse event
No studies reported bacterial infections after treatment, although
some opted for topical or oral antibiotic prophylaxis (Alam et al.,
2014; Gadkari and Nayak, 2014; Majid, 2009; Sharad, 2011). One
study reported infections with herpes simplex virus (HSV), but it was
unclear if these patients had acne scarring (Aust et al., 2008a). Reports
of HSV infections have been noted in other articles (Fernandes, 2005;
Torezan et al., 2013) and oral acyclovir was given to patients with a his-
tory of HSV in at least one study including patients with acne scarring
(Alam et al., 2014).
Post-inammatory hyperpigmentation as an adverse event
In an early study using rats, post-inammatory hyperpigmentation
after skin needling was found to be unlikely (Aust et al., 2008b). Of
the patients treated with skin needling alone, nine developed
postinammatory hyperpigmentation (Dogra et al., 2014; Majid,
2009; Sharad, 2011); all had skin phototypes of three or greater except
one, where the skin phototype was not mentioned. Not all studies re-
ported skin types, but in at least four studies (Alam et al., 2014; Dogra
et al., 2014; Fabbrocini et al., 2014b; Sharad, 2011), there were a total
of 105 patients with skin phototypes of three or greater.
Conclusion
Skin needling is a relatively simple, cost-effective technique used for
the treatment of acne scarring. A review of the current literature sug-
gests that it has moderate efcacy. However, the evidence for this is
limited as it is based on predominantly observational studies, which
are heterogeneous in design with some lacking statistical analysis and
internal validity.Skin needlingwas shown to work well in combination
with other treatments for acne scarring, but the results of each study
were specic for each treatment and lacked external validity. Skin
needling appeared to be safe with a low frequency of side effects. No
consensus has been reached on the use of antibiotic prophylaxis.
Double-blinded randomized controlled trials are needed to further
evaluate efcacy, and specic studies are needed to dene the optimal
number of treatments, duration between each treatment, and needle
depth, and to further characterize adverse reactions.
Supplementary data to this article can be found online at http://dx.
doi.org/10.1016/j.ijwd.2015.03.004.
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... Daha az basınç ve daha küçük iğneler kullanılarak bundan kaçınılabilir. 42 Mikroiğnelemeden sonra iğnelerin kendisine karşı sistemik aşırı duyarlılık reaksiyonu gelişebilir. 43 Ayrıca, iğnelerin deri içinde koparak yaralanmaya neden olmamasını sağlamak için yüksek kaliteli aletler kullan-mak son derece önemlidir. ...
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Mezoterapi, medikal ve kozmetik tedavi amacıyla çeşitli bileşenlerin mikroen-jeksiyon yoluyla dermise iletildiği minimal invaziv bir tekniktir. 1 İlk defa 1952 yılında Fransız hekim Michel Pistor tarafından tanımlanmıştır. Günümüzde, minimal invaziv ve görece ağrısız bir yöntem olması nedeni ile kozmetik dermatolojide selülit tedavisi, vücut şekillendirme, kırışıklıkların giderilmesi, pigmentasyon tedavisi ve saç dökülmesi gibi çeşitli endikasyonlarda sıklıkla tercih edilmektedir. 2,3 Mezoterapinin en önemli avantajları kullanılan bileşenlerin oral/intravenöz ilaç yo-lunun sistemik etkilerini atlaması ve basit bir topikal tedaviye kıyasla daha derine etki etmesidir. Vücudun dolaşım, lenfatik ve bağışıklık sistemini uyararak biyolojik bir ya-nıta sebep olur. Ayrıca, mezoterapi ile yüzeysel olarak verilen ilaçlar genel dolaşım ta-rafından daha yavaş temizlenir. Böylece, ilaçlar dermise kademeli olarak nüfuz eder, daha az doz ile daha uzun bir etki süresi ve daha hızlı sonuçlar elde edilir. 4 Saç dökülmesi hastaların yaşam kalitesini etkileyen önemli bir faktördür. Saç dö-külmesi tedavisinde mezoterapinin saç kalitesini ve nemini iyileştirdiği, anajen fazı uzat-tığı, mikrosirkülasyonu ve besin kaynağını iyileştirdiği ve 5-alfa redüktazı engellediği düşünülmektedir. Mezoterapinin kullanıldığı başlıca alopesi formları androgenetik alo-pesi (AGA), telogen effluvium ve alopesi areatadır. Mezoterapi, sikatrisyel alopesiler için önerilmemektedir, ancak kortikosteroidlerin deri içine uygulandığı intralezyonel 63 Saç Dökülmelerinde Mezoterapi ve Mikroiğneleme Mesotherapy and Microneedling in Hair Loss ÖZET Saç dökülmesi hastaların yaşam kalitesini etkileyen önemli bir faktördür. Son yıllarda saç dö-külmesi tedavisinde mezoterapi ve mikroiğneleme yöntemlerinin kullanımı oldukça yaygınlaşmıştır. Ancak, her iki yöntem için de uygulayıcılar tarafından kullanılan standart bir protokol yoktur. Ayrıca, bu yöntemlerin etkinliklerini ve güvenilirliklerini değerlendiren klinik çalışmalar az sayıda ve yetersiz-dir. Bu derlemede, saç dökülmesi tedavisinde kullanılan mezoterapi ve mikroiğneleme yöntemleri lite-ratür ışığında gözden geçirilmiştir. Anah tar Ke li me ler: Alopesi; mezoterapi; mikroiğneleme; saç dökülmesi ABS TRACT Hair loss has a significant burden on the quality of life of patients. Recently, the use of mesotherapy and microneedling in the treatment of hair loss has become a common practice. However, there is no standard protocols used by clinicians for both methods. In addition, clinical studies evaluating the efficacy and safety of these methods are scarse and inadequate. In this review, mesotherapy and microneedling methods used in hair loss treatment are reviewed in the light of the literature.
... A recent review concluded that, although the studies analyzed were varied in structure, there was acceptable evidence available that supported the use of microneedling and PCI for acne scarring, while criticizing study design. 17,18 Here, we present a suitably sized study reporting on the use of an automated microneedling system for the successful treatment of facial acne scarring in Fitzpatrick Skin Types I to IV. These data were used for successful clearance of a microneedling device for acne scar treatment in the United States (K182407) and Europe. ...
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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].
... Microneedle arrays have a wide range of uses from cosmetic 14,15 (e.g. Dermaroller™), diagnostic 16,17 , drug delivery [18][19][20] through to the most promising and most studied area, vaccine delivery 21 . ...
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The development of microarray patches for vaccine application has the potential to revolutionise vaccine delivery. Microarray patches (MAP) reduce risks of needle stick injury, do not require reconstitution and have the potential to enhance immune responses using a fractional vaccine dose. To date, the majority of research has focused on vaccine delivery with little characterisation of local skin response and recovery. Here we study in detail the immediate local skin response and recovery of the skin post high density MAP application in 12 individuals receiving 3 MAPs randomly assigned to the forearm and upper arm. Responses were characterised by clinical scoring, dermatoscopy, evaporimetry and tissue viability imaging (TiVi). MAP application resulted in punctures in the epidermis, a significant transepidermal water loss (TEWL), the peak TEWL being concomitant with peak erythema responses visualised by TiVi. TEWL and TiVi responses reduced over time, with TEWL returning to baseline by 48 h and erythema fading over the course of a 7 day period. As MAPs for vaccination move into larger clinical studies more variation of individual subject phenotypic or disease propensity will be encountered which will require consideration both in regard to reliability of dose delivery and degree of inherent skin response.
Chapter
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.
Thesis
Non-melanoma skin cancers are on the rise with 2 to 3 million people diagnosed each year and are sometimes treated by local ablation therapy. To avoid this surgery, photodynamic therapy (PDT) appears as an advantageous treatment. Currently used in clinics, PDT consists of applying a cream containing a photosensitive precursor to the damaged skin, which, then metabolizes and under light excitation inducescell death. However, this technique is not fully effective if the skin lesion extends into the deep skin layers. To improve the therapeutic treatment of this type of skin cancer, a patch with dissolving microneedles (MNs) was develop to reach the deep layers of lesions that are difficult to treat. Hyaluronic acid, known for its biocompatibility, solubility and biodegradability, was chosen as the constituent material, and mixed with the 5-aminolevulinic acid (photosensitive precursor, 5-ALA). To ensure the best penetration without causing pain by touching the nerve endings, an optimal “pencil-tip” design was defined with MNs length going from 400 to 750μm. A simple and robust manufacturing process called solvent casting molding method, has been set up which is an asset for potential industrialization. In absence of realistic skin lesions model,we chose to establish one on rats skin by applying daily UV-B doses. Histology and pharmacokinetic studies validated the presence of precancerous skin lesions and the MN-patch in vivo efficiency was therefore tested. After one hour application on the injured rat skin, the MN-patch dissolved and released the 5-ALA that further metabolized to protoporphyrin IX (PpIX). A significant level of PpIX fluorescence was recorded suggesting that after light excitation, a PDT session could be effective. In parallel, to reduce pain felt during PDT treatment, a light device with suitable optical and thermal properties was conceived and coupled to the MN-patch. The idea would be to start the illumination directly after MN-patch application in order to avoid a painful photochemical reaction. This wearable and easy to use system purpose a all-in-one PDT processing which fulfills the criterion of patient compliance, better efficiency and speed of treatment.
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Nonsurgical facelifts are a term for a heterogeneous group of procedures used by physicians to improve facial rejuvenation without the use of operative techniques. Patients demand these services due to the reduced recovery time and generally lower risk. However, nonsurgical techniques, to be effective, must induce conformational change in the cells and tissues of the face. Therefore, these techniques are significant procedures that have associated risks. Understanding the tissue modifications and mechanisms of action of these techniques is vital to their safe and effective use. The purpose of this article is to provide a background of tissue modification in nonsurgical facelift options.
Chapter
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.
Chapter
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.
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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.
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Background: Platelet-rich plasma (PRP) is an autologous preparation of platelets in concentrated plasma that may be beneficial in the treatment of atrophic acne scars by promoting collagen deposition. Skin needling is a technique that uses a sterile dermaroller to puncture the skin and release growth factors. The combination of skin needling and PRP could enhance the efficacy of both modalities. Chemical reconstruction of skin scars technique consists of focal application of high concentration of trichloroacetic acid (TCA) on the acne scars to stimulate collagen production. Objective: To evaluate the efficacy and safety of intradermal injection of PRP, 100% focal TCA, and combined skin needling plus topical PRP in the treatment of atrophic acne scars. Patients and methods: Forty-five patients with atrophic acne scars were randomly assigned to 3 equal groups; Group A received intradermal injection of PRP, Group B received chemical reconstruction of skin scars technique with TCA 100%, and Group C was treated by combined skin needling and PRP. Each patient underwent 3 sessions at 2-week interval. Results: All the patients completed the study. The 3 groups showed statistically highly significant improvement in the degree of acne scars after treatment (p < .001). No major adverse effects were observed in the studied groups. Conclusion: This is the first study to use intradermal injection of PRP alone for the treatment of atrophic acne scars. The 3 modalities showed a promising efficacy and safety in the treatment of atrophic acne scars.
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Atrophic acne scars are difficult to treat. The demand for less invasive but highly effective treatment for scars is growing. To assess the efficacy of combination therapy using subcision, microneedling and 15% trichloroacetic acid (TCA) peel in the management of atrophic scars. Fifty patients with atrophic acne scars were graded using Goodman and Baron Qualitative grading. After subcision, dermaroller and 15% TCA peel were performed alternatively at 2-weeks interval for a total of 6 sessions of each. Grading of acne scar photographs was done pretreatment and 1 month after last procedure. Patients own evaluation of improvement was assessed. Out of 16 patients with Grade 4 scars, 10 (62.5%) patients improved to Grade 2 and 6 (37.5%) patients improved to Grade 3 scars. Out of 22 patients with Grade 3 scars, 5 (22.7%) patients were left with no scars, 2 (9.1%) patients improved to Grade 1and 15 (68.2%) patients improved to Grade 2. All 11 (100%) patients with Grade 2 scars were left with no scars. There was high level of patient satisfaction. This combination has shown good results in treating not only Grade 2 but also severe Grade 4 and 3 scars.
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Melasma is a common cause of facial hyperpigmentation with significant cosmetic deformity. Although several treatment modalities are available, none is satisfactory. To compare the therapeutic efficacy and safety of tranexamic acid (TA) microinjections versus tranexamic acid with microneedling in melasma. This is a prospective, randomised, open-label study with a sample size of 60; 30 in each treatment arms. Thirty patients were administered with localised microinjections of TA in one arm, and other 30 with TA with microneedling. The procedure was done at monthly intervals (0, 4 and 8 weeks) and followed up for three consecutive months. Clinical images were taken at each visit including modified Melasma Area Severity Index MASI scoring, patient global assessment and physician global assessment to assess the clinical response. In the microinjection group, there was 35.72% improvement in the MASI score compared to 44.41% in the microneedling group, at the end of third follow-up visit. Six patients (26.09%) in the microinjections group, as compared to 12 patients (41.38%) in the microneedling group, showed more than 50% improvement. However, there were no major adverse events observed in both the treatment groups. On the basis of these results, TA can be used as potentially a new, effective, safe and promising therapeutic agent in melasma. The medication is easily available and affordable. Better therapeutic response to treatment in the microneedling group could be attributed to the deeper and uniform delivery of the medication through microchannels created by microneedling.
Article
Platelet-rich plasma (PRP) contains autologous growth factors, which could act synergistically with growth factors induced by skin needling in order to enhance the wound-healing response. The combination of treatments, carried out by using skin needling and PRP application, should enhance both efficacy of skin needling and PRP application. The objective of this study is to establish the effectiveness of the combined use of skin needling and PRP application in acne scarring treatment. Twelve patients affected with rolling acne scars were enrolled. Each patient underwent 2 sessions of treatments, each consisting of skin needling followed by PRP application on the right side of the face and skin needling alone on the left side of the face. Digital photographs of all patients were taken. Photographic data were analyzed by using the Sign Test (α<.05). The study showed that the scars severity grade in all patients was greatly reduced on all of the face, but the improvement was more efficient on the side treated with both skin needling and PRP. Our study showed that the combined use of skin needling and PRP is more effective than skin needling alone in improving acne scars.
Article
Aim: The use of skin needling is believed to aid the transdermal delivery of drugs, even if it is mostly used for skin collagen induction. The aim of this paper was to use skin needling, combined with a local anesthetic EMLA (eutectic mixture of lidocaine and prilocaine), as a way to enhance transdermal drug penetration and optimize the analgesic effects of common local anesthesia. Methods: We recruited 15 patients. For each patient of our study we defined a skin area of 3 cm2 from two forearms: on one side, we used skin needling first and immediately thereafter applied the EMLA in occlusion for 60 minutes; on the other one, we only applied EMLA in occlusion for 60 minutes. Then, pain was induced in each patient's forearm by introducing a 27 G needle into the skin 4 mm deep three times. Lastly, pain sensation measures were registered and a middle value was calculated. Results: When skin needling is used in conjunction with EMLA applied in occlusion for 60 minutes on skin forearms, the level of pain sensation registered was significantly reduced on a Visual Analogue Scale compared to the application of EMLA alone. Conclusion: The use of skin needling can improve the transdermal delivery of an emulsion-like eutectic mixture of local anesthetics (EMLA) and can introduce the use of this method for delivering topical molecules in dermatology.
Article
Background Postacne scarring is disfiguring, both physically as well as psychologically. Over the past two decades, multiple modalities for treatment of acne scars have emerged and microneedling with dermaroller is one of them.Objective To evaluate the efficacy and safety of microneedling treatment for atrophic facial acne scars.Material and Methods Thirty-six patients (female – 26, male – 10) of postacne atrophic facial scars underwent five sittings of dermaroller under topical anesthesia at monthly intervals. Objective evaluation of improvement was performed by recording the acne scar assessment score at baseline and thereafter at every visit. Pre- and posttreatment photographs were compared, and improvement was graded on quartile score. Final assessment was performed 1 month after the last sitting. Patients were asked to grade the improvement in acne scars on visual analog scale (VAS, 0–10 point scale) at the end of study.ResultsOf 36 patients, 30 completed the study. The age group ranged from 18 to 40 years, and all patients had skin phototype IV or V. There was a statistically significant decrease in mean acne scar assessment score from 11.73 ± 3.12 at baseline to 6.5 ± 2.71 after five sittings of dermaroller. Investigators' assessment based on photographic evaluation showed 50–75% improvement in majority of patients. The results on visual analog scale (VAS) analysis showed “good response” in 22 patients and “excellent response” in four patients, at the end of study. The procedure was well tolerated by most of the patients, and chief complications noted were postinflammatory hyperpigmentation in five patients and tram-trek scarring in two patients.Conclusion Microneedling with dermaroller is a simple and cheap, means of treatment modality for acne scars remodulation with little downtime, satisfactory results and peculiar side effects in Asian skin type.
Article
Importance Neocollagenesis can be achieved using a dermal rolling needle device, thereby reducing the appearance of acne scars.Objective To determine the efficacy of a needling device for treatment of acne scars.Design, Setting, and Participants We performed a single-center, rater-blinded, balanced (1:1), split-face, placebo-controlled, parallel-group randomized clinical trial at an urban academic institution. The study took place from November 30, 2009, through July 27, 2010. Twenty healthy adults (age range, 20-65 years) with acne scars on both sides of the face were enrolled. Fifteen individuals completed the study, and no enrolled participants were withdrawn for adverse effects.Interventions For each participant, one side of the face was randomized for needling. Three needling treatments were performed at 2-week intervals.Main Outcomes and Measures Two blinded dermatologists separately rated participants’ acne scars based on standard digital photographs obtained at baseline and at the 3-month and 6-month follow-up visits on the quantitative global scarring grading system.Results Mean scar scores were significantly lower in the treatment group compared with baseline at 6 months (mean difference, 3.4; 95% CI, 0.2-6.5; P = .03) and nominally but not significantly lower compared with baseline at 3 months (mean difference, 2.4; 95% CI, −0.01 to 4.8; P = .052). In the control group, mean scar scores did not vary significantly from baseline at 3 months (mean difference, 1.0; 95% CI, −1.4 to 3.4; P = .96) and at 6 months (mean difference, 0.4; 95% CI, −2.3 to 3.5; P > .99). The needling procedure was not particularly painful, with a mean pain rating of 1.08 of 10. Participants perceived a 41% mean improvement in overall scar appearance on the treated side. No adverse events were reported.Conclusions and Relevance After 3 needling treatments, there was improvement in the appearance of acne scars over time compared with the control group, with minimal pain reported.Trial Registration clinicaltrials.gov Identifier: NCT00974870
Article
Atrophic scars are a common complication of acne. Many modalities are proposed but each does not yield satisfactory clinical outcomes. Thus, a new combination therapy is suggested that incorporates (i) dot peeling, the focal application and tattooing of higher trichloroacetic acid concentrations; (ii) subcision, the process by which there is separation of the acne scar from the underlying skin; and (iii) fractional laser irradiation. In this pilot study, the efficacy and safety of this method was investigated for the treatment of acne scars. Ten patients received this therapy for a year. Dot peeling and subcision were performed twice, 2-3 months apart and fractional laser irradiation was performed every 3-4 weeks. Outcomes were assessed using scar severity scores and patients' subjective ratings. Acne scarring improved in all of the patients completing this study. Acne scar severity scores decreased by a mean of 55.3%. Eighty percent of the patients felt significant or marked improvement. There were no significant complications at the treatment sites. It would appear that triple combination therapy is a safe and very effective combination treatment modality for a variety of atrophic acne scars.
Article
Background Acne scars occur consequent to abnormal wound healing following sebaceous follicular inflammation in acne. Various types of acne scars are icepick, rolling, boxcar, hypertrophic, and keloidal. Different modalities of treatment include subcision, dermaroller, cryoroller, punch excision, chemical peeling, and lasers.Objectives To compare the efficacy of combined subcision and dermaroller vs. combined subcision and cryoroller in acne scar treatment.Methods Thirty patients (19 males and 11 females) with grade 2, 3, and 4 postacne scarring (Goodman and Baron qualitative grading system) were enrolled in the study. Three sittings each at 1-month interval were carried out of subcision under nerve block on the entire face followed by derma roller (2.5 mm) and cryoroller on one half of the face. Standardized digital photography was performed preprocedure and at 6 months. Grading of acne scar photographs using the Goodman and Baron qualitative and quantitative grading scale was carried out by a blinded observer pre- and postprocedure at 6 months. Patients' own evaluation based on patient scar severity perception scale of 1–10 was also taken into account.ResultsAssessment using the quantitative grading scale showed a 57% improvement using combined subcision and cryoroller against 40% improvement with combined subcision and dermaroller. Average improvement perceived by the subjects was 61% with combined subcision and cryoroller against 45% with combined subcision and dermaroller. The data were analyzed using Wilcoxon signed rank test and found statistically significant. Postinflammatory hyperpigmentation on the cryoroller side and erythema, edema, and hematoma formation due to subcision was transient.Conclusion Combined subcision and cryoroller is more effective than combined subcision and dermaroller for treatment of acne scars.
Article
Importance: Microneedle therapy includes skin puncture with multiple micro-sized needles to promote skin rejuvenation or increase transdermal delivery of topical medications. In cosmetic practices, various cosmeceuticals are applied before microneedling to enhance the therapeutic effects. This results in intradermal tattooing of the topical product. Despite rapid increase in the use of microneedles in dermatology, there are few data about their safety. Observations: We describe 3 women, aged 40s to 60s, who developed open [corrected] facial granulomas following microneedle therapy for skin rejuvenation. Two patients had undergone microinjection of the same branded topical moisturizer (Vita C Serum; Sanítas Skincare) during microneedle therapy. Biopsy in all cases showed foreign body-type granulomas. Results of tissue cultures were negative. Chest radiography and serum angiotensin-converting enzyme findings were normal. The first 2 patients had a positive patch test reaction to Vita C Serum. Initial treatment with topical and oral corticosteroids was ineffective. Therapy with doxycycline hydrochloride and minocycline hydrochloride led to partial improvement in one case and resolution in another. Conclusions and relevance: Application of topical products prior to microneedling can introduce immunogenic particles into the dermis and potentiate local or systemic hypersensitivity reactions. Because the microneedle therapy system is accessible for home use, health care providers need to be aware of its potential consequences.