Microneedling


Article Author:
Graham Litchman
Pragya Nair


Article Editor:
Talel Badri


Editors In Chief:
Ahmad Al Aboud
Jayakar Thomas
Pramod Nigam


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Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
6/10/2019 1:23:15 AM

Introduction

Microneedling also called "percutaneous collagen production" is a form of developing therapy using instruments which contain rows of thin needles. When these instruments are rolled over the surface of the skin, they induce rapidly-healing micropunctures. Subsequently, collagen and elastin fiber production is stimulated resulting in skin remodeling. Microneedling was also proposed to enable the penetration of high molecular weight drugs by creating transient aqueous transport microchannels through the stratum corneum, thus increasing the transcutaneous permeability. This procedure is called transdermal drug delivery. A peculiar type of microneedling is fractional radiofrequency microneedling in which, insulated needles release radiofrequency waves to act deeper in the dermis, thus preventing epidermal damages.[1][2][3]

Microneedling was initially used for scars, but now there are many indications for use. However, strong evidence for the efficiency of microneedling is not evident in the literature.[4][5][6]

Indications

Various indications of microneedling include:

  • Wrinkles due to skin aging (both chronologic aging and sun-induced aging)
  • Scars:
  1. Acne scars (atrophic, boxcar, rolling, and pitted scars). Grade 2 and grade 3 rolling/boxcar scars respond better than pitted scars. Deep pitted scars and liner scars do not respond
  2. Postburn scars
  3. Post-traumatic scars  
  4. Post-varicella scars  
  5. Hypertrophic scars
  • Stretch marks: striae rubra
  • Androgenetic alopecia and alopecia areata, with or without using platelet-rich plasma or 5% minoxidil.
  • Pigmentation: In melasma and periorbital melanosis using tranexamic acid or other bleaching agents
  • Primary axillary hyperhidrosis: using fractional radiofrequency microneedling
  • Moderate and severe acne: fractional radiofrequency microneedling acts by inducing a decrease in sebum excretion, thus improving acne lesions

Contraindications

Microneedling is contraindicated in:

  1. Patients with dermatosis like vitiligo, lichen planus and psoriasis as trauma leading to koebnerization can aggravate the dermatosis. Nevertheless, some authors have used microneedling with topical latanoprost to treat vitiligo.  
  2. Blood clotting disorders and patients on any anticoagulant therapy like warfarin, heparin, as it can cause uncontrolled bleeding.
  3. Rosacea
  4. Skin malignancy, moles, warts and solar keratosis: as the needles may disseminate abnormal cells by implantation
  5. Other chronic skin diseases like eczema
  6. Patients who have a history of taken isotretinoin within 6 months
  7. Microneedling on an infected area: impetigo or herpes labialis
  8. Extreme keloidal tendency
  9. Patient on chemo or radiotherapy

Equipment

The usual medical roller has a handle and a 2 cm wide barrel-shaped cylinder having 192 thin stainless steel needles, which are 0.5 mm to 3 mm in length and 0.1 mm to 0.25 mm in diameter. The microneedles are usually non-allergenic to humans.

The roller is pre-sterilized by gamma irradiation. Re-sterilization of the instrument using an autoclave or ultrasound is not indicated since needles may become less sharp and detach from the roller. Roller should always be maintained in isopropyl alcohol.

Other variations in microneedling devices include:

  1. Fractional radiofrequency microneedling 
  2. Stamps (needles of 2 mm in length and diameters of 0.12 mm) are used in the treatment of localized scars like varicella scars 
  3. Pens
  4. Home-care rollers (needles of about 0.1 mm in length) are used for transcutaneous delivery of anti-aging agents
  5. Devices combining microneedling and vacuum-assisted infusion
  6. LED microneedling rollers

Preparation

Topical anesthesia with lidocaine and prilocaine cream (EMLA) is applied to the area to be treated and covered with a cellophane tape for 15 to 45 minutes. EMLA is then removed using normal saline. An antiseptic solution should be applied before the procedure begins.

Technique

The skin of the face is stretched by one hand while the other hand is used to roll the instrument over in a direction perpendicular to that of stretching force. The roller is rolled 15 to 20 times in horizontal, vertical, and both oblique directions. The base of the scar is to be treated. Pinpoint bleeding should occur from the base of the scar. Saline pads are kept over the treated area.

The topical antibiotic cream is applied. The procedure takes 15 to 20 minutes. Treatment is to be repeated after 4 to 6 weeks.[7][8][9][10]

Pathophysiology of Collagen Induction Therapy

Rolling with a standard roller containing 192 needles of 2 mm length and 0.07 mm diameter over an area of skin for 15 times results in approximately 250 holes per square cm up to the papillary dermis depending on the pressure applied. Each pass produces 16 micropunctures in the stratum corneum per square cmThe needles are placed at an inclination of 15 degrees in relation to the surface of the derma roller to achieve a uniform depth of penetration, The depth of neocollagenesis was found to be average 5 micrometers to 600 micrometers with 1.5 mm length needle.

Microneedling aims to stimulate collagen production by producing micro wounds and initiating the normal post-inflammatory chemical cascade. There are three phases of the wound healing process which predictably follow each other as described by Falabella and Falanga.

  1. Platelets and neutrophils release growth factors such as, TGF beta, platelet-derived growth factor, connective tissue activating protein, connective tissue growth factor which increases the production of intercellular matrix.
  2. Monocytes then release growth factor to increase the production of collagen, elastin, glycosaminoglycans. After five days of injury, a fibronectin matrix forms with an alignment of fibroblast that determines the deposition of collagen, which remains for five to seven years and tightens naturally.
  3. It also increases gene and protein expression of collagen, glycosaminoglycans and growth factors, vascular endothelial growth factor, epidermal growth factor, fibroblast growth factor which are relevant for skin regeneration. 

Collagen fiber bundles qualitatively increase, thicken, and more loosely weave in both papillary and reticular dermis. It appears to lay more in a normal lattice pattern than in parallel bundles as in scar tissue. Neovascularization and neocollagenesis following treatment lead to the reduction of scars.

Postoperative Care

The treated area is swollen and superficially bruised. It should be covered with cool, damp swabs that are replaced for 2 hours to absorb the bleeding and serous discharge.

Topical antibiotic cream (mupirocin) is applied for few days to minimize the chance of bacterial infection.

Avoid sun exposure and harsh chemicals or any cosmetic procedure over the face for at least for 1 week.

Complications

Complications are almost negligible.

  1. Pain
  2. Reactivation of herpes simplex
  3. Impetigo
  4. Allergic contact dermatitis to the material used in needles
  5. Exposure to blood

Poor quality needles of the roller device often result in bending at needle tips after repeated treatments, which results in more tissue damages and hemorrhage with linear hypertrophic scars or post inflammatory hyperpigmentation. Over-aggressive needling using a tattoo gun may also cause scarring, but not with the special barrel of needles.

Clinical Significance

Advantages

  • It has a short healing time. 
  • The technique is easy to master.
  • It can be used in any skin where lasers and deep peels cannot be performed.
  • It is a convenient office procedure and more cost-effective than other alternative therapy like a laser.
  • Well tolerated by patients.
  • Minimal risk of post-inflammatory hyperpigmentation.
  1. Many therapies like CO2 laser resurfacing, dermabrasion and deep chemical peeling used for the treatment of scar ablate the epidermis with subsequent re-epithelialization, but render the skin more sensitive to photodamage and dyschromia.
  2. After microneedling therapy, the expression of MCIR (Melanocortin l receptor) gene coding for a melanocyte stimulating hormone indicates a faint down regulation up to two weeks postoperatively. Therefore, in opposite to dermabrasion, microneedling appear to have the lower risk of depigmentation.
  • Microneedling can be combined with other acne scar treatment like subcision, chemical peeling, microdermabrasion and fractional resurfacing maximum-giving benefits
  • It can be done on people who have had laser resurfacing or have very thin skin.

Disadvantage

Evidence-based recommendations for the use of microneedling could not be performed currently.

Enhancing Healthcare Team Outcomes

Microneedling is just another procedure designed to treat a range of dermatological conditions. Becaused cosmetic and plastic surgeons, nurses and even non-healthcare workers use this technique to treat skin disorders. Besides risk of infection, there is no solid evidence that the technique has any clinical benefits.


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Microneedling - Questions

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Which of the following conditions is not a contraindication to microneedling?



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A 50-year-old female with a history of actinic keratosis, oral herpes labialis, and plantar fasciitis presents to the office requesting to treat what she describes as “excessive wrinkling” of her face. She recently switched careers from lifeguard to receptionist, as she was worried about her inordinate amount of sun exposure. After an appropriate pre-procedure history and physical is performed, the patient is deemed eligible for microneedling. Which of the following is most accurate about the best practices of microneedling with this patient?



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A 29-year-old female with a past medical history for severe facial acne during her pubescent years presents for treatment for subsequent scarring. The procedure is performed successfully and without complications. The patient returns for her follow up visit and has concerns about her recovery. She reports that the treatment area was initially very swollen and bruised. She also reports serosanguinous drainage even a day after the procedure and new scar lines in the area of treatment that she didn’t notice prior to the procedure. Of the post-procedure symptoms provided above, which is least likely to occur if the procedure is performed correctly, and what is the most likely cause?



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A 31-year-old male who is ten days status post his second microneedling treatment for extensive post-acne and post-herpetic atrophic scarring, grades 1-4, presents to the clinic insisting that he be refunded because the “treatment is not working." He reports persistent scarring and darkened skin within the area of treatment. It is explained to the patient that the procedure is most effective with grade 1-3 scars and that, as described during the initial consult, his grade 4 scars will likely not improve with microneedling. What is the physiological mechanism responsible for the abnormal postoperative side effects mentioned above?



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Microneedling - References

References

Kwon HH,Jung JY,Lee WY,Bae Y,Park GH, Combined treatment of recalcitrant papulopustular rosacea involving pulsed dye laser and fractional microneedling radiofrequency with low-dose isotretinoin. Journal of cosmetic dermatology. 2019 May 18;     [PubMed]
Gamil HD,Nasr MM,Khattab FM,Ibrahim AM, Combined therapy of plantar warts with topical bleomycin and microneedling: a comparative controlled study‏. The Journal of dermatological treatment. 2019 May 17;     [PubMed]
Schoenberg E,O'Connor M,Wang JV,Yang S,Saedi N, Microneedling and PRP for acne scars: A new tool in our arsenal. Journal of cosmetic dermatology. 2019 May 9;     [PubMed]
Elghblawi E, Intense retroauricular lymphadenopathy post-microneedling. Journal of cosmetic dermatology. 2019 Apr 29;     [PubMed]
Caccavale S,Iocco A,Pieretti G,Alfano R,Argenziano G, Curettage microneedling topical ALA-PDT for the treatment of acral resistant warts: our experience. Photodiagnosis and photodynamic therapy. 2019 Apr 6;     [PubMed]
Dhurat R,Sharma A,Goren A,Daruwalla S,Situm M,Kovacevic M, Mission impossible: Dermal delivery of growth factors via microneedling. Dermatologic therapy. 2019 Apr 8;     [PubMed]
Jha AK,Vinay K, Androgenetic alopecia and microneedling: Every needling is not microneedling. Journal of the American Academy of Dermatology. 2019 Mar 21;     [PubMed]
Devgan L,Singh P,Durairaj K, Minimally Invasive Facial Cosmetic Procedures. Otolaryngologic clinics of North America. 2019 Jun;     [PubMed]
Boen M,Jacob C, A Review and Update of Treatment Options Using the Acne Scar Classification System. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.]. 2019 Mar;     [PubMed]
Almohanna HM,Perper M,Tosti A, Safety concerns when using novel medications to treat alopecia. Expert opinion on drug safety. 2018 Nov;     [PubMed]

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