Microneedling may provide alternative to lasers

A 35-year-old female before and two weeks after four sessions of microneedling and PRP for acne scarring. Photos: Mara Weinstein Velez, M.D.

Microneedling may provide a viable alternative to lasers in certain clinical situations, according to Mara Weinstein Velez, M.D., who spoke at the American Society for Laser Medicine and  Surgery (ASLMS) annual conference in April. Dr. Weinstein Velez is a New York-based dermatologist in private practice at Schweiger Dermatology Group.

Microneedling has received considerable hype in dermatology publications, but some physicians question overly exuberant claims due to inadequate clinical evidence needed to establish the technology as a viable therapeutic option for improving the appearance of skin. Without research and treatment guidelines, application techniques may differ significantly among physicians.

“In the clinical setting, most of us in the United States use the automated pen. Many people perform multiple passes, using different depths to treat different locations of the face and body. It’s a fuzzy line,” Dr. Weinstein Velez says.

“Post-inflammatory hyperpigmentation (PIH) is a major concern for patients with darker skin types when using laser devices, mainly because lasers generate heat,” she says.

For more on microneedling: RF microneedling applications

But in microneedling, the technique works through mechanical manipulation without heat, reducing the risk of hyperpigmentation by significantly downregulating melanocyte-stimulating hormone in the postinflammatory healing response.¹ One study showed that at 12 weeks, microneedling increases epidermal thickness and spurs collagen remodeling in scars.²

Acne scarring

A 2016 study from the journal Dermatologic Surgery found that “both nonablative fractional laser 1,340 nm and microneedling are comparable and effective in the treatment of atrophic acne scars,” with microneedling having fewer side effects and less down time. The patients received three dermaroller microneedling sessions one month apart. Six months post-treatment, investigators saw no difference between results of the two therapies.³

“The main difference was that with lasers, people had two to three days of redness, compared to one day on the microneedling side. Also, after microneedling, there was no PIH,” Dr. Weinstein Velez says.

In a randomized split-face study published in a January issue of Dermatologic Surgery, investigators treated 30 patients with atrophic acne scars (skin types III through V) with fractional erbium:YAG laser on one side and automated microneedling (one session monthly for five months) on the other.

At three months post treatment, the laser treated side averaged approximately 70% improvement as compared to 30% for microneedling (p> 0.001).⁴ Patients who received laser treatment experienced more side effects, including erythema, swelling and total downtime. One patient with skin type V developed PIH on the laser-treated side.

An article published in the Journal of Clinical and Aesthetic Dermatology in July 2015 reported “statistically significant” improvements in scarring for 10 patients who received six sessions of microneedling with a dermaroller at two week intervals.⁵

Transdermal drug delivery

For transdermal drug delivery, “The concept is that the device produces microscopic wounds in the skin, forming channels that stay open for a few minutes. While they’re open, you can deliver medicine through the channel” to address conditions including melasma, melanosis,⁶ aging skin, unwanted tattoos and androgenetic alopecia, and to deliver topical anesthesia.

A split-face study that included 15 patients with atrophic acne scars showed that performing 0.5 mm automated microneedling before applying lidocaine 2.5% and prilocaine 2.5% prior to full-face microneedling at 2.5 mm depth significantly reduced pain on the side treated with microneedling and topical anesthesia.⁷ With very few studies in this area, gauging exactly how deeply the drug is delivered can be difficult. “You think the depth you set on the microneedling device is the depth to which the drug is being delivered, but there haven’t been any studies using confocal microscopy or tracing to tell if the drug is actually being delivered at that depth,” she says.

Transdermal delivery of platelet-rich plasma (PRP) via microneedling has become a very popular treatment for hair loss. “There are studies that support its efficacy, but not enough of them,” she said. The same can be said of microneedling plus PRP for acne scars.

Transdermal delivery of topical drugs via microneedling can contribute to the development of allergies and other adverse reactions. In one case series, three women developed facial allergic granulomatous reactions and systemic hypersensitivity because they were allergic to a component of an antiaging serum applied in conjunction with microneedling.⁸ “The take-home message here is that if a patient has sensitive skin, you might want to test the medication on a small spot in an area such as the forearm to make sure they don’t react to it,” she says.

It’s somewhat troubling that patients can order manual dermarollers online, Dr. Weinstein Velez added. “As dermatologists, we need to be very careful counseling patients about sanitation issues, making sure they don’t introduce bacteria” by using dermarollers. Dermatologists also must impress upon patients the importance of getting an evaluation and guidance from a dermatologist before using these devices, she said.

Facial rejuvenation

Few studies look at microneedling for facial rejuvenation. For lines and wrinkles, one study showed that six dermaroller sessions spaced two weeks apart led to increases in collagen (particularly types I, III and VII), total elastin and tropoelastin. Study patients had Fitzpatrick skin types III and IV, and Glogau class II to III wrinkles. Average investigator-assessed improvement in wrinkle appearance and skin texture based on photographs increased from a range of 20 to 25% one month posttreatment to 55 to 65% at three months.⁹ “This is one of the only studies I found using microneedling for facial rejuvenation in terms of treating fine lines and wrinkles, however; I know controlled trials are currently being conducted and should be published very soon,” she says.

Many devices now provide fractional radiofrequency microneedling (RFMN). With this technology, insulated needles penetrate the skin to deliver RF energy (and controlled heat) to the deep dermis to stimulate collagen production, Dr. Weinstein Velez says. Fractional RFMN has been shown to be useful for the same indications as microneedling and for additional indications including treatment of excessive sebum secretion, active inflammatory acne and hyperhidrosis.

Disclosures:  Dr. Weinstein Velez reports no relevant financial interests.

References

• Aust MC, Reimers K, Repenning C, et al. Percutaneous collagen induction: minimally invasive skin rejuvenation without risk of hyperpigmentation-fact or fiction? Plast Reconstr Surg. 2008;122(5):1553-63.
• Zeitter S, Sikora Z, Jahn S, et al. Microneedling: matching the results of medical needling and repetitive treatments to maximize potential for skin regeneration. Burns. 2014;40(5):966-73.
• Cachafeiro T, Escobar G, Maldonado G, Cestari T, Corleta O. Comparison of nonablative fractional erbium laser 1340 nm and microneedling for the treatment of atrophic acne scars: a randomized clinical trial. Dermatol Surg. 2016;42(2):232-41.
• Osman MA, Shokeir HA, Fawzy MM. Fractional erbium doped yttrium aluminum garnet laser versus microneedling in treatment of atrophic acne scars: a randomized split-face clinical study. Dermatol Surg. 2017;43 Suppl 1:S47-S56.
• El-Domyati M, Barakat M, Awad S, Medhat W, El-Fakahany H, Farag H. Microneedling therapy for atrophic acne scars: an objective evaluation. J Clin Aesthet Dermatol. 2015;8(7):36-42.
• Sahni K, Kassir M. Dermafrac™: an innovative new treatment for periorbital melanosis in a dark-skinned male patient. J Cutan Aesthet Surg. 2013;6(3):158-60.
• El-Fakahany H, Medhat W, Abdallah F, Abdel-Raouf H, Abdelhakeem M. Fractional microneedling: a novel method for enhancement of topical anesthesia before skin aesthetic procedures. Dermatol Surg. 2016;42(1):50-5.
• Soltani-Arabshahi R, Wong JW, Duffy KL, Powell DL. Facial allergic granulomatous reaction and systemic hypersensitivity associated with microneedle therapy for skin rejuvenation. JAMA Dermatol. 2014;150(1):68-72.
• El-Domyati M, Barakat M, Awad S, Medhat W, El-Fakahany H, Farag H. Multiple microneedling sessions for minimally invasive facial rejuvenation: an objective assessment. Int J Dermatol. 2015;54(12):1361-9.