Microneedling for the Treatment of Scars

An Update for Clinicians Aesthetician

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.

Keywords: microneedling, laser, peel, platelet-rich plasma, scar

Introduction

Microneedling (MN), or percutaneous collagen induction therapy, has

been used within the dermatologic subspecialty for skin rejuvenation,
skin tightening including treatment of striae, scar remodeling of the
face and body, and hair growth. Due to the relative lack of post-
inflammatory hyperpigmentation, MN is often considered an
alternative to laser procedures in darker skin phototypes (Fitzpatrick
IV through VI). Although MN has been a popular, minimally invasive,
procedure performed in Asia and the Middle East, only recently has
MN garnered attention in the United States (US). Since the first clinical
descriptions of subcision and “needle dermabrasion” (using a tattoo
gun without ink), the production of MN devices has flourished.In the
US, MN devices exist as both rollers, stampers, and pens (electrically
powered or otherwise), and can be combined with radiofrequency
(RF) in an effort to deliver energy below the epidermal surface –
known as fractional radiofrequency microneedling (FRF-MN), thus
avoiding epidermal damage and subsequent dyspigmentation .

MN devices vary based on their needle length (i.e. depth of skin

penetration), diameter, density and material. Disposable needle tips
are considered safer from an infectious risk standpoint, especially
given the recent concern of bloodborne disease spread especially with
the aptly named “vampire facials” for skin rejuvenation, and reusable
home-use devices. Devices that allow for variation of needle length are
advantageous in that varying penetration depths may be necessary to
treat different areas of the face or body; sebaceous areas required
deeper needle penetration compared to the forehead or periocular
areas. Prior studies demonstrate a needle length of 1 mm as being the
most desirable and accurate setting, whereas needle lengths of 3 mm
may still only penetrate to a depth of 1.5 to 2.0 mm.4 ,

Animal models and in vitro examination of human tissue demonstrate

that MN creates micro-channels and micro-wounds at the level of the
dermis breaking compact, thickened collagen and inducing the wound
healing cascade. Micro-channels cause little epidermal damage making
MN safe to use in darker skin phototypes. Gene expression profiling
before and after MN treatment demonstrates an upregulation in type I
collagen expression, as well as glycosaminoglycans, vascular
endothelial growth factor (VEGF), fibroblast growth factor (FGF)-7,
epidermal growth factor (EGF), and transforming growth factor
(TGF)-β, all important signaling molecules for collagen production, as
well as neovascularization. Tissue histology after MN shows thickened
epidermis, and an increase in dermal collagen and elastic fiber
deposition. Over a period of weeks to months, newly formed type III
collagen becomes mature type I collagen causing skin tightening and a
decrease in the appearance of scars or rhytides.In this systematic
review, we will explore the efficacy and safety of MN for the treatment
of scarring.

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Materials and Methods

A systematic review using the PRISMA (Preferred Reporting Items for

Systemic Review and Meta-Analysis) was completed using the Medline
database in August 2020 using the search terms “microneedle” or
“microneedling” or “micro needle” or “micro needling” and “scar”.
Included manuscripts were case reports, case series and trials
discussing the use of microneedling (rolling device, stamping device,
fractional radiofrequency device) for the treatment of scars in humans
in English. Reviews, animal models, and in vitro studies were
excluded, as were articles not available in English.

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Results

Search terms revealed a total of 246 manuscripts; after removal of

duplicates, 58 studies ranging in date from 2011 to August 2020 were
included for review. A total of 1845 patients with acne scarring or
acne vulgaris, hypertrophic or keloid scarring, post-surgical or post-
traumatic scars, and varicella or smallpox scarring completed study
treatment protocol and follow-up. Protocols utilized included MN or
FRF-MN alone, as well as in combination with topicals, chemical peels,
subcision, platelet-rich plasma (PRP), laser, injectables or systemic
medications. MN devices were both automated or mechanical in
nature (such as rollers) (Table 1).6–63

Table 1
Summary of Protocols from Studies Discussing the Use of Microneedling for Scar
Treatment
Treatment
Combination Therapies
Protocol
Platelet-rich plasma
Num (PRP; n=6)
ber Subcision (n=3)
Proced
of 4–10 Incobotulinum toxin
ural
pass (n=1)
es Polymethylmethacryla
te-collagen gel (n=1)
Glycolic acid peel
Microneedling (n=36)
(n=3)
Trichloroacetic acid
Clinic
Uniform Topical peel (n=2)
al
pinpoint s or Amniotic fluid-derived
endp
bleeding peels mesenchymal stem
oint
cell, topical (n=1)
Hyaluronic acid (n=1)
Jessner’s solution peel
 (n=1)
Vitamin A and C,
topical (n=1)
Need System
le 1.5–3.0 ic Systemic isotretinoin
dept mm therap (n=1)
h y
1–12 treatment sessions, every 1–8 weeks
Continuously for 30 days (n=1), changed every 2–3
Microneedle patch (n=2)
days for 4–6 weeks (n=1)
Fractional carbon
Num dioxide (CO2; n=2)
Injecta
ber Fractional 1550 nm
ble/pr
of 2–8 erbium-glass (Er:glass;
ocedur
pass n=1)
al
es Hyaluronic acid (n=1)
Subcision (n=1)
Clinic Wheal-
al like Topical Poly-lactic acid (PLA;
endp papules/ s n=1)
Fractional radiofrequency oint plaques
microneedling (insulated and non- Need System
insulated, multiple and single- le 0.8–3.5 ic Systemic isotretinoin
needle heads, n=20) dept mm therap (n=1)
h y
6.82–70
Ener
W, 40–
gy
82 mJ
Dura 50–400
tion ms
Total
pulse 250–500
s
1–6 treatment sessions, every 4–12 weeks

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In all cases of MN or FRF-MN treatment, patients received pre-

treatment anesthesia. Although the most commonly reported
anesthesia was topical (lidocaine and/or prilocaine) applied in the
area to be treated with or without occlusion for a total of 30 to 90
minutes, 2 studies originating from Germany mentioned the use of
general anesthesia. Prior to starting MN, areas were cleansed with
either isopropyl or ethyl alcohol. Two studies utilizing FRF-MN used
epidermal cooling to decrease epidermal damage during the
procedure. Post-treatment regimens suggested included sunscreen
(n=19 studies), bland emollient (n=11), topical or systemic antibiotic
including topical fusidic acid (n=11), topical corticosteroids (n=3),
cold packs (n=2), as well as topical benzoyl peroxide,
cyclopentasiloxane/cyclohexasiloxine/sodium hyaluronate,
hyaluronic gel, L ascorbic acid/α-tocopherol/ferulic acid, non-steroid
anti-inflammatory drugs (NSAIDs), and tretinoin/kojic
acid/hydroquinone/hydrocortisone (n=1 each).

Acne scarring was by far the most discussed condition (n=43 studies).
In all studies, boxcar (U-shaped) and rolling (M-shaped) scars
demonstrated the greatest clinical improvement after MN or FRF-MN,
while icepick (V-shaped) scars were often recalcitrant.Patients treated
with MN or FRF-MN for other types of scars also demonstrated clinical
improvement. Scar improvement was measured using both patient
and investigator qualitative assessments, as well as the Echelle
d’evaluation Clinique des Cicatrices d’Acne (ECCA), Vancouver Scar
Scale (VSS), and Visual Analog Scales (VAS).Combination treatment
with laser, PRP, subcision, glycolic acid peel, Jessner’s peel,
trichloroacetic acid peel and topical amniotic fluid stem cells resulted
in greater scar improvement than MN or FRF-MN alone.Fifty to 100%
of patients were satisfied with MN or FRF-MN treatment; 33% of
patients reported they would want further treatment,while 94%
would recommend treatment to others.Combining treatment with
1550 nm laser or PRP resulted in higher patient satisfaction.In
addition, patients preferred MN to intralesional triamcinolone (ILTAC)
or 1450 nm diode laser.

Adverse events (AEs) due to MN or FRF-MN were mostly of minimal

severity; no serious AEs were reported. Almost all studies reported
pain and bleeding during the procedure; the most common post-
procedure AEs included transient post-procedure
pain/discomfort/burning, erythema and/or swelling. Further AEs are
discussed in Table 2. Post-inflammatory hyperpigmentation occurred
in 19 studies; 54.5% of studies used FRMN, while 45.5% used MN.
There was one case of herpes simplex reactivation which was
successfully treated with oral valacyclovir. The most feared AE of MN
treatment is the so-called “railroad” or “tramtrack” scarring that can
occur with aggressive treatment, and was only reported as an AE in 5
studies. One female patient with atrophic acne scars developed
scarring after an allergic reaction to the nickel contained in the
needles, which was subsequently treated with oral prednisolone and
topical steroids.38

Table 2
Summary of Rare AEs Occurring with Microneedling Treatment for Scars
Adverse Event Description Number of Studies Reporting (n)
Post-inflammatory hyperpigmentation 19
Scabbing/crusting 9
Purpura/ecchymosis 5
“Tramtrack”/“railroad” scarring 5
Acne flares 4
Cervical lymphadenopathy 3
Milia 2
Pustules/bullae 2
Allergic reaction to nickel 1
Herpes simplex reactivation 1

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Discussion

MN has gained popularity as a minimally invasive aesthetic technique

for the treatment of skin aging, scarring, striae, and hair loss, amongst
other indications. Although the US Food and Drug Administration
(FDA) initially classified MN as class I medical devices, recent
developments have elevated their classification to class II (special
controls) and they are currently approved for microdermabrasion,
scarring and rhytides. The literature suggests that MN and FRF-MN
are well tolerated and result in clinical improvement of scarring due
to acne or other infectious cause, hypertrophic or keloid scars, and
post-operative or traumatic scars, as well as high rates of patient
satisfaction. MN and FRF-MN were reportedly tolerated better by
patients than their laser resurfacing counterparts, namely the CO2,
Er:glass and diode lasers, with less reported downtime. MN and FRF-
MN can be combined with a variety of other surgical therapies
including laser resurfacing, chemical peels, PRP, filler and botulinum
toxin for greater clinical results.

As with many aesthetic procedures, MN and FRF-MN suffer from a

lack of standardized protocol. Animal and human studies suggest that
multiple passes per treatment and multiple treatment sessions
demonstrate greater skin regeneration potential.Further clinical
studies need to be completed to determine optimal number of passes,
number of treatment sessions, intertreatment duration intervals and
maintenance therapy.

Just like non-ablative laser techniques, MN is an effective

intraepidermal and intradermal delivery method for pharmaceuticals.
In addition to microneedles designed to contain substances such as
bleomycin or triamcinolone for treatment hypertrophic scarring, MN
can enhance the penetration of topicals such as anesthetics, chemical
peels, PRP or filler material such as hyaluronic acid as evidenced by
this review, and possibly nanoparticles and siRNA in the future.
Advances in MN delivery, such as the development of patches or use of
MN to deliver energy sources below the level of the epidermis have
both decreased the amount of discomfort associated with treatment,
and increased efficacy by combining multiple treatment modalities.It
is important to note that certain topical products may cause allergy,
and even granulomatous reaction, when introduced into the skin
through micro-channels created by MN devices; physicians should
counsel patients appropriately regarding these risks. Substances such
as bleomycin, triamcinolone and filler material should presumably be
safer to administer through micro-channels given that they are
designed as injectables.
Although no serious AEs were associated with MN and FRF-MN
treatment of scars, it is important to note that post-inflammatory
hyperpigmentation occurred in over 30% of studies and resolved
either spontaneously or with the help of topical bleaching creams
within months. Given that the majority of patients treated in this
review had a Fitzpatrick skin phototype of IV or greater, AE reporting
may have been biased towards events that more commonly occur in
this patient groups post-procedure, specifically dyspigmentation and
aberrant scarring (such as the “tramtracks”). Physicians should be
aware that MN is not without its risks, and appropriately counsel
patients during the consent process to avoid patient morbidity post-
treatment.

Limitations of this study include its lack of meta-analysis. Given the

heterogeneity of data presented by included studies, it was not
possible to combine and statistically analyze this data.

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Conclusions

MN and its relative FRF-MN are both well-tolerated, minimally

invasive procedures that can be used for the effective treatment of
scarring. Although there are no standard treatment protocols, clinical
improvement in many types of scars including acne, varicella and
smallpox, hypertrophic or keloid, and post-operative or post-
traumatic scars have been reported in the literature. MN and FRF-MN
can be used as stand-alone modalities, or can be combined with a
variety of topicals and other surgical procedures for superior results.
No serious AEs have been reported using MN or FRF-MN for the
treatment of scars; however, physicians should be aware that post-
inflammatory hyperpigmentation is still a relatively common event.
Large-scale, clinical trials need to be completed to determine optimal,
standardized protocols to treat scarring using MN or FRF-MN.
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