Review Of Applications Of Microneedling In Dermatology.

Dovepressthat follows. Each section concludes with our summary ofthe current state of the literature and future areas for researchspecific to each indication.ScarsSeveral studies show efficacy of MN for scar treatment(Table 1). In a pilot study, El-Domyati et al quantified thehistological changes induced by MN in ten patients withatrophic facial scars from acne.15 Skin biopsies were obtainedat baseline and post-treatment with Dermaroller. Therewas a statistically significant increase in the production ofcollagen types I, III, and VII and a decrease in total elastinby the end of treatment (p 0.05). All patients reportedmild pain and edema at the treatment site which resolvedwithin 24 hours. Otherwise, no adverse effects were noted.Patients collectively reported a 51%–60% improvement inscar appearance, 40%–50% improvement in skin texture,and 80%–85% overall satisfaction (p 0.001) following sixtreatment sessions over the course of 3 months.15In a cohort study, Majid relied on clinical outcomes ratherthan histologic changes to assess improvement of atrophicfacial scars in response to MN therapy.16 Thirty-seven patientswere offered Dermaroller treatments and followed over thecourse of 2 months. Over 80% of the patients assessed theirresponse to treatment as “excellent” on a 10-point scale.Of the patients who completed the study, 94.4% graded thereduction in the severity of their scars by at least one objective grade. No adverse effects were noted.16A clinical trial by Garg and Baveja assessed the efficacyof combination therapy using subcision, MN, and 15% trichloroacetic acid peel in the management of 50 patients withatrophic acne vulgaris scars.17 The patients were treated for atotal of six sessions with scar grading done at baseline and 1month after treatment. Complete remission was demonstratedin all patients with Grade 2 scars and 22.7% of patients withGrade 3 scars. Additionally, of the 16 patients with Grade 4scars at baseline, ten patients improved to Grade 2 and theremaining six improved to Grade 3. Overall, 100% of patientshad objective improvement in scars by at least 1 grade.Adverse events other than transient erythema and edemaincluded acne eruptions, post-inflammatory hyperpigmentation (PIH) resolving after 5 months of topical treatment (withcombination of tretinoin, hydroquinone, and mometasone),and cervical lymphadenopathy lasting 3 weeks.17Several studies have also compared the efficacy of laserand MN treatments. Cachafeiro et al compared 1,340 nm nonablative fractional erbium laser and Dr. Roller (VydenceMedical, São Carlos, São Paulo, Brazil) for the treatment ofClinical, Cosmetic and Investigational Dermatology 2017:10Microneedling: review of the literature46 patients with facial atrophic acne scars.18 These patientswere randomized to one of the two groups and received threetreatment sessions monthly regardless of assignment. Bothgroups demonstrated improvement at 2 and 6 months posttreatment, with no statistically significant difference betweenthem (p 0.264). While efficacy was similar, the adverseevent profile varied. The MN group experienced erythema foran average of 1 day compared to the laser group, for whichthe erythema lasted an average of 3 days. Additionally, 13.6%of the patients in the laser group experienced PIH while noneof the patients in the MN group did.18Another emerging field of study in MN is its applicabilityin the treatment of scars in various ethnic groups. One clinicaltrial by Dogra et al evaluated the utility of MN for treatingatrophic acne scars in Asian populations.19 On an objective scale of 18 points, patients’ assessments of their scarsdecreased from 11.73 to 6.5 following five MN treatments,indicating significant improvement. In a study with patientsof darker pigmented skin, the use of MN combined with glycolic acid peels for the treatment of acne scars was assessedin 30 Indian patients with atrophic box type and rolling scarswith PIH.20 Patients were assigned to receive treatment withMN only or with MN and 35% glycolic acid peels. Therewas significant improvement in skin texture, scarring, anda reduction in PIH in the group treated with the combinedapproach when compared to MN alone (p 0.001).20MN has also been used to enhance treatment of hypertrophic surgical scars by increasing drug delivery of topicalagents to the dermis.21 Aust et al demonstrated MN to bean effective alternative for burn patients with hypertrophicscars.22 In this study, 16 patients with post-burn scarringwere treated with MN after 4 weeks of preparation withtopical vitamin A and C to maximize collagen production.Each patient reported satisfaction with scar appearance onan objective visual analog scale (VAS) from 1 to 10, with10 indicating the most satisfaction. Prior to treatment, theaverage VAS score was 4.5. This score increased to 8.5 following one to four sessions of MN treatment with continuedapplication of topical vitamin A and C twice daily. Histologicanalysis of 3 mm punch biopsies at 1 year demonstrated anincrease in collagen and elastin deposition both quantitatively and qualitatively using van Gieson and hematoxylinand eosin stains.Studies with various-sized MN devices that evaluate thefrequency and interval between treatments for optimal effects,would be an appropriate next step in further elaborating on theefficacy of MN. Many of the aforementioned studies demonstrated that MN had comparable efficacy to laser treatmentssubmit your manuscript www.dovepress.comDovepress291

292submit your manuscript % TCA peel andsubcision /DermarollerNFEL 1340 nm /Dr. RollerDermaroller35% glycolic acidpeels /Dermaroller MF8Topical vitamins Aand C /- MedicalRoll-CITEl-Domyatiet al, 201515Majid, 200916Garg andBajeva, 201417Dogra et al,201419Sharad,2011201.0 mm1.5 mm1.5 mm2.0 mm1.5 mm1.5 mm1.5 mmNeedledepthAtrophicacne scarswith PIHHypertrophicburn scarsAtrophicacne scarsAtrophicacne scarsAtrophicacne scarsAtrophicfacial scarsAtrophicacne scarsType ofscarUncontrolled,prospective cohortstudyProspective RCTUncontrolled,prospective studyUncontrolled,prospective clinicaltrialUncontrolled,prospective clinicaltrialEvaluator-blinded,prospective RCTProspective clinicalstudyStudy design16303646503710No ofpatients(N)1–4 (4 weeks)5 (6 weeks)5 (4 weeks)3 (4 weeks)6 (2 weeks)4 (4 weeks)6 (2 weeks)No of sessions(interval)Increase in the mean of collagen types I, III, and VII, as well as newlysynthesized collagen at the end of treatment (p 0.05). There was a decreasein total elastin production. Patients reported an 80%-85% overall satisfaction(p 0.01).Per Goodman and Baron’s42 facial scar scale, 94% of patients had a reductionin scar severity by at least 1 grade. Over 80% of patients assessed theirresponse to treatment as “excellent”.Per Goodman and Baron’s42 facial scar scale, 63% with Grade 4 improved toGrade 2 and 38% improved to Grade 3. 23% with Grade 3 had full remissionand 68% improved to Grade 2. 100% of Grade 2 had full remission.Both groups demonstrated improvement in the degree of their acne scars,with no statistically significant difference found between the groups(p 0.264).Significant decrease in mean acne scar assessment score from 11.73 atbaseline to 6.5 after 5 sessions (p 0.05). Photographic improvement of 50%75% in majority of patients.There was 31% improvement in the MN alone group vs. 62% improvementin the MN with glycolic acid peels group in regards to skin texture and scarappearance (p 0.001).Reported satisfaction with scar on VAS increased from 4.5 to 8.5 followingtreatment. Histologic analysis at 1 year showed increase in collagen andelastin deposition.ResultsNotes: Dermaroller and Dermaroller MF8 ; Dermaroller Deutschland GmbH, Wolfenbuettel, Germany. Dr. Roller ; Vydence Medical, São Carlos, São Paulo, Brazil. Medical Roll-CIT ; Vivida, Cape Town, South Africa.Abbreviations: MN, microneedling; N, sample size; TCA, trichloroacetic acid; NFEL, non-ablative fractional erbium laser; RCT, randomized controlled trial; PIH, post-inflammatory hyperpigmentation; VAS, visual analog scale (gradedfrom 1 to 10).Aust et al,201022Cachafeiroet al, 201618Adjunctivetherapy /- MNtherapyReferenceTable 1 Scars treated with microneedling therapyIriarte et alDovepressClinical, Cosmetic and Investigational Dermatology 2017:10

DovepressMicroneedling: review of the literaturefor atrophic facial scars. However, MN is generally bettertolerated with fewer long-term adverse sequelae.23 Scar typeappears to be a factor affecting clinical response to MN, asicepick scars and deep-seated atrophic scars responded lessideally to treatment.15AlopeciaMN has been proposed as a mechanism for adjuvant hairregrowth in alopecia. The efficacy of MN in both androgenetic alopecia (AGA) and AA has been highlighted over thelast 5 years (Table 2).AGADhurat et al found that combination treatment of MN withminoxidil was statistically superior to minoxidil alone in thetreatment of 100 male patients with AGA.24 Over 12 weeks,Dermaroller treatment combined with 5% minoxidil lotionwas administered to half of the participants, with 80%showing moderately or greatly increased hair regrowth perthe investigators. Of the same subset, 82% of the patientsreported subjective improvement greater than 50% in theirhair growth. In the arm receiving 5% minoxidil alone, only4.5% of patients reported greater than 50% improvement. Bythe end of the study, mean change in hair count was significantly greater for the MN group (91.4 vs. 22.2, p 0.039).Additionally, the initiation of new hair growth was firstnoticeable at 6 weeks in the MN group compared to 10 weeksin the minoxidil alone group. No adverse effects were notedby any of the participants.24Dhurat and Mathapati then published a follow-up caseseries of four men with AGA unresponsive to conventionaltreatments. Combination therapy was administered to participants with their prior treatment regimen (either topicalminoxidil or oral finasteride) and Dermaroller over a courseof 6 months.25 All four patients had moderately or greatlyincreased hair regrowth and reported subjective increases inhair thickness after 1 month of treatment.25AAMN has been proposed as a viable alternative to conventionaltreatment for AA as well. The mainstay of therapy for AAis currently intralesional corticosteroids, such as kenalog(ILK). However, the collagen induction offered by MN isthought to counter steroid-induced atrophy as well as causeless pain than injection.26Chandrashekar et al analyzed outcomes from treatingresistant AA with MN and topical corticosteroids.26 Twoadult patients with AA recalcitrant to ILK, topical steroids,and minoxidil 5% lotion received topical triamcinoloneapplied before and after Dermaroller. Both patients gradedTable 2 Alopecia treated with microneedling therapyReferenceAdjunctivetherapy /MN therapyNeedledepthType ofalopeciaStudy designNo ofpatients(N)No ofsessions(interval)ResultsDhurat et al,2013245% topicalminoxidil /Dermaroller1.5 mmAGAProspective,evaluator-blindedRCT10012 (1 week)Dhurat andMathapati,2015255% topicalminoxidil andoral finasteride /- Dermaroller1.5 mmAGACase series44 (1 week) then11 (2 weeks)Chandrashekaret al, 2014260.1% topical TAC /- Dermaroller1.5 mmAACase series23 (3 weeks)Mean hair counts weresignificantly greater in MN minoxidil group comparedto minoxidil alone group(91.4 vs. 22.2, p 0.039). 82%in combination group reportedgreater than 50% improvementvs. 4.5% in minoxidil group.100% showed 2 or 3 responseson a 7-point standardized scalefor hair growth. Findings weresustained at final follow-up. 75%had subjective improvement inhair growth 75%.100% graded hair regrowth as“excellent” at 3-week follow-upwith no recurrence of AA at12 weeks.Notes: Dermaroller ; Dermaroller Deutschland GmbH, Wolfenbuettel, Germany.Abbreviations: MN, microneedling; N, sample size; AGA, androgenetic alopecia; RCT, randomized controlled trial; TAC, triamcinolone; AA, alopecia areata.Clinical, Cosmetic and Investigational Dermatology 2017:10submit your manuscript www.dovepress.comDovepress293

DovepressIriarte et alhair regrowth as “excellent” and had no recurrence at3-month follow-up. The ability to assess for commonadverse effects of steroid treatment such as atrophy, scarring, and increased susceptibility to infection were limitedin this study.While these clinical studies show promising data for theefficacy of MN in the treatment of alopecia, these resultsare limited by relatively small sample sizes. Additionally, itis unclear if similar results are reproducible in women withhair disorders. Further investigations of combination therapywith minoxidil and finasteride, including MN frequency,needle size, and duration of treatment are needed to see ifthese results are reproducible in both genders and sustainedover longer periods of time.Pigmentary disordersSeveral studies have proposed MN as an alternative to conventional treatment in disorders of pigmentation affectingdarker skin types, including melasma, vitiligo, and periorbitalhyperpigmentation (Table 3).MelasmaThe enhanced transdermal drug absorption seen with MN hasachieved better results than skin lightening agents alone inthe treatment of melasma.27–29 Budamakuntla et al observedenhanced results of MN followed by topical tranexamic acidin comparison to tranexamic acid microinjections in treating moderate to severe melasma in 60 patients.30 After threetreatment sessions (at 0, 4, and 8 weeks), the patients werefollowed for 3 months. There was 35.72% improvement in themean Melasma Area and Severity Index (MASI) score in themicroinjection group (p 0.01) compared to 44.41% in theMN group (p 0.001). Notably, only 26% of patients in themicroinjection group achieved 50% improvement comparedto 41% in the MN group. Neither group experienced majorside effects, but some reported mild discomfort, burningsensation, and erythema.30In a pilot study, the use of depigmentation serum containing 4-butylresorcinol and sophora-alpha (prenylatedflavonoids from the roots of Sophora flavescens) alone wascompared to the combination treatment of depigmentationserum and MN (MN serum) in 20 female patients (Fitzpatrick Skin Type III–IV) with melasma.27 In the MN serumgroup, baseline mean MASI score decreased by 9.9 points(p 0.001) compared to a 7.1 point decrease (p 0.05) inthe serum only group 2 months post-treatment. Results wereconfirmed by the significant increase in brightness of patients294submit your manuscript www.dovepress.comDovepressreceiving combination treatment in comparison to the groupreceiving serum alone (17.4% vs. 11.2%; p 0.05).27MN combination therapy also has favorable results inmelasma when combined with daily sunscreen use. In aretrospective analysis of 22 cases of recalcitrant melasma(unresponsive to topical bleaches and sunscreen), MN wasadministered followed by night time application of a depigmentation formula (0.05% tretinoin 4% hydroquinone 1% fluocinonide acetonide) and daily tinted sunscreen (SPF60) 24 hours after initial skin needling.31 The procedure wasrepeated 30 days after the first treatment. All 22 patientsreported satisfaction with results at 2 month follow-up. Photographic analysis at 24-month follow-up in eleven patientsdemonstrated continued maintenance of skin lighteningobserved at the 2-month visit.31VitiligoThe efficacy of MN in combination treatment for vitiligoremains unclear. Stanimirovic et al investigated repigmentation of patients with resistant bilateral symmetrical vitiligoby comparing treatment with narrowband ultraviolet B andtopical 0.005% latanoprost solution with and without Dermaroller.32 Seventeen patients in each group had repigmentation(37.8% of treated lesions) and only 8.8% of repigmentinglesions had greater than 50% repigmentation. However, therewas no statistically significant difference in repigmentationbetween groups.32Periorbital melanosisMN therapy has been successful in the treatment of periorbital hyperpigmentation. One male patient demonstrated75%–90% improvement with DermaFrac treatment (combination of MN and active ingredients, including kojic acidor anti-aging serum containing myristoyl pentapeptide 17[SymPeptide], acetyl octapeptide-3 [SNAP 8], palmitoylpentapeptide-4 [Matrixyl], acetyl hexapeptide-8 [Argirilene]and tripeptide [Syn-ake]) after 12 sessions.33 The patient alsoreported 7 out of 10 improvement on the Patient’s GlobalAssessment scale in his pigmentation.Kontochristopoulos et al also explored the use of MNin periorbital hyperpigmentation by treating 13 femalepatients with MN followed by 10% trichloroacetic acidpeels.34 Almost all patients (92.3%) demonstrated significant improvement (“fair or better”) according to patientglobal assessments. Transient side effects includingmild discomfort, edema, and erythema were commonlyobserved.34Clinical, Cosmetic and Investigational Dermatology 2017:10

CIT 8TM:0.5 mmDermaroller C8:0.13 mm1.5 mm2.0 mm1.5 mm0.25 mm0–2.5 mmDepigmentation serum* /- DermarollerCIT 8 in office andDermaroller C8 at homeTA /- DermarollerMS4Depigmentationformula** /Dr. RollerNB-UVB latanoprost /DermarollerAnti-aging serum*** /DermaFracTCA peels /Automatic MNFabbrocini et al,201127Lima, 201531Stanimirovic et al,201632Sahni and Kassir,201333Kontochristopouloset al, 201634Clinical, Cosmetic and Investigational Dermatology 2017:10Periorbital melanosisPeriorbital melanosisVitiligoMelasmaModerate to severemelasmaMelasmaDisorder ofpigmentationUncontrolled,prospective studyCase reportSplit-body,prospectivecontrolled e,controlled trialStudy design13125226020No ofpatients (N)11 session of MN latanoprost,9 sessions of NBUVB (3 times perweek)12 (2 weeks)2 (4 weeks)3 (4 weeks)1 in office, 60 athome (daily)No of sessions(interval)Per physician global assessment, there was 50%75% improvement after 4 sittings and 75%-90%improvement after 12 sittings.92.3% had fair, good, or excellent response onphysician and patient global assessments. Therewas no recurrence at 4 months.36% improvement in MASI score in TA alone vs.44% improvement in MASI score in TA MN.More patients in TA MN had greater than 50%improvement than TA alone (41% vs. 26%).100% demonstrated “good to very good”results and reported subjective satisfactionwith treatment. 50% of patients maintained skinlightening at 1-year follow-up.Equal repigmentation observed in pairedexperimental and control lesions in 77% oflesions.Mean MASI score improvement of 9.9 in serum MN (p 0.001) vs. improvement from 7.1 inserum alone (p 0.05).ResultsNotes: *Depigmentation serum: 4-butylresorcinol and sophora-alpha (prenylated flavonoids from the roots of Sophora flavescens). **Depigmentation formula: 0.05% tretinoin, 4% hydroquinone, and 1% fluocinonide and sunscreen SPF60. ***Anti-aging serum: myristoyl pentapeptide 17 (SymPeptide), acetyl octapeptide-3 (SNAP 8), palmitoyl pentapeptide-4 (Matrixyl), acetyl hexapeptide-8 (Argirilene) and tripeptide (Syn-ake

This review of the literature is focused on exploring the expanding indications of MN. In addition, this review will highlight the efficacy and adverse effect prolife of MN in comparison with more common treatment modalities used for various indications in dermatology. Methods The studies selected