Authors : Dr. Mohd Asif .

Abstract:

Microneedling is not a novel term now a days and it is frequently used by many a Dermatologist for several indication. One has to know the basis knowledge of Rollerlike quality, types, mode of action, indication, contraindication, and safety issues before doing the procedure. Microneedling works by collagen induction and can be used where collagen remodelling is needed like treatment of acne scars, skin rejuvenation, fine wrinkles etc. It can be combined with other procedure and simultaneously enhances the final clinical outcomes.

Introduction: -

The development of microneedling occurred in 1994. Electroridopuncture (ERP) for skin aging and acne scar was practiced in cosmetic dermatology since 1995, when orentreich & orentreich described subcision or dermal needling for scars ¹. Camirand and Doucet in 1997 evidenced described needle dermabrasion using “tattoo pistol” to treat scars ².

Microneedling is relatively a new modality for the treatment of Androgenic alopecia, Acne scars, stretch marks, facial and skin rejuvenation, &wrinkles; inducing collagen induction by microneedling. It is also done by motorised derma pen or meso pens which are commercially available and marketed by several companies.

Derma pen: These are the devices which have a fixed motorized system with or without drug delivery system and have removable head (10-12 needles). They are capable of forming 60,000- 70,000 channels/ min. Length of needle varies from .25-2.0mm. High cost of machine and desired thickness of needle are still the matter of concern. It has advantage of having removable head so single pen can be used on several patients with the same device and produce minimal side effects. Needle system should be specific for each patient and can be used multiple times as per quality of needles it contains.

Types of Dermaroller: Principally there are two types of Dermaroller; Medical and Home care Dermaroller. The length of home care Rolleris always less then .2mm.

There are mainly three version of Rollerfor medical use: -

Standard version: - It is drum shaped cylindrical roller containing 192 fine microneedles, which are arranged in eight rows. The needles are 0.5-5mm in length, diameter 0.1-0.25 mm and width 20mm (fig1a). Miniature version: - are used for localised scars and comes under several shapes and size like eye roller, nose roller, cushion head, meso roller head. There needles are 2mm in length with a diameter of 0.12mm (fig1b). Meso roller: -Meso roller contains >500 fine diamond shaped microneedles which are also arranged in eight-nine rows. The length ranging from 0.5-5mm, but diameter is smaller than standard version (fig 1c) .

Fig 1. (A) Standard version.

Fig 1. (B) Miniature version, & (C) Meso roller

Home-Care rollers less than 0.15 mm in length are available for transdermal delivery of substances like lipopeptides and other anti-ageing products. They can be used twice a week for up to one hundred times. After use, the rollers have to be cleaned in hot tap water and shaken dry. Peptide-based roller cleansers are available.

Factor affecting choice of Dermaroller:

1. Length: It ranges from .1 to 5mm in length and should be used as per indication. Higher the length more painful it will be with more depth of penetration.


2. Diameter: It also comes in different size and should be used as per indication. Choice should be made to avoid unnecessary scaring which may occur with larger diameter.


3. Base of microneedles within Dermaroller: - Disc based Rollerare usually preferred. If using non-disc based Dermaroller, there may be chances of needle breakage while performing procedure and clinician should carefully examine Rollerfor needle counts on subsequent visit.


4. Site of procedure: This is the most important parameter a clinician should look for which will decide the outcomes. Like for acne scars (1.5mm), eyes (.5mm), neck and wrist (1mm), scalp (.5-1mm), and stretch marks (3-5mm). For CIT (Collagen Induction Therapy) the needle needs to penetrate 0.5mm deep into dermis. Considering that the top layer of the skin has a thickness of 0.3-0.8mm (on a face) it gives you 1.00mm -1.50mm roller to work with. If you have fair, sensitive skin - downgrade it one size.


5. Durability: Physician should prefer new device on every visit if possible otherwise change the device after 4 sittings (75% alcohol sterlization) to avoid unwanted scaring on desired site with blunt needles.


6. Quality of micro needles: Two types; steel needles and titanium needle are commercially available. Stainless steel needles are made of medical grade SUS-304 steel similar type of steel used for manufacturing of hypodermic needles. The thickness of the wire, used for the needles is 0.20mm in diameter. Titanium needles are made of medical grade SUS-304 steel covered with titanium vapour - the composition widely used in implant surgery. It makes the steel stronger but at the same time the wire becomes thicker up to 0.30mm. The punctures made by titanium needles are larger and more visible. The span life of titanium needles is 6 month VS 3 months for stainless steel. Titanium vapour coated needles have golden look.

How to sterilize Dermaroller: -

The roller comes pre-sterilized in a sealed bag and should be used once. Many manufacturers claimed multiple sessions with single roller without compromising with efficacy and in that case proper sterilization is warranted. Denture tablets, alcohol or high temperature (boiling water) can be used for sterilisation.

Sanitation - Denture tablets (in water) are used to clean the roller. They are enzyme cleansers and take off fat as well as cause’s reduction of bacteria. Isopropyl alcohol can be used as an alternative to denture tablets. Fill the small saucer or tray with sterilization solution place soft cloth pad at the bottom and roll the roller into the pad with medium pressure. Leave the roller in the cleaning solution for about 15 minutes – ensure that the roller drum is constantly wet with the cleaning solution. Do not leave immersed in alcohol for a long time, although PE-500 polymer of the drum is chemical resistance, the long exposure may cause the polymer to swell.

Make sure you rinse the roller after sterilization and put it into the storage dry. Although the needles are made of SUS 304 steel (the same used for hypodermic needles) it is stain-less, not stain-proof and if stored moist in enclosed environment it may be prone to corrosion. The best way is to dry it with blow-dryer or leave it to dry completely in open air.

Mechanism of microneedling:

The principle of using micrneedliong is to provide collagen induction therapy. This is done by causing a minute injury to the dermis with use of microneedles. This results in starting of the wound healing cascade and hence utilizing the body self-healing mechanisms. The needles are so fine and thin that tissue damage is unlikely. However, this “nerve stimulus”, transported by electrical signals, triggers the cascade of the healing process releasing growth signals to undifferentiated cells and phase 1 inflammation starts immediately after the injury. The task of fibroblasts is, to migrate to the point of intrusion for wound closure and this new fibre formation thicken the skin and fills former atrophic scars called neo-collagenesis. There is stimulation of endothelial cells leads to neo-angiogenesis. The natural tissue remodelling will continue from 8 weeks up to 1 year.^3,4,5

Procedure: - At first, facial skin must be disinfected, and then a topical anesthetic is applied, left for 60 minutes. The skin needling procedure is achieved by rolling a performed tool on the cutaneous areas affected by Acne scars, backward and forward with some pressure in various directions. During treatment, the needles pierce the stratum corneum and create microconduits (holes) without damaging the epidermis. It has been shown that rolling with a roller (192 needles, 200 µm length and 70 µm diameter) over an area for 15 times will result in approximately 250 holes/ cm2.

As expected, the skin bleeds for a short time, but that soon stops. The skin develops multiple microbruises in the dermis that initiate the complex cascade of wound healing. The entire procedure lasts for 15 to 20 minutes, depending on the extent of the area to be treated.

Results generally start to be seen after about 6 weeks but the full effects can take at least three months to occur and, as the deposition of new collagen takes place slowly, the skin texture will continue to improve over a 12 month period. Clinical results vary between patients, but all patients achieve some improvements.

The number of treatments required varies depending on the individual collagen response, on the condition of the tissue and on the desired results. Most patients require around 3 treatments approximately 4 weeks apart.

Post-procedure care- Microneedling is well tolerated by patients but erythema may be seen after treatment, lasting for 2-3 days. Photoprotection for a week is advised as a routine and local antibiotic creams may be prescribed. The patients can go back to work the very next day.

As the microholes close immediately, postoperative infections do not occur usually. Side effects are few, and will be transient if they occur. The procedure is well tolerated and well accepted by the patients, is cost-effective, can be done on all skin types and on areas not suitable for peeling or laser resurfacing, such as near eyes. Microneedling with roller can be combined with other Acne scar treatments like subcision, chemical peels, microdermabrasion, and fractional resurfacing, thus maximizing the benefits to the patients.⁶

Uses:-

(1) Scar^{6,7,8,9,10,11}: - Scars are the troublesome manifestation following injury to skin or mucosal surface. Microneedling works for each type of scares like Acne scars, burns, chicken pox scars etc. The basis thing is to understand that on subsequent visits of rollersessions depth of each scar gets reduction to some extent but the margins of scar may not show significant changes except for rolling scars. Depth of the scars is the prime factor for the visibility of scar because deep scars causes more shadow formation and hence more visible. By Microneedling we try to gets maximum reduction in depth but margins of scar may remain there. It is always wise to take distant photographs of patients before and after procedure. The procedure can be repeated multiple times and at least monthly interval.

Several studies have been publishes over the use of microneedling for the treatment of acne scars. It works best for rolling and box scars while ice pick scars are quite resistant to it.

Before procedure topical anaesthetic cream is applied for 1-2 hours to get dermal penetration. Peripheral nerve block may be helpful in some cases and should be use cautiously and under supervision of skilled person for beginners. On face one can prefer facial block which is risky and less frequently done as caches of nerve injury are higher. After getting proper numbness, face is divided into zone of preference. Most of the acne scars are confined to malar region or cheeks followed by forehead and then other areas. Skin over the temple region is quite sensitive and pain is more market here followed by forehead. Rolling is done over the desired site and keeping in mind the pain sensitivity of the concerned area.

The skin is stretched with the other hand and drum is kept over the desired site. It is rolled at least four times in directions which are perpendicular and diagonal to each other. The pressure should be firm and steady. Pin point bleeding appears and it is a surest sign of dermal injury. Undue pressure and excess rolling is avoided to minimise complications. 4-10 times rolling is done at maximum in one direction or appearance of pinpoint bleeding can be taken as end point of the procedure.

Patient should be instructed for avoidance of any cosmetic at least for initial 6 hrs along with judicial use of sunscreen to minimise chances of Post inflammatory hyper pigmentation.

1st session	3rd session

(2) Alopecia: - Microneedling can be used for the treatment of androgenic or other alopecia. It provides injury to dermis followed by release of growth factors from platelet. There may be activation of quiescent stem cells at bulge region of hair follicle which eventually give rise to new hair follicle. Microneedling also provide channels through the skin and thus it can be combined with several therapies for better outcomes.

Mesotherapy in the form of peptides or Platelet rich plasma can be given through these channels. Multiple researches are going throughout the world over the role of platelet rich plasma (PRP) for the treatment of androgenic alopecia. Combining PRP with microneedling produce significant results in several studies. Skin over scalp is quite thick and rollerof size >.5mm should be used for the treatment. The procedure is quite safe and rolling is done in the line follicles over the desired site. Crisscross pattern of rolling is avoided.

(3) Skin rejuvenation: - Microneedling is used for the collagen induction using body self healing mechanism. It helps in the reduction of fine lines over the face along with reduction of sagging and folding. Mesotherapy can be combined with microneedling to maximise the clinical outcomes. Platelet rich plasma can be use for skin rejuvenation along with microneedling. There are various meso-solutions are available commercially for the reduction of black spot, wrinkles, skin luminosity, PIH, scars, acne etc.

Microneedling provide channels over the skin surface followed by topical application of meso solution. Procedure for rolling remains the same as done for the treatment of scaring. The difference is face is not divided as a zone of preference as it wise to cover whole face. The choice of roller is meso roller having > 500 fine needles.

The other mode of treatment for skin aging is the use of home care roller device. The size of needle is small <.2mm and can be used twice weekly. Dermal injury is unlikely and changes are limited to epidermis without any bleeding or complication.

Before procedure (zero day)	after two sessions (45 days)

(4) Periorbital melanosis:- Microneedling needling is also used for the treatment of dark circle and combined with meso solution which are meant for reducing pigmentation. The choice of roller is miniature version specific for eye. The skin over the eyelid is thin and firm pressure is avoided while doing the procedure. The length of needles should be less then 2mm always to avoid injury to deep structure and bruising. The roller should be moved cautiously over the globe as the convexity of eye boll won’t allow smooth passes.

(5) Other: - the basic mechanism of microneedling is to provide collagen induction therapy and it can be used for other indication where it is really required like stretch marks, large pores, post burn scars, and post inflammatory hyperpigmentation. At some places it has direct role and for some indication it provides channels for other substances for better absorption and hence better clinical outcomes.

Contraindication: Bleeding/ coagulation disorders, Extreme keloidal tendency, Presence of skin cancer, warts, solar keratosis, diabetes, patients on chemotherapy, radiotherapy and high doses of corticosteroids are the absolute contraindication of microneedling. Base line investigation should be performed before planning for dermaroller.

Complications:-

1. Infection: - Although not common but patient may complains pustular lesion on face, reactivation of quiescent acne, follicultis. Improper sterilisation or sanitation of rollerdevice may be the contributory factors. Prophylactic antibiotic can be given after each sitting to avoid such complication. Microneedling should be avoided during the active acne lesions over face as it may aggravate the condition.


2. Longitudinal streak or bruising: - While performing procedure one must be cautious while rolling over bony prominences. There may be chances of getting longitudinal bruising or streaks over the skin. Specific roller should be used over particular sites, like nose roller, eye roller etc. Pressure should be smooth and gentle on such area.


3. Postinflammatory hyperpigmentation: - Microneedling may causes hyperpigmentation especially in dark skin type. Patient should be advised to minimise sun exposure and directed for judicial use of sunscreen.


4. Damage to deep structure: - Injury to superficial or at times deep vessels or nerves may occur following the procedure. Bruising, local haematoma or echymosis may develop following injury. Warm or cold compression should be given with prophylactic antibiotics in such cases. Hard pressure and large size needle are avoided against specific sites.


5. Persistent erythema: - Although rare, but patient may develop persistent erythema which may last for weeks to year.


6. Side effects associated with Anaesthetic drugs: - Hypersensitivity, rashes, and systemic side effects are the common side effects associated with anaesthetic agents. Patient should be checked for xylocain sensitivity by performing sensitivity test prior to the procedure.

References:

1. Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction of depressed scars and wrinkles. Deratosurg 1995;22:6543-9.
2. Camirand A, Doucet J, Needle dermabresion, AesthetPlastsurg 1997;21:48-51.
3. Aust MC, Fernandes D, Kolokythes P, Kaplan HM, Vogt PM. Percutaneous collagen induction therapy; An alternative treatment for scars, wrinkels and skin laxity. PlastReconstsSurg 2008;21:1421-9.
4. Fernandes D,Signorini M. Combating photoaging with percutaneous collagen induction. ClinDermatol 2008- 26:192-9.
5. Aust MC, Reimers K, Repenning C, Stahi F, joahn S, Guggenheim M, et al. Percutaneous collagen induction: Minimelly invasive skin rejuvenation without risk of hyperpigmentation-fact or fiction. PlastReconstrsurg 2008; 122:15553-63.
6. Satish Doddaballapur; Microneedling with Rollerdoi: J Cutan Aesthet Surg. 2009 Jul-Dec; 2(2): 110–111.
7. Chawla S. Split Face comparative study of microneedling with PRP verses microneedling with vitamin C in treating atrophic Post Acne Scars 2014;7(4):209-12.
8. Dogra S,et al. Microneedling for acne scars in Asian skin type: an effective low cost treatment modality; J Cosmet Dermatol. 2014 Sep;13(3): 180-7.
9. Imran Majid, Microneedling therapy in atrophic facial acne scars. J Cutan Aesthet Surg; 2009 Jan-Jun; 2(1): 26–30.
10. El-Domyati M1, et al. J Clin Aesthet Dermatol 2005; .8(7):36-42.; Microneedling Therapy for Atrophic Acne Scars: An Objective Evaluation.

More references are availabe on request.