Authors : Dr. Mohd Asif .
 

Abstract

BACKGROUND: Atrophic and hyperpigmented macular scars are the troublesome manifestations following acne. Microneedling is used to treat atrophic acne scaring and simultaneously provides channels for absorption of meso solution. Mesolighten (mesosolution) comprises various depigmented agents and helps in reduction of hyperpigmentation.

OBJECTIVE: To evaluate the efficacy of Microneedling with Mesolighten for the treatment of post acne scaring, and hyperpigmentation.

METHODS: 12 patients with hyperpigmented macular and atrophic acne scar were enrolled. All patients were undergone for Microneedling on both sides of the face followed by topical application of Meso solution. Two sessions were done at an interval of 1 month. One independent dermatologist and patients itself scored clinical improvement on Visual analogue scale (VAS) of 0-10. Digital photography was done on each session and a month after final session.

RESULTS: Patient’s satisfaction scores showed excellent clinical response in seven patients, good response in four patients and fair response in one patient. Patients showed mean clinical improvement of 67.22% in terms of reduction in pigmented lesions counts. There also showed mean clinical improvement of 18.81% for acne scars in terms of Goodman’s Quantitative scores.

CONCLUSION: Mesolighten and microneedling provides significant reduction in pigmented macular and atrophic acne scars.
 

Introduction:

Acne vulgaris is a chronic inflammatory disease of pilosebaceous unit characterise by formation of comedons, papules, pustules, nodules or cystic lesions. Stress and environmental factors also influence the overall appearance of face by causing decrease skin luminosity (dullness) and appearance of new acne lesions. The lesions may subside without leaving any scar mark or pigmentory changes, but at times they produce visible atrophic acne scars or post inflammatory hyperpigmentation (PIH) or both.

Figure 1: Meso solution vials for skin lightening

The acne scars are broadly classified as macular, atrophis & hypertrophic or keloidal scars. Atrophic acne scar are further divided into; Ice pick, Box, & Rolling scars¹. There are numbers of patients who suffered from multiple squeal of acne vulgaris concurrently like atrophic acne scars, macular acne scars. It is difficult to treat all the lesions with lone therapy and need combination of modalities to counter all ailments simultaneously.

Mesotherapy is a non-surgical minimally invasive method of drug delivery which consists of multiple intradermal or subcutaneous injection of a mixture of compounds “melange” in minute doses². A melange can be plant extract, homeopathic agents, pharmaceuticals’, vitamins or any biological active substance. The term is derived from Greek word “mesos” meaning “middle” and “therapcia” meaning to treat medically i.e. injecting into the middle layer of skin or interdermotherapy³. Mesolighten is a melanage solution which contains combination of multiple depigmented agents of variable amounts in one preparation. Most of these agents mainly work on tyrosinase and thus help in reduction of skin pigmentation.

Microneedling is one of the important treatment modality for acne scars, stretch marks, wrinkles, and facial rejuvenation. It is performed by a rolling device which is embedded with multiple small needles. The principle of using microneedling is to initiate collagen induction. This new collagen eventually fills the gaps in scars and thus reducing the depth of it⁴. The process of remodelling continued up to one year. It also helps in the reduction of fine lines over the face along with reduction of sagging and folding⁵. The depth of penetration of needle should not exceed 4mm for it to be effective.⁶

We were not aimed to quantify response of each depigmented agent present in mesolighen used by us. The study was done to evaluate the combine effect of mesolighten along with microneedling for the treatment of hyperpigmentation, and atrophic acne scars.
 

Figure 2: Clinical response based on VAS scores of patients.	Figure 3. Pre and post treatment counts of hyperpigmented macular lesions for each patient by independent dermatologist.

 

Material and method

All patients suffering from both macular and atrophic acne scars visiting to outpatient clinic during 3 months were enrolled. Acne scars of grade 1-4 on Goodman’s qualitative scale were included (table 1). Keloidal tendencies, previous treatment with retinoids or any other treatment modalities in last 6 months period were taken as exclusion criteria. Patients with active lesion of face, like herpes, wart, mollouscum, any systemic or bleeding disorder were also excluded. The medical ethics and scientific committee of the hospital approved the study.

Patient’s information sheet was given to each patient. Informed consent was taken and case record form was filled for each patient. All patients were screened for Human immunodeficiency virus (HIV), Hepatitis B (HBsAG), Total leukocyte count (TLC), Haemoglobin (Hb), and Platelet count (P.C). The patients were photographed at 10 cm distance. Patients with atrophic acne scars were classified on Goodman’s Quantitative scale before commencement of treatment and one month after final session (table 2). Lesions counts were evaluated for hyperpigmented macular acne scars on each session and one month after final session.

The independent dermatologist examined each patient clinically before every session, and kept blinded from type of procedure and meso solution used on patients. A new roller device was used on each session. Topical anaesthetic cream was applied on face and draped with occlusion sheet before each session. Any adverse effects associated with anaesthetic creams were noted and cream was removed after 2 hours using sterile gauze peace.

Patients were kept in supine position with head stable. Face was divided into four quadrants & microneedling is performed using a roller of 1.5mm size with 540 fine needles embedded in drum. Rolling was done six times in four different directions which were perpendicular and diagonal to each other with to and fro motion. Firm pressure was applied to roller and performing physician remained the same throughout the study. Pinpoint bleeding was kept as endpoint of microneedling. The face was cleaned with normal saline and any bruise or adverse effects were noted.

One ml of meso solution (Arbutin, Glutathione, Glycolic acid, Vit-C, Kozic acid, Azelaic acid, Bearberry and Licorice Extracts) was poured uniformly over the face using insulin syringe. At the end of procedure erythema and oedema appears on face. Patient ware instructed for sun protection and avoiding face wash for 4 hrs following the procedure. Total two sessions of microneedling was performed at monthly interval. Patients were followed on 7^th day after each session for routine follow up. Photographs of both halves of face were taken prior to each session.

All patients were asked to score clinical improvement on visual analogue scale (VAS) of 0 (no response) to 10 (maximum) on each session. They were instructed to score themselves on reduction in skin lesions (both macular and atrophic). Score 0-1 assumed as no response, 2-4 as fair response, 5-7 as good response and 8-10 as excellent (table 3). Self Scores from previous sessions were shown to each patient and allowed to assess their degree of improvement and further addition or change in the scores if they needed.

Independent dermatologist calculated mean percentage for clinical improvement based on quantitative data using pre and post treatment Goodman’s Quantitative scores for atrophic acne scars and total reduction in lesions counts of pigmented macular acne scars.

Each patient was followed for 3 months after final session regarding persistent of any adverse effect.
 

Figure 4. Pre and post treatment Goodman’s quantitative scores for individual patient.

 

Results:

Twelve patients had completed the treatment in duration of 3 months. There was no dropout of any patient throughout the study and all patients were on regular follow up. All patients were female and distributed within a range of 20 to 29 years of age. There were no significant regional or occupational variations among patients. All patients were in between III to V fitzpatrick skin type.

All patients had tolerated the procedure, yet few adverse effects were noted with microneedling. One patient showed acne flare up, one developed milia. All patients were followed till three months post treatment. Milia were removed with electro-fulguration. Topical antibiotics were given for one week in flare up of acne, and bruise. Post treatment erythema and dryness with peeling of skin was observed in most of the patients and resolved completely on 4^th to 5^th day following procedure. Intra-operative bleeding was minimal. All patients were allowed daily activity following the procedure.
 

Figure 5. (A) Patient with noticeable scaring and postinflammatory hyperpigmented macular lesions on face. (B). Appearance after two sessions with microneedling and mesolighten. Scars are minimised and hyperpigmentation was barely visible after treatment.

Among 12 patients, 5 patients were suffering from box scars, 3 patients with rolling scars, 2 patients with ice pick scars and 2 patients with ice pick and box scars both. Patients with box scars and rolling scars showed considerable improvement while ice pick scars were almost refractory to the treatment.

Patient’s satisfaction score one month after final session showed excellent clinical response in seven patients, good response in four patients and fair response in one patient. None of the patient showed disappointment (Figure 2).

Patients showed mean clinical improvement of 67.22% in terms of reduction in pigmented lesions counts (Figure 3). Paired t test was applied among pre and post lesions counts and it showed significant improvement (t= -10.745432, p value <0.00001).
 

Fig 6. (A) Patient with noticeable hyperpigmented macular lesions on face. (B). Appearance after two sessions with microneedling and mesolighten. Scars are minimised and macular scars barely visible.

They also showed mean clinical improvement of 18.81% in terms of Goodman’s quantitative scores for acne scars (Figure 4). Paired t test was applied among pre and post Goodman’s score and showed significant improvement (t= 5.532513, p value <0.000177).
 

Discussion

In our study, we showed 67.22% reduction in lesion count and 18.81% reduction in acne scars after two sessions with microneedling and mesolighten. In best of our knowledge we didn’t found any similar study using mesolighten and microneedling for both atrophic and pigmented post acne scars. Virtually all patients have shown significant improvement except one patient of grade V skin type who only showed fair clinical response.

We used meso solution which was rich in Arbutin, Glutathione, Kozic acid, Azelaic acid, Bearberry, Licorice Extracts, Vit-C and Glycolic acid. All these extracts has proven efficacy in reducing skin pigmentation. Arbutin is a glycoside; a glycosylated hydroquinone extracted from bearberry plant⁷. It inhibits tyrosinase and thus prevents the formation of melanin. Glutathione is an antioxidant has recently been used as an inhibitor of melanin in the cosmetics industry. Glutathione competitively inhibits melanin synthesis in the reaction of tyrosinase and L-DOPA by interrupting L-DOPA's ability to bind to tyrosinase during melanin synthesis⁸.

Kojic acid is a chelation agent, and causes inhibition of melanin synthesis. It is used as depigmeneted agents and causes reduction of dark spots⁹. Bearberry extracts contains arbutin, ursolic acid, tannic acid, gallic acid, resin, hydroqinones etc; most of them are depigmented agents and used to decrease hyperpigmnetation¹⁰.

Licorice extracts Licorice extract is obtained from the root of Glycyrrhia Glabra Linneva. Glabridin has been shown to prevent UVB-induced pigmentation and to inhibit tyrosinase activity, superoxide anion production and cyclo-oxygenase activity^{11, 12}. Azelaic acid works as tyrosinase inhibitor and causes reduction of melanin synthesis. Azelaic acid has been used for treatment of skin pigmentation including melasma and post inflammatory hyperpigmentation, particularly in those with darker skin types¹³. Vit-c (ascorbic acid) is an antioxidant and neutralizes free radicals.
 

Figure 7. (A) Patient with noticeable scaring and hyperpigmented macular lesions on face. (B) Appearance after two sessions with microneedling and mesolighten.

It also reduces alpha tyrosinase activity causing inhibition of melanin synthesis. It helps in skin rejuvenation and whitening effects^{14, 15}. Glycolic acid is the smallest Alpha-hydroxy acid and used as a peeling agent. It causes keratinocyte dyscohesion, stimulation of basal keratinocyte and thus used in atrophic photoaged skin, decrease melanin synthesis by direct inhibition of tyrosinase, fibroblast modulation, and antioxidant with moisturizing action.

There are many meso solution preparations available commercially with variable proportion of individual extracts. It was not easy to choose best preparation among them so we have used one solution with depigmented agents and extracts having proven efficacy in the treatment of hyperpigmentation.

Microneedling leads to the formation of numerous fine channels through skin surface for better drug delivery without much damage to underlying tissue or epidermis subsequently early healing and recovery. Reduction in pigmented lesion showed much appreciable results in comparison to reduction in acne scars.

There are many other treatment modalities for treatment of such ailments like CO₂ laser resurfacing, microdermabrasion, chemical peeling and others. High cost and associated down time with CO₂ laser limits the use on large scale. Superficial chemical peels and microdermabrasion do not go deeper in to the skin and thus unable to induce collagen induction. Medium and deep chemical peels have risk of aggravation of post inflammatory hyperpigmentation which limits their use, especially in patients of Asian origin.

We proposed that microneedling provides channels for absorption of microneedling and simultaneously inducing collagen induction for the improvement in acne scars. Microneedling and mesotherapy are cheap, easy, safe, effective, and minimally invasive procedure to counter hyperpigmentation and scaring simultaneously. There is less downtime of the procedure thus increase the overall patient’s compliance. The procedure is performed in outpatient clinic and do not requires special or costly equipments. Associated side effects are less and if they occur; will be transient.

In our knowledge, it is the first study using mesolighten and microneedling to treat atrophic and macular acne simultaneously. Improvement in skin luminosity and its quantification on scale also aid to its efficacy. Yet more research is warrant for standardisation, and therapeutic outcome of meso solutions. Further researches can be made using different combination and comparing them with existing modalities of treatment.
 

Grades of Post Acne Scarring	Level of disease	Clinical features
1	Macular	These scars can be erythematous, hyper- or hypopigmented flat marks.
2	Mild	may not be obvious at social distances of 50 cm or greater and may be covered adequately by makeup or the normal shadow of shaved beard hair in men or normal body hair if extra facial
3	Moderate	Obvious at social distances of 50 cm or greater and is not covered easily by makeup or the normal shadow of shaved beard hair in men or body hair if extrafacial, but is still able to be flattened by manual stretching of the skin.
4	Severe	Evident at social distances greater than 50 cm and is not covered easily by makeup or the normal shadow of shaved beard hair in men or body hair if extrafacial and is not able to be flattened by manual stretching of the skin.
Table 1: Goodman’s Qualitative scoring grading system. (adapted from 16).

 

Grade or Type	Number of Lesions 1(1-10)	Number of Lesions 2(11-20)	Number of Lesions 3(>20)
A) Milder scarring (1 point each) Macular erythematous pigmented Mildly atrophic dish-like	1 point	2 points	3 points
B) Moderate scarring (2 points each) Moderately atrophic, dish like Punched out with shallow bases small cars (<5mm) Shallow but broad atrophic areas	2 points	4 points	6 points
C) Severe scarring (3 points each) Punched out with deep but normal bases, small scars (<5mm) Punched out with deep but abnormal bases, small scars (<5mm) Linear or troughed dermal scarring Deep, broad atrophic areas	3 points	6 points	9 points
D) Hyperplastic Papular scars Keloidal/Hypertrophic scars	2 points Area<5mm 6 points	4 points Area 5-20 cm2 12 points	6 points Area>20 cm2 18 points
Table 2: Goodman’s Quantitative global Acne scarring grading system (adapted from 17).

 

Score on scale	Clinical response
0-1	No response/ poor response
2-4	Fair response
5-7	Good response
8-10	Excellent response
Table 3. Grading system (10 point scale) used by patient for overall improvement of face and Independent dermatologist for reduction in macular scars.

 

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More references are availabe on request.