Skin needling as a treatment for acne scarring: An up-to-date review of the literature

Topical, light-based, and complementary interventions for acne: an overview of systematic reviews

BACKGROUND

Acne is a chronic inflammatory and immune-mediated disease of the pilosebaceous unit (the skin structure consisting of a hair follicle and its associated sebaceous gland). It is characterised by non-inflammatory lesions (open and closed comedones) and inflammatory lesions (papules, pustules, nodules, and cysts). Lesions may be present on the face, thorax, and back, with variable severity. Acne exhibits a global distribution and has a growing prevalence. Acne vulgaris is the most common form. Acne gives rise to complications such as scars and can seriously affect people's mental health, especially those with severe acne. Acne has a huge impact on the quality of life and self-esteem of those affected.

OBJECTIVES

To synthesise the existing evidence on the efficacy and safety of non-systemic pharmacological interventions and non-pharmacological interventions (physical therapy and complementary therapies) in the treatment of acne vulgaris and related skin complications.

METHODS

We searched the Cochrane Database of Systematic Reviews, Epistemonikos, MEDLINE, and Embase to 2 December 2021, and checked the reference lists of included reviews. At least two authors were responsible for screening, data extraction, and critical appraisal. We excluded reviews with high risk of bias as assessed with the ROBIS tool. We evaluated the overall certainty of the evidence according to GRADE (as carried out by the authors of the included reviews or ourselves). We provide comprehensive evidence from the review data, including summary of findings tables, summary of results tables, and evidence maps.

MAIN RESULTS

We retrieved and assessed a total of 733 records; however, only six reviews (five Cochrane reviews and one non-Cochrane review) with low risk of bias met the overview inclusion criteria. The six reviews involved 40,910 people with acne from 275 trials and 1316 people with acne scars from 37 trials. The age of the participants ranged from 10 to 59 years, with an average age range from 18 to 30 years. Four reviews included original trials involving only female participants and three reviews included original trials with only male participants. Main results for clinically important comparisons: Benzoyl peroxide versus placebo or no treatment: In two trials involving 1012 participants over 12 weeks, benzoyl peroxide may reduce the total (mean difference (MD) -16.14, 95% confidence interval (CI) -26.51 to -5.78), inflammatory (MD -6.12, 95% CI -11.02 to -1.22), and non-inflammatory lesion counts (MD -9.69, 95% CI -15.08 to -4.29) when compared to placebo (long-term treatment), but the evidence is very uncertain (very low-certainty evidence). Two trials including 1073 participants (time point: 10 and 12 weeks) suggested benzoyl peroxide may have little to no effect in improving participants' global self-assessment compared to placebo (long-term treatment), but the evidence is very uncertain (risk ratio (RR) 1.44, 95% CI 0.94 to 2.22; very low-certainty evidence). Very low-certainty evidence suggested that benzoyl peroxide may improve investigators' global assessment (RR 1.77, 95% CI 1.37 to 2.28; 6 trials, 4110 participants, long-term treatment (12 weeks)) compared to placebo. Thirteen trials including 4287 participants over 10 to 12 weeks suggested benzoyl peroxide may increase the risk of a less serious adverse event compared to placebo (long-term treatment), but the evidence is very uncertain (RR 1.46, 95% CI 1.01 to 2.11; very low-certainty evidence). Benzoyl peroxide versus topical retinoids: Benzoyl peroxide may increase the percentage change in total lesion count compared to adapalene (long-term treatment), but the evidence is very uncertain (MD 10.8, 95% CI 3.38 to 18.22; 1 trial, 205 participants, 12 weeks; very low-certainty evidence). When compared to adapalene, benzoyl peroxide may have little to no effect on the following outcomes (long-term treatment): percentage change in inflammatory lesion counts (MD -7.7, 95% CI -16.46 to 1.06; 1 trial, 142 participants, 11 weeks; very low-certainty evidence), percentage change in non-inflammatory lesion counts (MD -3.9, 95% CI -13.31 to 5.51; 1 trial, 142 participants, 11 weeks; very low-certainty evidence), participant's global self-assessment (RR 0.96, 95% CI 0.86 to 1.06; 4 trials, 1123 participants, 11 to 12 weeks; low-certainty evidence), investigators' global assessment (RR 1.16, 95% CI 0.98 to 1.37; 3 trials, 1965 participants, 12 weeks; low-certainty evidence), and incidence of a less serious adverse event (RR 0.77, 95% CI 0.48 to 1.25, 1573 participants, 5 trials, 11 to 12 weeks; very low-certainty evidence). Benzoyl peroxide versus topical antibiotics: When compared to clindamycin, benzoyl peroxide may have little to no effect on the following outcomes (long-term treatment): total lesion counts (MD -3.50, 95% CI -7.54 to 0.54; 1 trial, 641 participants, 12 weeks; very low-certainty evidence), inflammatory lesion counts (MD -1.20, 95% CI -2.99 to 0.59; 1 trial, 641 participants, 12 weeks; very low-certainty evidence), non-inflammatory lesion counts (MD -2.4, 95% CI -5.3 to 0.5; 1 trial, 641 participants, 12 weeks; very low-certainty evidence), participant's global self-assessment (RR 0.95, 95% CI 0.68 to 1.34; 1 trial, 240 participants, 10 weeks; low-certainty evidence), investigator's global assessment (RR 1.10, 95% CI 0.83 to 1.45; 2 trials, 2277 participants, 12 weeks; very low-certainty evidence), and incidence of a less serious adverse event (RR 1.27, 95% CI 0.98 to 1.64; 5 trials, 2842 participants, 10 to 12 weeks; low-certainty evidence). For these clinically important comparisons, no review collected data for the following outcomes: frequency of participants experiencing at least one serious adverse event or quality of life. No review collected data for the following comparisons: topical antibiotics versus placebo or no treatment, topical retinoids versus placebo or no treatment, or topical retinoids versus topical antibiotics.

AUTHORS' CONCLUSIONS

This overview summarises the evidence for topical therapy, phototherapy, and complementary therapy for acne and acne scars. We found no high-certainty evidence for the effects of any therapy included. Randomised controlled trials and systematic reviews related to acne and acne scars had limitations (low methodological quality). We could not summarise the evidence for topical retinoids and topical antibiotics due to insufficient high-quality systematic reviews. Future research should consider pooled analysis of data on new emerging drugs for acne treatment (e.g. clascoterone) and focus more on acne complications.

Evaluation of Ultrasound Changes With the Use of Microneedling Versus Fractional CO2 Laser in Atrophic Acne Scars

INTRODUCTION

Atrophic acne scarring, a common sequela of acne, can be treated by different interventions, including microneedling and laser resurfacing.

OBJECTIVES

We sought to evaluate the comparative efficacy of microneedling versus fractional CO2 laser in treating atrophic acne facial scars using imaging with high and ultra-high frequency ultrasound.

METHODS

Participants received 2 sessions, separated by 1 month, of microneedling on the left side of the face and fractional CO2 laser on the right. Color Doppler ultrasound evaluations (24 and 70 MHz) were conducted at baseline and 3 months after treatment. Each patient completed questionnaires on satisfaction, pain, and adverse effects.

RESULTS

Nine subjects were enrolled. The frequency order of scar types was boxcar, ice-pick, and rolling. At 3 months, using the acne scar clinical evaluation scale, a decrease in scar scores of both methods was observed for total scars (P = 0.0005), ice-pick scars (P = 0.0128), and rolling scars (P = 0.0007). Twenty-two scars analyzed by ultrasound demonstrated a trend to decrease in size; however, no significant changes were observed for either microneedling or CO2 laser treatments. Moreover, there were no significant differences between these methods. Both treatments were rated as good or very good by patient assessments. There was a low frequency of pain and hyperpigmentation reported with both modalities, albeit somewhat higher with microneedling.

CONCLUSIONS

Both microneedling and CO2 laser improved atrophic acne scars. Ultrasound did not show significant differences between these modalities.

PRP and its benefit as an adjunctive therapy with subcision and microneedling in atrophic scars: a comparative study

Context

Scarring is a biological process of wound repair which leads to a difference in the normal structure and function of the skin and manifests as a depressed or raised area. Treatment of scars is challenging. A number of therapeutic approaches like surgical techniques and non-surgical techniques are performed to improve scarring.

Aims and Objectives

The aim of this study was to compare the outcome of subcision followed by microneedling versus subcision followed by microneedling and topical platelet-rich plasma (PRP) in atrophic scars.

Materials and Methods

A comparative prospective study was conducted at a tertiary care hospital in North India to compare the efficacy of subcision followed by microneedling versus subcision followed by microneedling and topical PRP. A total of 40 cases were taken and were randomly divided into two groups, A and B of 20 patients in each group. Topical PRP was applied as an additional therapy in Group B in the same sitting. Minimum three sittings were done in each patient at an interval of 4 weeks and results were assessed after 1 month of the third session. The statistical software used is Microsoft Excel and SPSS software program, version 24.0 for analysis of data and Microsoft Word to generate graphs and tables.

Results

Improvement in scar grading was more in Group B as compared to Group A with statistically significant difference (P = 0.032). There was an improvement in scar grading from grade 4 scar to grade 2 in 15% and 30% patients of Groups A and B, respectively, with improvement in skin texture and pigmentation more in Group B.

Conclusion

PRP proved to add to the improvement of grade of atrophic scars when combined with subcision and microneedling.

Microbotox (Mesobotox) versus microneedling as a new therapeutic modality in the treatment of atrophic post-acne scars

BACKGROUND

Given that most patients with moderate to severe acne develop post-acne scars, many treatment modalities can be used to ameliorate scaring; chemical peels, surgical excision, dermabrasion, fat transfer, autologous collagen, punch grafting, diverse filler injection, and lasers. Microneedling is one of the promising modalities based on the breaking of dermis-damaged collagen and enhancing new collagen formation. Microbotox (Mesobotox) injection may have a beneficial effect by causing muscular paralysis with subsequent dermal edema due to transient and mild lymphatic insufficiency. The comparison between these two modalities has not been yet assessed. The aim of this study was to evaluate and compare the safety and efficacy of both methods (Microbotox and microneedling) in the treatment of atrophic post-acne scars.

METHODS

Between May 2021 to April 2022, patients with atrophic post-acne scars were selected from the out-patients clinics of the Department of Dermatology, Faculty of Medicine. The face was divided into two sides: the right side was treated with Mesobotox for three sessions once monthly and followed up 3 months later after the last session and the left side was treated with dermapen (microneedling) for six sessions every 2 weeks and followed up 3 months after the last session. The feasibility, safety, and efficacy of both lines of treatment were studied.

RESULTS

This study included 20 patients with atrophic post-acne scars. They were 13 females (65%) and 7 males (35%), and their ages ranged between 15 and 35 years with a mean ± sd age of 24.40 ± 5.90 based on the significant improvement between S1 (baseline acne scar score) and both S2 (acne scar score at end of treatment) and S3 (acne scar score 3 months after the last session). Microneedling showed also similar results to Mesobotox.

CONCLUSIONS

Microbotox and microneedling were effective and tolerated.

Successful Topical Application of Botulinum Toxin After Microneedling Versus Microneedling Alone for the Treatment of Atrophic Post Acne Scars: A Prospective, Split-face, Controlled Study

BACKGROUND

Acne scars are a source of cosmetic concern for most of the patients.

OBJECTIVE

We sought to compare the clinical efficacy and safety of topical botulinum toxin A (BTX-A) application immediately after microneedling (Mn) versus Mn with saline in the treatment of atrophic acne scars.

METHODS

Forty patients with atrophic acne scars (rolling, boxcar, and mixed types) were enrolled in a split-face study; microneedling was performed on both sides of the face followed by an application of topically diluted botulinum toxin on one side (Side A) and saline on the other (Side B) for two sessions both two weeks apart. Evaluation was done at baseline, two and four weeks after the session. Follow-up was performed after six months. The assessments included blinded clinical assessment and patient's satisfaction.

RESULTS

After the treatment, acne scars in (Side A) showed 70 percent overall improvement versus zero percent in Side B (P<0.0001). A statistically highly significant reduction of acne scars severity occurred in (Side A) (P=0.0008). Patient's satisfaction was higher in (Side A) (P<0.0001). No serious side effects were reported.

CONCLUSION

Microneedling delivery of BTX-A could be simple, safe, and innovative modality improving the appearance and decrease the depth of atrophic acne scars.

Tissue Modification in Nonsurgical Facelift Options

Nonsurgical facelifts are a term for a heterogeneous group of procedures used by physicians to improve facial rejuvenation without the use of operative techniques. Patients demand these services due to the reduced recovery time and generally lower risk. However, nonsurgical techniques, to be effective, must induce conformational change in the cells and tissues of the face. Therefore, these techniques are significant procedures that have associated risks. Understanding the tissue modifications and mechanisms of action of these techniques is vital to their safe and effective use. The purpose of this article is to provide a background of tissue modification in nonsurgical facelift options.

Innate local response and tissue recovery following application of high density microarray patches to human skin

The development of microarray patches for vaccine application has the potential to revolutionise vaccine delivery. Microarray patches (MAP) reduce risks of needle stick injury, do not require reconstitution and have the potential to enhance immune responses using a fractional vaccine dose. To date, the majority of research has focused on vaccine delivery with little characterisation of local skin response and recovery. Here we study in detail the immediate local skin response and recovery of the skin post high density MAP application in 12 individuals receiving 3 MAPs randomly assigned to the forearm and upper arm. Responses were characterised by clinical scoring, dermatoscopy, evaporimetry and tissue viability imaging (TiVi). MAP application resulted in punctures in the epidermis, a significant transepidermal water loss (TEWL), the peak TEWL being concomitant with peak erythema responses visualised by TiVi. TEWL and TiVi responses reduced over time, with TEWL returning to baseline by 48 h and erythema fading over the course of a 7 day period. As MAPs for vaccination move into larger clinical studies more variation of individual subject phenotypic or disease propensity will be encountered which will require consideration both in regard to reliability of dose delivery and degree of inherent skin response.

Derma rollers in therapy: the transition from cosmetics to transdermal drug delivery

Derma roller, a device rolled onto the skin to form micropores, is extensively used for cosmetic purposes. The pores thus created are utilized to either result in the induction of collagen production, leading to glowing and wrinkle-free skin or for permeating the applied formulations to the site of action within the skin. Recent studies have shown the benefits of using derma rollers for transdermal delivery of drugs. In the nascent stage, this approach paves a way to successfully breach the stratum corneum and aid in the movement of medications directed towards the dermis and the hair follicles. The review essentially summarizes the evidence of the use of derma rollers in cosmetic setup, their designing, and the preclinical and clinical reports of efficacy, safety, and concerns when translated for pharmaceutical purposes and transdermal drug delivery.

Safety and Effectiveness of an Automated Microneedling Device in Improving Acne Scarring

OBJECTIVE: To assess the effectiveness of the amiea med (amiea med, MT.DERM GmbH, Berlin, Germany) automated microneedling device in reducing facial atrophic acne scars. STUDY DESIGN: Open label, single center. PARTICIPANTS: Healthy males and females, aged 18 to 65 years, with signs of facial atrophic acne scarring were selected. After consenting and satisfying inclusion criteria, each subject underwent four microneedling sessions 30 days apart. Subjects were assessed at baseline and three months after the last treatment. MEASUREMENTS: Acne scars were classified according to Jacob classification. Physician assessment of acne scarring severity was carried out using the Goodman and Baron grading scale. Subjects graded their redness, pain and discomfort on the evening of the treatment and up to seven days posttreatment using a subject diary. RESULTS: Three months after the last treatment, facial acne scars had improved by 0.91 of a grade [CI. 0.78-1.05] according to Goodman and Baron Grading Scale (p<0.001). Improvement in acne scarring was not restricted to severity of grade,with no difference seen in Fitzpatrick skin types. According to Jacob classification, rolling scars showed the greatest improvement, with a mean improvement of 1.06 of a grade at the final assessment (p<0.001). CONCLUSION: This study demonstrates that four microneedling treatments of facial skin, spaced four weeks apart, significantly improves the appearance of facial acne scarring. The treatment is well tolerated with minimal pain, discomfort, and downtime. Side effects appear minor and easily managed compared to other more aggressive technologies. STUDY REGISTRATION: German Register for Clinical studies (DRKS) No [DRKS00013187].

Skin needling for the treatment of acne scarring: A comprehensive review

BACKGROUND

Skin needling, also called "collagen induction therapy," is a nonpharmacological treatment modality that has been increasingly utilized for the treatment of acne scars.

AIMS

To review the medical literature and to select the most significative and recent studies regarding skin needling as a treatment for acne scarring, used alone or combined with other treatments.

METHODS

A literature search was performed using the PubMed, Medline, and Embase databases, in addition to reviewing the bibliographies of relevant articles.

RESULTS

Almost all the articles evaluated showed improvement of acne scars severity after microneedling treatment. When combined with other treatments such as autologous platelet-rich plasma (PRP), chemical peels, filler injections, or laser treatment, a greater improvement was reported. Needling technique is well-tolerated with erythema and dryness representing the most frequent adverse events.

CONCLUSIONS

Microneedling is a useful treatment for acne scarring. Further studies are needed to evaluate its efficacy and safety and to create a standardized protocol to adopt for each patient according to the severity of acne scars.

Evaluation of the clinical impact of repeat application of hydrogel-forming microneedle array patches

Hydrogel-forming microneedle array patches (MAPs) have been proposed as viable clinical tools for patient monitoring purposes, providing an alternative to traditional methods of sample acquisition, such as venepuncture and intradermal sampling. They are also undergoing investigation in the management of non-melanoma skin cancers. In contrast to drug or vaccine delivery, when only a small number of MAP applications would be required, hydrogel MAPs utilised for sampling purposes or for tumour eradication would necessitate regular, repeat applications. Therefore, the current study was designed to address one of the key translational aspects of MAP development, namely patient safety. We demonstrate, for the first time in human volunteers, that repeat MAP application and wear does not lead to prolonged skin reactions or prolonged disruption of skin barrier function. Importantly, concentrations of specific systemic biomarkers of inflammation (C-reactive protein (CRP); tumour necrosis factor-α (TNF-α)); infection (interleukin-1β (IL-1β); allergy (immunoglobulin E (IgE)) and immunity (immunoglobulin G (IgG)) were all recorded over the course of this fixed study period. No biomarker concentrations above the normal, documented adult ranges were recorded over the course of the study, indicating that no systemic reactions had been initiated in volunteers. Building upon the results of this study, which serve to highlight the safety of our hydrogel MAP, we are actively working towards CE marking of our MAP technology as a medical device.

Platelet-rich Plasma, Collagen Peptides, and Stem Cells for Cutaneous Rejuvenation

In recent years, platelet-rich plasma (PRP), collagen peptides, and stem cells have become popular treatments for cutaneous rejuvenation. Mass marketing to consumers via the internet and social media has attracted the attention of the aesthetics industry to these treatments. However, the studies behind these treatment modalities have not supported the often exaggerated claims of effectiveness that have targeted consumers. It is important for clinicians to understand the evidence behind any new trends, especially in the fast-paced world of aesthetics, where treatments often outpace current medical understanding. Here, we summarize and evaluate the current prominent literature on these popular aesthetic treatments.

Photodynamic therapy for skin cancer: How to enhance drug penetration?

Photodynamic therapy (PDT) induced by protoporphyrin IX (PpIX) has been widely used in dermatological practices such as treatment of skin cancers. Clearance rate depends on different factors such as light irradiation, skin oxygenation and drug penetration. The poor penetration of 5-aminolevulinic acid (5-ALA) with topical application is limited and restrains the production of PpIX which could restrict PDT outcomes. This review will focus on techniques already used to enhance drug penetration in human skin, and will present their results, advantages, and drawbacks. Chemical and physical pretreatments will be discussed. Chemical pre-treatments comprise of drug formulation modification, use of agents that modify the heme cycle, enhance PpIX formation, and the combination of differentiation-promoting agent prior to PDT. On the other hand, physical pretreatments affect the skin barrier by creating holes in the skin or by removing stratum corneum. To promote drug penetration, iontophoresis and temperature modulation are interesting alternative methods. Cellular mechanisms enrolled during chemical or physical pretreatments have been investigated in order to understand how 5-ALA penetrates the skin, why it is preferentially metabolized in PpIX in tumour cells, and how it could be accumulated in deeper skin layers. The objective of this review is to compare clinical trials that use innovative technology to conventional PDT treatment. Most of these pretreatments present good or even better clinical outcomes than usual PDT.