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Table of Contents
REVIEW ARTICLE
Year : 2021  |  Volume : 25  |  Issue : 2  |  Page : 49-53

Microneedling: A means of collagen induction therapy


Department of Skin and VD, Shree Krishna Hospital, Anand, Gujarat, India

Date of Submission20-Nov-2020
Date of Acceptance23-Jul-2021
Date of Web Publication29-Mar-2022

Correspondence Address:
Dr. Pragya A Nair
OPD 111, Shree Krishna Hospital, Karamsad, Anand - 388 325, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdds.jdds_126_20

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  Abstract 


Background: Collagen induction therapy is a form of microneedling. It is cheap and effective and has less side effects than other alternative therapies. Purpose: It is done using dermaroller for the treatment of scars, wrinkles, stretch marks, hair growth, and transdermal delivery of substances like lipopeptides and antiaging products. Methods: It acts by stimulating collagen production, produces microwounds and thus release of various inflammatory mediators. It also increases electric potential, thus inducing cellular activity with release of cytokines and growth factors leading to wound healing with collagen induction. Results: There are various new modified instruments, and combination with other modalities of treatment increases its utility in different dermatological and cosmetic conditions. Conclusions: Microneedling is a simple, inexpensive procedure with no down time and good results in acne scars, hair loss and wrinkles.

Keywords: Collagen induction therapy, dermaroller, facial rejuvenation, microneedling, scars


How to cite this article:
Nair PA, Tandel J. Microneedling: A means of collagen induction therapy. J Dermatol Dermatol Surg 2021;25:49-53

How to cite this URL:
Nair PA, Tandel J. Microneedling: A means of collagen induction therapy. J Dermatol Dermatol Surg [serial online] 2021 [cited 2022 Aug 16];25:49-53. Available from: https://www.jddsjournal.org/text.asp?2021/25/2/49/341196




  Introduction Top


Microneedling is a treatment modality with a device called dermaroller carried out for improving atrophic scars, rhytides, aging skin (rejuvenation), or for transdermal delivery of drugs. Over the years, it has been named skin needling, needle dermabrasion, intradermabrasion, microneedling, percutaneous collagen induction, dermaroller, and collagen induction therapy.[1]

Important milestones in its development are as follows:

  • Orentreich and Orentreich invented subcision or dermal needling for scars in 1995[2]
  • Camirand and Doucet introduced needle dermabrasion using tattoo pistol to treat scars in 1997[3]
  • Fernandes developed Percutaneous Collagen Induction therapy with dermaroller to initiate the natural posttraumatic inflammatory cascade in 2006[4]
  • Escobar-Chavez and Bentilla-Martinez reported that microneedling is a physical enhancer to increase transdermal delivery in 2011.[5]



  Mechanism of Action of Microneedling Top


Microneedling acts by stimulating collagen production and produces microwounds and thus release of various inflammatory mediators helping in wound healing, which in turn follows three phases:[6]

  1. Platelets and neutrophils release growth factors such as transforming growth factor (TGF), platelet derived growth factor and connective tissue activating protein increase the production of intercellular matrix
  2. Monocytes release growth factors to increase the production of collagen, elastin, and glycosaminoglycans. After 5 days of injury – a fibronectin matrix forms with an alignment of β-fibroblast that determines the deposition of collagen, which remains for 5–7 years and tightens naturally
  3. Increase in gene and protein expression of collagen, glycosaminoglycans and growth factors such as vascular endothelial growth factor, epidermal growth factor and fibroblast growth factor help in skin regeneration.


Neovascularization and neocollagenesis leads to reduction of scars.[7]

Newer theory – Microinjuries induced by needles cause a rise in electric potential (-100 mV) which is a part of wounding and wound healing process. This gives rise to “demarcation current” which is further increased by needle's own electric potential inducing increased cellular activity with release of cytokines and growth factors leading to wound healing with collagen induction.

Microneedling induces hair growth in alopecia (androgenetic/areata) by stimulating hair follicles, by stimulation of dermal papillae and stem cells, increased blood supply, recruitment of cytokines, and growth factors released by platelets. Increased thickness of scalp skin is due to neocollagenesis.[7]


  Purpose Top


Microneedling has been reported for use in different indications including:

  1. Wrinkles-Wrinkles are seen commonly in areas which are stretched regularly such as forehead, mouth, and around the eyes (crow's feet). Increased production of collagen makes the skin plumped out, thick, and elastic.[8]
  2. Scars


    1. Acne scars such as atrophic, macular, boxcar, and rolling scars[9]


    2. Good-to-excellent response is seen in 88.7% of patients with Grade 2 and 3 rolling or boxcar scars and moderate response was seen in pitted scars reported by Majid et al.[10] Surgical corrections are needed in Grade 4 scar, Grade 2, and Grade 3 linear and deep-pitted scars which do not respond well with microneedling.

    3. Other atrophic scars: Surgical, traumatic, postburn scar[11]
    4. Open pores


  3. Stretch marks
  4. Mesotherapy – Microneedling creates transient aqueous transport pathways of micron dimensions and thus enhances the transdermal permeability, bypassing the stratum corneum. As the Fick's law suggests that molecules travel from a region of high concentration to low concentration resulting in complete diffusion. The high lipid content of facial skin allows diffusion of lipid-soluble products while water-based products require delivery systems and penetration enhancers.


  5. The application of microneedling to the skin results in the creation of aqueous channels that are orders of magnitude larger than molecular dimensions and, therefore, should readily permit the transport of macromolecules.[12] Introduction of nutrients, growth factors, and platelet-rich plasma therapeutics can be used in:[7]

    1. Facial rejuvenation
    2. Periorbital rejuvenation/hypermelanosis
    3. Scars/stretch marks
    4. Alopecia – male and female pattern – In androgenetic alopecia (AGA) and alopecia areata, 1 ml of 5% minoxidil is applied and roller is rolled over the scalp. Dermaroller along with minoxidil-treated group was statistically superior to minoxidil-treated group in promoting hair growth in men with AGA[13]
    5. Melasma[14]


  6. Cellulites[4]
  7. Lax skin (arms, abdomen, neck, thighs, breast, and buttocks)[4]
  8. To tighten skin after liposuction[4]
  9. Rejuvenation – Face – fine wrinkles and mild laxity[10]
  10. Other body parts – Neck, chest, abdomen, and arms
  11. Stable vitiligo.


Contraindications

  • Active acne or rosacea
  • Chronic skin diseases such as eczema and psoriasis
  • Blood clotting disorders and patients on any anticoagulant therapy such as aspirin, warfarin, and heparin. It should be discontinued before 3 days
  • Cutaneous malignancy, moles, and solar keratosis
  • Patients in whom priming was not done with topical retinoids
  • Patients with keloidal tendency
  • Pregnancy
  • Active secondary bacterial or viral infections such as herpes labialis and warts
  • Koebnerization (active psoriasis, vitiligo, and lichen planus)
  • Patients who have undergone facial surgeries (dermabrasion/facial ablation/permanent filler treatment in the last 6 months).[7],[15]



  Methods Top


Instrument

It is a simple handheld drum shaped roller consisting of handle with a cylinder studded with 192 microneedles all around in eight rows 0.5–1.5 mm in length and 0.1 mm in diameter.[7] The microneedles are synthesized by reactive ion-etching techniques on silicon or medical-grade fine stainless steel. High ratio of tip length versus diameter, quality, hardness, and sharpness of needles are important properties of good needles.[9] Neocollagenesis occurs with a 1.5-mm length needle at a depth of 5–600 μm. It is presterilized by gamma irradiation and should be kept in isopropyl alcohol solution.[6] Sterilization should not be done using autoclave or ultrasound as it affects the sharpness of needle.

Preoperative care[7]

  • Counseling – Explanation of steps of procedure, its outcome, side effects, and complications to the patients
  • Drugs withdrawn prior to treatment – oral isotretinoin (15 days), aspirin and nonsteroidal anti-inflammatory drugs (5–10 days), and topical retinoids and hydroquinone (7 days)
  • Informed written consent and photographs
  • Priming with topical retinoids and preoperative application of Vitamin C cream for 1 month will maximize dermal collagen formation.[10] Vitamin A controls the proliferation and differentiation of cells in epidermis and dermis and thus controls the release of TGFβ3. Vitamin C increases the production of collagen
  • Oral antibiotic to be started 1 day prior to procedure and to be continued for 5–6 days postoperatively
  • Patients with past history of herpes labialis should be given prophylactic antiviral medications.


Procedure

Cleansing with Cetavlon, spirit, and povidone-iodine and finally rinsing with normal saline.

Topical anesthesia, i.e., EMLA, is applied over the area to be treated before 45 min which is cleaned with normal saline before starting the procedure. The area to be treated is stretched with one hand and the instrument is rolled over in a direction perpendicular to that of stretching force with other hand.

Roller is rolled in horizontal, vertical, and both oblique directions for at least 15–20 times. Rolling with a standard dermaroller will result in approximately 250 holes per square cm up to the papillary dermis.[10] While rolling, the handle should form an angle of 30°–40° with the barrel for smooth to-and-fro movement of the barrel over the stretched skin.

In deep-seated scar pinpoint bleeding at the base is considered as clinical end point.[14] Erythematous flushing is the clinical end point where shorter needles are used such as periorbital and nose.

Saline pads with topical antibiotic cream (mupirocin) are applied.

Postoperative care

Swollen and superficially bruised area is covered with damp swabs to absorb the bleeding and serous discharge. Topical antibiotic cream (mupirocin), 3–4 coats, is applied for few days to minimize the chance of bacterial infection. Antibiotic analgesics and anti-inflammatory agents are given.

Avoid sun exposure for 7–10 days and topical retino/hydroquinone, any bleaching agents, or cosmetic procedure (chemical peeling, microdermabrasion, etc.) over the face for at least 3–4 weeks.

Schedule

Once a month for the 1st three sessions, the next 2 sessions every 6 weekly followed by one session at 8-week interval.

Histopathology

Normal stratum corneum with thickened epidermis. Increased and thickened collagen fiber bundles which are loosely woven in papillary and reticular dermis.[16]

Side effects or risk:

  1. Pain.
  2. Reactivation of viral infection
  3. Bacterial infection
  4. Allergic contact dermatitis
  5. Bleeding, small hematoma formation, and bruising
  6. Poor quality needles can cause tissue damages, lacerations, hemorrhage, linear hypertrophic scars, or postinflammatory hyperpigmentation. It is more common with a tattoo gun.



  Results Top


Variable results are achieved.

Advantages

  1. Used in any type of skin and body area where lasers and deep peels are contraindicated
  2. It is a convenient-to-use, cost-effective office procedure with minimum side effects and short healing time than other alternative therapies
  3. Accepted and tolerated by patients
  4. Less risk of postinflammatory hyperpigmentation[6]
  5. It can be combined with other treatments such as subcision, chemical peeling, microdermabrasion, and fractional resurfacing (Botox filler, radiofrequency, laser, and Intense Pulsed Light) giving maximum benefits
  6. Can be done on people with prior laser resurfacing treatment


Disadvantages

  • Multiple sittings are required and longer time interval for final outcome.
  • Boxcar and ice pick scars show less response.
  • Moderate and severe wrinkles give less response


Site-specific consideration for the type of dermaroller:[7]

  • Periorbital area: 0.5-mm diameter microneedle
  • Nose: 1-mm diameter
  • Perioral area: 1–1.5-mm length and narrow barrel
  • Scalp – thin and long (2–2.5 mm) needle
  • Atrophic scar – 1.5–2-mm length and 0.25-mm diameter


Other types of dermaroller:

  1. Dermastamp – It is a miniature version of dermaroller having needle heights of 200 μm in a 5-mm diameter circular arrangement. It is used for small areas such as upper lips and eye. Stretch marks and scars such as herpetic, varicella, and posttraumatic scars are treated by dermastamp
  2. Home care dermarollers[12],[15] – Length of home care dermarollers is <0.15 mm and used for transdermal delivery of substances. There are 24 circular arrays of 8 needles, each making a total of 192 microneedles, and the height of needles ranges between 0.5 mm and 3 mm depending on the indication and area of the body. It is used directly over the skin in multidirectional pattern. Different types include


    • C8 also known as cosmetic type. The needle length is 0.13–2 mm making it pain free. Its main indication is increasing penetration of topical drugs
    • Beauty mouse has 3 dermarollers and 480 needles. It is used for larger skin surface areas as arms, legs, and buttocks to treat stretch marks and cellulite
    • Medical models – CIT8 type with a needle length of 0.5 mm
    • MF8 type – Needle length of 1.5 mm used for atrophic acne scarring as it forms deeper microchannels till dermis and also disrupts collagen bundles in scars
    • A small dermaroller (MS-4 type) – Total 96 needles arranged in four rows have a needle length of 1.5 mm and used for facial scars where better precision is required and needle length around 0.5 mm is used for thin skin like periorbital or perioral areas.


  3. Automated rollers[17] – Operated by battery and have disposable heads which can be used in more than one patient. Uniform pressure can be applied.


  4. Advantages of automated microneedling device:

    • It is automatic, safe, easy to use, less painful, and rechargeable
    • Disposable needle tips with the same handpiece are used
    • Areas such as nose, periocular, and perioral areas can be treated conveniently with a needle tip of 10-mm diameter
    • Needle length is adjustable with the help of different guides for different areas
    • It is economical as there is no need to buy a new instrument every time and just replace the needle tip.


  5. Scalp roller: It uses titanium needles to treat thinning hair and alopecia.
  6. Dermapen[7]


  7. It is an electrically powered pen-like instrument with handle, disposable needles, and guides to adjust needle length. The needle tip has 9–12 needles arranged in rows with the high-speed mode (700 cycles/min) and the low-speed mode (412 cycles/min). Dermapen is also being used as a fractional microneedling device as it comes with an adjustment ring allowing for alteration of heights of needles so that fractional mechanical resurfacing can be performed

  8. DermaFrac:[18]


    • Dermafac is a modified technique that combines microneedling with microdermabrasion, deep tissue serum infusion, and light emitting diode (LED) therapy
    • It uses the microconduits formed by the microneedling to infuse various serums with pharmaceutical properties with the help of vacuum
    • It is used for the treatment of fine lines and wrinkles, sun spots, pigmentation, open pores, acne scars, and acne-prone skin
    • It acts by increase in hydration and formation of new collagen and elastin fibers in the skin, leading to thickened dermis, so the underlying congested vessels and pigment in the dermis were seen to a less extent. It uses the cool breeze handpiece-emitting high energy of LED light therapy keeping the skin cool at the same time
    • The red light (627 nm) helps in collagen building and reducing inflammation and blue (415 nm) helps in acne
    • It is a painless procedure with negligible downtime, less time taking, and cheaper than fractional lasers.


  9. Fractional microneedling radiofrequency (MFR)


    • MFR device creates radiofrequency thermal zones without causing epidermal injury. Damage to the reticular dermis causes long-term dermal remodeling, neoelastogenesis, and neocollagenogenesis which results in dermal thickening.[19]
    • It uses extra sharp microneedles to heat the depths of the dermis, promoting dermal collagen remodeling
    • It is used for skin tightening, wrinkle reduction, and acne scarring reduction.


    1. The first-generation microneedle RF technology – It uses insulated needles which allow energy to flow throughout the noninsulated tip of the needle, resulting in small coagulated area in the dermis. The needles can reach from 0.5 mm to 3.5 mm of depth and are used for acne scars and skin rejuvenation.


    2. Disadvantages:

      • Significant microbleeding
      • The need for several passes at different needle depths to treat the entire dermis depth.


    3. The newer-generation microneedle RF emission delivered over the whole needle length allows better coagulation and heating of higher volumes of dermal tissue compared to insulated needles.


    4. The noninsulated microneedle allows controlled heating to a predefined dermal depth without epidermal coagulation and thus reduces patient's discomfort.

      It is a minimally invasive treatment option with little downtime for the treatment of acne scars, improvement in skin texture, and reduced size of skin pores.

    5. Fractionated radiofrequency creates radiofrequency thermal zones causing coagulation of dermal collagen and immediate collagen contraction without damaging the epidermis. It consists of a disposable tip with 49 gold-plated needles and is used in acne, acne scars, open pores, fine lines, wrinkles, skin tightening, and primary axillary hyperhidrosis.[20]


    It is capable of delivering energy in increments of 2.5W up to 50W in 20 equally graded energy level settings with the duration of each energy pulse from 10 ms to 1,000 ms. Changing the exposure time can give good control over the tissue damage. Multiple needle depths per pass is an advantage, which allows discrete electrothermal coagulation at different layers of the dermis.

    Needle penetration stimulates the release of growth factors and spares epidermis and adnexal structures, thus acts by neocollagenogenesis contributing to rapid healing.

  10. LED microneedling devices: Used to increase the efficacy of photodynamic therapy in actinic keratosis[19]
  11. LED microneedling rollers with titanium microneedles and LED light.


Microneedling delivery systems

Microneedles can be fabricated into various types which include solid, dissolving, hydrogel, coated, and hollow. It is used in delivering oligonucleotide, vaccine, insulin, and various cosmetics.[21]

Transdermal delivery of peptide cosmetics is used which has a role in delivery of antiaging peptides such as melanostatin, Rigin, and Pal-KTTKS which boo the collagen production.


  Conclusions Top


Microneedling is a simple, inexpensive procedure with no downtime and good results in acne scars, hair loss, and wrinkles. There are many new modified versions available with its numerous applications and modifications which are feasible for home use.

Variable results are achieved with less side effects such as scarring and postinflammatory hyperpigmentation than other procedures.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Fernandes D. Percutaneous collagen induction: An alternative to laser resurfacing. Aesthet Surg J 2002;22:307-9.  Back to cited text no. 1
    
2.
Orentreich DS, Orentreich N. Subcutaneous incision less (subcision) surgery for the correction of depressed scars and wrinkles. Dermatol Surg 1995;21:543-9.  Back to cited text no. 2
    
3.
Camirand A, Doucet J. Needle dermabrasion. Aesthetic Plast Surg 1997;21:48-51.  Back to cited text no. 3
    
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Fernandes D. Minimally invasive percutaneous collagen induction. Oral Maxillofac Surg Clin North Am 2005;17:51-63, vi.  Back to cited text no. 4
    
5.
Escobar-Chávez JJ, Bonilla-Martínez D, Villegas-González MA, Molina-Trinidad E, Casas-Alancaster N, Revilla-Vázquez AL. Microneedles: A valuable physical enhancer to increase transdermal drug delivery. J Clin Pharmacol 2011;51:964-77.  Back to cited text no. 5
    
6.
Falabella AF, Falanga V. Wound healing. In: Feinkel RK, Woodley DT, editors. The Biology of Skin. New York: Parthenon; 2000. p. 281-99.  Back to cited text no. 6
    
7.
Savant S. Textbook of dermatosurgery and cosmetology-principles and practice, Microneedling. 3rd ed. Mumbai, India: Bhalani Publishing House; 2018. p. 1065-74.  Back to cited text no. 7
    
8.
Nair PA, Arora TH. Microneedling using dermaroller: A means of collagen induction therapy. GMJ 2014;69:24-7.  Back to cited text no. 8
    
9.
Aust MC, Fernandes D, Kolokythas P, Kaplan HM, Vogt PM. Percutaneous collagen induction therapy: An alternative treatment for scars, wrinkles, and skin laxity. Plast Reconstr Surg 2008;121:1421-9.  Back to cited text no. 9
    
10.
Majid I. Microneedling therapy in atrophic facial scars: An objective assessment. J Cutan Aesthet Surg 2009;2:26-30.  Back to cited text no. 10
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11.
Aust MC, Reimers K, Vogt PM. Medical Needling improving the appearance of hypertrophic burns scar. Aesthtic J 2011;1:42-9.  Back to cited text no. 11
    
12.
Garland MJ, Migalska K, Mahmood TM, Singh TR, Woolfson AD, Donnelly RF. Microneedle arrays as medical devices for enhanced transdermal drug delivery. Expert Rev Med Devices 2011;8:459-82.  Back to cited text no. 12
    
13.
Dhurat R, Sukesh M, Avhad G, Dandale A, Pal A, Pund P. A randomized evaluator blinded study of effect of microneedling in androgenetic alopecia: A pilot study. Int J Trichology 2013;5:6-11.  Back to cited text no. 13
    
14.
Lima Ede A. Microneedling in facial recalcitrant melasma: Report of a series of 22 cases. An Bras Dermatol 2015;90:919-21.  Back to cited text no. 14
    
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Doddaballapur S. Microneedling with dermaroller. J Cutan Aesthet Surg 2009;2:110-1.  Back to cited text no. 15
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16.
Shim EK, Barnette D, Hughes K, Greenway HT. Microdermabrasion: A clinical and histopathologic study. Dermatol Surg 2001;27:524-30.  Back to cited text no. 16
    
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Arora S, P. Gupta B. Automated microneedling device – A new tool indermatologist's kit – A review. J Pak Assoc Dermatol 2012;22:354-7.  Back to cited text no. 17
    
18.
Donnelly RF, Raj Singh TR, Woolfson AD. Microneedle-based drug delivery systems: Microfabrication, drug delivery, and safety. Drug Deliv 2010;17:187-207.  Back to cited text no. 18
    
19.
Hruza G, Taub AF, Collier SL, Mulholland SR. Skin rejuvenation and wrinkle reduction using a fractional radiofrequency system. J Drugs Dermatol 2009;8:259-65.  Back to cited text no. 19
    
20.
Calderhead RG, Goo BL, Lauro F, Gursoy D, Savant SS, Wronski A. The clinical efficacy and safety of microneedling fractional radiofrequency in the treatment of facial wrinkles: A multicenter study with the Infini System in 499 patients. In: White Paper. Goyang, South Korea: Lutronic Corp; 2013.  Back to cited text no. 20
    
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Singh A, Yadav S. Microneedling: Advances and widening horizons. Indian Dermatol Online J 2016;7:244-54.  Back to cited text no. 21
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