Collagen induction therapy – MicroNeedling

There’s always a new skin beauty treatment that promises younger looking skin – collagen induction therapy or microneedling is a natural collagen inducing treatment.

For years, Botox ruled this sector of anti-ageing and this month marks 15 years since the injectable received its approval from the FDA. Since then fillers and laser treatments have filtered in for plumper, fresher looking skin. Even more recently, collagen micro-needling has been heralded as a non-invasive way to achieve youthful, dewy looking skin [1]. But what is it and does it really deliver results?  

What is micro-needling?

Microneedling also known as a collagen induction therapy or skin needling is a skin beauty treatment whereby a device with small needles is pushed or rolled over your face and neck area to create controlled punctures, which force your skin into repair mode. Those with a fear of needles shouldn’t discard this technique straight away as, depending on the device used, the microneedle length can vary from 0.5 to 3.0 mm, which is incredibly tiny compared to a traditional needle. And, these devices are gentle enough to be used around the delicate eye area [1].  

Collagen induction therapy or microneedling is a skin beauty treatment used to tighten the skin, reduce the appearance of fine lines and wrinkles. This collagen inducing treatment can effectively treat the appearance of acne scars too. Microneedling can be used on all skin types and areas of the body including the face [2].

Microneedling is a very simple, safe, effective, and minimally invasive therapeutic technique. It was initially introduced for skin rejuvenation, however, now it is being used for a very wide range of indications including acne scar, acne, post-traumatic/burn scar, alopecia, skin rejuvenation, drug delivery, hyperhidrosis, stretch marks, and many more. Moreover, during the last 10 years, many new innovations have been made to the initial instrument, which was used for microneedling. This technique can be combined with other surgical techniques to provide better results. In particular, it is a very safe technique for dark skin types, where risk of postinflammatory pigmentation is very high with other techniques that damage the epidermis. In this review article, we are updating on the different instruments now available for this procedure, and its efficacy when performed alone or in combination with other techniques for various indications [3].

How did the concept of collagen microneedling evolve?

The advent of the concept of microneedling dates back to 1995 when Orentreich and Orentreich described dermal needling in the form of subcision for scar treatment and then independently in 1997 by a plastic surgeon Camirand who used tattoo guns without ink to take-off tension from postsurgical scars [4,5]. Microneedling technique was given further shape by a German inventor Liebl in 2000 and a plastic surgeon Fernandes in 2006 who self-designed a drum-shaped device with multiple fine protruding needles and used it for percutaneous collagen induction.[6,7]

What instruments are required for micro needling?

The standard medical dermaroller [Figure 1] has a 12 cm long handle with a 2 × 2 cm wide drum-shaped cylinder at one end studded with 8 rows and 24 circular arrays of 192 fine microneedles, usually 0.5–3 mm in length and 0.1–0.25 mm in diameter.[3] These single use microneedles are synthesized by reactive ion etching techniques on silicon or medical-grade stainless steel. The instrument is presterilized by gamma irradiation. Rolling with a standard dermaroller containing 192 needles of 2 mm length and 0.07 mm diameter over an area of skin for 15 times results in approximately 250 holes per square cm upto the papillary dermis depending on the pressure applied.[7] Each pass produces 16 micropunctures in the stratum corneum per square cm without damaging the epidermis significantly.[8]

Dermarollers used for collagen microneedling
Collagen Induction therapy micro needling dermarollers
Figure 1: Types of Dermarollers: (a) Dermaroller with small drum used for smaller areas like nose and eyelids; (b) Dermaroller with 540 needles used for skin; (c) Dermaroller with 192 needles old techniques but still used for skin.

Collagen Induction therapy (MicroNeedling) Procedure…

Microneedling is a simple office-based procedure lasting 10 to 20 minutes depending on the area to be treated. The patients must be counselled prior to the procedure explaining the expected outcomes, delayed response, and need for multiple sittings. The skin should preferably be prepared preoperatively for at least a month with vitamin A and C formulations twice a day to maximize dermal collagen formation. Vitamin A influences 400–1000 genes that control proliferation and differentiation of all major cells in epidermis and dermis, and Vitamin C is essential for production of normal collagen.[9]

The procedure is performed under topical anesthesia containing eutectic mixture of lignocaine and prilocaine/tetracaine for 45 minutes to 1 hour. After preparation of the area with antiseptic and saline, the skin is stretched with one hand, and perpendicularly, rolling is done 5 times each in the horizontal, vertical, and oblique directions with the other hand [Figure 2]. The treatment endpoint is identified as uniform pin-point bleeding which is easily controllable. Post-procedure, the area is made wet with saline, or ice packs can be used for comforting the patient. Thereafter, the patient is advised to use sunscreen regularly and follow sun-protective measures. The procedure is well-tolerated by the patients [3].

Figure 2: Pin-point bleeding after Microneedling which is easily controllable

MicroNeedling – How It Works?

Microneedling leads to reorganization of old collagen fibres and laying down of new collagen, elastin, and capillaries leading to the effect of skin tightening. A significant increase in level of collagen type I, III, and VII, newly synthesized collagen and tropoelastin from baseline was observed after 6 microneedling sessions at 2-week intervals by El-Domyati et al.[10] This percutaneous collagen induction leads to an overall youthful appearance of the skin by reducing fine lines and wrinkles, reducing pore size, more suppleness, and elasticity.

The effects are enhanced when the procedure is combined with topical anti-ageing vitamin C serum and tretinoin application. Microneedling has also been combined with human embryonic stem cells derived endothelial precursor cell conditioned medium and has shown significant reduction in wrinkles and pigmentation.[11,12] Fractional microneedling radiofrequency has been studied in a large multicentre trial and has found to be effective in reducing wrinkles.

Case Studies

Post-surgical scars were the first to be studied by Camirand [5] who used tattoo gun needles to reduce the scars. Since then, microneedling has been used for almost all types of surgical scars and are to be found useful. Microneedling has been found to be effective in reducing even burn scars by up to 80% in a study on 16 patients by Aust et al. It was stipulated that there is normalization of collagen-elastin matrix in the dermis at 1 year.[9,14] Microneedling is also effective for varicella scars [Figure 3] and post-traumatic scars.

Several studies show efficacy of microneedling for scar treatment. In a pilot study, El-Domyati et al quantified the histological changes induced by MN in ten patients with atrophic facial scars from acne [13]. Skin biopsies were obtained at baseline and post-treatment with Dermaroller. There was a statistically significant increase in the production of collagen types I, III, and VII and a decrease in total elastin by the end of treatment (p < 0.05). All patients reported mild pain and edema at the treatment site which resolved within 24 hours. Otherwise, no adverse effects were noted. Patients collectively reported a 51%–60% improvement in scar appearance, 40%–50% improvement in skin texture, and 80%–85% overall satisfaction (p = 0.001) following six treatment sessions over the course of 3 months.[13]

Figure 3: Varicella scars (a,c) showing improvement (b,d) after 3 microneedling sittings done 1 month apart.

Another study conducted by Lee et al. [11] reported significant difference after 5 treatment sessions. A total of 25 women were included in this randomized, controlled split-face study. The right and left sides of each participant’s face were randomly allocated to human embryonic stem cells conditioned medium or saline. To enhance epidermal penetration, a 0.25-mm microneedle roller was used. Five treatment sessions were repeated at 2-week intervals. Physician’s global assessment of pigmentation and wrinkles after treatment revealed statistically significant effects of microneedling. Skin measurements by Mexameter and Visiometer also revealed statistically significant effects of microneedling. The only minimal adverse event was mild desquamation in one participant.

Harris et al. [15] conducted a literature survey to highlight the effectiveness of Microneedling techniques. Total eighteen studies were included. Ten studies presented patients treated with skin needling alone, while eight studies discussed skin needling in combination with other treatments for acne scarring. All studies showed improvements in scarring after needling, with 12 reporting statistical significance. The median number of treatments when needling was used alone was three, the median duration between treatments was 4 weeks, and the median needle length used was 1.5 mm. Reported adverse events were infrequent and included post-inflammatory hyperpigmentation, “tram track” scarring, acne, and milia. There were no reports of bacterial infections.

Pragya Nair [16] reported that micro-needling is effective in grade 2 and 3 rolling/box car scars with good to excellent response and moderate response in pitted scars. Micro-needling aims to stimulate collagen production by producing micro wounds and initiating the normal post-inflammatory chemical cascade. Collagen fiber bundles qualitatively increase, thickens and are more loosely woven in both papillary and reticular dermis. It lays down in normal lattice pattern than in parallel bundles as in scar tissue. Neovascularization and neocollagenesis also occurs following treatment which leads to reduction of scars. It has a short healing time and can be used in any type of skin where lasers and deep peels cannot be performed. No risk of post inflammatory hyperpigmentation is evidenced [16].

New Approaches

Microneedling with dermaroller is a new treatment modality for the treatment of scars, especially acne scars, stretch marks, wrinkles, and for facial rejuvenation. It is a simple and relatively cheap modality that also can be used for transdermal drug delivery [17] .

The Principle of Collagen Induction Therapy

The medical dermaroller needles are 0.5-1.5 mm in length. During the skin beauty treatment, the needles pierce the stratum corneum and create microconduits (holes) without damaging the epidermis. It has been shown that rolling with a dermaroller (192 needles, 200 µm length and 70 µm diameter) over an area for 15 times will result in approximately 250 holes / cm2 . Microneedling leads to the release of growth factors which stimulate the formation of new collagen (natural collagen) and elastin in the papillary dermis. In addition, new capillaries are formed-this neovascularisation and neocollagenesis following treatment leads to reduction of scars.[9,18] The procedure is therefore aptly called “percutaneous collagen induction therapy” and has also been used in the treatment of photoageing. [17]

Expert Opinion

    1. Use good quality instruments—there are many instruments from different companies; using poor instruments may lead to breakage of needles in the skin.
    1. Counsel the patient that multiple sessions may be needed.
    1. Other treatments such as subcision, punch elevation may need to be combined for optimal results in acne scars.
    1. Application of EMLA cream anesthesia can prevent procedure pain and help in performing the procedure properly.
  1. Allow an interval of 4-6 weeks between the procedures to get good results.

Contraindications [8,19]

Microneedling is contradicted in following condition:

    1. Active acne
    1. Herpes labialis or any other local infection such as warts
    1. Moderate to severe chronic skin disease such as eczema and psoriasis
    1. Blood dyscrasias, patients on anticoagulant therapy
    1. Extreme keloidal tendency
  1. Patient on chemo/radiotherapy.

Adverse effects [11, 15]

Microneedling is safe and effective, but it has following minor adverse effects:

    1. Acne
    1. Milia
    1. Post-inflammatory hyperpigmentation
    1. Mild desquamation
  1. Tram track scarring

How many and how often will you need to have a treatment?

Normally 4-6 sessions in 4-6 week intervals with maintenance treatments every 6-9 months are required but the number of sessions can be decreased or increased as per skin condition and texture.

What does Microneedling treat?

Microneedling is beneficial in number of treatments…

    1. Skin tightening, lifting and rejuvenating
    1. Acne scars
    1. Stretch marks
    1. Axillary hyperhidrosis
    1. Wound healing
    1. Improving wrinkles and fine lines
    1. Actinic keratosis in photodamaged skin
    1. Alopecia areata
    1. Androgenic alopecia
  1. Minimizing pore size

References

  1. Telegraph Beauty. Why micro-needling could be the key to looking younger for women over 40. 2018  12 July 2018]; Available from: https://www.telegraph.co.uk/beauty/skin/micro-needling-key-looking-younger/.
  2. Ocean Medical Clinic. Micro-Needling and Collagen Booster Treatments. 2018  12 July 2018]; Available from: https://www.oceanmedicalclinic.gi/micro-needling-and-collagen-booster-treatments/.
  3. Singh, A. and S. Yadav, Microneedling: Advances and widening horizons. Indian Dermatology Online Journal, 2016. 7(4): p. 244-254.
  4. Orentreich, D.S. and N. Orentreich, Subcutaneous incisionless (subcision) surgery for the correction of depressed scars and wrinkles. Dermatologic Surgery, 1995. 21(6): p. 543-549.
  5. Camirand, A. and J. Doucet, Needle dermabrasion. Aesthetic plastic surgery, 1997. 21(1): p. 48-51.
  6. Bahuguna, A., Micro needling-Facts and Fictions. Asian Journal of Medical Sciences, 2013. 4(3): p. 1-4.
  7. Fernandes, D., Minimally invasive percutaneous collagen induction. Oral and Maxillofacial Surgery Clinics, 2005. 17(1): p. 51-63.
  8. Nair, P.A. and T.H. Arora, Microneedling using dermaroller: A means of collagen induction therapy. GMJ, 2014. 69(1): p. 24-27.
  9. Aust, M.C., et al., Percutaneous collagen induction therapy: an alternative treatment for scars, wrinkles, and skin laxity. Plastic and reconstructive surgery, 2008. 121(4): p. 1421-1429.
  10. El‐Domyati, M., et al., Multiple microneedling sessions for minimally invasive facial rejuvenation: an objective assessment. International journal of dermatology, 2015. 54(12): p. 1361-1369.
  11. Lee, H.J., et al., Efficacy of microneedling plus human stem cell conditioned medium for skin rejuvenation: a randomized, controlled, blinded split-face study. Annals of dermatology, 2014. 26(5): p. 584-591.
  12. Seo, K.Y., et al., Skin rejuvenation by microneedle fractional radiofrequency and a human stem cell conditioned medium in Asian skin: a randomized controlled investigator blinded split-face study. Journal of Cosmetic and Laser Therapy, 2013. 15(1): p. 25-33.
  13. El-Domyati, M., et al., Microneedling therapy for atrophic acne scars: an objective evaluation. The Journal of clinical and aesthetic dermatology, 2015. 8(7): p. 36.
  14. Aust, M.C., et al., Percutaneous collagen induction therapy: an alternative treatment for burn scars. Burns, 2010. 36(6): p. 836-843.
  15. Harris, A.G., C. Naidoo, and D.F. Murrell, Skin needling as a treatment for acne scarring: an up-to-date review of the literature. International journal of women’s dermatology, 2015. 1(2): p. 77-81.
  16. Nair, P., Micro needling: A form of collagen induction therapy for acne scars. Journal of Clinical and Experimental Dermatology Research, 2018. 8(1): p. 41.
  17. Doddaballapur, S., Microneedling with Dermaroller. Journal of Cutaneous and Aesthetic Surgery, 2009. 2(2): p. 110-111.
  18. Fernandes, D. and M. Signorini, Combating photoaging with percutaneous collagen induction. Clinics in dermatology, 2008. 26(2): p. 192-199.
  19. Bhardwaj, D., Collagen induction therapy with dermaroller. Community Based Medical Journal, 2013. 1(1): p. 35-37.