Microneedling advances and widening horizon .pptx

short overview of microneedling.
its introduction, indication, technique, complications.

1. Microneedling : Advances and widening horizons Kamal jung shahi 2 nd year Resident NGMC-TH

2. History 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. I n 1997 : plastic surgeon Camirand who used tattoo guns without ink to take-off tension from postsurgical scars . Later by a German inventor Liebl in 2000 and a plastic surgeon Fernandes in 2006 self-designed a drum-shaped device with multiple fine protruding needles and used it for percutaneous collagen induction.

3. Introduction Skin needling is also called collagen  induction therapy. It is a minimally-invasive non-surgical and non-ablative procedure for  skin rejuvenation  that involves the use of a micro-needling device to create a controlled skin injury . simple, cheap, safe, and effective technique requiring minimal training. 

4. Principle : collagen induction therapy. T he needles create holes by piercing through the stratum corneum . This leads to the release of growth factors, which stimulates collagen and elastin production in the papillary dermis. In addition to that, new capillaries are also formed .

5. Pathophysiology of percutaneous collagen induction: Platelets and eventually neutrophils release growth factors such as TGF-α, TGF-β, platelet-derived growth factor, connective tissue activating protein III, connective tissue growth factor, and others that work in concert to increase the production of intercellular matrix. Monocytes then also produce growth factor s to increase the production of collagen III, elastin, glycosaminoglycans , and so forth. Approx. 5 days after skin injury, a fibronectin matrix forms with an alignement of the fibroblasts that determines the deposition of collagen.

6. Scarless healing induced by transforming growth factor-beta3: Percutaneous collagen induction (PCI) initially upregulates TGF-β1 and -β2 levels at two and four weeks post-treatment, followed by a significant downregulation at eight weeks. TGF-β3 shows a strong upregulation two weeks post-needling, without downregulation at four and eight weeks after treatment. These findings suggest that PCI could offer a new approach to rejuvenate and enhance skin appearance and quality by reducing or preventing scarring

7. Skin regeneration and remodeling of extracellular matrix: PCI (Percutaneous Collagen Induction) impacts gene expression in skin, promoting extracellular matrix remodeling. Increase in Gene and protein expression of collagen I, glycosaminoglycans (GAGs), and growth factors like VEGF, EGF, and FGF7, crucial for skin regeneration. Collagen fiber bundles were qualitatively increased and more loosely woven after medical needling. Epidermal-dermal interface showed regular dermal papillae and maintained cellular polarity and differentiation . Connective tissue network within the reticular dermis was thickened and organized. This study observes regeneration processes after PCI, indicating potential for regenerating healthy skin in vivo.

8. Percutaneous collagen induction and postinflammatory dyspigmentation : The number of melanocytes was unchanged after medical needling. Additionally , DNA microarray experiments demonstrated (2 weeks post-operatively): Interleukin-10 was increased MC1R gene ( Melanocortin 1 receptor), coding for a melanocyte-stimulating hormone, indicated a faint down-regulation Therefore , in opposite to dermabrasive procedures, percutaneous collagen induction therapy appears to have a lower risk of dyspigmentation .

9. Phases of healing following microneedling : Inflammation: on average visible inflammation phase lasts approx 48 hours. Chilled cooled mask soaked in hyaluronic acid (reduce atleast 50% erythema in 30 minutes). Visible edema is minimal but if appears fade within 48 hours. Proliferation : Starts immediately and reaches peak approx 2 months later. R emodelling .: New collgen fibre III integrate into existing skin matrix. Improvement is seen 3-4 weeks after treatment. Longer duration to mature collgen III to I Atrophic scar: 2-3 weeks Hypertrophic scar: many months.

10. Important considerations: Devices based on needle length, drum size, and automation.   High ratio of tip length versus diameter of 13:1 is an important property of good needles . Length of needle = indication of procedure For acne and scars : 1.5–2 mm. For ageing skin and wrinkles : 0.5 mm or 1.0 mm Minimum time interval between two sittings of microneedling depends upon the indication. More is the needle length, greater should be the interval between two sittings of microneedling .

11. VARIOUS INSTRUMENTS AND TECHNIQUES Dermaroller Dermapen Dermafarc Derma-stamp Microneedle delivery systems Fractional radiofrequency microneedling Light emitting microneedling device

12. Dermaroller FDA registered Five basic types of medical dermarollers ; C-8 (Cosmetic type), is the basic dermaroller needle length of only 0.13 mm (130 μm ) used for enhancing penetration of topical agents . It is completely painless. C-8HE (Cosmetic type for hair-bearing surfaces, scalp) has a needle length of 0.2 mm (200 μm ). Even this length is below the pain threshold. CIT-8 (CIT: Collagen Induction Therapy, Medical type) has a needle length of 0.5 mm (500 μm ) and helps in collagen induction and skin remodelling . MF-8 type has a needle length of 1.5 mm (1500 μm ). This creates deeper microchannels on the whole epidermis and dermis and at the same time destroys scar collagen bundles. MS-4 is the only dermaroller that has a smaller cylinder, 1 cm length, 2 cm diameter, and subsequently 4 circular arrays of needles (total 96 needles) that have 1.5 mm length. It is mostly used on facial acne scars.

13. Home-care dermarollers (C-8) are U sed by patients themselves. N eedle length less than 0.15 mm and are A vailable for reduction of pore size, fine lines, and sebum production, as well as for transdermal delivery of substances such as lipopeptides and other antiageing products. C an be used twice or thrice a week for up to 100 times. C leaned in hot tap water and shaken dry. Beauty Mouse another approved device intended for home use. It contains a total of 480 needles of approximately 0.2 mm size on 3 separate drums strategically placed inside a computer mouse shaped device. It has been developed to ensure coverage of larger skin surface areas, such as the arms, legs, and buttocks for the treatment of stomach or thigh stretch marks and cellulite.

14. B. Derma-stamp These are miniature versions of the dermaroller . N eedle lengths (0.2–3 mm) and a diameter of 0.12 mm that are used for localized scars such as varicella scars. Advantage over the dermaroller is that a more focussed treatment of individual scars is possible. It causes vertical penetration to create infusion channels in the skin and is considered ideal for use on isolated scars and wrinkles

15. C. Dermapen Automated microneedling device which looks like a pen . Uses disposable needles and guides to adjust needle length for fractional mechanical resurfacing. The tip has 9–12 needles arranged in rows . R echargeable battery to operate in two modes, namely, the high speed mode (700 cycles/min) and the low speed mode (412 cycles/min) in a vibrating stamp-like manner . Advantage: R eusable in different patients . S afe as the needle tips are hidden inside the guide, and M ore convenient to treat narrow areas such as the nose, around the eyes and lips. L ess painful and more economical as there is no need to buy a new instrument every time . This technology has been designed to overcome the issues of varying pressure application and the subsequent depth of penetration achieved.

16. D. DermaFrac Combines microdermabrasion , microneedling , simultaneous deep tissue serum infusion, and light emitting diode (LED) therapy . DermaFrac treatments target aging and sun damaged skin, acne, enlarged pores, uneven skin tone, wrinkles, fine lines, hyperpigmentation, and superficial scars. It takes approximately 45 min to complete full face treatment when all four modalities are used. This noninvasive, cost-effective treatment carries the advantage of having no downtime with individualized selection of serums for infusion.

17. E. Microneedle delivery systems Microneedle delivery systems provide a minimally invasive and painless approach for transdermal drug administration, particularly suitable for vaccines. Types of microneedles include solid, coated, dissolving, hollow, and swellable polymer microneedles , fabricated using microfabrication techniques. Materials used for microneedle fabrication include silicon, metals like titanium, natural and synthetic polymers, and polysaccharides. Solid-coated microneedles pierce the superficial skin, allowing topical application and drug delivery. Dissolving or biodegradable and hollow microneedles directly deliver drugs into the dermis, bypassing the superficial layers for enhanced absorption.

18. G . Fractional radiofrequency microneedling . combines microneedling with radiofrequency technology, broadening its applications. Key points include: Insulated Needles : Insulated needles penetrate the skin and release radiofrequency currents from the tips, creating thermal zones in the dermis and accessory glands without harming the epidermis. Dermal Remodeling : This process stimulates long-term dermal remodeling, neoelastogenesis , and neocollagenesis , promoting skin rejuvenation. Adjustable Depth : Needle depth can be adjusted from 0.5 mm to 3.5 mm, allowing precise targeting of different dermal layers. Controlled Tissue Damage : Operators can control tissue damage by adjusting power levels and energy pulse durations. Disposable Tip : The main energy delivery system typically features a disposable tip with 49 gold-plated needles. Safe for Various Skin Types : As it doesn't harm the epidermis, fractional radiofrequency microneedling is considered safe for darker skin types. Indications : Applications include scar treatment, hyperhidrosis, skin tightening, rejuvenation, and more.

19. H. Light emitting microneedling device LED microneedling rollers have been recently launched. These incorporate titanium microneedles and LED light to combat wrinkles and scarring. These devices have not yet been explored and no published data is available regarding its efficacy

20. PROCEDURE S imple office-based procedure lasting 10 to 20 minutes depending on the area to be treated . Proper Counselling 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.

21. U nder topical anesthesia containing eutectic mixture of lignocaine and prilocaine / tetracaine for 45 minutes to 1 hour . P reparation of the area with antiseptic and saline. S kin is stretched with one hand, and perpendicularly, rolling is done 5 times each in the horizontal, vertical, and oblique directions with the other hand. T reatment endpoint is identified as uniform pin-point bleeding which is easily controllable.

22. 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 . No post-treatment sequelae except slight erythema and edema lasting for 2–3 days.

23. APPLICATIONS OF MICRONEEDLING IN DERMATOLOGY W ide range of indications. Tried alone as well as in combination with other treatment modalities such as chemical peeling, platelet rich plasma, radiofrequency, subcision , punch elevation, and lasers . It is often used in conjunction with a topical formulation, and hence, enhances its penetration and action.

24. I. Skin rejuvenation 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 .

25. II. Scars Acne scar Non acne scar

26. Table: Fractional microneedling radiofrequency trials for acne vulgaris 

27. III. Androgenic alopecia and alopecia areata

28. IV. Pigmentation— Melasma and periorbital hypermelanosis

29. V. Miscellaneous conditions

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

31. Advantage Disadvantage Preservation of Epidermis Blood Exposure : Repeatability : Anesthesia Requirement : Suitability for Sensitive Areas Swelling and Bruising : Short Healing Phase Longer Interval for Results :

32. Pre (a, c, e) and post (b, d, f) treatment photographs of post-acne atrophic scar patients after 4 sittings of microneedling done 1 month apart Post-varicella scars ( a,c ) showing improvement ( b,d ) after 3 microneedling sittings done 1 month apart

33. Significant improvement in post-traumatic scar over the nose after 1 sitting of subcision followed by 3 sittings of microneedling done 1 month apart

34. REFRENCES Ferguson Mark W. J.   and O'Kane Sharon 2004Scar–free healing: from embryonic mechanisms to adult therapeutic intervention Phil . Trans. R. Soc. Lond . B 359 839–850. Singh A, Yadav S. Microneedling : Advances and widening horizons. Indian Dermatol Online J. 2016 Jul-Aug;7(4):244-54. doi : 10.4103/2229-5178.185468. PMID: 27559496; PMCID: PMC4976400. The Role of the Anti-Inflammatory Cytokine Interleukin-10 in Tissue Fibrosis Emily H. Steen ,   Xinyi Wang ,   Swathi Balaji ,   Manish J. Butte , Paul L. Bollyky and   Sundeep G. Keswani