Dermaroller for management of acne scars

14 Pages·2009·2.2 MB·English

Page 1 of 13 Journal of Cosmetic Dermatology
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6 Percutaneous Collagen Induction with Dermaroller TM
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8 for Management of Atrophic Acne Scars in 31 Thai
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10 Patients
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13 Keywords: Percutaneous collagen induction, Skin needling, Acne scar,
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Asian patients
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18 Short title: Dermaroller TM in treatment of atrophic acne scars
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Abstract: o
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25 Percutaneous collagen inducti on with Dermaroller TM MF 8 (Horst, Liebel Co, Germany,US
26 FDA registered no.878-4800), 1.5 mm needles was used for treatment of atrophic ace scar
27 in 31 Thai patients. All patientsP had moderate to advance atrophic acne scar with Fitzpatrick
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skin type III to V. The treatment was performed under local anesthesia with sterile aseptic
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30 technique. The number of treatments ranged from 1 to 4 at monthly interval. Clinical
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evaluation was performed by side by side comparison of standard photographies by two
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non-medical independent observers. After six months follow up the clinical severity scores
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34 decreased from 4.24 to 2.33. The improvement of more than 50% was observed in 67.74 %
35 of cases. Complications were rare and transient,6.45% developed post treatmnent folliculitis
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which responded to oral antibiotics. Dermaroller TM had been shown to be effective and safe
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38 percutaneous collagen induction for treatment of atrophic acne scar in Fitzpatrick skin type
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Introduction:
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Acne vulgaris is one of the most common skin disease. After active inflammatory
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45 phase had subsided a large portion of patients have been left with atrophic scar.
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Many studies had confirmed the psycho-social significance of atrophic acne scar.
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48 Severe atrophic acne scar which happened at important period of life i.e.
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adolescence had important psychologic impact to the patients. Higher incidence of
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51 introvert personality changes and depression were common in severe acne scar
52 cases. In the past treatments of atrophic acne scar were difficult and complicated.
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Chemical peels, dermabrasion ,laser resurfacing and non-ablative laser resurfacing
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55 had produced false hope. These treatments were complicated, expensive ,with high
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complications and inconsistent results. Recently percutaneous collagen induction
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58 (PCI) with Dermaroller TM device had been introduced in Europe with impressive
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results. Dr.Des Fernandes was the first to call this technique skin needling or
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percutaneous collagen induction (PCI) and presented his study at the XIIth Congress
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of the International Society of Aesthetic Plastic Surgery in Paris, France in 1993.He
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5 had also published the technique in detail in 2005.1Together with his collegues he
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had published the first article on PCI for treatment of scars, wrinkles and skin laxity
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in his large study of 480 patients from South Africa and Germany , he had reported
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9 good result in majority of cases.2 . The author had been performing this treatment
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since 2006 . Since there was no data on efficacy and complications of this technique
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12 for management of atrophic scars in Asians’ Fitzpatrick skin type III to V .This article
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will describe clinical findings in the first batch of 31 Thai patients.
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Study design:
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18 Long-term (6 months) open prospective study with independent observers
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evaluation
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Patients and method:
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24 Thirty one patients with mroderate to severe atrophic acne scar . Twenty were male
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and ten were female with age ranging from 24 to 45 years old . After fully informed
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27 of the procedures all patientsP agreed to sign the informed consents. After
28 throughoutly cleansing of the face, five standard ( direct infront, 45o and 90o to left
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and right side of face) studio-type photographies with fixed studio lighting and fixed
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31 distance were taken with digital cameera ( Olympus C760, Japan).
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Local anesthesia with topical xylocaine and pilocaine mixture (EMLA, Astra , Sweden)
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35 were applied over the whole face and covered with cellophane tape for one hour.
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54 Figure 1: Skin needling device ( Dermaroller TM, MF 8, 1.5 mm needles,
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56 Horst Liebel Co, Germany)
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EMLA was then removed with sterile water. The face was then painted with 1%
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60 Betadine solution. Sterile drape was applied to the face and exposed only the
treatment area.
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Additional to EMLA , infraorbital, supraorbital, mental and superficial nasal nerves
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5 blocks were performed with 1% Xylocaine (Astra, Sweden) injection. Field block with
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the same anesthetic was performed at lateral mandibular areas.
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Sterile single use disposable skin needling instrument ( DermarollerTM, MF 8,Horst
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10 Liebel Co, Germany, European FDA approval number CE 0373, US FDA registered
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number 878,4800) with 1.5 mm 192 needles was used for the treatment.(Figure 1)
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13 The treatment area was tightened while with firm pressure ,the author hold the
14 handle of the device and rolled the instrument on a small plot of treatment area.
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Each pass of rolling produced 16 micro-punctures/cm2. The instrument was rolled
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17 back and forth with different directions for 10-20 times on the treatment plot. During
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treatment few drops of Oxoferin TM solution (,Holopack Verpackungstechnik GmBH,
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20 Germany) were applied to the treatment areas. The purpose of application of this
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21 solution was to enhance wound healing .(Figure 2) The Dermaroller TM device would
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23 produced tangentially oneedle holes 250 micrometers down into middermis. (Figure
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Minimal bleeding from needle holes were observed while the author varied directions
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28 to avoid repeated puntures on the same needle holes. The treatment was repeated
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on adjacent areas to cover the entire faces. After treatments ,the bleeding was
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31 controlled with light pressure with seterile gauze and application of Oxoferin TM.1%
32 Fucidic acid ointment ( Fucidin TM, Leor, UK ) was then applied to the treatment area.
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All the treatments had been performed by the author.
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Figure 2: Treatment of atrophic acne scar with Dermaroller TM
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10-20 passes of firm pressure, multi-dirction rolling of device on each area
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24 Figure 3: Hisrtologic changes immediately after DermarollerTM
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26 (MF 8, 1.5 mm needles) . There was 1-1.5 mm. deep
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needle holes into the dermis.
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Oral antibiotics ( Cloxacillin, Dicloxacillin ,Augmentin or Co-trimoxazole) for seven
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34 days were prescribed in some cases with active acne pustules.
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The patient was advice to clean face with sterile normal saline and applied open
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38 wound care technique with application of FucidinTM ointment twice daily until the
39 wounds were completely healed ( between 5-7 dvays). There was mild to moderate
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facial edema for few days. Usually the post treatment pain was minimal.
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43 Follow up and retreatments:
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45 The patient was followed up at seven days. Topical sunscreen and emollients were
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then prescribed. Standard studio type photographies similar to pre treatment were
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48 taken. Post treatment facial skin usually was not sensitive to sunlight which was
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differed from after laser resurfacing.
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52 The repeated treatments were performed at interval of 1-2 months. The number of
53 repeated treatments were as followed 7 cases had one treatment,12 cases had two
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treatments, 5 cases had three treatments and 7 cases had four treatments. The
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56 duration of follow-up was six months.
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Acessment of results:
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Two independence nonmedical observers were requested to evaluate clinical
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7 improvement scores from side by side comparison of recorded standard
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photographies. Standard six points improvement scores were used.
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11 5 = severe atrophic scar pre treatment
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13 4 = improvement between 0-25%
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15 3 = improvement between 26-50%
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2 = improvement between 51 – 75%
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1 = improvement between 76 – 90%
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0 = improvement > 91%
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24 Results: r
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26 Figure 4 demonstrated clinical severity scores after 1-4 treatment with Dermaroller
27 TM in 31 patients. The numbePr of treatments varied from 1 to 4 . Usually the mild
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29 cases were treated once, while seevere cases had 3-4 treatments.
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33 Clinical Improvement of acn e scar after dermaroller in 31 cases
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1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31
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54 Case No.
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59 Figure 4: Clinical improvement as graded by independent observers in 31 cases. All cases
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had clinical improvement at six months. The number of treatment ranged from 1 to 4.
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The mean clinical scores decreased from 4.24 to 2.33 at six months of follow-up.
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5 (Figure 4).Five case ( 16.13%) had improvement more than 75% while 21 cases
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(67.74%) had improvement more than 50%.(Figure 5,6,7,8) Two cases(6.45%)
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developed folliculitis within a few days after treatments. This cleared rapidly after
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9 oral antibiotics.
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Table 1: Mean acne scar severity scores after 1-4 Skin needling (Dermaroller TM)
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by two indepencence non-medical observers for side by side standard
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18 photographies comparison in 31 cases.
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22 Mean, Pre treatment Mean, Post treatment
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26 4.24 2.33
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Discussions:
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33 Management of atrophic acne scar in da rk skin types were difficult. The standard
34 treatments in white skin (Fitzpatrick skin type I,II) included dermabrasion, chemical
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peels, carbondioxide or erbium laser resurRfacing. 3,4,5,6 Even in white skin patients
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37 results from these treatments were far from seatisfactory. 4The treatments were
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complicated to perform with prolong healings and long term dyschromias. Post
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40 treatments erythema was found in all cases, lastingi average 4.5 weeks after CO2
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laser and 3.6 weeks after long-pulsed Er:YAG laser. Hyperpigmentation was seen in
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43 46% after CO2laser and 42% after Er:YAG laser .This hyperpigmentation lasted 12.7
44 and 11.4 weeks respectively 7 .In dark skin types ( Fitzpwatrick skin type III –VI)
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these laser treatments were abandoned because of serious post treatment
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47 complications especially post inflammatory hyperpigmentation and late onset
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permanent hypopigmentation . Alster TS and West TB had reported 81.4%
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50 improvement after pulsed CO laser in Fitzpatrick skin type I-IV but also observed
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51 prolong erythema in all cases with 36% post treatment hyperpigmentation.3
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53 Nonablative laser resurfacing with absence of downtime often resulted in minimal
54 improvement. Most of the study had shown that after repeated treatment the
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degree of improvement were less than 30%.8,9.Chan et al had found that after 1,320
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57 nm Nd:YAG laser treatment monthly for six months, patients’ satisfaction score was
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4 from scale 0-10. From an independent observer the improvement was considered
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60 to be mild or no changes in majority of cases .8Only recently with introduction of
fractional laser resurfacing with Erbium-doped or laser which produced array of
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minutes thermal necrotic holes deep into the dermis that there were fair to good
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5 clinical improvement after multiple treatments (30-50%). Lee et al had reported
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marked improvement in the appearance of acne scars at 3 months post-treatment in
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27 Korean patients. Patients' self-assessed degrees of improvement were as follows:
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9 excellent improvement in eight patients (30%), significant improvement in 16
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patients (59%), and moderate improvement in three patients (11%). Adverse events
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12 were limited to transient pain, erythema and edema. 9 The complications after
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fractional laser resurfacing was related to thermal injuries. Too high density of laser
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15 spots often resulted in post treatment erythema and post inflammatory
16 hyperpigmentation especially in dark skin type. PIH after fractional laser resurfacing
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in Asians had been reported in 15% of cases. The cost of fractional laser equipment
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19 and high consumable cost had discouraged wide acceptance of this laser in most of
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developing countriFes.
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23 Skin needling with speocial roller instrument with 298 tiny sharp stainless steel
24 needles (250 Km, diametrer) and length between 0.5 to 2 mm. had been introduced
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in Europe and South Africa by Des Fernandes since 1993.1He named this technique
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27 minimally invasive percutanePous collagen induction and had the first publication in
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2005.1 The result after treatment of atrophic acne scar had been found to be
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30 satisfactory with minimum downtimes. 2 The mechanism behind clinical improvement
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was purposed to be results of tangentially cutting of fibrotic scars by pressure rolling
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33 and induction of blood clot, platelets act ivation, released of cytokines especially
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etc. These resulted in induction of new coRllagen formation together with scar
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37 remodeling. This results in elevation of atropheic scar and reduction of fibrotic
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scarborders.1 Due to small size of needle holes healing was rapid. Usually the tiny
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40 needle wounds healed in three days. The degree ofi scar improvement from wound
41 remodeling went on for many months after even single treatments.1,2
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Since this PCI technique had gained acceptance in Europe and South Africa1,2 but
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45 the clinical study in Asians’ skin was lacking. This study had shown that with good
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patients selection, sterile method and good technique the degree of clinical
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48 improvement for treatment of atrophic acne scar in Fitzpatrick skin type III to V
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,Asian patients was moderate to good result, with 67.74% had more than 50%
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51 clinical improvement. This result was almost equal to those after CO2 laser
52 resurfacing3 but with better healing and much lower post treatment complications. It
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also is about the same efficacy with fractional laser resurfacing.10 Post inflammatory
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55 hyperpigmentation which was directly related to thermal injury was more common
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after fractional laser resurfacing 11 was absent after skin needling. The overall cost
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58 after multiple treatments with skin needling was much lower than fractional laser
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resurfacing.
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The quality ,hardness and sharpness of needles are important property of good skin
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5 needling device. Basically ice-hardening steel with tensile strength more than 2,200
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Newtons will ensure better chance of good result and also without complications.
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High ratio of tip length VS diameter of 13:1 is another important property of good
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9 needles .The depth of neocollagenesis was found to be average 5-600 micrometers
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even after 1.5 mm length needle. So the needle length longer than 1.50 mm was
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12 unnecessary. 1The Dermaroller TM had obtained CE approval and US FDA approval as
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medical device from Germany and USA since January 2006. Poor quality needles of
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15 the roller device often resulted in bending at needle tips after repeated treatments
16 .Thes resulted in in more tissue damages and hemorrhage with linear hypertrophic
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scars or post inflammatory hyperpigmentation.1This reason together with problems
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19 of cross contamination is the reason why single-use device is recommended. To
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avoid any possible Fcomplications doctors who are interested in performing this
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22 technique should attend a hand-on training course from experience dermatologic
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surgeons.
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In conclusion, percutaneous collagen induction by skin needling with high quality
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27 single-use device (DermarollePr TM, Horst Liebel Co, Germany) had been shown to be
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highly effective and safe method for treatment of atrophic scar in Fitzpatrick skin
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30 type III to V Thai patients.
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32 References: r
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1.Fernandes D. Minimally invasive percutaneous collagen induction. Oral Maxillofacial
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36 Surg Clin N Am. 2005;17: 51-63
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38 2.Aust MC, Fernandes D, Kolokvthas P, Kaplan HM, Vogt PM. Percutaneous collagen
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induction therapy: an alternative treatment of scars, wrinkles, and skin laxity. Plast
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41 Reconstr Surg. 2008; 121(4):1421-9
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3.Alster T, West TB. Resurfacing of atrophic facial acne scars with a high-energy
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45 pulsed carbondioxide laser. Dermatol Surg. 1996:22(2),154-155
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47 4.Goldman MP, Manuskiatti W. Combined laser resurfacing with the 950 microsecond
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pulsed CO2 + Er:YAG lasers. Dermatol Surg . 1999: 25(3): 160-3
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51 5.Woo SH, Park JH, KveYC. Resurfacing of different types of facial acne scar with
52 short-pulsed, variable-pulsed , and dual-mode Er:YAG laser. Dermatol Surg .
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2004;30:488-93
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56 6.Jeong JT, Kve YC. Resurfacing of pitted facial acne scars with a long-pulsed
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Er:YAG laser. Dermatol Surg. 2001;276:107-10
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7.Tanzi EL, Alster T. Single-pass carbon dioxide versus multiple-pass Er:YAG laser
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5 skin resurfacing:a comparison of post operative wound healing and side effect rates.
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Dermatol Surg .2003:29;80-4
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8.Chan Hm ,Lam LKm Wong DS, KonoT, Trendekk-Smith N. Use of 1320 nm NdYAG
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10 laser for wrinkle reduction and the treatment of atrophic acne scarring in Asians.
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Lasers Surg Med .2004;34:98-103
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9.Chua SH, Ang P, Khoo LS, Goh CL. Nonablative 1450 nm diode laser in the
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15 treatment of facial atrophic acne scars in type IV to V Asian skin: a prospective
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clinical study. Dermatol Surg. 2004:30;1287-91
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19 10.Lee HS, Lee JH, Ahn GY, Lee DH, Shin JW, Kim DH, Chung JH. Fractional
20 photothermolysis for the treatment of acne scars: A report of 27 Korean patients. : J
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Dermatolog Treat. 2008;19(1):45-9.
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24 11. Kono T, Chan HH, Grroff WF, Manstein D, Sakurai H, Takeuchi M, Yamaki T,
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Soejima K, Nozaki M. Prospective direct comparison study of fractional resurfacing
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27 using different fluences and Pdensities for skin rejuvenation in Asians. Lasers Surg
28 Med. 2007 Apr;39(4):311-4.
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