Skin condition is an important determinant of human attractiveness, 1 but with age and increased exposure to ultraviolet radiation and other lifestyle factors such as poor nutrition, alcohol consumption, and smoking, the complexion is subject to a number of undesirable changes including dryness, roughness, development of surface blood vessels, uneven pigmentation, loss of elasticity, and wrinkling. In younger patients, atrophic scarring commonly as a complication of acne vulgaris can have a significant effect on self-esteem and quality of life. 2
A number of minimally invasive skin rejuvenation and resurfacing procedures are available to correct or ameliorate these changes, such as ablative and nonablative lasers, radiofrequency, ultrasound, chemical peels, dermabrasion, injectable fillers, and microneedling. All are designed to create dermal injury and thereby, stimulate wound repair and neocollagenesis, but differ in the type of injury utilized. Microneedling, or collagen induction therapy, is one such technique that uses fine needles to puncture the skin at various depths and create controlled skin injury without damaging the full epidermis ( ▶ Fig. 10.1). 3 Each puncture creates a channel in the dermis, triggering the release of growth factors and cytokines. 4, 5 These, in turn, stimulate neocollagenesis, neoelastogenesis, and angiogenesis. A number of microneedling devices are available such as dermal rollers and the more recently developed, dermal stamps or automated pens. 6 Microneedling is safe on any skin type due to the lack of thermal energy and is an effective technique for the treatment of fine lines, wrinkles, loose skin, acne or other scarring, stretch marks, and potentially melasma or hyperpigmentation as well as alopecia. Combining it with other topical products, such as growth factors, vitamin A and/or C, and more recently, platelet-rich plasma (PRP), may enhance drug delivery and overall benefits. It is hypothesized that the additional growth factors and cytokines from the PRP act synergistically with the already accelerated neocollagenesis from microneedling for even more rapid and robust collagen remodeling. This chapter will review the techniques for optimal results and complication avoidance with microneedling and PRP.
Fig. 10.1 Needle length (mm) and skin structure targeted. Note: True depth of penetration depends on anatomic location.
10.2 Patient Suitability
Both microneedling and PRP are suitable for all skin types, even darker Fitzpatrick tones with minimal risk of inducing hypopigmentation. 4, 7 Contraindications are primarily disease related. For microneedling, care must be taken not to treat patients with any active infections or conditions that may be spread or exacerbated by skin puncture (i.e., pathergy). History of keloidal or hypertrophic scars may also limit therapy, particularly at certain anatomic locations.
Contraindications for PRP include metastatic or systemic diseases that prevent the patient’s blood from being used for therapy; low platelet or fibrinogen counts; anemia; infections in the therapy areas; and heavy nicotine and alcohol consumption. Corticosteroid injections and nonsteroidal anti-inflammatory drugs should be avoided if possible, as they may prevent the inflammation that is essential for the PRP serum to work. In addition, anticoagulant prescription medications or antiplatelet therapy should be stopped for a few weeks before and after PRP therapy. Certain chemotherapy agents such as tamoxifen alter platelet function and thus should also be taken into consideration when designing an optimal treatment plan, though the true effects on outcomes is unknown at this time.
10.3 Pre- and Postprocedure Care
A careful patient history should be taken to obtain information on any allergic reactions, in particular reactions to the topical treatments that will be used before and after therapy and to metals that may be present in the microneedles such as nickel, silver, or gold. Data suggest that at least 1 month prior to treatment, patients should begin applying vitamins A and C formulations twice-daily to the target area to maximize dermal collagen formation. 7 Vitamin A influences numerous genes that control the proliferation and differentiation of epidermal and dermal cells, while vitamin C is essential for normal collagen production. 7
The treatment area should be cleansed fully of makeup or other debris then anesthetized with topical anesthetic for 45 minutes to 1 hour, during which time the PRP can be prepared. Immediately prior to treatment, the skin is disinfected again with normal saline and 70% ethanol to remove all anesthetic. The skin should be wiped with sterile saline pads/gauze after the session. During combination treatments, some providers leave PRP on the surface of the skin for up to 24 hours to allow for full platelet degranulation. Cold compresses can be applied to reduce swelling. Application of nonapproved topical products prior to, during, and after microneedling can introduce immunogenic particles into the dermis and cause hypersensitivity reactions, so should be avoided. Space treatments by approximately 4 weeks duration, and patients should be advised that the full cycle of collagen synthesis and remodeling is a slow, multistage process that can take up to 10 to 12 months, so improvement will likely not be evident during their first sessions. 4 It is important to adhere to the schedule and not discontinue after one or two sessions; photos of the skin before and after microneedling treatments will help patients judge their progress. Diligent sun protection and sunscreen is paramount. Patients can generally return to work the next day, but should avoid applying makeup or other topical agents (other than those provided) for the first 24 hours while the needling channels reseal.
10.4 Adverse Events: Avoidance and Treatment
The rate of adverse events associated with microneedling and PRP is low and the majority mild as a result of trauma from needles piercing the skin ( ▶ Fig. 10.2, ▶ Fig. 10.3, ▶ Fig. 10.4, ▶ Fig. 10.5). Small-scale studies evaluating the effects of microneedling with and without the application of PRP, most often for the treatment of atrophic scars, have shown that patients tend to experience 2 to 3 days of mild bruising, erythema, edema, and peeling after treatment regardless of the addition of PRP. 8, 9, 10, 11, 12 Skin may also feel warm, tight, and pruritic for a short while (much like an ultraviolet burn), but this sensation normally resolves in 12 to 48 hours.
Fig. 10.2 Patient immediately after microneedling to a depth of 1 mm illustrating erythema and pinpoint bleeding.
Fig. 10.3 Patient immediately after microneedling to a depth of 3 mm.
Fig. 10.4 (a, b) Patient at days 1 and 2 post-microneedling with topical platelet-rich plasma.
Fig. 10.5 (a, b) Erythema and swelling in a patient immediately after receiving injections of platelet-rich plasma with a 30-gauge needle.