Rejuvenation of severe acne scars by microneedling

Abstract

Abstract
Objectives: To find the effect of microneedling dermapen© on dark skin individuals and
severe form of atrophic acne scar.
Patients and methods: The study was conducted as open clinical trial in dermatology clinic at
Ibn-Sina Teaching Hospital in Mosul, Iraq. Twenty-five patients were included in the study.
The severity of acne scars was determined by using Goodman and Baron global quantitative
acne scar grading system (GBGQASGS). Patients with grade 3 and 4 were eligible for the
study. All patients underwent 4sessions of dermapen microneedling treatment at six-week
intervals.
Results: The studied individuals consisted of 15 (60%) patients with Grade 3, and 10 (40%)
patients with Grade 4 acne scars. The results revealed that 12% of the patients had minimal
improvement, 48% had a moderate improvement, 40% had good improvement and no patients
showed excellent improvement according to GBGQASGS. The mean ± SD of GBGQASGS
was reduced from 16.39±3.43 to 7.78±2.79 at the end of sessions (p-value <0.0001). The
results showed an inverse relationship between the baseline severity score and the degree of
improvement of acne scars. The effect of dermapen© on acne scars showed the largest effect
on the depth of scar (Cohen d =1.53), then on number of scar (Cohen d =1.37), and lastly on
size of the scar (Cohen d =1.26). No serious post treatment complications were reported.
Conclusion: Dermapen© microneedling therapy can be used for the treatment of atrophic
acne scars, but it is not the treatment of choice in severe form of acne scars.

Full text

European Journal of Molecular & Clinical Medicine
ISSN 2515-8260 Volume 07, Issue 09, 2020
1966
Rejuvenation of severe acne scars by
microneedling
Qasim S. Al Chalabi1 , Mohammed N. Al Malah2, Haitham B. Al Badrani2
1Department of Medicine, College of Medicine, University of Mosul, Mosul, Iraq
2 Department of Medicine, College of Medicine, University of Nineveh, Mosul, Iraq
Abstract
Objectives: To find the effect of microneedling dermapen© on dark skin individuals and
severe form of atrophic acne scar.
Patients and methods: The study was conducted as open clinical trial in dermatology clinic at
Ibn-Sina Teaching Hospital in Mosul, Iraq. Twenty-five patients were included in the study.
The severity of acne scars was determined by using Goodman and Baron global quantitative
acne scar grading system (GBGQASGS). Patients with grade 3 and 4 were eligible for the
study. All patients underwent 4sessions of dermapen microneedling treatment at six-week
intervals.
Results: The studied individuals consisted of 15 (60%) patients with Grade 3, and 10 (40%)
patients with Grade 4 acne scars. The results revealed that 12% of the patients had minimal
improvement, 48% had a moderate improvement, 40% had good improvement and no patients
showed excellent improvement according to GBGQASGS. The mean ± SD of GBGQASGS
was reduced from 16.39±3.43 to 7.78±2.79 at the end of sessions (p-value <0.0001). The
results showed an inverse relationship between the baseline severity score and the degree of
improvement of acne scars. The effect of dermapen© on acne scars showed the largest effect
on the depth of scar (Cohen d =1.53), then on number of scar (Cohen d =1.37), and lastly on
size of the scar (Cohen d =1.26). No serious post treatment complications were reported.
Conclusion: Dermapen© microneedling therapy can be used for the treatment of atrophic
acne scars, but it is not the treatment of choice in severe form of acne scars.
Introduction
Acne is a common skin disorder seen in about 80 percent of young people (1). In some patients
unfortunately has severe form of acne with severe inflammatory changes in the superficial and
deep dermis, leading to post-acne scars (2). Many patients with acne scar develop psychological
upset and they suffer from low self-esteem and many other mental health disorders because of
this condition (3).
There are many types of acne scars, and can be classified into icepick, boxcar, rolling scars,
hypertrophic and keloidal form (2). More than one type might be seen on the same patient (2).
There are several methods of treatment developed to reduce the severity and intensity of
post acne scar including topical treatment (4), dermabrasion (5), chemical peeling (6), ablative
and non-ablative lasers (7), microneedling (8,9) and several other modality of treatment (10).
Many methods have been proposed and practiced to induce minute injuries at the site of acne

European Journal of Molecular & Clinical Medicine
ISSN 2515-8260 Volume 07, Issue 09, 2020
1967
scare (11). Unfortunately they produced uncontrolled micro-injuries with variable elastin and
collage synthesis (11).
Recently, the principal of microneedling as a method for remodeling acne scar was
improved by the introduction of automated electrical device dermapen© (12). The device
induced fast, adjustable microneedling and hence controlled elastin and collagen synthesis.
Different guidelines of treatment of acne scar were used, resulted in different success rate.
Two studies of micro-needling technique aided in standardizing the dermapen© micro-needling
therapy. First, a serial histopathological study which determined the best frequency and depth of
applying needling to induce proper amount of elastin and collagen (11). Second, the introduction
of reliable objective Goodman and Baron method to assess and grade acne scar and its response
to treatment (13).
Most workers on microneedling studied treatment of mild and moderate form of acne scars
with variable scoring system (8,9,10,14). Most of those workers used derma rollers
microneedling that had limited control in the depth of the needle insertions in the skin and has
limited movement in narrow anatomical areas in the face (8,9).
The objective of this study is to find the effect of microneedling dermapen© on remodeling
acne scars of dark skin individuals and severe form of atrophic acne scar.
Patients and methods
Twenty five patients suffering from different kinds of acne scars (box scar, ice pick scar,
atrophic and rolling atrophic scar) were asked voluntarily to participate in the current study.
Their skin colors were Fitzpatrick skin type III and IV. The patient’s age ranged from 18 to 45
years (mean ± SD: 29 ± 8.04 years). The study was conducted as open trial in dermatology clinic
at Ibn Sina Teaching Hospital in Mosul, Iraq from 1st of April, 2019 to end of March, 2020.
The severity of acne scars was determined by using Goodman and Baron global quantitative
acne scar grading system (GBGQASGS) (13). Patients with grade 3 and 4 (GBGQASGS) were
eligible for the study. Those with bleeding tendencies, pregnant, autoimmune diseases, abnormal
wound healing and history of using topical or systemic retinoid therapy in past 3 months were
excluded from the study.
All patients underwent 4 sessions of Dermapen© microneedling treatment at six weeks
interval. Each session started by anesthetizing the sites using thick layer topical application of
eutectic cream (a mixture of prilocaine and lidocaine) about one hour prior to the procedure and
sterilizing it using povidone iodine. The session of microneedling was performed using
Dermapen© microneedling with disposable 36 needle tips. The depth of dermapen©
microneedling tips was adjusted to 0.5-1.5 mm on forehead and temple areas. Patients with
predominantly ice pick scars and boxcar scarring were given a needle depth of 3.5 mm on the
cheek areas. The treated area was soothed by topical anti-biotic cream at the end of the
procedure. The patients used broad spectrum sun blockers before they left the clinic.
The baseline and follow up assessment was performed using Goodman and Baron global
quantitative acne scar grading system (GBGQASGS). The improvement in acne scar was graded
as mild (<5 degree reduction in GBGQASGS), moderate (5-10 degree reduction in
GBGQASGS), good (11-15 degree reduction in GBGQASGS) and very good (>15 degree
reduction in GBGGS). A standardized photograph of the lesions was taken at beginning and the
end of the study.
Friedman test was used to determine the serial differences in GBGQASGS scores across
multiple treatment sessions. Paired t-test was used to study the significance of reduction in

European Journal of Molecular & Clinical Medicine
ISSN 2515-8260 Volume 07, Issue 09, 2020
1968
number, size, and depth of scars at the end of the study compared with baseline scores. The
effect size of treatment was further assessed using Cohen d effect size (difference between two
means divided by pooled standard deviation) and classified as small (d =0.2), medium (d =0.5),
large (d =0.8) and very large (d =1.2). p value < 0.5 was considered statistically significant. The
data was processed using statistical package SPSS version 23.
Results
The baseline assessment of the studied individuals revealed that they were consisted of 15 (60%)
patients with Grade 3, and 10 (40%) patients with Grade 4 acne scars. Their mean number of
lesions was 22.71±8.59 scar lesions. The average size of the scars was 3.64±1.54 mm, and the
depth of the lesions was on average 2.21±1.18 mm. Their pretreatment global GBGQASGS
scores ranged from 10-24 points with mean ± SD: 16.39±3.43. Table 1 shows the change in
GBGQASGS after each session which was significantly reduced each time. The mean ± SD of
GBGQASGS score was reduced to 12.95±3.67 after the first session. The score was further
reduced to 10.04±3.43 after the second session. The score reach its lowest level at the end of the
study with a mean ± SD: 7.78±2.79. A serial comparison of score at each treatment revealed a
significant lower level in compared with the score of the preceding session (p-value <0.0001).
Table 1 depicted a marked reduction in GBGQASGS scores in the first two sessions then slow
down after that.
Table 1. Comparison of differences in scores of Goodman and Baron global quantitative acne
scar grading system (GBGQASGS) after each session of dermapen© microneedling
Session
GBGQASGS score of acne scar
P-value
Min-Max
Mean±SD
95%CI of mean
Baseline score
10-24
16.39±3.43
15.19-18.00
-
1st session score
8-20
12.95±3.67
11.64-14.67
<0.0001
2nd session score
4-16
10.04±3.43
8.80-11.59
<0.0001
Last session score
3-11
7.78±2.79
6.57-8.99
<0.0001
Based on grading system of GBGQASGS, the results revealed that 12% of the patients had
minimal improvement (<5 reduction in GBGQASGS score), 48% had a moderate improvement
(5-10 reduction in GBGQASGS score), and 40% had good improvement (11-15 reduction in
GBGQASGS score). No patients showed very good improvement. (Figure 1 and 2) The results
show an inverse relationship between the baseline severity score and the degree of improvement
of acne scars. Furthermore, rolling and box scars had a better response compared to ice-pick
scars.

European Journal of Molecular & Clinical Medicine
ISSN 2515-8260 Volume 07, Issue 09, 2020
1969
Figure 1. (A) Grade 3 according to GBGQASGS before treatment. (B) Reduction in acne scar
after treatment.
Figure 2. (A) Grade 4 according to GBGQASGS before treatment. (B) Reduction in acne scar
after treatment
The detailed assessment of scars and their responses to dermapen© micro-needling is shown
in Table 2. The result revealed the number of the acne scars was reduced significantly at the end
of the study (p<0.0001). The size of the lesions was minimized (p<0.0001). In addition, the
depth of the lesions was declined significantly (p<0.0001). Table 2 also shows the effect of
dermapen© micro-needling on acne scars was classified as large effect size (Cohen d <1.2). The
largest effect was noted on the depth of scar (Cohen d =1.53), then on number of scar (Cohen d
=1.37), and lastly on size of the scar (Cohen d =1.26).

European Journal of Molecular & Clinical Medicine
ISSN 2515-8260 Volume 07, Issue 09, 2020
1970
Table 2. Changes in number, size, and depth of acne scar after 4 sessions of dermapen©
microneedling
Acne scar
Pre-treatment
Mean± SD
Post-treatment
Mean± SD
Difference
Mean± SD
Effect size
(cohen d)
P-value
Number
22.71±8.59
9.92±5.32
12.78±5.57
1.37
<0.0001
Size
3.64±1.54
1.73±0.86
1.90±0.98
1.26
<0.0001
Depth
2.21±1.18
1.17±0.74
1.03±0.60
1.53
<0.0001
The treatment was generally well tolerated, with topical anesthesia. The patients suffered from
tolerable pain. All patients reported mild erythema and edema for three days and ecchymosis was
noted in 3 patients especially in the forehead which last for two weeks. Social activity could
commence as early as one day after treatment. (Figure 3)
Figure 3. (A) Before sitting. (B) Mild erythema and edema after treatment. (C) Bruises on the
forehead after sitting.
Discussion
Dermapen© microneedling became very popular device in the treatment of acne scars and
rejuvenation of the skin in the last years; it is cost effective, minimum complication and short
healing time. Dermapen© induced collagen and elastic tissue synthesis with minimum epidermal

European Journal of Molecular & Clinical Medicine
ISSN 2515-8260 Volume 07, Issue 09, 2020
1971
injuries which in turn enhance acne scar remodeling (11). Many studies were conducted to
evaluate the effectiveness of dermapen© microneedling treatment (8-11), but fewer of them spot
the light on the effectiveness of dermapen© in sever form of atrophic acne scar and dark skin
individuals.
In the current study, the sessions were done every six weeks, since maximum synthesis of
collagen type I, III, VII, and other collagen occurred within six weeks after the sitting (11,12).
However, total elastin was remarkably decreased during this period (11).
The improvement of acne scars, in this study, did not show very good response to
dermapen© microneedling. These results are consistent with other workers (9), since about two
third of the patients had good response and twenty percent had poor response although they used
a different scoring system (VAS score). However, about half of the patients showed excellent
response (8). This may be due to different scoring system (Goodman and Baron scaring grading
system (13), and Lipper and Perez score) (15), with less severe form of atrophic acne scars and
more number of sessions.
In this study, dermapen© microneedling treatment revealed marked reduction in the
number, size and depth of the scar which is not assessed as far as we know in previous studies.
However, majority of the patients had moderate to good improvement after sessions according to
Goodman and Baron scaring grading system and none of them showed excellent response, due to
the severity of patient`s acne scars and limitation of dermapen© microneedling device to produce
more collagen and elastic fibers to rejuvenate the skin.
The studied dermapen© microneedling technique had satisfactory results in atrophic acne
scars. Similar results for the microneedling technique were obtained by other associates (8,9,16).
Other methods of treatments were used for acne scars such as fractional carbon dioxide (CO2)
laser resurfacing unites (17), and radiofrequency microneedling (10). Ochi et al. (7) treated 107,
about two third of the patients with fractional carbon dioxide (CO2) laser treatment reported poor
improvement, about one third of the patients had moderate improvement, four percent had good
improvement, and less than one percent had very good improvement. Recently, Elawar et al. (10)
treated nineteen patients by using non insulated radiofrequencies microneedling (10). About half
of the patients had moderate improvement in their acne scars and one third of the patients had
good improvement.
Most of the present patients suffered from erythema and edema which subsided after 3 days
from the sitting, ecchymosis was noted in 3 patients especially in the forehead which last for two
weeks. Dogra et al. (9) found one patient suffered from tram trek scaring using derma roller,
such complication was not appeared in our study. Post inflammatory hyperpigmentation and
infection were not a side effect in this research; this may be due insufficient inflammation and
damage induced by dermapen© microneedling to the epidermis that stimulate melanocyte to
synthesis melanin, and the emphasis on the protective measure used by the patients of sun
blocker and topical antibiotics .
In conclusion, dermapen© microneedling therapy had a moderate to good response in sever
form of acne scars, but not excellent results which needs further studies.
Limitation of this study
This study lacked histological assessment before and after the end of sittings, limited number of
sessions for each patient and relative small sample of patients with severe acne scars.

European Journal of Molecular & Clinical Medicine
ISSN 2515-8260 Volume 07, Issue 09, 2020
1972
Future studies
We suggest further studies which includes detailed histological assessment, adjuvant topical
treatment during sessions and combination of other modalities of treatment to enhance the
effectiveness of Dermapen© in treatment of severe acne scars.
Ethical Issues
The present study was approved by Medical Research Ethics Committee, College of Medicine,
University of Mosul (Ethical approval code: UOM.COM.MEREC. 20-21(7)). Additionally,
written informed consent was obtained from all patients before treatment.
Acknowledgment
This study financially was supported by College of Medicine, University of Mosul, and Ibn Sina
Teaching Hospital, Mosul, Iraq.
References
1. Lynn DD, Umari T, Dunnick CA, Dellavalle RP. The epidemiology of acne vulgaris in
late adolescence. Adolesc Health Med Ther. 2016;7:13-25. Published 2016 Jan 19.
doi:10.2147/AHMT.S55832
2. Fabbrocini G, Annunziata MC, D'Arco V, et al. Acne scars: pathogenesis, classification
and treatment. Dermatol Res Pract. 2010;2010:893080. doi:10.1155/2010/893080
3. Coşkun Öztekin, Aynure Öztekin. The association of depression, loneliness and internet
addiction levels in patients with acne vulgaris. Biopsychosoc Med. 2020; 14: 17.
Published online 2020 Aug 5. doi: 10.1186/s13030-020-00190-y
4. Levy LL, Zeichner JA. Management of acne scarring, part II: a comparative review of
non-laser-based, minimally invasive approaches. Am J Clin Dermatol. 2012;13(5):331-
340. doi:10.2165/11631410-000000000-00000
5. Kravvas G, Al-Niaimi F. A systematic review of treatments for acne scarring. Part 1:
Non-energy-based techniques. Scars Burn Heal. 2017;3:2059513117695312. Published
2017 Mar 30. doi:10.1177/2059513117695312
6. Basta-Juzbašić A. Current therapeutic approach to acne scars. Acta Dermatovenerol
Croat. 2010;18(3):171-175.
7. Ochi H, Tan L, Tan WP, Goh CL. Treatment of Facial Acne Scarring With Fractional
Carbon Dioxide Laser in Asians, a Retrospective Analysis of Efficacy and
Complications. Dermatologic Surgery : Official Publication for American Society for
Dermatologic Surgery [et al.]. 2017 Sep;43(9):1137-1143. DOI:
10.1097/dss.0000000000001219.
8. Minh PPT, Bich DD, Hai VNT, et al. Microneedling Therapy for Atrophic Acne Scar:
Effectiveness and Safety in Vietnamese Patients. Open Access Maced J Med Sci.
2019;7(2):293-297. Published 2019 Jan 29. doi:10.3889/oamjms.2019.098
9. Dogra S, Yadav S, Sarangal R. Microneedling for acne scars in Asian skin type: an
effective low cost treatment modality. J Cosmet Dermatol. 2014;13(3):180–187
10. Elawar A, Dahan S. Non-insulated Fractional Microneedle Radiofrequency Treatment
with Smooth Motor Insertion for Reduction of Depressed Acne Scars, Pore Size, and
Skin Texture Improvement: A Preliminary Study. J Clin Aesthet Dermatol.
2018;11(8):41-44

European Journal of Molecular & Clinical Medicine
ISSN 2515-8260 Volume 07, Issue 09, 2020
1973
11. El-Domyati M, Barakat M, Awad S, Medhat W, El-Fakahany H, Farag H. Microneedling
Therapy for Atrophic Acne Scars: An Objective Evaluation. J Clin Aesthet Dermatol.
2015;8(7):36-42
12. Arora, S. & Gupta, P.. (2012). Automated microneedling device - A new tool in
dermatologist's kit - A review. Journal of Pakistan Association of Dermatologists. 22.
354-357
13. Goodman GJ, Baron JA. Postacne scarring: a qualitative global scarring grading
system. Dermatologic Surgery. 2006;32(12):1458–1466.
14. Majid I. Microneedling therapy in atrophic facial scars: an objective assessment. J Cutan
Aesthet Surg. 2009;2(1):26-30. doi:10.4103/0974-2077.53096
15. Lipper GM, Perez M. Nonablative acne scar reduction after a series of treatments with a
short-pulsed 1,064-nm neodymium:YAG laser. Dermatologic surgery. 2006;32(8):998–
1006. PMid:16918561
16. Fabbrocini G, Fardella N, Monfrecola A, Proietti I, Innocenzi D. Acne scarring treatment
using skin needling. Clinical and Experimental Dermatology:Experimental
dermatology. 2009;34(8):874–9
17. Petrov A, Pljakovska V. Fractional Carbon Dioxide Laser in Treatment of Acne
Scars. Open Access Maced J Med Sci. 2016;4(1):38-42. doi:10.3889/oamjms.2016.004