For Peer Review

Percutaneous Collagen Induction with Dermaroller TM for Management of Atrophic Acne Scars in 31 Thai Patients

Keywords Percutaneous collagen induction Skin needling Acne scar

Asian patients

Short title Dermaroller TM in treatment of atrophic acne scars

Abstract

Percutaneous collagen induction with Dermaroller TM MF 8 (Horst Liebel Co GermanyUS FDA registered no878-4800) 15 mm needles was used for treatment of atrophic ace scar in 31 Thai patients All patients had moderate to advance atrophic acne scar with Fitzpatrick skin type III to V The treatment was performed under local anesthesia with sterile aseptic technique The number of treatments ranged from 1 to 4 at monthly interval Clinical evaluation was performed by side by side comparison of standard photographies by two non-medical independent observers After six months follow up the clinical severity scores decreased from 424 to 233 The improvement of more than 50 was observed in 6774 of cases Complications were rare and transient645 developed post treatmnent folliculitis which responded to oral antibiotics Dermaroller TM had been shown to be effective and safe percutaneous collagen induction for treatment of atrophic acne scar in Fitzpatrick skin type III to V Thai patients

Introduction

Acne vulgaris is one of the most common skin disease After active inflammatory phase had subsided a large portion of patients have been left with atrophic scar Many studies had confirmed the psycho-social significance of atrophic acne scar Severe atrophic acne scar which happened at important period of life ie adolescence had important psychologic impact to the patients Higher incidence of introvert personality changes and depression were common in severe acne scar cases In the past treatments of atrophic acne scar were difficult and complicated Chemical peels dermabrasion laser resurfacing and non-ablative laser resurfacing had produced false hope These treatments were complicated expensive with high complications and inconsistent results Recently percutaneous collagen induction (PCI) with Dermaroller TM device had been introduced in Europe with impressive results DrDes Fernandes was the first to call this technique skin needling or percutaneous collagen induction (PCI) and presented his study at the XIIth Congress

Page 1 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

of the International Society of Aesthetic Plastic Surgery in Paris France in 1993He had also published the technique in detail in 20051 Together with his collegues he had published the first article on PCI for treatment of scars wrinkles and skin laxity in his large study of 480 patients from South Africa and Germany he had reported good result in majority of cases2 The author had been performing this treatment since 2006 Since there was no data on efficacy and complications of this technique for management of atrophic scars in Asiansrsquo Fitzpatrick skin type III to V This article will describe clinical findings in the first batch of 31 Thai patients

Study design

Long-term (6 months) open prospective study with independent observers evaluation

Patients and method

Thirty one patients with moderate to severe atrophic acne scar Twenty were male and ten were female with age ranging from 24 to 45 years old After fully informed of the procedures all patients agreed to sign the informed consents After throughoutly cleansing of the face five standard ( direct infront 45o and 90o to left and right side of face) studio-type photographies with fixed studio lighting and fixed distance were taken with digital camera ( Olympus C760 Japan)

Local anesthesia with topical xylocaine and pilocaine mixture (EMLA Astra Sweden) were applied over the whole face and covered with cellophane tape for one hour

Figure 1 Skin needling device ( Dermaroller TM MF 8 15 mm needles

Horst Liebel Co Germany)

EMLA was then removed with sterile water The face was then painted with 1 Betadine solution Sterile drape was applied to the face and exposed only the treatment area

Page 2 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

Additional to EMLA infraorbital supraorbital mental and superficial nasal nerves blocks were performed with 1 Xylocaine (Astra Sweden) injection Field block with the same anesthetic was performed at lateral mandibular areas

Sterile single use disposable skin needling instrument ( DermarollerTM MF 8Horst Liebel Co Germany European FDA approval number CE 0373 US FDA registered number 8784800) with 15 mm 192 needles was used for the treatment(Figure 1) The treatment area was tightened while with firm pressure the author hold the handle of the device and rolled the instrument on a small plot of treatment area Each pass of rolling produced 16 micro-puncturescm2 The instrument was rolled back and forth with different directions for 10-20 times on the treatment plot During treatment few drops of Oxoferin TM solution (Holopack Verpackungstechnik GmBH Germany) were applied to the treatment areas The purpose of application of this solution was to enhance wound healing (Figure 2) The Dermaroller TM device would produced tangentially needle holes 250 micrometers down into middermis (Figure 3)

Minimal bleeding from needle holes were observed while the author varied directions to avoid repeated puntures on the same needle holes The treatment was repeated on adjacent areas to cover the entire faces After treatments the bleeding was controlled with light pressure with sterile gauze and application of Oxoferin TM1 Fucidic acid ointment ( Fucidin TM Leo UK ) was then applied to the treatment area All the treatments had been performed by the author

Figure 2 Treatment of atrophic acne scar with Dermaroller TM

10-20 passes of firm pressure multi-dirction rolling of device on each area

Page 3 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

Figure 3 Histologic changes immediately after DermarollerTM

(MF 8 15 mm needles) There was 1-15 mm deep

needle holes into the dermis

Oral antibiotics ( Cloxacillin Dicloxacillin Augmentin or Co-trimoxazole) for seven days were prescribed in some cases with active acne pustules

The patient was advice to clean face with sterile normal saline and applied open wound care technique with application of FucidinTM ointment twice daily until the wounds were completely healed ( between 5-7 days) There was mild to moderate facial edema for few days Usually the post treatment pain was minimal

Follow up and retreatments

The patient was followed up at seven days Topical sunscreen and emollients were then prescribed Standard studio type photographies similar to pre treatment were taken Post treatment facial skin usually was not sensitive to sunlight which was differed from after laser resurfacing

The repeated treatments were performed at interval of 1-2 months The number of repeated treatments were as followed 7 cases had one treatment12 cases had two treatments 5 cases had three treatments and 7 cases had four treatments The duration of follow-up was six months

Page 4 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

Acessment of results

Two independence nonmedical observers were requested to evaluate clinical improvement scores from side by side comparison of recorded standard photographies Standard six points improvement scores were used

5 = severe atrophic scar pre treatment

4 = improvement between 0-25

3 = improvement between 26-50

2 = improvement between 51 ndash 75

1 = improvement between 76 ndash 90

0 = improvement gt 91

Results

Figure 4 demonstrated clinical severity scores after 1-4 treatment with Dermaroller TM in 31 patients The number of treatments varied from 1 to 4 Usually the mild cases were treated once while severe cases had 3-4 treatments

Figure 4 Clinical improvement as graded by independent observers in 31 cases All cases had clinical improvement at six months The number of treatment ranged from 1 to 4

Clinical Improvement of acne scar after dermaroller in 31 cases

0

1

2

3

4

5

6

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31

Case No

Acn

esc

arse

veri

tysc

ores

P re Rx

Post Rx

Page 5 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

The mean clinical scores decreased from 424 to 233 at six months of follow-up (Figure 4)Five case ( 1613) had improvement more than 75 while 21 cases (6774) had improvement more than 50(Figure 5678) Two cases(645) developed folliculitis within a few days after treatments This cleared rapidly after oral antibiotics

Table 1 Mean acne scar severity scores after 1-4 Skin needling (Dermaroller TM)

by two indepencence non-medical observers for side by side standard

photographies comparison in 31 cases

Mean Pre treatment Mean Post treatment

( 6 months)

424 233

Discussions

Management of atrophic acne scar in dark skin types were difficult The standard treatments in white skin (Fitzpatrick skin type III) included dermabrasion chemical peels carbondioxide or erbium laser resurfacing 3456 Even in white skin patients results from these treatments were far from satisfactory 4 The treatments were complicated to perform with prolong healings and long term dyschromias Post treatments erythema was found in all cases lasting average 45 weeks after CO2

laser and 36 weeks after long-pulsed ErYAG laser Hyperpigmentation was seen in 46 after CO2 laser and 42 after ErYAG laser This hyperpigmentation lasted 127 and 114 weeks respectively 7 In dark skin types ( Fitzpatrick skin type III ndashVI) these laser treatments were abandoned because of serious post treatment complications especially post inflammatory hyperpigmentation and late onset permanent hypopigmentation Alster TS and West TB had reported 814 improvement after pulsed CO2 laser in Fitzpatrick skin type I-IV but also observed prolong erythema in all cases with 36 post treatment hyperpigmentation3

Nonablative laser resurfacing with absence of downtime often resulted in minimal improvement Most of the study had shown that after repeated treatment the degree of improvement were less than 3089Chan et al had found that after 1320 nm NdYAG laser treatment monthly for six months patientsrsquo satisfaction score was 4 from scale 0-10 From an independent observer the improvement was considered to be mild or no changes in majority of cases 8 Only recently with introduction of fractional laser resurfacing with Erbium-doped or laser which produced array of

Page 6 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

minutes thermal necrotic holes deep into the dermis that there were fair to good clinical improvement after multiple treatments (30-50) Lee et al had reported marked improvement in the appearance of acne scars at 3 months post-treatment in 27 Korean patients Patients self-assessed degrees of improvement were as follows excellent improvement in eight patients (30) significant improvement in 16 patients (59) and moderate improvement in three patients (11) Adverse events were limited to transient pain erythema and edema 9 The complications after fractional laser resurfacing was related to thermal injuries Too high density of laser spots often resulted in post treatment erythema and post inflammatory hyperpigmentation especially in dark skin type PIH after fractional laser resurfacing in Asians had been reported in 15 of cases The cost of fractional laser equipment and high consumable cost had discouraged wide acceptance of this laser in most of developing countries

Skin needling with special roller instrument with 298 tiny sharp stainless steel needles (250 microm diameter) and length between 05 to 2 mm had been introduced in Europe and South Africa by Des Fernandes since 19931He named this technique minimally invasive percutaneous collagen induction and had the first publication in 20051 The result after treatment of atrophic acne scar had been found to be satisfactory with minimum downtimes 2 The mechanism behind clinical improvement was purposed to be results of tangentially cutting of fibrotic scars by pressure rolling and induction of blood clot platelets activation released of cytokines especially platelet-derived growth factor fibrous growth factor transforming growth factor etc These resulted in induction of new collagen formation together with scar remodeling This results in elevation of atrophic scar and reduction of fibrotic scarborders1 Due to small size of needle holes healing was rapid Usually the tiny needle wounds healed in three days The degree of scar improvement from wound remodeling went on for many months after even single treatments12

Since this PCI technique had gained acceptance in Europe and South Africa12 but the clinical study in Asiansrsquo skin was lacking This study had shown that with good patients selection sterile method and good technique the degree of clinical improvement for treatment of atrophic acne scar in Fitzpatrick skin type III to V Asian patients was moderate to good result with 6774 had more than 50 clinical improvement This result was almost equal to those after CO2 laser resurfacing3 but with better healing and much lower post treatment complications It also is about the same efficacy with fractional laser resurfacing10 Post inflammatory hyperpigmentation which was directly related to thermal injury was more common after fractional laser resurfacing 11 was absent after skin needling The overall cost after multiple treatments with skin needling was much lower than fractional laser resurfacing

Page 7 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

The quality hardness and sharpness of needles are important property of good skin needling device Basically ice-hardening steel with tensile strength more than 2200 Newtons will ensure better chance of good result and also without complications High ratio of tip length VS diameter of 131 is another important property of good needles The depth of neocollagenesis was found to be average 5-600 micrometers even after 15 mm length needle So the needle length longer than 150 mm was unnecessary 1The Dermaroller TM had obtained CE approval and US FDA approval as medical device from Germany and USA since January 2006 Poor quality needles of the roller device often resulted in bending at needle tips after repeated treatments Thes resulted in in more tissue damages and hemorrhage with linear hypertrophic scars or post inflammatory hyperpigmentation1This reason together with problems of cross contamination is the reason why single-use device is recommended To avoid any possible complications doctors who are interested in performing this technique should attend a hand-on training course from experience dermatologic surgeons

In conclusion percutaneous collagen induction by skin needling with high quality single-use device (Dermaroller TM Horst Liebel Co Germany) had been shown to be highly effective and safe method for treatment of atrophic scar in Fitzpatrick skin type III to V Thai patients

References

1Fernandes D Minimally invasive percutaneous collagen induction Oral Maxillofacial Surg Clin N Am 200517 51-63

2Aust MC Fernandes D Kolokvthas P Kaplan HM Vogt PM Percutaneous collagen induction therapy an alternative treatment of scars wrinkles and skin laxity Plast Reconstr Surg 2008 121(4)1421-9

3Alster T West TB Resurfacing of atrophic facial acne scars with a high-energy pulsed carbondioxide laser Dermatol Surg 199622(2)154-155

4Goldman MP Manuskiatti W Combined laser resurfacing with the 950 microsecond pulsed CO2 + ErYAG lasers Dermatol Surg 1999 25(3) 160-3

5Woo SH Park JH KveYC Resurfacing of different types of facial acne scar with short-pulsed variable-pulsed and dual-mode ErYAG laser Dermatol Surg 200430488-93

6Jeong JT Kve YC Resurfacing of pitted facial acne scars with a long-pulsed ErYAG laser Dermatol Surg 2001276107-10

Page 8 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

7Tanzi EL Alster T Single-pass carbon dioxide versus multiple-pass ErYAG laser skin resurfacinga comparison of post operative wound healing and side effect rates Dermatol Surg 20032980-4

8Chan Hm Lam LKm Wong DS KonoT Trendekk-Smith N Use of 1320 nm NdYAG laser for wrinkle reduction and the treatment of atrophic acne scarring in Asians Lasers Surg Med 20043498-103

9Chua SH Ang P Khoo LS Goh CL Nonablative 1450 nm diode laser in the treatment of facial atrophic acne scars in type IV to V Asian skin a prospective clinical study Dermatol Surg 2004301287-91

10Lee HS Lee JH Ahn GY Lee DH Shin JW Kim DH Chung JH Fractional photothermolysis for the treatment of acne scars A report of 27 Korean patients JDermatolog Treat 200819(1)45-9

11 Kono T Chan HH Groff WF Manstein D Sakurai H Takeuchi M Yamaki T Soejima K Nozaki M Prospective direct comparison study of fractional resurfacing using different fluences and densities for skin rejuvenation in Asians Lasers Surg Med 2007 Apr39(4)311-4

Page 9 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

of the International Society of Aesthetic Plastic Surgery in Paris France in 1993He had also published the technique in detail in 20051 Together with his collegues he had published the first article on PCI for treatment of scars wrinkles and skin laxity in his large study of 480 patients from South Africa and Germany he had reported good result in majority of cases2 The author had been performing this treatment since 2006 Since there was no data on efficacy and complications of this technique for management of atrophic scars in Asiansrsquo Fitzpatrick skin type III to V This article will describe clinical findings in the first batch of 31 Thai patients

Study design

Long-term (6 months) open prospective study with independent observers evaluation

Patients and method

Thirty one patients with moderate to severe atrophic acne scar Twenty were male and ten were female with age ranging from 24 to 45 years old After fully informed of the procedures all patients agreed to sign the informed consents After throughoutly cleansing of the face five standard ( direct infront 45o and 90o to left and right side of face) studio-type photographies with fixed studio lighting and fixed distance were taken with digital camera ( Olympus C760 Japan)

Local anesthesia with topical xylocaine and pilocaine mixture (EMLA Astra Sweden) were applied over the whole face and covered with cellophane tape for one hour

Figure 1 Skin needling device ( Dermaroller TM MF 8 15 mm needles

Horst Liebel Co Germany)

EMLA was then removed with sterile water The face was then painted with 1 Betadine solution Sterile drape was applied to the face and exposed only the treatment area

Page 2 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

Additional to EMLA infraorbital supraorbital mental and superficial nasal nerves blocks were performed with 1 Xylocaine (Astra Sweden) injection Field block with the same anesthetic was performed at lateral mandibular areas

Sterile single use disposable skin needling instrument ( DermarollerTM MF 8Horst Liebel Co Germany European FDA approval number CE 0373 US FDA registered number 8784800) with 15 mm 192 needles was used for the treatment(Figure 1) The treatment area was tightened while with firm pressure the author hold the handle of the device and rolled the instrument on a small plot of treatment area Each pass of rolling produced 16 micro-puncturescm2 The instrument was rolled back and forth with different directions for 10-20 times on the treatment plot During treatment few drops of Oxoferin TM solution (Holopack Verpackungstechnik GmBH Germany) were applied to the treatment areas The purpose of application of this solution was to enhance wound healing (Figure 2) The Dermaroller TM device would produced tangentially needle holes 250 micrometers down into middermis (Figure 3)

Minimal bleeding from needle holes were observed while the author varied directions to avoid repeated puntures on the same needle holes The treatment was repeated on adjacent areas to cover the entire faces After treatments the bleeding was controlled with light pressure with sterile gauze and application of Oxoferin TM1 Fucidic acid ointment ( Fucidin TM Leo UK ) was then applied to the treatment area All the treatments had been performed by the author

Figure 2 Treatment of atrophic acne scar with Dermaroller TM

10-20 passes of firm pressure multi-dirction rolling of device on each area

Page 3 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

Figure 3 Histologic changes immediately after DermarollerTM

(MF 8 15 mm needles) There was 1-15 mm deep

needle holes into the dermis

Oral antibiotics ( Cloxacillin Dicloxacillin Augmentin or Co-trimoxazole) for seven days were prescribed in some cases with active acne pustules

The patient was advice to clean face with sterile normal saline and applied open wound care technique with application of FucidinTM ointment twice daily until the wounds were completely healed ( between 5-7 days) There was mild to moderate facial edema for few days Usually the post treatment pain was minimal

Follow up and retreatments

The patient was followed up at seven days Topical sunscreen and emollients were then prescribed Standard studio type photographies similar to pre treatment were taken Post treatment facial skin usually was not sensitive to sunlight which was differed from after laser resurfacing

The repeated treatments were performed at interval of 1-2 months The number of repeated treatments were as followed 7 cases had one treatment12 cases had two treatments 5 cases had three treatments and 7 cases had four treatments The duration of follow-up was six months

Page 4 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

Acessment of results

Two independence nonmedical observers were requested to evaluate clinical improvement scores from side by side comparison of recorded standard photographies Standard six points improvement scores were used

5 = severe atrophic scar pre treatment

4 = improvement between 0-25

3 = improvement between 26-50

2 = improvement between 51 ndash 75

1 = improvement between 76 ndash 90

0 = improvement gt 91

Results

Figure 4 demonstrated clinical severity scores after 1-4 treatment with Dermaroller TM in 31 patients The number of treatments varied from 1 to 4 Usually the mild cases were treated once while severe cases had 3-4 treatments

Figure 4 Clinical improvement as graded by independent observers in 31 cases All cases had clinical improvement at six months The number of treatment ranged from 1 to 4

Clinical Improvement of acne scar after dermaroller in 31 cases

0

1

2

3

4

5

6

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31

Case No

Acn

esc

arse

veri

tysc

ores

P re Rx

Post Rx

Page 5 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

The mean clinical scores decreased from 424 to 233 at six months of follow-up (Figure 4)Five case ( 1613) had improvement more than 75 while 21 cases (6774) had improvement more than 50(Figure 5678) Two cases(645) developed folliculitis within a few days after treatments This cleared rapidly after oral antibiotics

Table 1 Mean acne scar severity scores after 1-4 Skin needling (Dermaroller TM)

by two indepencence non-medical observers for side by side standard

photographies comparison in 31 cases

Mean Pre treatment Mean Post treatment

( 6 months)

424 233

Discussions

Management of atrophic acne scar in dark skin types were difficult The standard treatments in white skin (Fitzpatrick skin type III) included dermabrasion chemical peels carbondioxide or erbium laser resurfacing 3456 Even in white skin patients results from these treatments were far from satisfactory 4 The treatments were complicated to perform with prolong healings and long term dyschromias Post treatments erythema was found in all cases lasting average 45 weeks after CO2

laser and 36 weeks after long-pulsed ErYAG laser Hyperpigmentation was seen in 46 after CO2 laser and 42 after ErYAG laser This hyperpigmentation lasted 127 and 114 weeks respectively 7 In dark skin types ( Fitzpatrick skin type III ndashVI) these laser treatments were abandoned because of serious post treatment complications especially post inflammatory hyperpigmentation and late onset permanent hypopigmentation Alster TS and West TB had reported 814 improvement after pulsed CO2 laser in Fitzpatrick skin type I-IV but also observed prolong erythema in all cases with 36 post treatment hyperpigmentation3

Nonablative laser resurfacing with absence of downtime often resulted in minimal improvement Most of the study had shown that after repeated treatment the degree of improvement were less than 3089Chan et al had found that after 1320 nm NdYAG laser treatment monthly for six months patientsrsquo satisfaction score was 4 from scale 0-10 From an independent observer the improvement was considered to be mild or no changes in majority of cases 8 Only recently with introduction of fractional laser resurfacing with Erbium-doped or laser which produced array of

Page 6 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

minutes thermal necrotic holes deep into the dermis that there were fair to good clinical improvement after multiple treatments (30-50) Lee et al had reported marked improvement in the appearance of acne scars at 3 months post-treatment in 27 Korean patients Patients self-assessed degrees of improvement were as follows excellent improvement in eight patients (30) significant improvement in 16 patients (59) and moderate improvement in three patients (11) Adverse events were limited to transient pain erythema and edema 9 The complications after fractional laser resurfacing was related to thermal injuries Too high density of laser spots often resulted in post treatment erythema and post inflammatory hyperpigmentation especially in dark skin type PIH after fractional laser resurfacing in Asians had been reported in 15 of cases The cost of fractional laser equipment and high consumable cost had discouraged wide acceptance of this laser in most of developing countries

Skin needling with special roller instrument with 298 tiny sharp stainless steel needles (250 microm diameter) and length between 05 to 2 mm had been introduced in Europe and South Africa by Des Fernandes since 19931He named this technique minimally invasive percutaneous collagen induction and had the first publication in 20051 The result after treatment of atrophic acne scar had been found to be satisfactory with minimum downtimes 2 The mechanism behind clinical improvement was purposed to be results of tangentially cutting of fibrotic scars by pressure rolling and induction of blood clot platelets activation released of cytokines especially platelet-derived growth factor fibrous growth factor transforming growth factor etc These resulted in induction of new collagen formation together with scar remodeling This results in elevation of atrophic scar and reduction of fibrotic scarborders1 Due to small size of needle holes healing was rapid Usually the tiny needle wounds healed in three days The degree of scar improvement from wound remodeling went on for many months after even single treatments12

Since this PCI technique had gained acceptance in Europe and South Africa12 but the clinical study in Asiansrsquo skin was lacking This study had shown that with good patients selection sterile method and good technique the degree of clinical improvement for treatment of atrophic acne scar in Fitzpatrick skin type III to V Asian patients was moderate to good result with 6774 had more than 50 clinical improvement This result was almost equal to those after CO2 laser resurfacing3 but with better healing and much lower post treatment complications It also is about the same efficacy with fractional laser resurfacing10 Post inflammatory hyperpigmentation which was directly related to thermal injury was more common after fractional laser resurfacing 11 was absent after skin needling The overall cost after multiple treatments with skin needling was much lower than fractional laser resurfacing

Page 7 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

The quality hardness and sharpness of needles are important property of good skin needling device Basically ice-hardening steel with tensile strength more than 2200 Newtons will ensure better chance of good result and also without complications High ratio of tip length VS diameter of 131 is another important property of good needles The depth of neocollagenesis was found to be average 5-600 micrometers even after 15 mm length needle So the needle length longer than 150 mm was unnecessary 1The Dermaroller TM had obtained CE approval and US FDA approval as medical device from Germany and USA since January 2006 Poor quality needles of the roller device often resulted in bending at needle tips after repeated treatments Thes resulted in in more tissue damages and hemorrhage with linear hypertrophic scars or post inflammatory hyperpigmentation1This reason together with problems of cross contamination is the reason why single-use device is recommended To avoid any possible complications doctors who are interested in performing this technique should attend a hand-on training course from experience dermatologic surgeons

In conclusion percutaneous collagen induction by skin needling with high quality single-use device (Dermaroller TM Horst Liebel Co Germany) had been shown to be highly effective and safe method for treatment of atrophic scar in Fitzpatrick skin type III to V Thai patients

References

1Fernandes D Minimally invasive percutaneous collagen induction Oral Maxillofacial Surg Clin N Am 200517 51-63

2Aust MC Fernandes D Kolokvthas P Kaplan HM Vogt PM Percutaneous collagen induction therapy an alternative treatment of scars wrinkles and skin laxity Plast Reconstr Surg 2008 121(4)1421-9

3Alster T West TB Resurfacing of atrophic facial acne scars with a high-energy pulsed carbondioxide laser Dermatol Surg 199622(2)154-155

4Goldman MP Manuskiatti W Combined laser resurfacing with the 950 microsecond pulsed CO2 + ErYAG lasers Dermatol Surg 1999 25(3) 160-3

5Woo SH Park JH KveYC Resurfacing of different types of facial acne scar with short-pulsed variable-pulsed and dual-mode ErYAG laser Dermatol Surg 200430488-93

6Jeong JT Kve YC Resurfacing of pitted facial acne scars with a long-pulsed ErYAG laser Dermatol Surg 2001276107-10

Page 8 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

7Tanzi EL Alster T Single-pass carbon dioxide versus multiple-pass ErYAG laser skin resurfacinga comparison of post operative wound healing and side effect rates Dermatol Surg 20032980-4

8Chan Hm Lam LKm Wong DS KonoT Trendekk-Smith N Use of 1320 nm NdYAG laser for wrinkle reduction and the treatment of atrophic acne scarring in Asians Lasers Surg Med 20043498-103

9Chua SH Ang P Khoo LS Goh CL Nonablative 1450 nm diode laser in the treatment of facial atrophic acne scars in type IV to V Asian skin a prospective clinical study Dermatol Surg 2004301287-91

10Lee HS Lee JH Ahn GY Lee DH Shin JW Kim DH Chung JH Fractional photothermolysis for the treatment of acne scars A report of 27 Korean patients JDermatolog Treat 200819(1)45-9

11 Kono T Chan HH Groff WF Manstein D Sakurai H Takeuchi M Yamaki T Soejima K Nozaki M Prospective direct comparison study of fractional resurfacing using different fluences and densities for skin rejuvenation in Asians Lasers Surg Med 2007 Apr39(4)311-4

Page 9 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

Additional to EMLA infraorbital supraorbital mental and superficial nasal nerves blocks were performed with 1 Xylocaine (Astra Sweden) injection Field block with the same anesthetic was performed at lateral mandibular areas

Sterile single use disposable skin needling instrument ( DermarollerTM MF 8Horst Liebel Co Germany European FDA approval number CE 0373 US FDA registered number 8784800) with 15 mm 192 needles was used for the treatment(Figure 1) The treatment area was tightened while with firm pressure the author hold the handle of the device and rolled the instrument on a small plot of treatment area Each pass of rolling produced 16 micro-puncturescm2 The instrument was rolled back and forth with different directions for 10-20 times on the treatment plot During treatment few drops of Oxoferin TM solution (Holopack Verpackungstechnik GmBH Germany) were applied to the treatment areas The purpose of application of this solution was to enhance wound healing (Figure 2) The Dermaroller TM device would produced tangentially needle holes 250 micrometers down into middermis (Figure 3)

Minimal bleeding from needle holes were observed while the author varied directions to avoid repeated puntures on the same needle holes The treatment was repeated on adjacent areas to cover the entire faces After treatments the bleeding was controlled with light pressure with sterile gauze and application of Oxoferin TM1 Fucidic acid ointment ( Fucidin TM Leo UK ) was then applied to the treatment area All the treatments had been performed by the author

Figure 2 Treatment of atrophic acne scar with Dermaroller TM

10-20 passes of firm pressure multi-dirction rolling of device on each area

Page 3 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

Figure 3 Histologic changes immediately after DermarollerTM

(MF 8 15 mm needles) There was 1-15 mm deep

needle holes into the dermis

Oral antibiotics ( Cloxacillin Dicloxacillin Augmentin or Co-trimoxazole) for seven days were prescribed in some cases with active acne pustules

The patient was advice to clean face with sterile normal saline and applied open wound care technique with application of FucidinTM ointment twice daily until the wounds were completely healed ( between 5-7 days) There was mild to moderate facial edema for few days Usually the post treatment pain was minimal

Follow up and retreatments

The patient was followed up at seven days Topical sunscreen and emollients were then prescribed Standard studio type photographies similar to pre treatment were taken Post treatment facial skin usually was not sensitive to sunlight which was differed from after laser resurfacing

The repeated treatments were performed at interval of 1-2 months The number of repeated treatments were as followed 7 cases had one treatment12 cases had two treatments 5 cases had three treatments and 7 cases had four treatments The duration of follow-up was six months

Page 4 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

Acessment of results

Two independence nonmedical observers were requested to evaluate clinical improvement scores from side by side comparison of recorded standard photographies Standard six points improvement scores were used

5 = severe atrophic scar pre treatment

4 = improvement between 0-25

3 = improvement between 26-50

2 = improvement between 51 ndash 75

1 = improvement between 76 ndash 90

0 = improvement gt 91

Results

Figure 4 demonstrated clinical severity scores after 1-4 treatment with Dermaroller TM in 31 patients The number of treatments varied from 1 to 4 Usually the mild cases were treated once while severe cases had 3-4 treatments

Figure 4 Clinical improvement as graded by independent observers in 31 cases All cases had clinical improvement at six months The number of treatment ranged from 1 to 4

Clinical Improvement of acne scar after dermaroller in 31 cases

0

1

2

3

4

5

6

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31

Case No

Acn

esc

arse

veri

tysc

ores

P re Rx

Post Rx

Page 5 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

The mean clinical scores decreased from 424 to 233 at six months of follow-up (Figure 4)Five case ( 1613) had improvement more than 75 while 21 cases (6774) had improvement more than 50(Figure 5678) Two cases(645) developed folliculitis within a few days after treatments This cleared rapidly after oral antibiotics

Table 1 Mean acne scar severity scores after 1-4 Skin needling (Dermaroller TM)

by two indepencence non-medical observers for side by side standard

photographies comparison in 31 cases

Mean Pre treatment Mean Post treatment

( 6 months)

424 233

Discussions

Management of atrophic acne scar in dark skin types were difficult The standard treatments in white skin (Fitzpatrick skin type III) included dermabrasion chemical peels carbondioxide or erbium laser resurfacing 3456 Even in white skin patients results from these treatments were far from satisfactory 4 The treatments were complicated to perform with prolong healings and long term dyschromias Post treatments erythema was found in all cases lasting average 45 weeks after CO2

laser and 36 weeks after long-pulsed ErYAG laser Hyperpigmentation was seen in 46 after CO2 laser and 42 after ErYAG laser This hyperpigmentation lasted 127 and 114 weeks respectively 7 In dark skin types ( Fitzpatrick skin type III ndashVI) these laser treatments were abandoned because of serious post treatment complications especially post inflammatory hyperpigmentation and late onset permanent hypopigmentation Alster TS and West TB had reported 814 improvement after pulsed CO2 laser in Fitzpatrick skin type I-IV but also observed prolong erythema in all cases with 36 post treatment hyperpigmentation3

Nonablative laser resurfacing with absence of downtime often resulted in minimal improvement Most of the study had shown that after repeated treatment the degree of improvement were less than 3089Chan et al had found that after 1320 nm NdYAG laser treatment monthly for six months patientsrsquo satisfaction score was 4 from scale 0-10 From an independent observer the improvement was considered to be mild or no changes in majority of cases 8 Only recently with introduction of fractional laser resurfacing with Erbium-doped or laser which produced array of

Page 6 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

minutes thermal necrotic holes deep into the dermis that there were fair to good clinical improvement after multiple treatments (30-50) Lee et al had reported marked improvement in the appearance of acne scars at 3 months post-treatment in 27 Korean patients Patients self-assessed degrees of improvement were as follows excellent improvement in eight patients (30) significant improvement in 16 patients (59) and moderate improvement in three patients (11) Adverse events were limited to transient pain erythema and edema 9 The complications after fractional laser resurfacing was related to thermal injuries Too high density of laser spots often resulted in post treatment erythema and post inflammatory hyperpigmentation especially in dark skin type PIH after fractional laser resurfacing in Asians had been reported in 15 of cases The cost of fractional laser equipment and high consumable cost had discouraged wide acceptance of this laser in most of developing countries

Skin needling with special roller instrument with 298 tiny sharp stainless steel needles (250 microm diameter) and length between 05 to 2 mm had been introduced in Europe and South Africa by Des Fernandes since 19931He named this technique minimally invasive percutaneous collagen induction and had the first publication in 20051 The result after treatment of atrophic acne scar had been found to be satisfactory with minimum downtimes 2 The mechanism behind clinical improvement was purposed to be results of tangentially cutting of fibrotic scars by pressure rolling and induction of blood clot platelets activation released of cytokines especially platelet-derived growth factor fibrous growth factor transforming growth factor etc These resulted in induction of new collagen formation together with scar remodeling This results in elevation of atrophic scar and reduction of fibrotic scarborders1 Due to small size of needle holes healing was rapid Usually the tiny needle wounds healed in three days The degree of scar improvement from wound remodeling went on for many months after even single treatments12

Since this PCI technique had gained acceptance in Europe and South Africa12 but the clinical study in Asiansrsquo skin was lacking This study had shown that with good patients selection sterile method and good technique the degree of clinical improvement for treatment of atrophic acne scar in Fitzpatrick skin type III to V Asian patients was moderate to good result with 6774 had more than 50 clinical improvement This result was almost equal to those after CO2 laser resurfacing3 but with better healing and much lower post treatment complications It also is about the same efficacy with fractional laser resurfacing10 Post inflammatory hyperpigmentation which was directly related to thermal injury was more common after fractional laser resurfacing 11 was absent after skin needling The overall cost after multiple treatments with skin needling was much lower than fractional laser resurfacing

Page 7 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

The quality hardness and sharpness of needles are important property of good skin needling device Basically ice-hardening steel with tensile strength more than 2200 Newtons will ensure better chance of good result and also without complications High ratio of tip length VS diameter of 131 is another important property of good needles The depth of neocollagenesis was found to be average 5-600 micrometers even after 15 mm length needle So the needle length longer than 150 mm was unnecessary 1The Dermaroller TM had obtained CE approval and US FDA approval as medical device from Germany and USA since January 2006 Poor quality needles of the roller device often resulted in bending at needle tips after repeated treatments Thes resulted in in more tissue damages and hemorrhage with linear hypertrophic scars or post inflammatory hyperpigmentation1This reason together with problems of cross contamination is the reason why single-use device is recommended To avoid any possible complications doctors who are interested in performing this technique should attend a hand-on training course from experience dermatologic surgeons

In conclusion percutaneous collagen induction by skin needling with high quality single-use device (Dermaroller TM Horst Liebel Co Germany) had been shown to be highly effective and safe method for treatment of atrophic scar in Fitzpatrick skin type III to V Thai patients

References

1Fernandes D Minimally invasive percutaneous collagen induction Oral Maxillofacial Surg Clin N Am 200517 51-63

2Aust MC Fernandes D Kolokvthas P Kaplan HM Vogt PM Percutaneous collagen induction therapy an alternative treatment of scars wrinkles and skin laxity Plast Reconstr Surg 2008 121(4)1421-9

3Alster T West TB Resurfacing of atrophic facial acne scars with a high-energy pulsed carbondioxide laser Dermatol Surg 199622(2)154-155

4Goldman MP Manuskiatti W Combined laser resurfacing with the 950 microsecond pulsed CO2 + ErYAG lasers Dermatol Surg 1999 25(3) 160-3

5Woo SH Park JH KveYC Resurfacing of different types of facial acne scar with short-pulsed variable-pulsed and dual-mode ErYAG laser Dermatol Surg 200430488-93

6Jeong JT Kve YC Resurfacing of pitted facial acne scars with a long-pulsed ErYAG laser Dermatol Surg 2001276107-10

Page 8 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

7Tanzi EL Alster T Single-pass carbon dioxide versus multiple-pass ErYAG laser skin resurfacinga comparison of post operative wound healing and side effect rates Dermatol Surg 20032980-4

8Chan Hm Lam LKm Wong DS KonoT Trendekk-Smith N Use of 1320 nm NdYAG laser for wrinkle reduction and the treatment of atrophic acne scarring in Asians Lasers Surg Med 20043498-103

9Chua SH Ang P Khoo LS Goh CL Nonablative 1450 nm diode laser in the treatment of facial atrophic acne scars in type IV to V Asian skin a prospective clinical study Dermatol Surg 2004301287-91

10Lee HS Lee JH Ahn GY Lee DH Shin JW Kim DH Chung JH Fractional photothermolysis for the treatment of acne scars A report of 27 Korean patients JDermatolog Treat 200819(1)45-9

11 Kono T Chan HH Groff WF Manstein D Sakurai H Takeuchi M Yamaki T Soejima K Nozaki M Prospective direct comparison study of fractional resurfacing using different fluences and densities for skin rejuvenation in Asians Lasers Surg Med 2007 Apr39(4)311-4

Page 9 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

Figure 3 Histologic changes immediately after DermarollerTM

(MF 8 15 mm needles) There was 1-15 mm deep

needle holes into the dermis

Oral antibiotics ( Cloxacillin Dicloxacillin Augmentin or Co-trimoxazole) for seven days were prescribed in some cases with active acne pustules

The patient was advice to clean face with sterile normal saline and applied open wound care technique with application of FucidinTM ointment twice daily until the wounds were completely healed ( between 5-7 days) There was mild to moderate facial edema for few days Usually the post treatment pain was minimal

Follow up and retreatments

The patient was followed up at seven days Topical sunscreen and emollients were then prescribed Standard studio type photographies similar to pre treatment were taken Post treatment facial skin usually was not sensitive to sunlight which was differed from after laser resurfacing

The repeated treatments were performed at interval of 1-2 months The number of repeated treatments were as followed 7 cases had one treatment12 cases had two treatments 5 cases had three treatments and 7 cases had four treatments The duration of follow-up was six months

Page 4 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

Acessment of results

Two independence nonmedical observers were requested to evaluate clinical improvement scores from side by side comparison of recorded standard photographies Standard six points improvement scores were used

5 = severe atrophic scar pre treatment

4 = improvement between 0-25

3 = improvement between 26-50

2 = improvement between 51 ndash 75

1 = improvement between 76 ndash 90

0 = improvement gt 91

Results

Figure 4 demonstrated clinical severity scores after 1-4 treatment with Dermaroller TM in 31 patients The number of treatments varied from 1 to 4 Usually the mild cases were treated once while severe cases had 3-4 treatments

Figure 4 Clinical improvement as graded by independent observers in 31 cases All cases had clinical improvement at six months The number of treatment ranged from 1 to 4

Clinical Improvement of acne scar after dermaroller in 31 cases

0

1

2

3

4

5

6

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31

Case No

Acn

esc

arse

veri

tysc

ores

P re Rx

Post Rx

Page 5 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

The mean clinical scores decreased from 424 to 233 at six months of follow-up (Figure 4)Five case ( 1613) had improvement more than 75 while 21 cases (6774) had improvement more than 50(Figure 5678) Two cases(645) developed folliculitis within a few days after treatments This cleared rapidly after oral antibiotics

Table 1 Mean acne scar severity scores after 1-4 Skin needling (Dermaroller TM)

by two indepencence non-medical observers for side by side standard

photographies comparison in 31 cases

Mean Pre treatment Mean Post treatment

( 6 months)

424 233

Discussions

Management of atrophic acne scar in dark skin types were difficult The standard treatments in white skin (Fitzpatrick skin type III) included dermabrasion chemical peels carbondioxide or erbium laser resurfacing 3456 Even in white skin patients results from these treatments were far from satisfactory 4 The treatments were complicated to perform with prolong healings and long term dyschromias Post treatments erythema was found in all cases lasting average 45 weeks after CO2

laser and 36 weeks after long-pulsed ErYAG laser Hyperpigmentation was seen in 46 after CO2 laser and 42 after ErYAG laser This hyperpigmentation lasted 127 and 114 weeks respectively 7 In dark skin types ( Fitzpatrick skin type III ndashVI) these laser treatments were abandoned because of serious post treatment complications especially post inflammatory hyperpigmentation and late onset permanent hypopigmentation Alster TS and West TB had reported 814 improvement after pulsed CO2 laser in Fitzpatrick skin type I-IV but also observed prolong erythema in all cases with 36 post treatment hyperpigmentation3

Nonablative laser resurfacing with absence of downtime often resulted in minimal improvement Most of the study had shown that after repeated treatment the degree of improvement were less than 3089Chan et al had found that after 1320 nm NdYAG laser treatment monthly for six months patientsrsquo satisfaction score was 4 from scale 0-10 From an independent observer the improvement was considered to be mild or no changes in majority of cases 8 Only recently with introduction of fractional laser resurfacing with Erbium-doped or laser which produced array of

Page 6 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

minutes thermal necrotic holes deep into the dermis that there were fair to good clinical improvement after multiple treatments (30-50) Lee et al had reported marked improvement in the appearance of acne scars at 3 months post-treatment in 27 Korean patients Patients self-assessed degrees of improvement were as follows excellent improvement in eight patients (30) significant improvement in 16 patients (59) and moderate improvement in three patients (11) Adverse events were limited to transient pain erythema and edema 9 The complications after fractional laser resurfacing was related to thermal injuries Too high density of laser spots often resulted in post treatment erythema and post inflammatory hyperpigmentation especially in dark skin type PIH after fractional laser resurfacing in Asians had been reported in 15 of cases The cost of fractional laser equipment and high consumable cost had discouraged wide acceptance of this laser in most of developing countries

Skin needling with special roller instrument with 298 tiny sharp stainless steel needles (250 microm diameter) and length between 05 to 2 mm had been introduced in Europe and South Africa by Des Fernandes since 19931He named this technique minimally invasive percutaneous collagen induction and had the first publication in 20051 The result after treatment of atrophic acne scar had been found to be satisfactory with minimum downtimes 2 The mechanism behind clinical improvement was purposed to be results of tangentially cutting of fibrotic scars by pressure rolling and induction of blood clot platelets activation released of cytokines especially platelet-derived growth factor fibrous growth factor transforming growth factor etc These resulted in induction of new collagen formation together with scar remodeling This results in elevation of atrophic scar and reduction of fibrotic scarborders1 Due to small size of needle holes healing was rapid Usually the tiny needle wounds healed in three days The degree of scar improvement from wound remodeling went on for many months after even single treatments12

Since this PCI technique had gained acceptance in Europe and South Africa12 but the clinical study in Asiansrsquo skin was lacking This study had shown that with good patients selection sterile method and good technique the degree of clinical improvement for treatment of atrophic acne scar in Fitzpatrick skin type III to V Asian patients was moderate to good result with 6774 had more than 50 clinical improvement This result was almost equal to those after CO2 laser resurfacing3 but with better healing and much lower post treatment complications It also is about the same efficacy with fractional laser resurfacing10 Post inflammatory hyperpigmentation which was directly related to thermal injury was more common after fractional laser resurfacing 11 was absent after skin needling The overall cost after multiple treatments with skin needling was much lower than fractional laser resurfacing

Page 7 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

The quality hardness and sharpness of needles are important property of good skin needling device Basically ice-hardening steel with tensile strength more than 2200 Newtons will ensure better chance of good result and also without complications High ratio of tip length VS diameter of 131 is another important property of good needles The depth of neocollagenesis was found to be average 5-600 micrometers even after 15 mm length needle So the needle length longer than 150 mm was unnecessary 1The Dermaroller TM had obtained CE approval and US FDA approval as medical device from Germany and USA since January 2006 Poor quality needles of the roller device often resulted in bending at needle tips after repeated treatments Thes resulted in in more tissue damages and hemorrhage with linear hypertrophic scars or post inflammatory hyperpigmentation1This reason together with problems of cross contamination is the reason why single-use device is recommended To avoid any possible complications doctors who are interested in performing this technique should attend a hand-on training course from experience dermatologic surgeons

In conclusion percutaneous collagen induction by skin needling with high quality single-use device (Dermaroller TM Horst Liebel Co Germany) had been shown to be highly effective and safe method for treatment of atrophic scar in Fitzpatrick skin type III to V Thai patients

References

1Fernandes D Minimally invasive percutaneous collagen induction Oral Maxillofacial Surg Clin N Am 200517 51-63

2Aust MC Fernandes D Kolokvthas P Kaplan HM Vogt PM Percutaneous collagen induction therapy an alternative treatment of scars wrinkles and skin laxity Plast Reconstr Surg 2008 121(4)1421-9

3Alster T West TB Resurfacing of atrophic facial acne scars with a high-energy pulsed carbondioxide laser Dermatol Surg 199622(2)154-155

4Goldman MP Manuskiatti W Combined laser resurfacing with the 950 microsecond pulsed CO2 + ErYAG lasers Dermatol Surg 1999 25(3) 160-3

5Woo SH Park JH KveYC Resurfacing of different types of facial acne scar with short-pulsed variable-pulsed and dual-mode ErYAG laser Dermatol Surg 200430488-93

6Jeong JT Kve YC Resurfacing of pitted facial acne scars with a long-pulsed ErYAG laser Dermatol Surg 2001276107-10

Page 8 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

7Tanzi EL Alster T Single-pass carbon dioxide versus multiple-pass ErYAG laser skin resurfacinga comparison of post operative wound healing and side effect rates Dermatol Surg 20032980-4

8Chan Hm Lam LKm Wong DS KonoT Trendekk-Smith N Use of 1320 nm NdYAG laser for wrinkle reduction and the treatment of atrophic acne scarring in Asians Lasers Surg Med 20043498-103

9Chua SH Ang P Khoo LS Goh CL Nonablative 1450 nm diode laser in the treatment of facial atrophic acne scars in type IV to V Asian skin a prospective clinical study Dermatol Surg 2004301287-91

10Lee HS Lee JH Ahn GY Lee DH Shin JW Kim DH Chung JH Fractional photothermolysis for the treatment of acne scars A report of 27 Korean patients JDermatolog Treat 200819(1)45-9

11 Kono T Chan HH Groff WF Manstein D Sakurai H Takeuchi M Yamaki T Soejima K Nozaki M Prospective direct comparison study of fractional resurfacing using different fluences and densities for skin rejuvenation in Asians Lasers Surg Med 2007 Apr39(4)311-4

Page 9 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

Acessment of results

Two independence nonmedical observers were requested to evaluate clinical improvement scores from side by side comparison of recorded standard photographies Standard six points improvement scores were used

5 = severe atrophic scar pre treatment

4 = improvement between 0-25

3 = improvement between 26-50

2 = improvement between 51 ndash 75

1 = improvement between 76 ndash 90

0 = improvement gt 91

Results

Figure 4 demonstrated clinical severity scores after 1-4 treatment with Dermaroller TM in 31 patients The number of treatments varied from 1 to 4 Usually the mild cases were treated once while severe cases had 3-4 treatments

Figure 4 Clinical improvement as graded by independent observers in 31 cases All cases had clinical improvement at six months The number of treatment ranged from 1 to 4

Clinical Improvement of acne scar after dermaroller in 31 cases

0

1

2

3

4

5

6

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31

Case No

Acn

esc

arse

veri

tysc

ores

P re Rx

Post Rx

Page 5 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

The mean clinical scores decreased from 424 to 233 at six months of follow-up (Figure 4)Five case ( 1613) had improvement more than 75 while 21 cases (6774) had improvement more than 50(Figure 5678) Two cases(645) developed folliculitis within a few days after treatments This cleared rapidly after oral antibiotics

Table 1 Mean acne scar severity scores after 1-4 Skin needling (Dermaroller TM)

by two indepencence non-medical observers for side by side standard

photographies comparison in 31 cases

Mean Pre treatment Mean Post treatment

( 6 months)

424 233

Discussions

Management of atrophic acne scar in dark skin types were difficult The standard treatments in white skin (Fitzpatrick skin type III) included dermabrasion chemical peels carbondioxide or erbium laser resurfacing 3456 Even in white skin patients results from these treatments were far from satisfactory 4 The treatments were complicated to perform with prolong healings and long term dyschromias Post treatments erythema was found in all cases lasting average 45 weeks after CO2

laser and 36 weeks after long-pulsed ErYAG laser Hyperpigmentation was seen in 46 after CO2 laser and 42 after ErYAG laser This hyperpigmentation lasted 127 and 114 weeks respectively 7 In dark skin types ( Fitzpatrick skin type III ndashVI) these laser treatments were abandoned because of serious post treatment complications especially post inflammatory hyperpigmentation and late onset permanent hypopigmentation Alster TS and West TB had reported 814 improvement after pulsed CO2 laser in Fitzpatrick skin type I-IV but also observed prolong erythema in all cases with 36 post treatment hyperpigmentation3

Nonablative laser resurfacing with absence of downtime often resulted in minimal improvement Most of the study had shown that after repeated treatment the degree of improvement were less than 3089Chan et al had found that after 1320 nm NdYAG laser treatment monthly for six months patientsrsquo satisfaction score was 4 from scale 0-10 From an independent observer the improvement was considered to be mild or no changes in majority of cases 8 Only recently with introduction of fractional laser resurfacing with Erbium-doped or laser which produced array of

Page 6 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

minutes thermal necrotic holes deep into the dermis that there were fair to good clinical improvement after multiple treatments (30-50) Lee et al had reported marked improvement in the appearance of acne scars at 3 months post-treatment in 27 Korean patients Patients self-assessed degrees of improvement were as follows excellent improvement in eight patients (30) significant improvement in 16 patients (59) and moderate improvement in three patients (11) Adverse events were limited to transient pain erythema and edema 9 The complications after fractional laser resurfacing was related to thermal injuries Too high density of laser spots often resulted in post treatment erythema and post inflammatory hyperpigmentation especially in dark skin type PIH after fractional laser resurfacing in Asians had been reported in 15 of cases The cost of fractional laser equipment and high consumable cost had discouraged wide acceptance of this laser in most of developing countries

Skin needling with special roller instrument with 298 tiny sharp stainless steel needles (250 microm diameter) and length between 05 to 2 mm had been introduced in Europe and South Africa by Des Fernandes since 19931He named this technique minimally invasive percutaneous collagen induction and had the first publication in 20051 The result after treatment of atrophic acne scar had been found to be satisfactory with minimum downtimes 2 The mechanism behind clinical improvement was purposed to be results of tangentially cutting of fibrotic scars by pressure rolling and induction of blood clot platelets activation released of cytokines especially platelet-derived growth factor fibrous growth factor transforming growth factor etc These resulted in induction of new collagen formation together with scar remodeling This results in elevation of atrophic scar and reduction of fibrotic scarborders1 Due to small size of needle holes healing was rapid Usually the tiny needle wounds healed in three days The degree of scar improvement from wound remodeling went on for many months after even single treatments12

Since this PCI technique had gained acceptance in Europe and South Africa12 but the clinical study in Asiansrsquo skin was lacking This study had shown that with good patients selection sterile method and good technique the degree of clinical improvement for treatment of atrophic acne scar in Fitzpatrick skin type III to V Asian patients was moderate to good result with 6774 had more than 50 clinical improvement This result was almost equal to those after CO2 laser resurfacing3 but with better healing and much lower post treatment complications It also is about the same efficacy with fractional laser resurfacing10 Post inflammatory hyperpigmentation which was directly related to thermal injury was more common after fractional laser resurfacing 11 was absent after skin needling The overall cost after multiple treatments with skin needling was much lower than fractional laser resurfacing

Page 7 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

The quality hardness and sharpness of needles are important property of good skin needling device Basically ice-hardening steel with tensile strength more than 2200 Newtons will ensure better chance of good result and also without complications High ratio of tip length VS diameter of 131 is another important property of good needles The depth of neocollagenesis was found to be average 5-600 micrometers even after 15 mm length needle So the needle length longer than 150 mm was unnecessary 1The Dermaroller TM had obtained CE approval and US FDA approval as medical device from Germany and USA since January 2006 Poor quality needles of the roller device often resulted in bending at needle tips after repeated treatments Thes resulted in in more tissue damages and hemorrhage with linear hypertrophic scars or post inflammatory hyperpigmentation1This reason together with problems of cross contamination is the reason why single-use device is recommended To avoid any possible complications doctors who are interested in performing this technique should attend a hand-on training course from experience dermatologic surgeons

In conclusion percutaneous collagen induction by skin needling with high quality single-use device (Dermaroller TM Horst Liebel Co Germany) had been shown to be highly effective and safe method for treatment of atrophic scar in Fitzpatrick skin type III to V Thai patients

References

1Fernandes D Minimally invasive percutaneous collagen induction Oral Maxillofacial Surg Clin N Am 200517 51-63

2Aust MC Fernandes D Kolokvthas P Kaplan HM Vogt PM Percutaneous collagen induction therapy an alternative treatment of scars wrinkles and skin laxity Plast Reconstr Surg 2008 121(4)1421-9

3Alster T West TB Resurfacing of atrophic facial acne scars with a high-energy pulsed carbondioxide laser Dermatol Surg 199622(2)154-155

4Goldman MP Manuskiatti W Combined laser resurfacing with the 950 microsecond pulsed CO2 + ErYAG lasers Dermatol Surg 1999 25(3) 160-3

5Woo SH Park JH KveYC Resurfacing of different types of facial acne scar with short-pulsed variable-pulsed and dual-mode ErYAG laser Dermatol Surg 200430488-93

6Jeong JT Kve YC Resurfacing of pitted facial acne scars with a long-pulsed ErYAG laser Dermatol Surg 2001276107-10

Page 8 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

7Tanzi EL Alster T Single-pass carbon dioxide versus multiple-pass ErYAG laser skin resurfacinga comparison of post operative wound healing and side effect rates Dermatol Surg 20032980-4

8Chan Hm Lam LKm Wong DS KonoT Trendekk-Smith N Use of 1320 nm NdYAG laser for wrinkle reduction and the treatment of atrophic acne scarring in Asians Lasers Surg Med 20043498-103

9Chua SH Ang P Khoo LS Goh CL Nonablative 1450 nm diode laser in the treatment of facial atrophic acne scars in type IV to V Asian skin a prospective clinical study Dermatol Surg 2004301287-91

10Lee HS Lee JH Ahn GY Lee DH Shin JW Kim DH Chung JH Fractional photothermolysis for the treatment of acne scars A report of 27 Korean patients JDermatolog Treat 200819(1)45-9

11 Kono T Chan HH Groff WF Manstein D Sakurai H Takeuchi M Yamaki T Soejima K Nozaki M Prospective direct comparison study of fractional resurfacing using different fluences and densities for skin rejuvenation in Asians Lasers Surg Med 2007 Apr39(4)311-4

Page 9 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

The mean clinical scores decreased from 424 to 233 at six months of follow-up (Figure 4)Five case ( 1613) had improvement more than 75 while 21 cases (6774) had improvement more than 50(Figure 5678) Two cases(645) developed folliculitis within a few days after treatments This cleared rapidly after oral antibiotics

Table 1 Mean acne scar severity scores after 1-4 Skin needling (Dermaroller TM)

by two indepencence non-medical observers for side by side standard

photographies comparison in 31 cases

Mean Pre treatment Mean Post treatment

( 6 months)

424 233

Discussions

Management of atrophic acne scar in dark skin types were difficult The standard treatments in white skin (Fitzpatrick skin type III) included dermabrasion chemical peels carbondioxide or erbium laser resurfacing 3456 Even in white skin patients results from these treatments were far from satisfactory 4 The treatments were complicated to perform with prolong healings and long term dyschromias Post treatments erythema was found in all cases lasting average 45 weeks after CO2

laser and 36 weeks after long-pulsed ErYAG laser Hyperpigmentation was seen in 46 after CO2 laser and 42 after ErYAG laser This hyperpigmentation lasted 127 and 114 weeks respectively 7 In dark skin types ( Fitzpatrick skin type III ndashVI) these laser treatments were abandoned because of serious post treatment complications especially post inflammatory hyperpigmentation and late onset permanent hypopigmentation Alster TS and West TB had reported 814 improvement after pulsed CO2 laser in Fitzpatrick skin type I-IV but also observed prolong erythema in all cases with 36 post treatment hyperpigmentation3

Nonablative laser resurfacing with absence of downtime often resulted in minimal improvement Most of the study had shown that after repeated treatment the degree of improvement were less than 3089Chan et al had found that after 1320 nm NdYAG laser treatment monthly for six months patientsrsquo satisfaction score was 4 from scale 0-10 From an independent observer the improvement was considered to be mild or no changes in majority of cases 8 Only recently with introduction of fractional laser resurfacing with Erbium-doped or laser which produced array of

Page 6 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

minutes thermal necrotic holes deep into the dermis that there were fair to good clinical improvement after multiple treatments (30-50) Lee et al had reported marked improvement in the appearance of acne scars at 3 months post-treatment in 27 Korean patients Patients self-assessed degrees of improvement were as follows excellent improvement in eight patients (30) significant improvement in 16 patients (59) and moderate improvement in three patients (11) Adverse events were limited to transient pain erythema and edema 9 The complications after fractional laser resurfacing was related to thermal injuries Too high density of laser spots often resulted in post treatment erythema and post inflammatory hyperpigmentation especially in dark skin type PIH after fractional laser resurfacing in Asians had been reported in 15 of cases The cost of fractional laser equipment and high consumable cost had discouraged wide acceptance of this laser in most of developing countries

Skin needling with special roller instrument with 298 tiny sharp stainless steel needles (250 microm diameter) and length between 05 to 2 mm had been introduced in Europe and South Africa by Des Fernandes since 19931He named this technique minimally invasive percutaneous collagen induction and had the first publication in 20051 The result after treatment of atrophic acne scar had been found to be satisfactory with minimum downtimes 2 The mechanism behind clinical improvement was purposed to be results of tangentially cutting of fibrotic scars by pressure rolling and induction of blood clot platelets activation released of cytokines especially platelet-derived growth factor fibrous growth factor transforming growth factor etc These resulted in induction of new collagen formation together with scar remodeling This results in elevation of atrophic scar and reduction of fibrotic scarborders1 Due to small size of needle holes healing was rapid Usually the tiny needle wounds healed in three days The degree of scar improvement from wound remodeling went on for many months after even single treatments12

Since this PCI technique had gained acceptance in Europe and South Africa12 but the clinical study in Asiansrsquo skin was lacking This study had shown that with good patients selection sterile method and good technique the degree of clinical improvement for treatment of atrophic acne scar in Fitzpatrick skin type III to V Asian patients was moderate to good result with 6774 had more than 50 clinical improvement This result was almost equal to those after CO2 laser resurfacing3 but with better healing and much lower post treatment complications It also is about the same efficacy with fractional laser resurfacing10 Post inflammatory hyperpigmentation which was directly related to thermal injury was more common after fractional laser resurfacing 11 was absent after skin needling The overall cost after multiple treatments with skin needling was much lower than fractional laser resurfacing

Page 7 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

The quality hardness and sharpness of needles are important property of good skin needling device Basically ice-hardening steel with tensile strength more than 2200 Newtons will ensure better chance of good result and also without complications High ratio of tip length VS diameter of 131 is another important property of good needles The depth of neocollagenesis was found to be average 5-600 micrometers even after 15 mm length needle So the needle length longer than 150 mm was unnecessary 1The Dermaroller TM had obtained CE approval and US FDA approval as medical device from Germany and USA since January 2006 Poor quality needles of the roller device often resulted in bending at needle tips after repeated treatments Thes resulted in in more tissue damages and hemorrhage with linear hypertrophic scars or post inflammatory hyperpigmentation1This reason together with problems of cross contamination is the reason why single-use device is recommended To avoid any possible complications doctors who are interested in performing this technique should attend a hand-on training course from experience dermatologic surgeons

In conclusion percutaneous collagen induction by skin needling with high quality single-use device (Dermaroller TM Horst Liebel Co Germany) had been shown to be highly effective and safe method for treatment of atrophic scar in Fitzpatrick skin type III to V Thai patients

References

1Fernandes D Minimally invasive percutaneous collagen induction Oral Maxillofacial Surg Clin N Am 200517 51-63

2Aust MC Fernandes D Kolokvthas P Kaplan HM Vogt PM Percutaneous collagen induction therapy an alternative treatment of scars wrinkles and skin laxity Plast Reconstr Surg 2008 121(4)1421-9

3Alster T West TB Resurfacing of atrophic facial acne scars with a high-energy pulsed carbondioxide laser Dermatol Surg 199622(2)154-155

4Goldman MP Manuskiatti W Combined laser resurfacing with the 950 microsecond pulsed CO2 + ErYAG lasers Dermatol Surg 1999 25(3) 160-3

5Woo SH Park JH KveYC Resurfacing of different types of facial acne scar with short-pulsed variable-pulsed and dual-mode ErYAG laser Dermatol Surg 200430488-93

6Jeong JT Kve YC Resurfacing of pitted facial acne scars with a long-pulsed ErYAG laser Dermatol Surg 2001276107-10

Page 8 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

7Tanzi EL Alster T Single-pass carbon dioxide versus multiple-pass ErYAG laser skin resurfacinga comparison of post operative wound healing and side effect rates Dermatol Surg 20032980-4

8Chan Hm Lam LKm Wong DS KonoT Trendekk-Smith N Use of 1320 nm NdYAG laser for wrinkle reduction and the treatment of atrophic acne scarring in Asians Lasers Surg Med 20043498-103

9Chua SH Ang P Khoo LS Goh CL Nonablative 1450 nm diode laser in the treatment of facial atrophic acne scars in type IV to V Asian skin a prospective clinical study Dermatol Surg 2004301287-91

10Lee HS Lee JH Ahn GY Lee DH Shin JW Kim DH Chung JH Fractional photothermolysis for the treatment of acne scars A report of 27 Korean patients JDermatolog Treat 200819(1)45-9

11 Kono T Chan HH Groff WF Manstein D Sakurai H Takeuchi M Yamaki T Soejima K Nozaki M Prospective direct comparison study of fractional resurfacing using different fluences and densities for skin rejuvenation in Asians Lasers Surg Med 2007 Apr39(4)311-4

Page 9 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

minutes thermal necrotic holes deep into the dermis that there were fair to good clinical improvement after multiple treatments (30-50) Lee et al had reported marked improvement in the appearance of acne scars at 3 months post-treatment in 27 Korean patients Patients self-assessed degrees of improvement were as follows excellent improvement in eight patients (30) significant improvement in 16 patients (59) and moderate improvement in three patients (11) Adverse events were limited to transient pain erythema and edema 9 The complications after fractional laser resurfacing was related to thermal injuries Too high density of laser spots often resulted in post treatment erythema and post inflammatory hyperpigmentation especially in dark skin type PIH after fractional laser resurfacing in Asians had been reported in 15 of cases The cost of fractional laser equipment and high consumable cost had discouraged wide acceptance of this laser in most of developing countries

Skin needling with special roller instrument with 298 tiny sharp stainless steel needles (250 microm diameter) and length between 05 to 2 mm had been introduced in Europe and South Africa by Des Fernandes since 19931He named this technique minimally invasive percutaneous collagen induction and had the first publication in 20051 The result after treatment of atrophic acne scar had been found to be satisfactory with minimum downtimes 2 The mechanism behind clinical improvement was purposed to be results of tangentially cutting of fibrotic scars by pressure rolling and induction of blood clot platelets activation released of cytokines especially platelet-derived growth factor fibrous growth factor transforming growth factor etc These resulted in induction of new collagen formation together with scar remodeling This results in elevation of atrophic scar and reduction of fibrotic scarborders1 Due to small size of needle holes healing was rapid Usually the tiny needle wounds healed in three days The degree of scar improvement from wound remodeling went on for many months after even single treatments12

Since this PCI technique had gained acceptance in Europe and South Africa12 but the clinical study in Asiansrsquo skin was lacking This study had shown that with good patients selection sterile method and good technique the degree of clinical improvement for treatment of atrophic acne scar in Fitzpatrick skin type III to V Asian patients was moderate to good result with 6774 had more than 50 clinical improvement This result was almost equal to those after CO2 laser resurfacing3 but with better healing and much lower post treatment complications It also is about the same efficacy with fractional laser resurfacing10 Post inflammatory hyperpigmentation which was directly related to thermal injury was more common after fractional laser resurfacing 11 was absent after skin needling The overall cost after multiple treatments with skin needling was much lower than fractional laser resurfacing

Page 7 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

The quality hardness and sharpness of needles are important property of good skin needling device Basically ice-hardening steel with tensile strength more than 2200 Newtons will ensure better chance of good result and also without complications High ratio of tip length VS diameter of 131 is another important property of good needles The depth of neocollagenesis was found to be average 5-600 micrometers even after 15 mm length needle So the needle length longer than 150 mm was unnecessary 1The Dermaroller TM had obtained CE approval and US FDA approval as medical device from Germany and USA since January 2006 Poor quality needles of the roller device often resulted in bending at needle tips after repeated treatments Thes resulted in in more tissue damages and hemorrhage with linear hypertrophic scars or post inflammatory hyperpigmentation1This reason together with problems of cross contamination is the reason why single-use device is recommended To avoid any possible complications doctors who are interested in performing this technique should attend a hand-on training course from experience dermatologic surgeons

In conclusion percutaneous collagen induction by skin needling with high quality single-use device (Dermaroller TM Horst Liebel Co Germany) had been shown to be highly effective and safe method for treatment of atrophic scar in Fitzpatrick skin type III to V Thai patients

References

1Fernandes D Minimally invasive percutaneous collagen induction Oral Maxillofacial Surg Clin N Am 200517 51-63

2Aust MC Fernandes D Kolokvthas P Kaplan HM Vogt PM Percutaneous collagen induction therapy an alternative treatment of scars wrinkles and skin laxity Plast Reconstr Surg 2008 121(4)1421-9

3Alster T West TB Resurfacing of atrophic facial acne scars with a high-energy pulsed carbondioxide laser Dermatol Surg 199622(2)154-155

4Goldman MP Manuskiatti W Combined laser resurfacing with the 950 microsecond pulsed CO2 + ErYAG lasers Dermatol Surg 1999 25(3) 160-3

5Woo SH Park JH KveYC Resurfacing of different types of facial acne scar with short-pulsed variable-pulsed and dual-mode ErYAG laser Dermatol Surg 200430488-93

6Jeong JT Kve YC Resurfacing of pitted facial acne scars with a long-pulsed ErYAG laser Dermatol Surg 2001276107-10

Page 8 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

7Tanzi EL Alster T Single-pass carbon dioxide versus multiple-pass ErYAG laser skin resurfacinga comparison of post operative wound healing and side effect rates Dermatol Surg 20032980-4

8Chan Hm Lam LKm Wong DS KonoT Trendekk-Smith N Use of 1320 nm NdYAG laser for wrinkle reduction and the treatment of atrophic acne scarring in Asians Lasers Surg Med 20043498-103

9Chua SH Ang P Khoo LS Goh CL Nonablative 1450 nm diode laser in the treatment of facial atrophic acne scars in type IV to V Asian skin a prospective clinical study Dermatol Surg 2004301287-91

10Lee HS Lee JH Ahn GY Lee DH Shin JW Kim DH Chung JH Fractional photothermolysis for the treatment of acne scars A report of 27 Korean patients JDermatolog Treat 200819(1)45-9

11 Kono T Chan HH Groff WF Manstein D Sakurai H Takeuchi M Yamaki T Soejima K Nozaki M Prospective direct comparison study of fractional resurfacing using different fluences and densities for skin rejuvenation in Asians Lasers Surg Med 2007 Apr39(4)311-4

Page 9 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

The quality hardness and sharpness of needles are important property of good skin needling device Basically ice-hardening steel with tensile strength more than 2200 Newtons will ensure better chance of good result and also without complications High ratio of tip length VS diameter of 131 is another important property of good needles The depth of neocollagenesis was found to be average 5-600 micrometers even after 15 mm length needle So the needle length longer than 150 mm was unnecessary 1The Dermaroller TM had obtained CE approval and US FDA approval as medical device from Germany and USA since January 2006 Poor quality needles of the roller device often resulted in bending at needle tips after repeated treatments Thes resulted in in more tissue damages and hemorrhage with linear hypertrophic scars or post inflammatory hyperpigmentation1This reason together with problems of cross contamination is the reason why single-use device is recommended To avoid any possible complications doctors who are interested in performing this technique should attend a hand-on training course from experience dermatologic surgeons

In conclusion percutaneous collagen induction by skin needling with high quality single-use device (Dermaroller TM Horst Liebel Co Germany) had been shown to be highly effective and safe method for treatment of atrophic scar in Fitzpatrick skin type III to V Thai patients

References

1Fernandes D Minimally invasive percutaneous collagen induction Oral Maxillofacial Surg Clin N Am 200517 51-63

2Aust MC Fernandes D Kolokvthas P Kaplan HM Vogt PM Percutaneous collagen induction therapy an alternative treatment of scars wrinkles and skin laxity Plast Reconstr Surg 2008 121(4)1421-9

3Alster T West TB Resurfacing of atrophic facial acne scars with a high-energy pulsed carbondioxide laser Dermatol Surg 199622(2)154-155

4Goldman MP Manuskiatti W Combined laser resurfacing with the 950 microsecond pulsed CO2 + ErYAG lasers Dermatol Surg 1999 25(3) 160-3

5Woo SH Park JH KveYC Resurfacing of different types of facial acne scar with short-pulsed variable-pulsed and dual-mode ErYAG laser Dermatol Surg 200430488-93

6Jeong JT Kve YC Resurfacing of pitted facial acne scars with a long-pulsed ErYAG laser Dermatol Surg 2001276107-10

Page 8 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

7Tanzi EL Alster T Single-pass carbon dioxide versus multiple-pass ErYAG laser skin resurfacinga comparison of post operative wound healing and side effect rates Dermatol Surg 20032980-4

8Chan Hm Lam LKm Wong DS KonoT Trendekk-Smith N Use of 1320 nm NdYAG laser for wrinkle reduction and the treatment of atrophic acne scarring in Asians Lasers Surg Med 20043498-103

9Chua SH Ang P Khoo LS Goh CL Nonablative 1450 nm diode laser in the treatment of facial atrophic acne scars in type IV to V Asian skin a prospective clinical study Dermatol Surg 2004301287-91

10Lee HS Lee JH Ahn GY Lee DH Shin JW Kim DH Chung JH Fractional photothermolysis for the treatment of acne scars A report of 27 Korean patients JDermatolog Treat 200819(1)45-9

11 Kono T Chan HH Groff WF Manstein D Sakurai H Takeuchi M Yamaki T Soejima K Nozaki M Prospective direct comparison study of fractional resurfacing using different fluences and densities for skin rejuvenation in Asians Lasers Surg Med 2007 Apr39(4)311-4

Page 9 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

7Tanzi EL Alster T Single-pass carbon dioxide versus multiple-pass ErYAG laser skin resurfacinga comparison of post operative wound healing and side effect rates Dermatol Surg 20032980-4

8Chan Hm Lam LKm Wong DS KonoT Trendekk-Smith N Use of 1320 nm NdYAG laser for wrinkle reduction and the treatment of atrophic acne scarring in Asians Lasers Surg Med 20043498-103

9Chua SH Ang P Khoo LS Goh CL Nonablative 1450 nm diode laser in the treatment of facial atrophic acne scars in type IV to V Asian skin a prospective clinical study Dermatol Surg 2004301287-91

10Lee HS Lee JH Ahn GY Lee DH Shin JW Kim DH Chung JH Fractional photothermolysis for the treatment of acne scars A report of 27 Korean patients JDermatolog Treat 200819(1)45-9

11 Kono T Chan HH Groff WF Manstein D Sakurai H Takeuchi M Yamaki T Soejima K Nozaki M Prospective direct comparison study of fractional resurfacing using different fluences and densities for skin rejuvenation in Asians Lasers Surg Med 2007 Apr39(4)311-4

Page 9 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

Figure 5 Good clinical improvement (gt75) after two monthly

Dermaroller TM treatment of moderate atrophic acne scars

Page 10 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

Figure 6 Good clinical improvement (gt75 ) in severe atrophic acne scar after

fourth monthly treatments

Page 11 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

Figure 7 Good clinical improvement after fourth Dermaroller TM treatments

Page 12 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

Figure 8 Good clinical improvement (gt75) after fourth monthly Dermaroller TM

treatments of moderate atrophic acne scar

Page 13 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

• asian journal coverpdf
• Dermaroller for management of acne scars

For Peer Review

Figure 6 Good clinical improvement (gt75 ) in severe atrophic acne scar after

fourth monthly treatments

Page 11 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

Figure 7 Good clinical improvement after fourth Dermaroller TM treatments

Page 12 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

Figure 8 Good clinical improvement (gt75) after fourth monthly Dermaroller TM

treatments of moderate atrophic acne scar

Page 13 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

• asian journal coverpdf
• Dermaroller for management of acne scars

For Peer Review

Figure 7 Good clinical improvement after fourth Dermaroller TM treatments

Page 12 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review

Figure 8 Good clinical improvement (gt75) after fourth monthly Dermaroller TM

treatments of moderate atrophic acne scar

Page 13 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

• asian journal coverpdf
• Dermaroller for management of acne scars

For Peer Review

Figure 8 Good clinical improvement (gt75) after fourth monthly Dermaroller TM

treatments of moderate atrophic acne scar

Page 13 of 13

Journal of Cosmetic Dermatology

Journal of Cosmetic Dermatology

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

• asian journal coverpdf
• Dermaroller for management of acne scars