Evaluation of Microneedling Fractional Radiofrequency Device for Treatment of Acne Scars

Transcription

1 Originl Article Evlution of Microneedling Frctionl Rdiofrequency Device for Tretment of Acne Scrs Bylekere Shivnn Chndrshekr, Rshmi Srirm, Rjdeep Mysore, Spnshree Bhskr, Ahishek Shetty Deprtment of Dermtology, CUTIS Acdemy of Cutneous Sciences, Bengluru, Krntk, Indi Address for correspondence: Dr. B S Chndrshekr, CUTIS Acdemy of Cutneous Sciences, 5/1, 4 th min, MRCR Lyout, Vijyngr, Bnglore , Krntk, Indi. E-mil: cutisclinic@gmil.com ABSTRACT Bckground: Vrious tretment modlities including non-invsive methods such s chemicl peels, topicl retinoids, microdermrsion, minimlly invsive techniques such s microneedling, frctionl lsers, microneedling rdiofrequency devices nd invsive procedures such s cne scr surgeries nd ltive lsers re used for cne scrs, ech with its own unique dvntges nd disdvntges. This study is retrospective ssessment of efficcy nd sfety of microneedling frctionl rdiofrequency in the tretment of cne scrs. Methods: Thirty one ptients of skin types III-V with moderte nd severe fcil cne scrring received four sequentil frctionl rdiofrequency tretments over period of 6 months with n intervl of 6 weeks etween ech session. Goodmn & Bron s cne scr grding system ws used for ssessment y side y side comprison of preopertive nd post- opertive photogrphs tken t their first visit nd t the end of 3 months fter the lst session. Results: Estimtion of improvement with Goodmn nd Bron s Glol Acne Scrring System showed tht y qulittive ssessment of 31 ptients with grde 3 nd grde 4 cne scrs, 80.64% showed improvement y 2 grdes nd 19.35% showed improvement y 1 grde. Quntittive ssessment showed tht 58% of the ptients hd moderte, 29% hd miniml, 9% hd good nd 3% showed very good improvement. Adverse effects were limited to trnsient pin, erythem, edem nd hyperpigmenttion. Conclusion: Microneedling frctionl rdiofrequency is efficcious for the tretment of moderte nd severe cne scrs. KEYWORDS: Acne scrs, microneedling frctionl rdiofrequency, tretment for cne scrs REC Review: Risk : 4 0 = mximum risk 5 = lest risk Efficcy : 4 0 = minimum efficcy 5 = mximum efficcy Cost : 3 0 = very expensive 5 = lest expensive INTRODUCTION Post-cne scrring is very distressing prolem. Atrophic cne scrs re derml depressions commonly cused y destruction of collgen fter inflmmtory cne. [1] Mny therpeutic mesures such s chemicl peeling, sucision, dermrsion, fillers nd punch techniques hve een performed to improve cne scrring ut with su-optiml outcomes. [2-6] Altive lsers such s Er:YAG Quick Response Code: Access this rticle online Wesite: DOI: / lsers or CO 2 lsers produce significnt improvement t the cost of long recovery times nd post-inflmmtory hyperpigmenttion. [7,8] Recently, newer techniques such s microneedling frctionl rdiofrequency (MFR) hs een shown to e cliniclly efficient in mnging cne scrs without cusing direct dmge to the epidermis. [9] MFR device works y creting rdiofrequency therml zones without epiderml injury. After dmge to the reticulr dermis, long-term derml remodelling, neoelstogenesis, nd neocollgenogenesis results in derml thickening. [10] MFR device ws evluted over period of 1 yer (Dec 2012 to Nov 2013) in 31 ptients of skin type III V with Grde 3 nd 4 trophic cne scrs. METHODS A retrospective photogrphic nlysis of 31 ptients treted with MFR for fcil trophic cne scrring ws done etween Novemer 2012 nd Decemer None of the ptients hd received ny previous tretment Journl of Cutneous nd Aesthetic Surgery - Apr-Jun 2014, Volume 7, Issue 2 93

2 for their cne scrs. Ptients were excluded if they hd received tretment with ny other lsers during tretment or follow-up period. Thirty-one ptients (15 mle nd 16 femle) met the inclusion criteri. The men ge ws 27.2 yers. Ptients hd undergone four sessions of MFR tretment for their cne scrs with n intervl of 6 weeks etween ech session, since the time for collgen remodelling lsts round 4-6 weeks. Tretment regimen ws individulised sed on predominnt scr type nd scr depth. The procedure re ws pinted with povidone iodine nd clened with rectified surgicl spirit prior to the procedure. Procedure ws performed under topicl nesthesi or nerve locks, using sterile precutions. Penetrtion depth ws limited to 1.5 mm on forehed, temple res nd res with ony prominences. Ptients with predominntly ice pick scrs nd mixed scrring were given needle depth of 3.5 mm on the first pss, 2.5 mm on the 2 nd pss nd 1.5 mm on the 3 rd pss with miniml or no overlpping. Higher energy settings (35 W-40 W) t depths of 3.5 mm with successively lower energy levels (30 W-35 W, 25 W-30 W, respectively) were used t lower penetrtion depths to prevent epiderml cogultion. Post-procedure pin ws mnged y orl non steroidl nti-inflmmtory drugs (NSAIDs) for 2 to 5 dys. Ptients were dvised strict sun protection long with re-epithelizing gents contining cyclopentsiloxne, cyclohexsiloxone nd sodium hyluronte. Assessment of efficcy Ojective ssessment of Physicin scores of improvement ws determined y glol cne scrring clssifiction of [11, 12] Goodmn & Bron [Tles 1 nd 2 nd ]. RESULTS All ptients completed the study, including the 3-month follow-ups. Most ptients hd mixed types of trophic cne scrs, including ice pick, oxcr nd rolling scrs. MFR ws ssocited with sustntil improvement in the ppernce of ll types of cne scrs, which included Tle 1: Goodmn nd Bron s qulittive cne scr grding system [11,12] Grde Level of disese Chrcteristics Exmples 1 Mculr disese Erythemtous, hyper- or hypopigmented flt mrks visile to ptient or oserver irrespective of distnce 2 Mild disese Mild trophy or hypertrophy tht my not e ovious t socil distnces of 50 cm or greter nd my e covered dequtely y mkeup or the norml shdow of shved erd hir in mles or norml ody hir if extrfcil 3 Moderte disese Moderte trophic or hypertrophic scrring tht is ovious t socil distnces of 50 cm or greter nd is not covered esily y mke-up or the norml shdow of shved erd hir ut is still le to e flttened y mnul stretching of the skin 4 Severe disese Severe trophic or hypertrophic scrring tht is ovious t socil distnces of 50 cm or greter nd is not covered esily y mke-up or the norml shdow of shved erd hir in mles or ody hir (if extrfcil) nd is not le to e flttened y mnul stretching of the skin Erythemtous, hyper- or hypopigmented flt mrks Mild rolling, smll soft ppulr More significnt rolling, shllow oxscr, mild to moderte hypertrophic or opulr scrs Punched out trophic (deep oxscr ), ice pick, ridges nd tunnels, gross trophy, dystrophic scrs significnt hypertrophy or keloid Tle 2: () Goodmn nd Bron s quntittive cne scr grding system [11,12] Grde or Type Milder scrring (1 point ech) Mculr erythemtous pigmented Mildly trophic dish-like Moderte scrring (2 points ech) Modertely trophic, dish like Punched out with shllow ses smll crs (<5 mm) Shllow ut rod trophic res Severe scrring (3 points ech) Punched out with deep ut norml ses, smll scrs (<5 mm) Punched out with deep ut norml ses, smll scrs (<5 mm) Liner or troughed derml scrring Deep, rod trophic res Hyperplstic Ppulr scrs Keloidl/Hypertrophic scrs 1 (1-10) 2 (11-20) 1 point 2 points 3 point 2 points 4 points 6 points 3 points 6 points 9 points 2 points Are<5 mm 6 points 4 points Are 5-20 mm2 12 points 3 (>20) 6 points Are>20 cm2 18 points 94 Journl of Cutneous nd Aesthetic Surgery - Apr-Jun 2014, Volume 7, Issue 2

3 the softening of scr contours s well s reduction in scr depth. Glol qulittive Acne Scrring System ws done. Out of 31 ptients who completed the tretment, 14 ptients hd Grde 4, 17 ptients hd Grde 3 efore tretment. The physicin s ssessment of response to tretment sed on Goodmn nd Bron Qulittive scr grding system is summrised in Tle 3. In ptients with Grde 4 scrs, 12 ptients (85.71%) showed improvement y 2 grdes, i.e. their scrs improved from Grde 4 to Grde 2 of Goodmn nd Bron scle [Figure 1 nd ]. Two ptients (14.28%) with Grde 4 scrs showed improvement y 1 grde with scrs eing ovious t socil distnces of 50 cm or greter. In 17 ptients with Grde 3 scrs, 13 ptients (76.47%) improved y 2 grdes [Figure 2 nd ] nd 4 ptients (23.52%) showed improvement y 1 grde [Figure 3 nd ]. Rolling nd ox scrs showed etter response thn ice-pick scrs. Estimtion of improvement with Goodmn nd Bron s Glol quntittive Acne Scrring System showed tht 58% of the ptients hd moderte improvement, 29% hd miniml improvement, 9% hd good improvement nd 3% showed very good improvement [Figure 4]. The tretment ws generlly well tolerted. All ptients underwent tretment-relted pin. All ptients hd reported mild erythem for two dys, two ptients hd oedem for more thn three dys, five ptients reported post inflmmtory hyperpigmenttion nd two ptients hd trck mrks of the device proe [Figure 5]. Socil ctivity could commence s erly s one dy fter tretment. Figure 1: () Grde 4 cne scrs, () Improvement in cne scrs from Grde 4 to Grde 2 fter tretment Figure 2: () Grde 3 cne scrs, () Improvement in cne scrs from Grde 3 to Grde 1 fter tretment Figure 3: () Grde 3 cne scrs, () Improvement in cne scrs from Grde 3 to Grde 2 fter tretment Tle 2: () Assessment of improvement using Goodmn nd Bron s quntittive cne scr grding system Grdes Improvement sttus 0-5 Miniml reduction in GSGS scores 5-10 Moderte reduction in GSGS scores Good reduction in GSGS scores >15 Very good reduction in GSGS scores Figure 4: Br grph representing improvement in cne scrs y Goodmn nd Bron s quntittive cne scr grding system Tle 3: Physicin ssessment response sed on Goodmn nd Bron s qulittive cne scr grding Previous to tretment grde of cne scr No of ptients y 3 grdes (%) y 2 grdes (%) y 1 grde (%) No post-tretment (%) Grde (0) 13 (76.47) 4 (23.52) 0 (0) Grde (0) 12 (85.71) 2 (14.28) 0 (0) Journl of Cutneous nd Aesthetic Surgery - Apr-Jun 2014, Volume 7, Issue 2 95

4 Review of technology A microneedling frctionl rdiofrequency (RF) device is ville for commercil use (Lutronic corportion USA) with mximum energy output of 50 W nd cple of delivering energy in increments of 2.5 W in 20 eqully grded energy level settings (Level W to level W). Figure 5: Adverse effect trck mrks of the device proe DISCUSSION Acne scrring occurs susequent to visile resolution of deep inflmmtion. Scrring my occur regrdless of the severity of cne. Although cne scrring is likely to e ssocited more often with nodulocystic cne, it my occur in cses with only superficil forms of cne s well, especilly when effective tretment is delyed. [13,14] A study showed tht pproximtely 16% of ptients with cne seek proper tretment, nd mong those seeking such help, 74% wit greter thn 12 months, 12% wit for 6 to 12 months, 6% wit for 6 months nd only 7% wit for less thn 3 months to e seen professionlly for therpy of their cne. [15] Atrophic cne scrring ppers to e most common type ssocited with cne. The mjor clinicl types of trophic scrs re ice pick, rolling or superficil nd deep soft scrs, nd oxcr or depressed firotic scrs. Although ltive nd non-ltive lser skin resurfcing hs gretly improved the tretment of trophic cne scrs, they re not without disdvntges. [14,16] Altive lsers such s CO 2 nd Er:YAG lser hve efficcy of 25-90% for tretment of cne scrs ut re ssocited with erythem for more thn 3 months, dyspigmenttion nd scrring. [17] Non-ltive lsers such s 1064 nm Nd YAG nd 1450 nm diode lsers hve n efficcy of 40-50% fter series of tretments, with effect only on shllow ox scrs with no significnt epiderml improvement. [17,18] In contrst to ltive nd non ltive lsers, tretment with the MFR device cn e controlled y vrying the depth. The durtion of ech energy pulse cn e set from 10 ms to 1,000 ms. A good control over the tissue dmge cn e chieved y chnging the exposure time rther thn ltering the power level. Although the mximum power is higher thn mny other devices, the lrge rnge of exposure time enles the user to pply sfe nd consistent levels of cogultion in the dermis to chieve the desired effect. The energy delivery system consists of disposle tip with 49 gold-plted needles. The entire length of the needle is insulted nd it delivers ursts of RF energy through the tip. The depth of the needles cn e djusted from minimum of 0.5 mm to mximum of 3.5 mm. [19] The ility to set multiple needle depths per pss is n dvntge, llowing discrete electrotherml cogultion t different lyers of the dermis. The insulted needles prevent electrotherml dmge from occurring nywhere in the dermis ut t the very tip of the needle nd never in the epidermis. The mechnisms involved re neo-collgenogenesis y needle penetrtion stimulting the relese of growth fctors nd reltive spring of epidermis nd dnexl structures which contriute to rpid heling. [19] Rmesh et l. treted fcil cne scrs of 30 sujects with mtrix tunle rdiofrequency device pretreted with orl ntiiotics, topicl tretinoin nd sucision. The visul nlog scle of improvement in scrs rnged from 10-50% t end of 2 months to 20-70% t the end of 6 months. [20] Despite these differences oth studies show tht frctionl rdiofrequency is oth sfe nd effective for tretment of cne scrs in skin types 3, 4 nd 5. Gold et l., conducted study where in 13 ptients with mild to moderte cne scrs were treted with ipolr frctionl rdiofrequency nd concluded tht frctionl ipolr rdiofrequency is sfe nd n effective tretment for cne scrs with 67-92% ptients stisfied with the results. [9] Cho et l. evluted efficcy of frctionl rdiofrequency in tretment of 30 ptients with mild to moderte cne scrs nd lrge fcil pores. The grde of cne scrs nd investigtor glol ssessment of lrge pores improved in more thn 70% of the ptients. [21] The encourging results prompted us to conduct retrospective nlysis of efficcy nd sfety of MFR 96 Journl of Cutneous nd Aesthetic Surgery - Apr-Jun 2014, Volume 7, Issue 2

5 to tret trophic cne scrs in ptients of Indin ethnicity, skin type 4 nd 5. Glol qulittive Acne Scrring System showed tht in 14 ptients with Grde 4 scrs, 85.71% showed improvement y 2 grdes, 14.28% showed improvement y 1 grde. In 17 ptients with Grde 3 scrs, 76.47% improved y 2 grdes nd 23.52% showed improvement y 1 grde. Of the 31 ptients with Grde 3 nd Grde 4 cne scrs, 80.64% showed improvement y 2 grdes nd 19.35% showed improvement y 1 grde. Rolling nd ox scrs showed etter response thn ice-pick scrs. Glol quntittive Acne Scrring System showed tht 58% of the ptients hd moderte improvement, 29% hd miniml improvement, 9% hd good improvement nd 3% showed very good improvement Hence, ll 31 ptients (100%) showed improvement in their scrs with no filure rte. The tretment ws well tolerted with trnsient side effects such s mild erythem, post-inflmmtory hyperpigmenttion nd trck mrks of the device. CONCLUSION MFR tretment cn e considered s n effective modlity of tretment for moderte to severe cne scrs in ptients with n dded dvntge of miniml downtime nd effective improvement. REFERENCES 1. Hollnd DB, Jeremy AH, Roerts SG, Seukrn DC, Lyton AM, Cunliffe WJ. Inflmmtion in cne scrring: A Comprison of the responses in lesions from ptients prone nd not prone to scr. Br J Dermtol 2004;150: Slvin JW. Trichlorocetic cid peels. Aesthetic Surg J 2004;24: Orentreich DS, Orentreich N. Sucutneous incisionless (sucision) surgery for the correction of depressed scrs nd wrinkles. Dermtol Surg 1995;21: Alkhwn L, Alm M. Dermrsion nd microdermrsion. Fcil Plst Surg 2009;25: Hirsch RJ, Cohen JL. Soft tissue ugmenttion. Cutis 2006;78: Grevelink JM, White VR. Concurrent use of lser skin surfcing nd punch excision in tretment of fcil cne scrring. Dermtol Surg 1998;24: Hu S, Chen MC, Lee MC, Yng LC, Keoprsm N. Frctionl resurfcing for the tretment of trophic fcil cne scrs in sin skin. Dermtol Surg 2009;35: Chrstil B, Glich AS, Golderg LH, Friederg PM. Second genertion 1550 nm frctionl photothermolysis for tretment of cne scrs. Dermtol Surg 2008;34: Gold M, Biron J. Tretment of cne scrs y frctionl ipolr rdiofrequency energy. J Cosmet Lser Ther 2012;14: Hruz G, Tu AF, Collier SL, Mulhollnd SR. Skin rejuvention nd wrinkle reduction using frctionl rdiofrequency system. J Drugs Dermtol 2009;8: Goodmn GJ, Bron JA. Post cne scrring: A qulittive glol scrring grding system. Dermtol Surg 2006;32: Goodmn GJ, Bron JA. Postcne scrring: A quntittive glol scrring grding system. J Cosmet Dermtol 2006;5: Goodmn G. Mngement of post cne scrring: Wht re the options for tretment? Am J Clin Dermtol 2000;1: River A. Acne scrring: A review of current tretment modlities. J Am Acd Dermtol 2008;59: Tn J, Vsey T, Fung K. Beleifs nd perceptions of ptients with cne. J Am Acd Dermtol 2001;44: Jco C, Dover J, Kminer M. Acne scrring: A clssifiction system nd review of tretment options. J Am Acd Dermtol 2001;45: Jordn R, Cummins C, Burls A. Lser resurfcing of skin for improvement of cne scrring: A systemtic review of evidence. Br J Dermtol 2000;142: Munvlli GS, Weiss RA, Hlder RM. Photoging nd non ltive photorejuvention in ethnic skin. Dermtol Surg 2005;31: Clderhed RG, Goo BL, Luro F, Gursoy D, Svnt S, Wronski A. The clinicl efficcy nd sfety of microneedling frctionl rdiofrequency in the tretment of fcil wrinkles: A multicenter study with the INFINI system in 499 ptients [WWW document] Aville from: www. lutronic.com/.../infini (free rticle). 20. Rmesh M, Gopl M, Kumr S, Tlwr A. Novel technology in tretment of cne scrs: The mtrix tunle rdiofrequency technology. J Cutn Aesthet Surg 2010;214: Cho SI, Chung BY, Choi MG, Bek JH, Cho HJ, Prk CW, et l. Evlution of the clinicl efficcy of frctionl rdiofrequency microneedle tretment. In cne scrs nd lrge fcil pores. Dermtol Surg 2012;38: How to cite this rticle: Chndrshekr BS, Srirm R, Mysore R, Bhskr S, Shetty A. Evlution of microneedling frctionl rdiofrequency device for tretment of cne scrs. J Cutn Aesthet Surg 2014;7:93-7. Source of Support: Nil. Conflict of Interest: None declred. Journl of Cutneous nd Aesthetic Surgery - Apr-Jun 2014, Volume 7, Issue 2 97