Microneedling represents a cosmetic dermatology treatment with multiple uses. Originally touted as a collagen-inducing therapy for wrinkles and skin tightening, microneedling has evolved into an effective modality for treating acne, acne scars, and hyperpigmentation.
My love affair with microneedling began in 2008 while it was still a new and under-explored treatment. It proved safe on my primary demographic – skin of color – when few rejuvenating options were available. I performed treatments on all skin colors and skin types. The results suggested that this therapy safely harmonized the primary dermal cells involved in skin rejuvenation: keratinocytes, melanocytes, fibroblasts, and sebocytes, on all skin tones.
Aesthetic dermatology thrives on the synergies of multimodal treatments, hence the further evolution of my microneedling treatments. I now utilize various techniques and have also begun using rejuvenation secrets gained from my South Korean colleagues.
Acne scars are prevalent on skin of color. Unfortunately, effective treatments such as CO2 laser resurfacing are not viable options for darker Fitzpatrick skin types IV-VI. CO2 laser resurfacing carries a risk of melanocyte hyperstimulation, resulting in undesirable post-inflammatory hyperpigmentation (PIH) on darker skin tones. My current treatment protocol for darker skin revolves around a systematic and stepwise approach that combines microneedling with subdermal fiber dissection, radiofrequency (RF) cellular stimulation, dermal fillers and polydioxanone (PDO) thread lifting techniques.
Each of these treatments individually reduces acne scar depth, but my combined approach achieves a synergistic bilayer improvement in acne scar rejuvenation. Both the epidermis and the dermis are maximally stimulated with mechanical and energy-based devices, which ensures minimal risk of melanocyte stimulation.
Pretreatment
Baseline photography should be done prior to the first treatment. Before embarking upon any skin rejuvenation program on skin of color, it is recommended that the skin be conditioned for at least two weeks. I suggest my patients use a superficial chemical peel and a skincare regimen that consists of retinoids, 4% hydroquinone, and a hydroxy acid for home use.
Patient expectations need to be managed prior to treatment. It is important to have a discussion on a realistic timeline for visible results. A series of three treatments is normally the minimum, spaced approximately two weeks apart. Most patients experience an appreciable improvement within the first month of treatment.
Treatment Session One:
The first treatment involves microneedling followed by subdermal scar dissection (sub-cision) with an 18-gauge Nokor™ needle attached to a 1 mL syringe. Energy treatments may also be employed during this session. Local anesthesia will be required for the targeted areas, which can be administered either via infiltration or local blocks. Edema and tenderness are common post-treatment and can be managed with NSAIDs.
Treatment Session Two:
This session focuses on the targeted placement of smooth PDO threads for the further encouragement of neocollagenesis. Topical anesthesia suffices for this treatment.
Treatment Session Three:
Patient response will be assessed during the third session. Each patient will present with a different clinical response; therefore, meticu-lous photographs should be taken. The patient’s skin should be palpated to assess the degree of scar softening and the breakdown of dermal scar tissue. At this appointment, dermal fillers are placed in localized areas re-quiring greater scar rejuvenation. Microneedling is also often performed during this appointment, to aid with the improvement of the epidermal surface texture.
Not all patients will follow the three-session rule. For example, patients presenting with shallower rolling and box scars respond well to the typical three sessions outlined above. Patients with icepick and deeper scars will pres-ent the greatest challenge. With such cases,you can consider a second subcision surgery at session three, concurrently injecting dermal filler through your Nokor needle for large scar areas. A fourth session with PDO threads and microneedling may be performed one month later. Other treatments such as TCA CROSS (trichloroacetic acid chemical reconstruction of skin scars) can also be incorporated into your treatment regime, especially on Fitzpatrick types  I-IV.  Microdermabrasion has also proven to aid epidermal resurfacing and smooth the skin texture.
Treatment Pearls: Thinking Out of the Box
Managing PIH & Skin TextureHaving over a decade of experience with microneedling on dark skin has taught me a great deal. Through experience, I have learned that microneedling on skin of color is not without risk, and PIH development is possible in a few cases. My clinic relies on skin conditioning protocols based on mandelic acid, our choice of hydroxy acid for skin color. We combine this with tretinoin and hydroquinone and have found a superior patient response with mandelic acid over glycolic acid-based skin conditioning protocols. Skin texture and skin tone are also greatly improved with this method.
The Dermal / Epidermal Connection Traditional microneedling treatments still represent a relatively superficial epidermal treatment and should be combined with deeper  stimulation  modalities.  For example, RF can be used to achieve enhanced fibroblastic and dermal stimulation. Acne scars are primarily a dermal concern, therefore greater focus should be applied to dermal plumping and dermal stimulatory treatments. Hence the reason for my focus on PDO treatments for greater predictability of fibroblastic stimulation and dermal fillers for volume enhancement.
The Time Factor
Neocollagenesis and acne scar rejuvenation both require time and patience. Some clients may not see results until three months post-treatment. At this stage, comparison photos can be made. Physicians who utilize cosmeceuticals to improve skin condition and tone will appreciate the three months mark. At this point, the skin becomes a canvas. Not only should light reflection and shadowing be less pronounced with acne scar combination treatments, but the skin should also appear clearer and healthier.
Final Thoughts
Microneedling as a treatment is here to stay for acne scars. Clinicians that can venture deeper with surgical scar treatments and utilize the power of smooth PDO threads will enjoy enhanced treatment results. The combination of in-depth microneedling and PDO threads will provide patients with higher levels of satisfaction and fewer treatment complications
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About the Author
Dr. Destang is a dual qualified physician from St. Lucia, who has spent the last 25 years aesthetically enhancing her patients. She is a qualified specialist in both orthodontics and aesthetic dermatology. Dr. Destang possesses the ability to not only appreciate ideal facial aesthetics and modify jaw structures, but also recognizes the importance of harmonizing facial balance. Her unique education and experience enable her to be a valuable contributor, innovator, lecturer and educator in aesthetics.
