percutaneous collagen induction in the...

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PERCUTANEOUS COLLAGEN INDUCTION IN THE TREATMENT OF

ATROPHIC ACNE SCARS USING AN AUTOMATED MICRONEEDLING

DEVICE- A NOVEL APPROACH

This dissertation is submitted to

THE TAMILNADU DR.M.G.R. MEDICAL UNIVERSITY

In partial fulfilment of the requirement of the award for the degree of

M.D DEGREE IN

DERMATOLOGY, VENEREOLOGY AND LEPROSY

BRANCH XX

GOVERNMENT STANLEY MEDICAL COLLEGE

CHENNAI- 600 001

MAY 2019

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DECLARATION BY THE CANDIDATE

I, Dr. SIVARANJANI. J, solemnly declare that the dissertation titled

“PERCUTANEOUS COLLAGEN INDUCTION IN THE TREATMENT

OF ATROPHIC ACNE SCARS USING AN AUTOMATED

MICRONEEDLING DEVICE- A NOVEL APPROACH’’ is a bonafide work

done by me at the Department of Dermatology, Venereology and Leprosy,

Government Stanley Medical College and Hospital during 2016-2019 under the

guidance of my Guide, Prof. Dr. V. ANANDAN, M.D(Derm) and under the

supervision of my HOD, Prof. Dr. PARIMALAM KUMAR, M.D,D.D., Dip.,

N.B., MNAMS., FIAD., FRCP.

The dissertation is submitted to THE TAMILNADU DR. M.G.R.

MEDICAL UNIVERSITY towards the partial fulfilment of requirement for

the award of M.D. Degree in DERMATOLOGY, VENEREOLOGY &

LEPRSOY (BRANCH XX).

Place:

Date: Signature of the candidate

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CERTIFICATE BY THE INSTITUTE

Certified that this dissertation entitled “PERCUTANEOUS COLLAGEN

INDUCTION IN THE TREATMENT OF ATROPHIC ACNE SCARS

USING AN AUTOMATED MICRONEEDLING DEVICE- A NOVEL

APPROACH” is a bonafide work done by Dr. SIVARANJANI. J, Post Graduate

Student of the Department of Dermatology, Venereology, Leprosy, Government

Stanley Medical College and Hospital, Chennai-600 001 during the academic year

2016- 2019 for the partial fulfilment of university rules and regulation for the award of

M.D. Degree in DERMATOLOGY, VENEREOLOGY AND LEPROSY (Branch XX).

This work has not been submitted previously for the award of any degree.

Dr. PARIMALAM KUMAR ,., Dr. S. PONNAMBALA NAMASIVAYAM,

M.D, D.D, DNB, MNAMS, FIAD, FRCP, M.D.,D.A.,DNB

Professor & Head Of Department, Dean,

Department of Dermatology, Govt. Stanley Medical College,

Govt. Stanley Medical College, Chennai-600 001.

Chennai-600 001.

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CERTIFICATE BY GUIDE

Certified that this dissertation entitled “PERCUTANEOUS COLLAGEN

INDUCTION IN THE TREATMENT OF ATROPHIC ACNE SCARS

USING AN AUTOMATED MICRONEEDLING DEVICE- A NOVEL

APPROACH” is a bonafide work done by Dr. SIVARANJANI. J, Post Graduate

Student of the Department of Dermatology, Venereology, Leprosy, Government

Stanley Medical College and Hospital, Chennai-600 001 during the academic year

2016- 2019 for the partial fulfilment of university rules and regulation for the award of

M.D. Degree in DERMATOLOGY, VENEREOLOGY AND LEPROSY (Branch XX).

This work has not been submitted previously for the award of any degree.

Dr. V.ANANDAN, M.D.,

Professor ,

Department of Dermatology,

Govt. Stanley Medical College,

Chennai-600 001.

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ACKNOWLEDGEMENT

It is with immense pleasure and gratitude that I thank Dr. PONNAMBALA

NAMASIVAYAM M.D.,D.A., Dean, GOVERNMENT STANLEY

MEDICAL COLLEGE for bestowing me the permission and privilege of

presenting this study and for enabling me to avail the institutional facilities.

I am gratefully indebted to Prof. Dr. PARIMALAM KUMAR M.D(Derm).,

D.D., Dip., N.B., MNAMS., FIAD., FRCP., Professor and Head of

Department of Dermatology and Leprosy for her invaluable guidance and

motivation. I would like to express my sincere and heartfelt thanks to

Prof.Dr.V.ANANDAN M.D.,(Derm), for his guidance and encouragement.

I express my deep sense of gratitude to Prof. Dr. MANIMEGALAI . M

M.D.,D.D., Professor and Head of Department of Venereology and

Dr. SENTHIL KUMAR D.V, DNB(Derm), Associate professor, Department

of Dermatology, for their constant support and motivation.

Words will not suffice the gratitude I owe to my beloved co-guide Dr. N.S.

Jayanthi M.D DVL, Assistant Professor, Department of Dermatology, for her

guidance and endless patience in moulding of the study.

I would like to extend my thanks to all our Assistant professors, Department of

Dermatology, Dr. NITHYAGAYATHRI M.D (DVL), Dr. SOWMIYA M.D

(DVL), , Dr. MOHANASUDARI M.D (DVL), Dr. MANI SURYA KUMAR M.D

(DVL), Dr. SARASWATHI M.D(DVL), Dr. ANBULAKSHMI D.D, are thanked

for their enthusiasm in motivating me with their efforts to materialize this study.

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I am inclined to thank Assistant professors, Department of venereology for their help

and suggestions.

I wholeheartedly thank my colleagues for their constant help and favours. I also

acknowledge the help provided by the paramedical staffs.

A sincere thanks to all my patients for their co-operation and participation in the

study.

Last but not the least I thank my parents and the Almighty God, whose blessings are

always with me.

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CONTENTS

S.NO. TITLE PAGE NO. 1. INTRODUCTION 1 2. REVIEW OF LITERATURE 5 3. AIMS AND OBJECTIVES 45 4. MATERIALS AND METHODS 47 5. OBSERVATION AND RESULTS 62 6. CLINICAL PHOTOGRAPHS 84 6. DISCUSSION 95 7. CONCLUSION 100 8. BIBLIOGRAPHY 102 ANNEXURE PATIENT CONSENT FORM PROFORMA ETHICAL COMMITTEE APPROVAL PLAGIARISM APPROVAL MASTERCHART ABBREVIATIONS

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PERCUTANEOUS COLLAGEN INDUCTION IN THE

TREATMENT OF ATROPHIC ACNE SCARS USING

AN AUTOMATED MICRONEEDLING DEVICE- A

NOVEL APPROACH

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INTRODUCTION

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Acne vulgaris can be defined as a chronic inflammatory disease which involves

pilosebaceous unit, due to increased sebum production, disordered keratinization,

microbial colonisation of hair follicles and inflammation.[1] It is clinically characterized

by pleomorphic lesions like comedones, papules, pustules, nodules and cysts.

Seborrheic areas like face, upper chest and back of trunk are usually affected. Though

it is a self-limiting disease in many, the post-inflammatory changes like pigmentation

and scarring can have a great deal of psychological morbidity in the patients, pushing

them even to the extent of suicide. Acne scars of the face are seen in approximately

20% of teenagers. This facial scarring, especially in males, is identified to be a risk

factor for suicide. [2]

Inflammatory acne lesions are usually responsible for the scar formation. Duration of

initial inflammatory lesions left untreated correlates positively with the severity of

scarring. Thus, early and adequate treatment of acne vulgaris is needed for preventing

scar formation.

Though various topical and systemic drugs are available in market for the acne vulgaris

management, acne scars show poor response with such treatments. Various procedural

modalities are available in management of acne scars. This study involves a novel

technique called micro needling using an advanced automated device, dermapen in

managing facial acne scars.

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NEED FOR THE STUDY:

Post acne scarring results from the damage to collagen tissue due to the excessive

inflammation in the healing acne lesion. It can be broadly classified into two types,

depending on whether the scar is due to increased tissue formation or due to tissue

damage and loss. Hypertrophic and keloidal scars are due to the former whereas scars

due to damage and loss of tissue, are of three types namely: icepick, rolling, boxcar.[3]

Damage limited to epidermis results in pigmentary changes.

Presence of post acne scarring can have various psychosocial effects on the individual,

in the form of low self- esteem, embarrassment, frustration, unemployment, depression,

anxiety, poor social interaction, anger, poor academic performance etc... [4]

Atrophic acne scars require surgical or procedural management for their better outcome.

Most of such treatment options are ablative, causing huge damage to epidermis and

dermis. This results in several undesirable side-effects like increased downtime,

pigmentation, pain, edema, excess scarring and photosensitivity.

Microneedling is an unique technique in which the skin is penetrated, non-invasively,

thus retaining epidermal barrier. It is performed using small needles which cause

controlled injury to skin, which heals by increased collagen formation, with little

downtime, no excess scarring or photosensitivity.[5]

This study makes use of this non-ablative microneedling technique in treating atrophic

post acne scars, with the use of an advanced automated microneedling device known as

dermapen. Dermapen has many added advantages over the traditional dermaroller and

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overcomes it’s flaws and disadvantages. There are not much studies available on

treating atrophic acne scars with this advanced instrument.

This study aims at objectively assessing the efficacy of automated microneedling

device, in the treatment of atrophic acne scars.

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REVIEW

OF

LITERATURE

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HISTORY OF ACNE VULGARIS:

Acne, also known as acne vulgaris has its mention from very ancient times. It is not a

disease of modern age. The first description of it could be found in the Sushrut Samhita

under Kshudra Roga as Mukha Dushika. Ancient Egyptian writings mentions that

several pha-raohs suffered with acne. They had superstitious belief that breakouts of

acne are due to telling lies and used magic, spells and charms for their cure. In Ebers

Papyrus dating to 1550 b.c, the word aku-t is used which means boils, sores, pustules

or any inflammatory swelling.

Earliest mention of acne in Greece is seen in writings of Aetius Amidenus. The word

acne is believed to have been originated from the Greek word acme, meaning point or

spot. Mentions about the disease by Aristotle and Hippocrates is also seen where acne

was referred to as tovoot, meaning “the first growth of the beard”. [6]

EPIDEMIOLOGY

Acne vulgaris is so common, that some degree of the disease is seen in nearly all

individuals between 15-17 years of age. Around 15-20% of adolescents suffer moderate

to severe acne. Acneform eruptions are seen in around 20% neonates, which

spontaneously resolves by 3 months. Prevalence of acne was found to be around 64%

in people aged 20-29 years, 43% in those of 30-39 years and 3-5% among 40-49

years.[7,8] However, these are population based studies and the incidence and prevalence

of acne varies depending on various environmental factors.

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SOCIO-ECONOMIC INFLUENCE:

Studies have shown a higher prevalence of acne vulgaris among high socio-economic

classes.[9] But, this may be due to lower rate of referral among those with lower

socioeconomic conditions. The rate of unemployment was found to be high among the

acne sufferers.

GENETICS:

Around 78% of individuals with acne vulgaris had a first-degree relative suffering from

the same, in one population based study. Early onset and greater severity of the disease

was found in those having a positive family history. [10]

ETHNICITY:

Contrary to the previous belief of higher prevalence of acne among whites when

compared to blacks, recent studies shows that the disease is common in both the

population and that there is no difference in management consensus between them. [11]

DIET:

Acne is more prevalent among westernized societies, with prevalence ranging from

79% to 95% among adolescent population. Acne vulgaris is not known in some of the

non-westernized societies like inhabitants of Kitavan island in Papua New Guinea and

in Ache hunter- gatherers of Paraguay. This striking difference is attributed mainly to

the environmental factors like consumption of diet rich in low glycemic index food,

resulting in high insulin sensitivity and low level of free insulin. [12]

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Hyperinsulinemia results in elevated free IGF-1 levels, which is a potent mitogen for

various body tissues including hair follicle, thus promoting acne via follicle

hyperkeratinisation. In addition, hyperinsulinemia and high IGF-1 levels will increase

sebum production and thus acne formation. Low glycemic index carbohydrates increase

SHBG levels, thus proving to have therapeutic benefit.

SUNLIGHT:

Studies have shown that Sunlight does not improve acne. Short term light therapy with

blue, infra-red, blue-red lights have been more beneficial than red, yellow or green

light[13].

HYGIENE:

On contrary to the common belief that poor hygiene exacerbates acne, there is no

evidence to supports this. [14]

SMOKING:

Smoking had seen to ameliorate acne because of its anti-inflammatory property in few

studies. [15] But, this still remains controversial.

STRESS AND PICKING:

Stress has been implicated as a major exacerbating factor in acne vulgaris [16].

Relaxation and biofeedback trainings showed to decrease the severity of acne in few

studies.

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PATHOGENESIS OF ACNE VULGARIS:

Acne vulgaris is formed due to obstruction, which is followed by inflammation in the

sebaceous follicle, having predominant sebaceous gland and rudimentary hair.[figure1].

Figure 1: Sebaceous follicle

Microcomedone is the pathognomonic lesion of acne vulgaris, which further evolves to

become either a non-inflammatory open or closed comedo or an inflammatory pustule,

papule or nodule.[figure2]

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Figure 2: Formation of micro comedone

For the microcomedone to develop, the following four factors undergo a complex

interplay: [figure 3]

- Altered keratinization of hair follicle

- Sebaceous hyperplasia

- Microbial colonization

- Inflammation and immunology

1.ALTERED KERATINIZATION OF HAIR FOLLICLE:

Altered keratinization pattern is the primary change which happens in the sebaceous

follicle. [17] This happens first in infra infundibular portion. Comedone formation occurs

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due to accumulation of abnormally desquamated corneocytes in the sebaceous follicle,

resulting in a keratinous plug.

This plug enlarges to become visible as whitehead, otherwise known as closed

comedone. When the follicular pore dilate, it forms a blackhead otherwise known as

open comedone. These changes subsequently leads to microbial proliferation, releasing

inflammatory mediators and appearance of inflammatory lesions. Reduced sebaceous

linoleic acid, abnormal lipid inclusions, defective androgen controlled 5α-reductase are

the reasons for these changes. Highly active IL-1α, is a major culprit involved in

comedogenesis by compromising follicular barrier and thus inducing inflammation. [18]

2.SEBACEOUS HYPERPLASIA:

The size and function of sebaceous gland increases at adrenarche, around 7-8 years of

age, under the influence of androgen. Sebum excretion is seen to be higher in patients

with acne vulgaris than normal individuals.

Enzymes for metabolizing androgens are present in follicular keratinocytes and

sebocytes. These enzymes are located in the undifferentiated basal sebocytes and the

differentiation starts by uptake of androgen into cells which in turn cause gene

transcription and cell differentiation. [19]

Difference in the target organ responsiveness to the circulating androgens explain the

asymmetry in facial lesions and non-occurence of acne in lower limbs.

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3.MICROBIAL COLONIZATION:

Propionibacterium acnes is a component of normal skin flora, especially of

pilosebaceous follicle. Altered keratinization leads to infra infundibular obstruction and

abnormal microbial proliferation in acne. Positive correlation is seen between its

colonization and microcomedo formation, but no correlation with severity of acne. [20]

Reduction in P.acnes colonization showed clinical improvement of the disease. P.acnes

binds and activates TLR-2, thus increasing inflammatory cytokine production. [21]

Porphyrin production by P.acnes is the basis for light base therapies introduced for acne.

4.INFLAMMATION AND IMMUNOLOGY:

The most important cause for acne related morbidity and sequelae like pigmentary

changes post acne scarring are due to inflammation. It may be the primary reason behind

comedone formation, via production of interleukin-1. Also, inflammation elaborates

LT-B4, which on binding to sebocytes, secrete sebum.[22] Aggravation of acne during

stress can be explained by production of substance P and neutral endopeptidases.

Inflammation due to P.acnes is by release of pro-inflammatory lipase, hyaluronidase,

protease and chemotactic factors. The released lipase converts triglycerides to free fatty

acid which is a primary irritant resulting in comedogenesis. Inflammation at cellular

level starts with influx of helper T-cells, which is followed by macrophages, Langerhan

cells and cells with HLA-DR. In patients prone for scarring, the immune response was

mild initially, progressed slowly and the inflammation persisted for a longer duration.[23]

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Figure 3: Pathogenesis of acne

GRADING OF ACNE VULGARIS:

A simple system for grading acne vulgaris was formulated by Indian authors, that

classifies the disease into four grades as follows: [45]

• Grade 1- predominantly comedones, occasional papules

• Grade 2- predominantly papules, comedones, few pustules

• Grade 3- predominantly pustules, nodules, abscess

• Grade 4- predominantly cysts, abscess and widespread scarring

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INDIAN ACNE ALLIANCE (IAA) GRADING OF ACNE VULGARIS: [figure 4]

Figure 4: IAA grading of acne vulgaris

COMPLICATIONS OF ACNE VULGARIS:

- Post-acne scarring

- Post-inflammatory hyperpigmentation

- Depression, anxiety

- Suicidal ideation

- Social inhibition

- Body dysmorphic disorder

- Somatisation disorder like pain, discomfort

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- Embarrassment

- Unemployment

TREATMENT OF ACNE VULGARIS: [figure 5]

Since prevention is better than cure, prompt and early management of active acne

vulgaris lesions, is the first important step in the treatment ladder of post acne scars.

Acne management aims at relieving the symptoms, limitation of disease activity to

prevent new lesions and thus post acne scarring and negative impact on quality of life.

VARIOUS MODALITIES IN MANAGEMENT OF ACNE VULGARIS:

1.TOPICAL THERAPY:

➢ Topical antibiotics: clindamycin, erythromycin are usually used in combination

with topical benzoyl peroxide.

➢ Benzoyl peroxide: This is a strong antimicrobial agent. Till date, no resistance

has been reported. Controlled and targeted drug delivery has been achieved

through microsponge delivery system, which also reduces the irritancy of the

drug.

➢ Azelaic acid: It is a dicarboxylic acid with comedolytic and anti-microbial

properties. Also, acts as a depigmenting agent which can be employed in

reducing the post-inflammatory pigmentation.

➢ Topical retinoids: These drugs have antimicrobial activity against

Propionibacterium acnes and comedolytic, anti-inflammatory actions as well.

➢ Topical dapsone

➢ Topical nicotinic acid

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2.SYSTEMIC THERAPY:

➢ Tetracyclines: They are commonly used drugs which reduce the levels of free

fatty acids in sebum, inhibits the Propionibacterium acnes and are anti-

inflammatory

➢ Macrolides: Erythromycin and azithromycin are used

➢ Oral retinoids: Retinoids have revolutionized the management of acne vulgaris

by acting through various mechanism of actions like

- Decreased seborrhea

- Comedolytic

- Anti-microbial action inhibiting P.acnes

- Anti-inflammatory

➢ Others: trimethoprime-sulphamethoxazole, clindamycin, dapsone.

3.HORMONAL THERAPY:

Oral contraceptives, antiandrogens, Gonadotropin releasing hormone agonists

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Figure 5: Global alliance treatment algorithm of acne vulgaris

4.PHYSICAL MODALITIES:

➢ Phototherapy- UV light, photodynamic therapy. In photodynamic therapy, a

photosensitizer is applied to the lesions which is then activated by a light source

so that reactive oxygen species is generated, which damages the glands and

reduces the Propionibacterium acnes growth.

➢ Lasers- Pulsed potassium titanyl phosphate laser (532nm), 1320nm Nd-YAG

laser, 1540 Erbium glass laser.

5.NEWER THERAPIES:

➢ Green tea: It has anti-inflammatory properties and interferes with IGF-1

signalling, thereby reducing sebum production.

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POST-ACNE SCARRING:

Acne scars is a commonly reported sequelae of acne vulgaris, clearance of which is

usually the first request by patients. Often the patient’s scar severity perception and the

severity assessment done by the dermatologist does not match. In a survey conducted

in patients with acne vulgaris, post acne scarring was present in 49% of patients.

Most common site affected with acne scars is face, accounting for around 95% and

truncal scars were more common among male patients. [25] Development of acne scars

depends on two main factors:

• Severity of the initial acne vulgaris lesions, which is high with inflammatory

lesions like pustules, abscess.

• Time of delay between onset of acne lesions and initiation of acne treatment,

which is positively correlated with development of acne scars.

In addition, few studies have also pointed out the impact of genetic factors in the

development of acne scars. [26] These scars are basically produced as a result of damage

to skin during wound healing process, in response to infra infundibular inflammation in

active acne. Wound healing is a complex biological process which progress through

three stages:

• Inflammation

• Formation of granulation tissue

• Remodelling of matrix

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During the first step, blood cells like neutrophils, lymphocytes, macrophages, platelets,

fibroblasts are activated, which release inflammatory mediators and keep the site

prepared for granulation tissue formation.

In the second step, there is formation of new blood vessels and the macrophages release

various growth factors like platelet derived growth factor, fibroblast growth factor,

transforming growth factors α and β, which ultimately results in migration and

proliferation of fibroblasts.

As the scar matures, type 1 collagen is seen as a predominant sub-type. In the final step

of matrix remodelling, enzymes like matrix metalloproteinase (MMP) which damage

the collagen and tissue inhibitor of metalloproteinase (TIMP) are secreted by the

keratinocytes and fibroblasts. Excess of MMP results in atrophic acne scars and excess

TIMP activity results in hypertrophic post acne scars.

INFLAMMATION

VASODILATATION, ERYTHEMA AND MELANOGENESIS

(post-acne erythema and hyperpigmentation)

Activation of Neutrophils, macrophage, lymphocytes, platelets and fibroblasts

INFLAMMATORY MEDIATORS

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(inflammation is stronger slower and prolonged)

GRANULATION TISSUE

TISSUE REMODELLING

(imbalance in the ratio of MMPs and tissue inhibitors of MMPs)

SCAR FORMATION

CLASSIFICATION OF ACNE SCARS:

Acne scars are broadly classified into two types based on whether there is net loss or

gain of collagen:

• Atrophic post-acne scars- seen in around 80-90% of those with acne scars

• Hypertrophic post-acne scars

Atrophic post- acne scars are further subclassified as follows: [figure 6]

• Ice-pick scars (60-70%)

• Rolling scars (15-25%)

• Boxcar scars (20-30%)

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Figure 6: Types of atrophic acne scars

ICE-PICK SCARS: [figure 7]

These are punctate, narrow scars measuring less than 2mm in diameter. Here, the

opening is wider than the deeper infundibulum, which results in formation of a V shape.

Figure 7: Ice-pick post acne scars

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ROLLING SCARS: [figure 8]

These are formed due to tethering of dermis to the underlying subcutis and are wider

than 4-5mm. they give a rolling appearance to the skin, forming M shape.

Figure 8: rolling post acne scars

BOXCAR SCARS: [figure 9]

These are scars with well established vertical edges, shaped round or oval . the surface

is wider than icepick scar and can be seen as a U shaped scar with wide base. This can

be further classified as

- Shallow boxcar

- Deep boxcar

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Figure 9: Boxcar post acne scars

These atrophic acne scars are renamed by the European acne group as follows: [27]

• V-shaped (ice-pick)

• U-shaped (boxcar)

• W-shaped (rolling)

The characteristics of scar can further be assessed using silicon elastomer moulds which

can then be examined under a light microscope.

HYPERTROPHIC AND KELOIDAL SCARS:

These are formed due to excess collagen deposition and are seen mostly in dark-skinned

individuals, predominantly over trunks. Hypertrophic scars are pink, firm and raised,

remaining within the margins of original injury site. Whereas keloids are reddish-purple

papules that proliferate beyond the margins of original wound.

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GRADING OF ACNE SCARS:

Various classification and grading system has been proposed for acne scars by different

authors. The most commonly used qualitative scale was proposed by Goodman and

Baron. [28] [Figure 10]

Figure 10: Goodman and Baron grading of atrophic acne scars.

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Also, a quantitative score for acne scars was proposed by Goodman and Baron as

follows: [29] [figure 11]

Figure 11: Global acne scarring classification

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Another quantitative scoring available for acne scars is the ECCA (Echelle d’Evaluation

Clinique des Cicatrices d’acne), aims standardizing treatment on acne scars. [figure 12]

Figure 12: ECCA quantitative scoring of acne scars

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TREATMENT OPTIONS AVAILABLE FOR ACNE SCARS:

A number of options are available in the treatment of acne scars, but prevention is

mainly by reducing the duration and intensity of inflammation, thus reinforcing the need

for early and prompt treatment of acne vulgaris.

The use of retinoids topically will prevent the formation of scar effectively more than

any other measures and silicone gel usage plays a vital role in prevention of

hypertrophic scars and keloids formation.

TREATMENT OPTIONS FOR ATROPHIC ACNE SCARS:

CHEMICAL PEELING:

Peels act by causing controlled destruction of outer damaged layers of skin, thus

speeding-up the repair process. Acne scars is one of the major clinical indication for

chemical peels.

Macular scars show best results, whereas ice Pick and rolling scars need sequential

peeling with other alpha hydroxy acids. The results expected vary highly from person

to person depending on their skin types and scar types. Glycolic acid peels stimulate

dermal collagen and hyaluronic acid gene expression by increasing the secretion of IL-

6. [30] Side effects were transient hyperpigmentation and irritation.

Salicylic acid is a beta hydroxy acid and is one of the best peeling agents for acne scar

management. 30% concentration was noted to produce best results in acne scars with

very rare scarring and persistent PIH as adverse effects , hence suitable for dark-skinned

individual. [31]

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TCA CROSS with as less as 50% concentration of trichloroacetic acid can give good

results in patients with few isolated facial acne scars.

DERMABRASION AND MICRODERMABRASION:

These are ablative techniques which remove the damaged upper layers of skin, thus

promoting re-epithelialisation, utilising different equipments and technical

execution.[32]

Dermabrasion is performed under anaesthesia, using a handheld motorized diamond

tipped hand piece, completely removing epidermis and reaching the level of papillary

or reticular dermis, thus promoting remodelling of extracellular matrix.

Microdermabrasion does not require anaesthesia and is a superficial process of

removing outer layers of epidermis using pump which generates aluminium oxide

crystals and vacuum which exfoliates the skin. Procedure is painless but does not treat

deep scars. [33]

LASER TREATMENT IN ACNE SCARS:

LASER is indicated in the management of boxcar scars and rolling scars. Ablative lasers

work by removing the damaged superficial tissue and tightening the collagen fibres

underneath, the most commonly used being CO2 and Er:YAG. Non-ablative lasers work

by stimulating neo-collagen formation without removing the tissue. [34]

Since, ablative lasers are associated with high degree of adverse effects like persistent

erythema, pigmentation and scarring, non ablative lasers are being preferred for treating

37

acne scars which induce controlled thermal injury to the dermis and subsequent neo-

collagenesis.

PUNCH TECHNIQUES:

Punch excision of atrophic acne scars gives good improvement when combined with

laser resurfacing. Punch elevation is also practised when the scars are few and discrete.

DERMAL GRAFTING:

Various modalities available are dermal punch grafting, face lifting and excision. The

type of treatment depends on individual’s type and severity of scars.

TISSUE AUGMENTATION:

Variety of autologous and non-autologous agents are available for augmentation of acne

scars. Fat is easily available and has low incidence of adverse effects. [35]

Other agents available are autologous collagen, bovine collagen, alloderm, isologen,

artecoll, fibrel, silicon, hyaluronic acid, of which hyaluronic acid is widely

recommended due to its lower incidence of side effects.

COMBINATION THERAPY:

Subcision followed by dot peeling with TCA, to release the scar from underlying tether,

done twice 2 months apart, followed by LASER resurfacing every 3-4 weeks for a

period of 12 months, was seen to be an effective and safe combination for a variety of

atrophic post acne scars. [36]

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TREATMENT OPTIONS FOR HYPERTROPHIC SCARS:

SILICON GEL:

Several hypothesis that have been proposed to explain the mechanism of action of

silicon gel in the management of hypertrophic acne scars includes: [37]

- Increased hydration

- Increased temperature

- Increased oxygen tension

- Protection of scars

- Action on immune system

INTRALESIONAL STEROID THERAPY:

Mechanism of action of steroids in hypertrophic scar are:

- Anti-inflammatory

- Vasoconstriction

- Anti-mitotic

- Reduced proliferation of keratinocytes and fibroblasts [38]

- Inhibition of collagenase inhibitor, α2 microglobulin

- Reduction of volume and thickness of scars is seen along with symptomatic

improvement in itching and discomfort.

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CRYOTHERAPY:

Low temperature of Liquid nitrogen reduces blood flow to tissues, causing tissue

anoxia and necrosis. Scars that are smaller in size and of shorter duration, responds

well with cryotherapy. [39]

Pain, altered skin pigmentation, atrophy are the possible side-effects, therefore

preferred for truncal scars than facial scars.

PULSED DYE LASER:

PDL acts by reducing the number and proliferation of skin fibroblasts and by

stimulating collagenase-3 activity, thus preventing the type-3 collagen

deposition.[40]Thus there is flattening of scars along with improved skin texture and

elasticity. [41]

OTHER OPTIONS:

W-plasty, elastic compression, intralesional bleomycin, 5-flurouracil, imiquimod,

interferon, radiotherapy are other treatment options available for hypertrophic scars.

Though there is no single and definitive treatment option available for acne scar

management, it is appropriate to choose procedures depending on individual

patient’s features.

40

MICRONEEDLING:

Otherwise known as skin needling, is a modestly invasive relatively novel technology

which combines ancient Chinese acupuncture with mesotherapy practice. Dr.Andre

Camirand, a Canadian plastic surgeon, in 1997 stated his observations that improvement

in skin texture and color was seen at the site of skin scars which were tattooed before

1-2 years. He explained these observations by stating that the tattoo gun needles

damaged the scar collagen, thus stimulating new healthy collagen deposition along with

melanin synthesis stimulation. [42]

Other important milestones in development of this technique are:

- Description of subcision for scars by Orentreich and Orentreich in 1995 [43]

- Development of PCI therapy with dermaroller by Fernandes in 2006. [44]

Microneedling is thus a form of collagen induction therapy, used by dermatologists

since 1990s in scar management and skin rejuvenation. Later, this technique found its

use in transdermal delivery of topical drugs, proteins, vitamins, anti-ageing products;

providing higher serum concentrations at dermal level, making the topical drugs more

affordable and effective. This effective and valuable procedure of collagen induction,

tighten, rejuvenate and regenerate the skin, giving it a young, resilient and healthier

look in a natural way.

PRINCIPLES OF MICRONEEDLING IN SCAR REDUCTION:

Atrophic scars are formed when the epidermal damage is rapidly repaired with

elaboration of TGF β1 and 2. Inhibition of these promotes scarless healing.[45]

41

Microneedling produces controlled smaller tissue injuries which heals without

elaboration of TGF β1 and 2, thus providing a scar free healing. It allows for controlled

induction of skin’s self-healing mechanism and collagen deposition. [46]

This benefit of collagen induction was confirmed in a study where histological

examination of the skin done after 6 months of microneedling therapy showed

significant new collagen and elastin deposition, with upto 40% improvement in

thickness of epithelium after 1 year of treatment completion. [47] The healing time is

less with this technique and there is less adverse effects like hyperpigmentation since it

is a non-ablative technique which works without removal of epidermis. [48]

The microchannels which are created with microneedling will close within 10 minutes

without disturbing the barrier function of epidermis. [49] The growth factors released in

the procedure are by puncturing and micro-tunneling the dermal vessels. The released

transforming growth factor will work on remodelling of scar by staying in dermis for

around 2 weeks.

The principle of microneedling is based on the controlled mechanical stimulation of

wound-healing process, which usually occurs in 3 stages.

Recently, a new hypothesis has been put forth which explains the mechanism of action

of percutaneous collagen induction. [50] It states that the fine microneedles of high

quality microneedling device does not produce a classic wound, but just fools the body

into believing that an injury has taken place. In this new theory, the healing process is

cut short and the bioelectricity current also known as the demarcation current, triggers

a cascade of growth factors which stimulates healing phase. Fine wounds are produced

42

in the skin when the penetration of microneedles occur. In response to this intrusion,

cells produce demarcation current, which is further increased by electric potential of the

needles. The resting membrane potential of a living cell is -70mV. With interaction with

microneedle, the inner potential increases to above -100mV. This change in electric

potential, activates cell and leads to the release of growth factors, potassium ions and

proteins from the cell membranes. Though this mechanism of action is not fully

understood, the ultimate result was deposition of new collagen in the papillary dermis.

Thus, microneedling becomes a reliable alternative to ablative skin rejuvenation

techniques. [51] Traditional use of ablative techniques like LASER resurfacing and

dermabrasion, will cause enormous damage to the epidermis and upper dermis. This

results in prolonged down timing, that is delayed wound healing and added

complications like post-inflammatory hyperpigmentation. [52]

Collagen induction technique is a simple and effective procedure, full result of which

will be seen at the end of 8-12 months as the new collagen deposition occurs slowly. [53]

Collage induction has many undeniable advantages when compared to other

conventional techniques like maintenance of an intact epidermis and removal of many

adverse effects of chemical peeling and laser resurfacing.

With additional benefits like re-vascularization and repigmentation, needling is also

safe, simple and rapid method of treating various other dermatological conditions other

than atrophic acne scars as follows:

43

1.SKIN REJUVENATION:

Percutaneous collagen induction therapy is used to treat various skin changes due to

ageing like wrinkles. Various studies have shown proven efficacy in the correction of

signs of photoageing with 2-6 sitting on MN, according to wrinkle severity rating scale

and glogau scale. These improvements also correlated with histological increase in

collagen types 1,3 and 7 along with topoelastin. [54,55]

Microneedling combined with fractional radiofrequency, utilises insulated MN

electrodes which selectively ablates dermis by sending RF energy, without damaging

the epidermis. [56] In this technique, thermal zones are created in the reticular dermis,

which induces long-term neocollagenesis and neoelastogenesis, thus the dermal

remodelling.

Skin wrinkling and laxity also showed improvement when microneedling was

combined with platelet rich plasma, but the results were comparable even when

microneedling was done alone. [57]

2.NON-ACNE SCARS:

Several case reports of improvement in burns scar and varicella scar has been reported

with microneedling therapy without complications like hyperpigmentation.

These improvements were also histologically compatible showing increased collagen

and elastin deposition.

44

3.ACNE VULGARIS:

Active lesions of acne vulgaris has been treated with microneedling fractional

radiofrequency. In various studies, moderate to severe acne vulgaris treated with this

technique showed objective clinical improvement in terms of number and severity of

inflammatory lesions, which responded better than non-inflammatory lesions. In

addition to this, improvements were also seen with respect to decreased sebum

production, improved skin tone and texture and scar improvement. [58,59]

4.HYPERPIGMENTATION:

Pigmentary disorders like periorbital melanosis and melasma has been treated

effectively with MN. Patients with melasma showed significant improvement in MASI

and luminosity index levels when conventional tranexamic acid microinjections and

depigmenting serums were used in combination with MN, than when used alone. [60]

Similarly, periorbital melanosis excellently improved when serum infusions and 10%

TCA were combined with MN technique.

5.ALOPECIA:

Significant regrowth of hair was seen in patients with androgenetic alopecia and

alopecia areata when MN was combined with conventional minoxidil and triamcinolone

acetonide than when these agents were used alone.

Also in resistant cases of AGA treated with finasteride and minoxidil, regrowth of hair

was seen after introduction of MN to the therapy. [61]

45

6.HYPERHIDROSIS:

Primary axillary hyperhidrosis when treated with microneedling fractional

radiofrequency, showed significant improvement both subjectively and objectively in

terms of remarkable reduction in starch iodine test, hyperhidrosis disease severity

scale[HDSS] and histological reduction in the number of apocrine and eccrine

glands.[62]

7.DRUG DELIVERY:

MN is used to augment transdermal delivery of drugs. Complete Cure of plantar warts

with decreased adverse effects was seen in patients treated with combination of MN and

bleomycin than with bleomycin alone. [63]

MN is also used to deliver topical lidocaine transdermally, facilitating rapid onset of

anaesthesia within minutes for emergency procedures.

MN-assisted transdermal delivery of photosensitizing drugs like aminolevulinic acid

and methyl aminolevulinate exhibited superior outcomes in actinic keratosis, superficial

BCC, SCC in terms of fine lines, roughness, global score, shallowness, mottled

pigmentation when compared with conventional MAL-PDT. Though time taken for

resolution of adverse effects was longer, the clinical responsiveness was higher in MN-

assisted sites.

MN-assisted delivery of 5-FU in SCC, can save the patient from the side effects of intra-

lesional 5-FU like persistent erythema, pain, induration and erosion, with added benefit

of drug delivery in anatomically challenging sites. [64]

46

Other drugs that has been delivered transdermally with the use of MN technique

includes insulin, heparin, growth hormone, albumin, tretinoin, aspirin, L-ascorbic acid

and immunobiologicals like tetanus toxoid, hepatitis B, influenza vaccine.

Thus, microneedling is an effective modality in the treatment of Fitzpatrick type IV and

V skin, due to lesser potential to produce side effects like hyperpigmentation and

scarring which is more prominent in ablative procedures which damages the overlying

epidermis.

CONTRAINDICATIONS FOR MICRONEEDLING:

- Patients having active acne vulgaris lesions

- Herpes labialis

- Active infection at procedure site like verruca vulgaris

- Patients with keloidal tendency

- Other active skin diseases with tendency to koebnerize like psoriasis vulgaris,

vitiligo vulgaris

- Patients with bleeding tendencies like those on anticoagulant therapies and those

with blood dyscrasias

- Patients undergoing chemotherapy or radiotherapy

ADVERSE EFFECTS AND LIMITATIONS OF MICRONEEDLING:

- Isolated microneedling was seen to be less efficacious in pitted scars, deep box

scars. This could be overcome by combining MN with other procedures

- Post procedural erythema

- Irritation

47

- Postinflammatory hyperpigmentation

- Aggravation of acne vulgaris

- Reactivation of herpes

- Systemic hypersensitivity

- Allergic granulomatous reactions

- Local pustules, abscess due to unsterile instruments usage

- Allergic contact dermatitis to the needle material

- Tram-track effect when used in areas of bony prominences.

DEVICES USED IN MICRONEEDLING:

DERMAROLLER:

It is a simple device with 12cm long handle with 2×2cm wide drum-shaped cylinder at

one end which has 8 rows and 24 circular arrays of 192 microneedles; of 0.5-3mm

length and 0.1-0.25mm diameter. They are made-up of stainless steel and is disposable

after single use. It is pre-sterilized with gamma irradiation. Rolling in skin with a

standard dermaroller containing 192 needles for 15 times will create 250 microchannels

per square cm of skin approximately. Also, it reaches upto level of papillary dermis and

this depth depends on the pressure applied over the skin. Each role with the instrument

will create 16 microchannels per square cm of skin without causing much damage to

the epidermis.

Various modifications of the standard dermaroller has been made and the advancements

were made based on needle length, size of drum and automation. Better needles should

have high length:diameter ratio which is usually 13:1. The length of needle varies

48

according to the indication for which the instrument is used. A length of 1.5 to 2mm is

usually used in the management of acne scars; whereas for the procedures of skin

rejuvenation and skin wrinkles a length of 0.5-1mm is used.

The pain associated with the procedure is directly proportional to the length of the

needle used. With needle length of 0.5mm, the procedure will be painless. The pain will

also depend upon the thickness of dermis and epidermis. Also, the interval between the

procedures is directly proportional to the length of the needles. Greater length requires

longer interval between 2 sittings. With needle length of 1.5mm, a minimal interval of

3 weeks between 2 sittings is required.

There are 5 types of dermarollers used for medical purposes, which are approved by

FDA. They are as follows:

- C-8 or the cosmetic type: The needle length here is 0.13mm, serving the purpose

of topical drug penetration enhancement. It does not produce any pain owing to the

smaller length of the needle.

- C-8HE or cosmetic type for hair-bearing areas like scalp: this has 0.2mm long

needles and cause no pain

- CIT-8 [Collagen Induction Therapy, medical type]: Has needle length of 0.5mm

and is used for percutaneous collagen induction and remodelling of skin.

- MF-8: is with 1.5mm needle and forms deep channels on skin reaching dermis,

thereby damaging the scar collagen fibres.

49

- MS-4: Has small cylinder of 1cm length and 2 cm diameter, 4 circular arrays and

a 96 needles in total with 1.5mm long needles. It is used in treating atrophic acne scars

on face. Many similar devices with much shorter needles of 0.5-0.75mm are developed

for treating areas which needs much precision like periorbital and perioral regions.

HOMECARE DERMAROLLER:

It is C-8 type of dermaroller, with length of needle <0.15mm. They are used for the

aesthetic indications like reduction of pore size and sebum production, reducing the fine

lines and also for transdermal delivery of anti-ageing products like lipopeptides. These

can be used upto 3 times a week for a total of 100 times. Each time after the use the

dermaroller should be cleaned with hot water and shaken dry.

BEAUTY MOUSE:

This is also a device which is approved for usage at home and has a total of 480 needles,

with needle length of 0.2mm on 3 separate drums which are placed inside a computer

mouse shaped device. It is used to cover regions with larger skin surface areas like upper

limbs, lower limbs, buttocks, stomach for treating stretch marks, thighs for the treatment

of cellulite.

DERMASTAMP:

It is a miniature of dermaroller and has a needle length of 0.2-3mm, with diameter

0.12mm. it is indicated for use in localized scars like varicella scars. This device offers

a very focused treatment and thus forms the device of choice in treatment of isolated

scars and wrinkles.

50

DERMAFRAC:

This is a modified microneedling treatment which combines microdermabrasion,

microneedling with deep tissue infusion of serum and light emitting diode therapy. It is

indicated in management of ageing skin, sun damaged skin, acne scars, large pores,

wrinkles, fine lines, uneven skin tones, pigmentary disorders like melasma and

superficial scars. The time taken for completion of all 4 procedures in face is

approximately 45 minutes. It has advantages of being non-invasive and having very less

downtime.

MICRONEEDLE DRUG DELIVERY SYSTEMS:

These make use of various types of microneedles like solid, coated, hollow, dissolving

and swellable polymer microneedles which are manufactured by microfabrication

technique.

These microneedles are fabricated with various materials like silicon, titanium, natural

and synthetic polymers and polysaccharides. This method of transdermal drug delivery

is minimally invasive and painless. Superficial skin is punctured with solid coated

needles which follows topical drug application, while biodegradable hollow needles

delivers the drug into dermis directly.

LIGHT EMITTING MICRONEEDLING DEVICE:

They are recently introduced devices which makes use of titanium needles and LED

light in treatment of wrinkles and scar.

51

FRACTIONAL RADIOFREQUENCY MICRONEEDLING:

This device combines the benefits of radiofrequency with microneedling. Here, skin is

penetrated with insulated needles and radiofrequency currents are passed on to the

dermal structures and glands without damaging the overlying epidermis, thus producing

no pigmentary changes later. There is enhanced dermal remodelling, long-term

neocollagenesis and neoelastogenesis. Depth of needle penetration can be adjusted from

0.5mm to 3.5mm. it is indicated in treating hyperhidrosis, scars, skin rejuvenation.

DERMAPEN:

It is an automated microneedling device which looks like a pen [figure 14]. It has

disposable needles attached at the tip which contains 9-12 needles in rows [figure 13].

The depth of needle penetration is adjustable and the tips are hidden making it safe to

use [figure 15]. Also, it is convenient to use in narrow areas like perioral, periorbital

without causing much damage to surrounding skin. It works on rechargeable battery at

both high speed [700 cycles/minute] and low speed mode [412cycles/min].

It is much safe and effective when compared to traditional skin needling rollers in

piercing the skin. It has adjustable speed and needles of adjustable length and thus can

be effectively used to treat hard to reach areas. It has a very good effect on the

rejuvenation of collagen and elastic fibres. There is minimal down-time with the

procedure since it facilitates scar-less healing. At present three models of dermapen

needling devices are available in the market. Dermapen 3MD, Dermapen 3PRO,

MyDermapen. Dermapen 3MD is used for more aggressive skin remodelling

procedures and skin rejuvenation procedures. It allows penetration into skin up to a

52

depth of 2.5mm. This deeper penetration will lead to breakage of collagen fibres in scar

tissue and activation of fibroblasts in the deeper dermis, which forms normal collagen

replacing the scar tissue. The Dermapen 3PRO will reach a depth of only 1mm in the

skin and thus is indicated in the treatment of fine lines, post inflammatory pigmentation,

stretch marks and dilated pores. This depth of 1mm will help to improve the texture,

skin tone and overall rejuvenation. My Dermapen is a device for home use which can

be self-used by the patients to maintain the effect of the treatment done by the physician.

Vertical needle insertion in dermapen reduces pain and the heavy duty motor backed by

AVON technology ensures the optimal number of punctures per second. The most

advanced and the latest model of the dermapen system is the Dermapen 3, which is

faster, stronger and more robust than any previous models of dermapen. Gamma ray

radiation is used to sterilize the needle catridges which gives a 3-5 years of guaranteed

sterility from the date of manufacture. The needle tips are designed to be disposable and

are for single use only to prevent cross contamination and infection.

ADVANTAGES OF DERMAPEN OVER DERMAROLLER:

- Adjustable length of needles

- Depth adjustment feasible according to the site treated

- Can be used in hard to reach areas

- No need to replace whole instrument in each sitting

- Cost effective

- Less traumatic

- Lesser downtime

- No tram track ulcers when treating skin over bony prominences

53

AIMS AND

OBJECTIVES

54

This study is aimed at objectively assessing the improvement in the grading of

atrophic facial acne scars.

The objective is to perform microneedling in the study participants, using an

automated microneedling device.

55

MATERIALS AND

METHODS

56

SOURCE:

Acne patients with grade 2-4 atrophic acne scars attending skin Out Patient Department.

PLACE OF STUDY :

Depatment of Dermatology,

Govt.Stanley medical college.

TYPE OF STUDY:

Prospective, open labeled, interventional study.

TIME DURATION:

1 year. [April 2017- April 2018]

SAMPLE SIZE:

Sample size n= z2 pq/d2

Where p= 10% (based on study conducted by Asif et al, in which excellent improvement

in acne scar grading was seen in 10% of study participants with microneedling.)

q= 100-p

= 100- 10 = 90

Z= 1.96 (standard normal deviate at 95% confidence limit)

Allowable error (d)= 9%

Final sample size calculated= 40

57

SAMPLING METHOD:

Convenient sampling

INCLUSION CRITERIA:

Age - ≥ 18 years and <40 years

Belonging to either sex

Atrophic acne scars showing grade 2 -4.

Those giving informed consent for the procedure

EXCLUSION CRITERIA:

Active acne

Keloidal tendency

Use of systemic or topical retinoids or any scar treatment procedure in the previous 3

months.

Bleeding tendencies

Patients on anti-coagulant medications

History of Herpes labialis

History of allergy to lidocaine and prilocaine

Chronic skin conditions like psoriasis, lichen planus.

Local infections including warts at the site of procedure.

Pregnancy and lactation.

58

PRE-PROCEDURE:

A brief and relevant medical history and physical examination was conducted at the

screening visit to ensure relevant eligibility criteria.

Detailed explanation about the procedure was done in regional language. Patients were

also explained about the benefits, duration, possible side-effects and prognosis of the

treatment.

An informed and written consent was obtained.

Complete history regarding the onset, duration, co-existence of other systemic illness,

past history of treatment for acne vulgaris and other systemic illness if any were noted.

History of use of retinoids, immunosuppressive drugs, blood thinning agents were

noted.

Hepatitis-B and C co-infection were also screened for.

42 patients with atrophic acne scars, satisfying the inclusion criteria, attending our skin

Outpatient department were selected.

Proper councelling was given and motivation of the patient was assessed.

59

PRE-PROCEDURAL WORKUP OF PATIENTS:

- Hb, TC, DC, platelet count, ESR

- bleeding time, clotting time

- fasting blood glucose

- renal function test- blood urea, serum creatinine

- liver function tests- SGOT, SGPT, SAP, serum albumin

- screening for HIV, RPR

- screening for hepatitis-B and C

- Urine pregnancy test in female patients

SCAR GRADING:

Severity of the acne scar was graded using Goodman and Baron grading system by a

non-treating dermatologist at the screening visit:

60

- clinical photograph of the scars were taken at screening visit and also at each visits

after obtaining informed consent from the patients.

- Patient were asked to avoid retinoids, exfoliants, benzoyl peroxide 3 days prior to

procedure.

- No waxing, depilating creams 7 days prior to the procedure.

61

ON THE DAY OF PROCEDURE:

- Patient were asked to avoid make-up, lotion, oil or sunscreen application.

- No shaving on the day of procedure.

The procedure was repeated at monthly intervals for 4 sittings.

During each sitting, the area of interest was cleansed with clean water and patted dry

with a clean towel.

Topical anaesthetic cream was applied for a contact period of 45-60 minutes, after being

tested on a small patch for any allergic reaction, on the back of the hand.

The cream was wiped off with normal saline prior to the procedure.

Treatment area was again wiped with surgical spirit to disinfect the area.

Pre-procedural photographs of both sides of face was taken.

PROCEDURE PROPER:

Microneedling was done with the help of dermapen’s disposable needles [figure

13,14,15], which enter the skin at 90degree angle, in a stamping motion over the scars

[figure 16].

Each stamping lasted for duration of 3 seconds.

62

Depth of penetration was adjusted according to the area of face where the scar is present.

The needling was first done to cover scars over right and left cheek with needle depth

of around 1-1.5mm depending on skin texture of the patient, then the depth was reduced

to around 0.5-0.75 mm to treat the forehead area and again the depth was adjusted to

0.25-0.5mm to treat any scars over peri-orbital and peri-oral regions.

This eliminates the pain and epidermal tearing associated with other microneedling

devices. End point for procedure is uniform pin point bleeding at the treatment site

[figure 17]

Figure 13: Disposable microneedles

Sterile, disposable

microneedles tips [36

in number]

Cap to protect the

microneedles

63

Figure 14: Dermapen with facility for adjusting depth and speed of microneedling

Facility for depth adjustment

from 0.25mm-3mm

Facility for speed adjustment

of the motor.

64

The needle tip has a much smaller surface area which comes in contact with the skin,

allowing to treat hard to reach areas, such as those around the eyes, nose and mouth,

quickly, easily and effectively.

Figure 15: Dermapen with attached disposable microneedle tip. The needle tips are

hidden when not in use.

65

Figure 16: stamping method with dermapen held at 90° to skin surface

Figure 17: End point for procedure- uniform pin point bleeding at the treatment site.

66

POST PROCEDURE INSTRUCTIONS:

- Mild, transient erythema is expected post procedure. Ice cold compress was

given for smoothening effect and to prevent any further bleeding.

- Patients were adviced to avoid any vigorous rubbing of face post procedure and

to abstain from the use of aspirin or other anti-inflammatory drugs while on

treatment.

- Patients were advised to use topical antibiotics in the form of topical

2%mupirocin, twice daily application for 3 days.

- Photoprotection with topical 32% zinc oxide cream was adviced for 1 atleast

week following the procedure.

- Make –up was allowed to be used after a period of 24 hours.

FOLLOW-UP:

On completion of 4 sittings, patients were followed up every month for period of 2

months and final grading of the scar was done then.

Post procedural photograph of both sides of face was taken at the end of follow-up

period and grading of scars was done by the same non-treating dermatologist.

- Patients who had poor response at the end of follow-up period, was treated with

procedures like subcision or TCA CROSS at our OPD.

67

ASSESSMENT:

PATIENT SATISFACTION SCORE:

Patients were asked to grade their satisfaction between 0 and 10 post procedure follow-

up:

A score of 0-3 is graded as poor satisfaction

A score of 4-6 is graded as good satisfaction

A score of 7-10 is graded as excellent satisfaction

QUALITY OF LIFE INDEX:

This questionnaire was filled by patients before and after treatment period. Scoring was

noted and assessed as follows:

69

In Goodman and Baron grading,

Improvement of scaring by 2 grades was termed excellent response,

Improvement by 1 grade was termed as good response,

No change in grade but depth of scar improved (NGDI) was termed as mild response

No improvement in grading was termed as poor response.

70

OBSERVATION AND

RESULTS

71

STUDY POPULATION

This study included 42 patients, of which 29 were male and 13 were female. Youngest

age included is 18yrs whereas the oldest age is 34yrs.

Table 1: Age distribution of study population

Chart 1: Age distribution of study population

Mean age of population: 24±4.3 yrs

5 (12%)

23 (54%)

12 (29%)

2 (5%)

0

5

10

15

20

25

<20 yrs 20-25 yrs 26-30 yrs >30 yrs

Age distribution of the study population

Age distribution of the study population

Age No.of patients Percentage (%)

<20 5 12

20-25 23 54

26-30 12 29

>30 2 5

72

Gender distribution:

Chart 2: Gender distribution among study population

Male predominance was seen in our study.

29 (69.1%)

13 (30.9)

0

5

10

15

20

25

30

35

male female

Gender distribution among study population

Number of patients

73

Occupation distribution:

Chart 3: Distribution of occupation among study population

Majority of participants in our study were students.

students, 16

engineer, 4housewives, 4

IT, 4

unemployed, 4

office employee, 3

doctors, 2

miscellaneous, 5

students engineer housewives IT unemployed office employee doctors miscellaneous

74

Inflammatory lesions in the past:

Chart 4: History of inflammatory acne lesions in the past

Around 79% of the patients gave history of inflammatory acne lesions like pustules,

abcess in the past. Though no significance was established between presence of

inflammatory acne and grading of acne scars, there is a visible role for inflammation in

scarring process.

33

9

H/O INFLAMMATORY LESIONS IN THE PAST

YES NO

75

PREVIOUS ACNE TREATMENT:

Chart 5: History of treatment for acne lesions in the past

Only about 14% of patients, who presented with scarring had given a history of regular

treatment of acne in the past and 86% reported either no or intermittent treatment for

acne in the past, indicating the need for adequate need for active acne lesions.

The mean age of acne onset was 17 years in the participants.

76

Pre-treatment acne scar grade distribution:

Chart 6: Distribution of acne scar grades among the participants prior to the treatment

11 (26.2%)

18 (42.8%)

13 (31%)

0

2

4

6

8

10

12

14

16

18

20

grade 2 grade3 grade 4

No.of patients having each grade of acne scars before treatment

number

77

Chart 7: Distribution of scar morphology in the study participants:

Both boxcar and rolling scars were seen predominantly in equal number of participants

of the study. Only 2 patients had their predominant scar morphology as ice-pick scar.

boxscar 20 (47%)

icepick 2 (5%)

rolling 20 (48%)

scar morphology distribution among patients

boxscar icepick rolling

78

Post-treatment grade distribution:

2 patients lost follow-up from the study.

Chart 8: Distribution of acne scar grades among study participants after the treatment

Before treatment, majority belonged to grade 3, whereas after treatment majority

belonged to grade 1. The changes in the grade before and after treatment is significant

with p value <0.05.

2 (5%)

14 (35%)

12 (30%)

7 (17.5%)

5 (12.5%)

0

2

4

6

8

10

12

14

16

grade 0 grade 1 grade 2 grade 3 grade 4

No.of patients having each grade of acne scars after treatment

number

79

Post-treatment improvement in each grade:

Outcome seen in Grade 2 patients:

1 patient lost follow-up

Table 2: Final outcome seen among grade 2 patients after treatment

Initial grade Final grade No.of Grade 2 pts Percentage %

2 0 2 20%

2 1 4 40%

2 2 1 10%

2 NGDI 3 30%

Chart 9: Final outcome seen among grade 2 patients after treatment

Among grade 2 patients, majority (40%) showed good response with improvement in 1

grade.

2, 20%

4, 40%1, 10%

3, 30%

OUTCOME AMONG GRADE 2 PATIENTS

improved to 0

improved to 1

remained same

NGDI

80


Initial grade Final grade No.of Grade 3 patients Percentage %

3 2 5 27.7

3 3 2 11.11

3 NGDI 1 5.6

3 1 10 55.5


Among grade 3 patients, majority (55%) had excellent improvement with improvement

in 2 grades.

10, 56%

5,28%

2,11%

1,5%


GRADE 1

GRADE 2

GRADE 3

NGDI

81


1 patient lost follow-up

Initial grade Final grade No.of Grade4 patients Percentage %

4 2 3 25%

4 3 4 33.33%

4 4 2 16.66%

4 NGDI 3 25%


Among grade 4 patients, majority (33.33%) showed good response.

25%

33%

17%

25%


grade 2

grade 3

grade 4

NGDI

82

Table 5: Overall No.of grades improved in the study:

No.of grades improved Inference Number Percentage

(%)

0 [no improvement] poor 5 12.5

1 good 13 32.5

Uncertainty to conclude

[No grade change but depth of

scar improved-NGDI]

moderate 7 17.5

2 excellent 15 37.5

2 patients lost follow-up to the procedure. Mean improvement of grades post-treatment

was 1±0.6

Outcome according to scar morphology:

Table 6: Improvement of grade according to scar morphology:

Outcome Boxcar type Rolling scar Ice-pick scar total

Poor 2 1 2 5

Mild 2 5 0 7

Good 8 5 0 13

Excellent 7 8 0 15

Lost to follow-up 1 1 0 2

The chi-square statistic is 2.378 for boxcar ad rolling scar. P value is not significant at

p<0.05. This indicates that type of scar did not influence the outcome in this procedure.

83

Chart 12: Improvement of grade according to scar morphology:

Most patients with boxcar showed good response with improvement by 1 grade and

most of them with rolling scars showed excellent response with improvement in 2

grades. All patient with ice-pick scars showed poor response.

2(10.5%)

1(5%)

2(100%)2(10.5%)

5(26%)

0

8(42%)

5(26%)

0

7(36.8%)

8(43%)

00

1

2

3

4

5

6

7

8

9

Boxcar Rolling Ice-pick

IMPROVEMENT IN GRADE ACCORDING TO SCAR TYPE

poor mild good excellent

84

Table 7: No.of sittings required to see some improvement in acne scars even

without change in grade:

No. of sittings

needed

Grade 2 Grade 3 Grade 4 Total no.of

patients

1 0 2 1 3

2 5+2 NGDI 11+1 NGDI 1+2 NGDI 22

3 1+1 NGDI 2 5+1 NGDI 10

4 0 0 0 0

Grade unaltered 1 2 2 5

Lost to follow-up 1 0 1 2

85

Chart 13: No.of sittings required to see some improvement in acne scars even

without change in grade:

On the whole, majority of patients in the study started improving with 2 sittings [p-0.03]

But, in grade 4, most of the patients started showing improvement only after 3 sittings.

Almost all patients showed some improvement after 3rd sitting.

0

21

7

12

32 2

6

0 0 01

2 21

01

0

2

4

6

8

10

12

14

GRADE 2 GRADE 3 GRADE 4

No.of sittings required to see some improvement in acne scars even without change in grade

1st sitting 2nd sitting 3rd sitting 4th sitting grade unaltered lost to follow-up

86

Table 8: Patients QOL before treatment:

Grading Number Percentage (%)

Small effect in QOL 5 12.5

Moderate effect in QOL 12 30

Very large effect in QOL 23 57.5

Table 9: Patients QOL after treatment:

Grading Number Percentage (%)

No effect in QOL 2 5

Small effect in QOL 19 47.5

Moderate effect in QOL 12 30

Very large effect in QOL 7 17.5

87

Chart 14: comparison of QOL before and after treatment

The mean DLQI of patients before study 11.2 and the mean DLQI after treatment was

6.18, with minimum score of 0 and maximum of 15 after treatment.

0

5

12

23

2

19

12

7

0

5

10

15

20

25

no effect small effect moderate effect very large effect

QOL before and after treatment

QOL before treatment QOL after treatment

88

Chart 15: Patient satisfaction score in each grade:

Table 10: Patient satisfaction score in each grade

Patient satisfaction

score

Inference Grade 2 Grade 3 Grade 4

0-2 poor 1 0 0

3-6 good 3 6 6

7-10 excellent 6 12 6

Lost to follow-up 1 0 1

P value 0.0001 chi square analysis

Mean(SD) patient satisfaction score: 7±1.5

1 (10%)

0 0

3(30%)

6(33%) 6(50%)6(60%)

12(67%)

(6(50%)

0

2

4

6

8

10

12

14

Grade 2 Grade 3 Grade 4

patient satisfaction score in each grade

poor good excellent

89

Majority of patients in grade 2 and 3 had excellent satisfaction. Poor satisfaction is seen

in only 1 patient with grade 2 scarring.

Table 11: Overall patient satisfaction score with the outcome:

Patient satisfaction

score

Inference No.of patients percentage

0-2 poor 1 2.5%

3-6 good 15 37.5%

7-10 excellent 24 60%

2 patients lost to follow-up from the study.

Chart 16: Overall patient satisfaction score with the outcome:

1 ( 2%)

15 ( 38%)

24 ( 60%)

overall patient satisfaction score

poor satisfaction

good satisfaction

excellent satisfaction

90

Other benefits from microneedling:

Chart 17: Benefits seen in addition to scar improvement with microneedling

In addition to the improvement in the appearance of acne scars, there were additional

benefits reported by the patients, like reduction in oiliness of face and improvement in

their skin texture.

4 (10%)

2 (5%)

Additional benefits

reduced seborrhea improved skin texture

91

SIDE-EFFECTS SEEN DURING PROCEDURE:

Chart 18: Adverse effects seen due to microneedling

Almost all patients experienced transient erythema and edema following the procedure,

but it did not affect patient’s daily activities. None of the patients complained of

prolonged erythema or pain following the procedure.

3 ( 7.5%)

1 (2.5%)

ADVERSE OUTCOMES

Post-inflammatory hyperpigmentation acne aggravation

92

CLINICAL

PHOTOGRAPHS

93

GRADE 2- EXCELLENT IMPROVEMENT

94


95


96


97


98

GRADE 3- GOOD IMPROVEMENT

99

GRADE 3-GOOD IMPROVEMENT

100

GRADE 2- GOOD IMPROVEMENT

101

GRADE 3-GOOD IMPROVEMENT

102

GRADE 4 – NO CHANGE IN GRADE BUT DEPTH IMPROVED [NGDI]

103

DISCUSSION:

Microneedling with dermapen is a novel approach in the management of acne scars.

The results are comparable with other approaches for acne scars when used singly.

AGE DISTRIBUTION:

In our study, majority (83%) belonged to age group of 20-30 years with mean age of

24yrs. In a study conducted by Shekar Pradhan et al also 83.3% belonged to 21-30yrs.

In a study by Amil Deepak Badheka, majority of 60% fell within age group of 21-30yrs.

In Majid et al study mean age of participants was 22.4yrs. [71]

GENDER DISTRIBUTION:

In our study, male predominance was seen (69.1%) and female constituted 30.9%. This

male predominance was also seen in studies conducted by Shekar Pradhan et al, where

61.1% were male, 38.8% were female and a study by Amil Deepak Badheka et al, where

66.67% were male and 33.33% were females. [71] But in contrast, in a study by Majid et

al, females predominated over males and in a study conducted by Rajnesh Chakrawarty

et al, 46% were male and 54% were female.

PRE-TREATMENT ACNE SCAR GRADE DISTRIBUTION:

In our study, 26.4% belonged to grade 2, 42.8% to grade 3 and 31% to grade 4 before

treatment, with majority belonging to grade 3. Similarly, in a study by Amil Dheepak

Badheka et al, majority participants in grade 3 was seen before treatment, where 46.67%

to grade 3, 26.67% belonged to grade 2 and 26.67% to grade 4. [71]

104

IMPROVEMENT IN GRADE:

In our study, out of 40 patients, 37.5% (15) showed excellent improvement in the

grading of acne scars. It means they improved by 2 or more grades with the treatment.

This was similar to outcome in Shekar Pradhan et al, with excellent response in 37%

and much higher when compared to Asif M et al and Amil Deepak Badheka et al

showing 10% and 6.67% of excellent responses respectively. [70,71] However, I Majid et

al in his study showed excellent response in 72.2%. [67]

In our study, good response was seen in 32.5% (13) of the patients. These patients

improved by 1 grade. This was higher when compared to I Majid et al, with 16.7% and

lower when compared to Asif M et al and Shekar Pradhan et al, showing good

improvement in 84% and 50% respectively. [67,70]

In our study, in 17.5% (7) of the patients, visible improvement in the appearance of acne

scars was seen, but grading did not change and only 12.5%(5) of the patients did not

show any improvement in the acne scars even after 4 sittings of microneedling with

dermapen, who were candidates for combination treatment with other treatment

modalities. In a study by Majid et al and Asif M et al, no improvement in 11.1% and

6% of patients respectively. [67,70]

In our study, an overall 87.5% of patients showed some improvement in scar from

baseline. In a study by I Majid et al, around 95% of the patients and in a study by Shekar

Pradhan et al, overall 87% had good to excellent response.

105

In our study, Majority of grade 2 and grade 4 patients showed good response, whereas

patients with grade 3 exhibited excellent response in majority. In Majid et al, excellent

response was seen in majority of grade 2 and 3 patients, whereas in only 1 patient of

grade 4. [67]

SITTINGS DISTRIBUTION:

Among the patients who showed improvement, majority of 55% (22) patients showed

improvement after second sitting, while 25% (10) patients showed improvement after

third sitting. In a small number of patients, 7.5% (3) improvement was appreciated by

the end of first sitting itself. 12.5% had no change in grade even after 4 sittings. In study

by Fabbrocini et al which treated rolling acne scars, all patients with rolling scars

showed visible reduction in the scar severity following even 2 sittings of

microneedling.[66]

PATIENT SATISFACTION SCORE:

In our study, about 60% of patients had an excellent satisfaction score at the end of

follow-up period, whereas 37.5% of patients had good satisfaction and only 2.5% of

patients gave a poor satisfaction score. The mean patient satisfaction score was 7 over

a 10 point scale. Similarly, in a study by I Majid et al, majority reported excellent

satisfaction on a 10 point scale. In a study by El Domyati et al, patient satisfaction was

documented as 80-85%. [69] In a study by Asif M et al, patient satisfaction score was

excellent in 9, good in 30, fair in 10 and poor in 1 patients. [70]

106

QUALITY OF LIFE SCORE:

DLQI with Very large effect was seen in 57.5% (23) of patients before treatment

reduced to 17.5% (7) of patients after treatment period and 5% of patients did not have

any disturbance in quality of life after the treatment.

SIDE-EFFECTS:

Adverse effects in treatment was seen in the form of post-inflammatory

hyperpigmentation in only one patient (2.5%) and active acne lesions developing in 3

patients (7.5%) in our study. No other major complications or limitation of daily

activities seen as the result of procedure. In a study by Majid et al, 1 patient had post-

inflammatory hyperpigmentation. In a study by Pahwa et al, tram track scar was

reported with dermaroller due to excess pressure applied with needling. [72] In a study

by Amil Deepak Badheka et al, Hyperpigmentation was seen in 1 patient, prolonged

erythema in 1 and hypertrophic scar in 1 patient. [71]

ADDITIONAL BENEFITS:

Though the study aimed only at assessing the improvement in acne scars, few additional

benefits were noted in the patients like reduced seborrhea which was noted in 2 (5%)

patients and improved skin texture which was reported by 4 (10%) patients. In a study

conducted by Sharad J et al there was improvement in skin tone and texture. [68] In a

study by El Domyati et al, 40-50% improvement in skin texture was seen. [69]

107

INFLAMMATORY ACNE IN PAST:

Of the 42 patients, 33 gave history of inflammatory acne lesions in the past, accounting

for about 78.57%. only 6 (14.28%) of them gave history of regular treatment in the past

for active acne lesions and majority (52.38%) gave history of intermittent treatment. In

a study by Fernanda Tcatch Lauermann et al, positive correlation was established

between intensity of active acne lesions and presence of acne scarring. [65] This indicates

the need for prompt and early treatment of acne in the prevention of scarring.

SCAR TYPES DISTRIBUTION:

Predominant scar morphology in most of the patients were of boxcar and rolling, which

accounted for 47.5% each and remaining 5% of them had predominantly ice-pick scars.

Excellent improvement was seen in 43% of rolling scar and 36.8% of boxcar patients

and good improvement was seen in 26% of rolling scar and 42% of boxcar. 100% of

patients with ice-pick scars had poor response. In a study by Rajnesh Chakrawarthy et

al, Maximum response was for rolling scar 71%, good response was seen in boxcar

63.33% and least response for ice-pick scars 28.67% which was consistent with

Fabbrocini et al, Leheta et al. In Majid et al, Good to excellent response was seen in box

and rolling scars, whereas only moderate improvement in pitted scars.

Most of the studies available with microneedling as treatment for acne scars, combines

other conventional procedure or has been done after topical application of various

agents. Also, no Indian studies has used dermapen for microneedling to the best of our

knowledge. The purpose of this study was to assess the individual role of microneedling

in the management of acne scars using automated microneedling device, dermapen.

108

CONCLUSION:

- In our study, male patients outnumbered female patients in contrary to the belief

that females are more concerned about their physical appearance. The male :

female is 2.2 : 1.

- The age group most commonly observed was 20-30 years. This is the age group

when patients tends to have remissions in active acne lesions and used to get

more concerned about the post-acne sequelae like acne scars.

- Most of our patients were students.

- Majority of patients had history of inflammatory acne lesions in the past, but

only minority of them had taken regular treatment for the same. This indicates

the vital role played by inflammation in the formation of acne scars and the need

for prompt and early adequate treatment for acne lesions, to prevent it’s sequelae.

- In the pre-treatment observation, majority of the patients had grade 3 acne scars.

Both rolling and boxcar types of scars were equally distributed.

- Following treatment, majority of patients had grade1 acne scars with no

significant difference in grade improvement between boxcar and rolling scars.

However, poor improvement was seen in those with ice-pick scars.

- Around 37.5% exhibited excellent improvement and around 87.5% had visible

improvement in the appearance of scars which was comparable with other

modalities of acne scar management.

- Atleast 2 sittings were required to produce some improvement in scar

appearance, in most of the study participants. But, most patients in grade 4

exhibited improvement after 3 sittings.

109

- Acne scars has significant impact on social and emotional aspect of patient’s life

and in this study betterment in patient’s quality of life was seen with improved

DLQI scoring.

- Patient’s satisfaction score was also on the higher side, with excellent

satisfaction seen in majority of the study subjects.

- Apart from improvement in acne scars, few other benefits like reduced seborrhea

and improved skin texture were reported by the patients.

- Only minimal side-effects like post-inflammatory pigmentation and acne lesion

aggravation was seen in participants. No prolonged pain, erythema, tram track

ulcers as seen in other microneedling devices or ablative procedures.

- Thus, microneedling with automated dermapen is a relatively safe, effective

procedure having almost no downtime in the management of grade 2-4 boxcar

and rolling scars. Dermapen allowed treating acne scars in difficult to reach areas

and areas with thin skin like peri-orbital region, nose and forehead without much

damage. In addition, this procedure not only improves the appearance of acne

scars, but also improves the overall skin texture and reduces seborrhea of the

face in many patients. Ice-pick scars need combination with other modalities like

subcision and TCA CROSS for better outcomes.

110

.

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1108.

PATIENT CONSENT FORM

117

Mr/Ms/Mrs :

Age :

Address :

Phone :

Treatment group :

Treatment given :

I undersigned Mr/Ms/Mrs

have been explained about the above said procedure in my regional language. I am fully

aware of the possible side effects, like redness of skin, dryness of skin or infection, hematoma

that can occur following the procedure. I am also aware that the procedure may not always

produce complete clearance of the scarring and that no guarantee can be given for the

complete clearance. I am informed that this study requires my clinical photographs to assess

the efficacy of the procedure.

I have been explained that this procedure will be performed by Dr. J.Sivaranjani.

I have also been explained that during this procedure, if any complications arise, I may be

given any treatment best suited, without asking my prior permission.

I understand that my participation is voluntary and that Iam free to withdraw at any time,

without giving any reason, without any medical care being affected or any legal issues.

I further state that I have carefully read and understood all the information provided in this

form and with full consciousness I hereby give my consent for the said procedure with it’s

risks involved and for my clinical photographs before and after the study.

Signature/ thumb impression of the patient :

WITNESS :

Name : signature :

Date :

PROFORMA

Name :

118

Age :

Sex :

Marital status :

Occupation :

Address :

Phone number :

1. complaints of :

2. duration of complaints :

3. previous treatment history :

4. history of reddish ,raised skin lesions in past :

5. history of any infections :

6. history of bleeding disorders :

7. history of any previous procedures for the lesions :

8. history of any drug allergy :

9. menstrual history :

10. personal history :

11. general examination :

12. vitals : pulse rate- BP- RR-

13. Systemic examination :

14. Dermatological examination :

119

CLINICAL GRADING :

Goodman and Baron grading of atrophic acne scars.

INVESTIGATIONS :

Complete blood count

Bleeding time

Clotting time

Renal function test

Liver function test

Urine pregnancy test

HBsAg

Anti- HCV

ICTC

RPR

121

ABBREVIATIONS

IGF- Insulin like Growth Factor

SHBG- Sex Hormone Binding Globulin

IL- Interleukin

TLR- Toll Like Receptor

LT-B4- Leukotriene B4

MN-Microneedling

MSAI- Melasma Area Severity Index

TCA- Trichloro Acetic acid

MAL-PDT- Methyl Amino Levulinate Photodynamic Therapy

5-FU- 5-Flurouracil

SCC- Squamous Cell Carcinoma

P.acnes- Propionibacterium acnes

TGF- Tissue Growth Factor

LASER- Light Amplification by Stimulated Emission of Radiation

TC- Total count

DC- Differential count

ESR- Erythrocyte Sedimentation Rate

Hb- Hemoglobin

UV- Ultraviolet

122

S.NO NAME

SEX

AGE

Occupation

Grade before

Grade after

No.of grade improved at the end of 4 sessions

QOL BEFORE TREATMENT

QOL AFTER TREATMENT

PATIENT SATISFACTION SCORE

NO.OF SIITINGS TAKEN TO SEE SOME AMOUNT OF IMPROVEMENT

S.E

AGE OF ONSET OF ACNE

PREVIOUS TREATMENT FOR ACNE

H/O INFLAMMATORY LESIONS

PREDOMINANT SCAR MORPHOLOGY

OTHER BENEFITS

1 AJITH 1 22 O 3 2 1 L L 6 2 18 I Y B

2 AKASH 1 21 S 3 2 1 L M 7 2 15 I N B

3 AKBARALI 1

33 B 2 1 1 L M 8 2 P 20 N Y R

4 ASHOK 1 34 EL 4 L - - - - - 18 N Y B

5 AZARUDIN 1

21 A 3 1 2 L S 10 1 15 I Y B

6 DHARMARAJ 1

24 ST 4 4 NGDI L L 6 2 18 N Y B

7

DINESH KUMAR 1

19 S 2 2 NGDI M S 8 2 16 I N R

8 KARTHIK 1

29 O 4 4 0 L L 4 - 18 N Y B

9

KISHORE KUMAR 1

16 S 4 3 1 S S 6 3 15 N Y B

10

MANOJ 1

28 O 2 2 0 M M 7 - 20 I N I RS

11

MOHAN 1

23 I 2 2 NGDI M S 7 2 17 I N R

12

MOHANRAJ 1

20 S 2 0 2 M S 6 2 15 R Y R

13

NAVEEN KUMAR 1

18 S 3 1 2 L M 8 2 16 I Y R

14

PAVITHRAN 1

23 U 3 1 2 L M 8 2 16 I Y R

15

PERUMAL 1

24 S 3 3 0 L M 9 - 18 R Y B

16

RAJASEKAR 1

28 I 4 2 2 S S 7 3 20 N Y B

17

RAJESH 1

25 E 4 4 NGDI L M 7 2 17 N Y R

18

RAVINRAJ 1

21 S 2 1 1 L M 8 3

AG 17 I Y B

19

RIZWAN 1

22 S 3 2 1 M S 6 2 16 N Y R

20

SELVAKUMAR 1

20 S 4 4 0 S S 7 - 16 N N I RS

21

SELVARAJ 1

24 E 3 1 2 M M 5 3 18 I Y R

22

SHANKAR GANESH 1

25 E 4 3 1 L L 6 2 20 N Y B

23

SHARUK 1

20 S 2 L - - - - - 18 R Y R

123

24

SRINIVASAN 1

22 S 2 0 2 M S 6 2 15 I Y R

25

SRIRAM 1

25 D 3 1 2 L S 10 1 16 I Y R IST

26 SURYA 1

28 E 4 4 NGDI S N 10 3 17 N Y B RS

27

VIGNESH 1

16 S 2 1 1 S S 7 2 14 I N R

28 VIJAY 1

29 I 4 3 1 L L 4 3 19 I Y B

29

YUVARAJ 1

26 D 4 2 2 M S 6 1 16 I Y B

30

ABIRAMI 2

30 H 2 1 1 L S 6 2 20 I Y R

31

BHAVANI 2

26 H 3 2 1 M N 9 2 18 N Y B

32

JENNIFER 2

23 U 3 3 NGDI M S 9 2 17 I N R IST

33

KANIMOZHI 2

27 U 3 3 0 L S 4 - P 17 I Y R

34

KARTHIGA 2

24 I 3 2 1 L M 6 2 19 R Y R

35

KEERTHI 2

18 S 4 2 2 L M 8 3 15 I Y R RS

36

MANJULA 2

30 H 4 3 1 M S 7 3 16 N Y B

37

PONDHEEPA 2

20 S 3 1 2 L S 8 2 P 19 I N B

38

SANDHYA 1 2

23 S 3 1 2 L L 7 3 20 I Y B

39

SANDHYA 2 2

29 H 3 1 2 L S 8 2 18 N Y R

40

SANDRA 2

22 U 3 1 2 L L 6 2 16 R Y B

41

SELVARANI 2

20 S 3 1 2 M S 7 2 15 I Y B

42

CHITHRA 2

28 P 2 2 NGDI L M 2 3 16 R N R

124

KEY TO MASTERCHART

SEX:

1- Male

2- Female

OCCUPATION:

O- Office

S- Student

E- Engineer

D- Doctor

B- Business

H- Housewife

ST- Stuntman

EL- Electrician

I-IT

U- Unemployed

P- Paramedical

A-Accountant

GRADE AFTER TREATMENT:

L- Lost to follow-up

No. of grades improved at the end of 4 sessions:

NGDI- No improvement in grade but depth improved

QOL before and after treatment:

N- No effect [0-1]

S- Small effect [2-5]

M- Moderate effect [6-10]

L- Very large effect [11-20]

125

Patient satisfaction score:

0-3: poor

4-6: good

7-10: excellent

S.E- Side effects:

P- Post inflammatory hyperpigmentation

AG- Acne aggravation

Previous treatment for acne:

N- Nil

I-Intermittent

R- Regular

History of inflammatory lesions:

Y- Yes

N- No

Predominant scar morphology:

B- Boxcar

R- Rolling

I-Icepick

Added benefits:

RS- Reduced seborrhea

T- Texture improvement

percutaneous collagen induction in the...

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