Abstract
Background:
Microneedling is one of the cost-efficient and safe procedures for treatment of atrophic scars. Previous studies have shown variable results regarding the increased efficacy of platelet-rich plasma (PRP) when combined with microneedling.
Objectives:
The aim of this split-face study was to compare the efficacy of PRP combined with microneedling versus microneedling alone in acne scars in type 3-6 skin in South Indian patients. The primary objective was to compare the mean reduction in acne scar using Goodman Baron quantitative scale on the side of the face treated with PRP and microneedling, with the side of the face treated with microneedling alone.
Patients and Methods:
A total of 64 patients were recruited, and three sessions of microneedling with PRP on the right side and microneedling on the left side were done with an interval of 4 weeks between the sittings. Results were evaluated after 1 month of the last sitting using Goodman and Baron’s score and physician and patient satisfaction score.
Results:
There was significant improvement in atrophic acne scars on both sides of the face before and after treatment. While comparing efficacy between sides, the side treated additionally with PRP had significantly more improvement than the side treated with microneedling alone.
Limitations:
The trial was non-randomized, and complete blinding was not done. The study had a shorter follow -up interval. We did not analyze results based on the site of scar.
Conclusion:
PRP combined with microneedling is more effective than microneedling alone for the treatment of atrophic acne scars. Larger studies with longer follow-up are needed to confirm this result.
Keywords: Acne scars, microneedling, platelet-rich plasma, split-face design
Introduction
Scarring is a common complication of acne vulgaris, causing cosmetic disfigurement, low self-esteem, and reduced quality of life.[1] In a survey of acne patients, 49% of patients were reported to have scars.[2] A variety of techniques are used for scar management.[3] Combination therapies are more effective than individual treatments because patients typically have different types of scars that require volume restoration, tightening, and/or tissue movement along with resurfacing.[4]
Microneedling is a very safe, effective, and minimally invasive therapeutic technique. Microneedling functions based on percutaneous collagen induction (PCI).[5] It is a very safe technique for dark skin types.[6] The microinjuries caused by the procedure induce only minor bleeding on the surface and initiate the release of a cascade of wound healing growth factors.[7] This results in neovascularization and neocollagenosis. It is thought that the addition of growth factors linked to platelet rich plasma (PRP) enhances the benefits of microneedling by promoting more visually pleasing tissue remodeling.[8]
There have been previous studies assessing the addition of PRP to microneedling. Some studies have shown that the addition of PRP to microneedling produced significantly better outcome than microneedling alone.[1] Other studies did not find statistically significant improvement by combining PRP with microneedling.[9,10,11,12] In a systematic review, Hesseler et al.[13] concluded that paucity of studies, smaller studies, and insufficient evidence meant that it was difficult to conclude that adding PRP to the treatment regimen significantly improved acne scars. Due to variable results in previous studies,[14,15,16] we decided to do a comparative analysis of PRP with microneedling and microneedling alone in the treatment of atrophic acne scars. Our study aimed to generate new robust evidence supporting the addition of PRP to microneedling and to identify other factors influencing the therapeutic benefit of PRP through subgroup analysis.
Patients and Methods
The study was a non-randomized split-face single-blinded study carried out in the dermatology department of Indira Gandhi Medical College and Research Institute, Pondicherry. The study was registered in the Clinical Trial Registry of India (CTRI registration no: CTRI/2022/12/048400). After obtaining ethics committee approval (No 395/IEC-34/IGMC and RI/PP-3/2022), patients aged above 18 years having atrophic grade 1 to grade 4 acne scars, with equal Goodman and Baron’s quantitative and qualitative scores on both halves of the face, were included. Patients with keloidal tendency, bleeding disorders, acute infections on the face, human immunodeficiency virus infection, hepatitis B infections, pregnancy, and lactation were excluded. Demographic details, skin type, and other variables influencing acne like body mass index (BMI) were noted for all patients. The prevalence of acne has been found to be more in adolescents with high BMI. Inflammatory lesions have been observed more frequently in patients with a higher BMI; however, there are contradictory reports on the correlation of BMI with severity of acne; hence, BMI was included as a study variable. BMI was calculated by dividing the patients’ weight in kg by the square of their height in meters.
Patients and methods
After obtaining informed consent from the patients, microneedling was done on both sides of the face; then the right side was treated intradermally and topically with the patient’s autologous PRP, while the left side was treated with normal saline. PRP and normal saline were administered using insulin syringes. The patient was blinded regarding the side receiving PRP by covering the saline and PRP syringes using paper. Three treatment sessions were given at an interval of 1 month, consecutively. Evaluation of the reduction of scars was done using Goodman and Baron’s scale at the end of each session. Physician satisfaction score and patient satisfaction scores were evaluated 1 month after the end of study.
Method of preparing PRP
For the preparation of PRP, 10 ml whole blood was collected and separated into two sodium citrate tubes with 3 ml blood in each tube, and was subjected to first centrifugation at 2400 rpm for 5 min. The separated plasma was subjected to further centrifugation at 3000 rpm for 10 min, which resulted in a dense layer of platelets at the bottom and a clear fluid layer on the top. This setting ensured that the platelet yield was at least 23 × 103 cells/ml. One ml of prepared PRP was injected intradermally (0.1 ml was injected at 1 cm intervals around the area of the scars, to make a total of 1 ml), and the remaining 1–2 ml was applied on the right side of the face before microneedling, thereby using 2–3 ml in total.
Method of microneedling
After gentle cleansing, the area of interest was anesthetized using a thick application of topical anesthetic cream under occlusion for about 45 to 60 minutes. Microneedling was carried out using a derma roller studded with 192 microneedles in eight rows and 1.5 mm in length. Dermaroller was applied sequentially in horizontal, vertical, and diagonal directions until pinpoint bleeding occurred. PRP and normal saline were administered using insulin syringes on the right and left sides of the face, respectively, using intradermal and topical routes. The face was cleaned with normal saline at the end, and ice compresses were applied if necessary. The patients were advised to observe strict photoprotection.
Before each session, digital photographs were captured at a 50 cm distance, with and without flash, of both halves of the face. Later, these photographs were assessed by an independent dermatologist, who was also blinded regarding the side receiving PRP, for the final evaluation of acne scars.
Sample size calculation
Determination of sample size was done using hypothesis testing for two means (equal variances) with the standard deviation in group 1 taken as 0.6 and group 2 as 0.8.[17] The sample size was calculated so that the power of the study is 80% and the alpha error is 5% and was estimated to be 64 in each group. As this was a split-face study, 64 patients with acne scars were recruited.
Results
A total of 64 patients were enrolled in the study, out of which 49 patients completed three sittings and attended the follow-up visit. Overall, 15 patients dropped out, some due to lack of fast response, and some because they were unwilling to attend regular visits. The mean age of the patients was 24.84 years, with a range of 18–42 years. In this study, there were 31 male and 33 female patients [Table 1]. All patients were of III to VI Fitzpatrick skin type. There was no significant difference between the Goodman and Baron scores at baseline between the two sides (P = 0.163). While comparing the mean values of Goodman Baron score between before and after treatment separately, there was statistically significant improvement in both microneedling with PRP side (P < 0.001) and plain microneedling side (P < 0.001) [Figures 1 and 2].
Table 1.
Baseline characteristics of patients
| n | Percentage | ||
|---|---|---|---|
| Sex | Male | 33 | 51.5 |
| Female | 31 | 48.5 | |
| Fitzpatrick skin type | III | 10 | 15.6 |
| IV | 35 | 54.7 | |
| V | 17 | 26.6 | |
| VI | 2 | 3.1 | |
| Age (in years) | 18-24 | 41 | 64 |
| 25-30 | 10 | 15.6 | |
| >30 | 13 | 20.3 | |
| Grade of scar | Mild | 6 | 9.4 |
| Moderate | 34 | 53.1 | |
| Severe | 24 | 37.5 | |
| Education | School student | 2 | 3.1 |
| College student | 27 | 42.2 | |
| Graduate and above | 35 | 54.7 | |
| Predominant scar type | Icepick | 19 | 29.7 |
| Rolling | 45 | 70.3 | |
| BMI | <18.5 | 5 | 7.8 |
| 18.5-24.9 | 35 | 54.7 | |
| >25 | 24 | 37.5 |
BMI – Body Mass Index
Figure 1.
Right side of face before (a) and after (b) 3 sessions of microneedling with PRP. Left side of face before (c) and after (d) 3 sessions of microneedling
Figure 2.
Right side of face before (a) and after (b) 3 sessions of microneedling with PRP. Left side of face before (c) and after (d) 3 sessions of microneedling
At the end of the study, the mean difference in the Goodman and Baron’s score between the two sides was statistically significant, with a greater reduction in the side treated with microneedling and PRP [Table 2]. While comparing the percentage reduction in total score between the two sides, the mean difference was 16.825 (95% CI: 9.84, 23.8), which was significant (P value < 0.001). The physician satisfaction scores did not show a statistically significant difference between the two sides at the end of the study. However, patient satisfaction scores between the right and left sides at the end of the study were significantly (P value < 0.001) different.
Table 2.
Mean reduction in scores of both sides of face between the baseline and last follow-up
| Mean | SD | P | Mean difference | 95% confidence interval | |||
|---|---|---|---|---|---|---|---|
|
| |||||||
| Upper limit | Lower limit | ||||||
| Goodman and Baron score | R side | 8.51 | 5.140 | ||||
| L side | 11.20 | 5.427 | <0.001 | - 2.694 | - 3.216 | - 2.172 | |
| Physician satisfaction score | R side | 4.66 | 1.397 | ||||
| L side | 4.75 | 1.314 | 0.569 | - 0.091 | - 0.411 | 0.229 | |
| Patient satisfaction score | R side | 6.62 | 1.917 | ||||
| L side | 5.43 | 2.051 | <0.001 | 1.196 | 0.797 | 1.595 | |
Wilcoxon Signed Ranks test was applied; PRP: Platelet-rich plasma, R side: Right side, treated with microneedling with PRP; L side: Left side, treated with microneedling
Almost all patients tolerated the procedure well, yet a few adverse effects were noted. Postinflammatory hyperpigmentation (PIH) was seen in six patients, postinflammatory erythema with edema in one, and pustules in one patient. On follow-up visits, no residual side effects were observed. Postprocedure erythema spontaneously resolved within 1 or 2 days. There was no significant difference in the frequency of adverse effects between the sides.
Subgroup analysis [Table 3] was done for the mean of total score at the end of study based on their age, sex, Fitzpatrick skin type, BMI, predominant acne scar type, and grade of acne scar during the baseline. This analysis has shown that there was no impact of age or sex or scar type on the improvement in acne scar score after treatment. We found that significant improvement was not seen in patients with mild grade of acne scar, patients with Fitzpatrick skin type VI, and patients with BMI less than 18.5.
Table 3.
Subgroup analysis of final Goodman and Baron score
| Variable | Category | Side | Mean | SD | P |
|---|---|---|---|---|---|
| Age | 18-24 | R side | 8.19 | 3.167 | <0.001 |
| L side | 10.78 | 3.876 | |||
| 25-30 | R side | 9 | 7.411 | 0.003 | |
| L side | 12.07 | 7.671 | |||
| >30 | R side | 8.75 | 5.445 | 0.016 | |
| L side | 11.13 | 5.890 | |||
| Sex | Male | R side | 10 | 5.978 | <0.001 |
| L side | 12.92 | 5.853 | |||
| Female | R side | 7.08 | 3.774 | <0.001 | |
| L side | 9.56 | 4.510 | |||
| Fitzpatrick skin type | Type III | R side | 9.88 | 8.149 | 0.026 |
| L side | 11.63 | 8.450 | |||
| Type IV | R side | 8.17 10.76 | 4.209 4.549 | 0.003 | |
| L side | |||||
| Type V | R side | 7.8 | 5.181 | 0.005 | |
| L side | 11.20 | 5.514 | |||
| Type VI | R side | 11.50 | 4.950 | 0.180 | |
| L side | 16 | 2.828 | |||
| BMI | <18.5 | R side | 8 | 3.162 | 0.102 |
| L side | 9.75 | 4.573 | |||
| 18.5-24.9 | R side | 8.45 | 5.421 | <0.001 | |
| L side | 11.39 | 5.673 | |||
| >25 | R side | 8.79 | 5.221 | 0.001 | |
| L side | 11.21 | 5.381 | |||
| Predominant scar type | Icepick | R side | 9.50 | 7.526 | 0.002 |
| L side | 12.67 | 7.548 | |||
| Rolling | R side | 8.19 | 4.182 | <0.001 | |
| L side | 10.73 | 4.574 | |||
| Grade of scar | Mild | R side | 3.25 | 1.258 | 0.059 |
| L side | 5.50 | 1 | |||
| Moderate | R side | 6.84 | 5.121 | <0.001 | |
| L side | 9.60 | 5.575 | |||
| Severe | R side | 11.65 | 3.675 | <0.001 | |
| L side | 14.35 | 3.787 |
BMI: Body mass index, L side: Left side, R side: Right side, SD: Standard deviation. Wilcoxon signed ranks test was applied
Discussion
Microneedling and PRP are relatively new minimally invasive procedures to treat acne scars. Our study was designed as a comparative split-face study of PRP with microneedling versus microneedling alone in the treatment of atrophic acne scars. We found that the PRP treated side had a better improvement in acne scars. Some previous studies assessed the efficacy of microneedling and PRP seperately for atrophic acne scars.[18,19] Other studies have shown results similar to our study, i.e. combining PRP with microneedling is better than microneedling alone in the treatment of acne sacrs.[1,14,15] In a systematic review, Hesseler et al.[13] noted that adding PRP in the treatment regimen significantly improved acne scars, increased patient satisfaction, and reduced post-procedure downtime. However, they concluded that larger studies are required. Other similar split-face studies found an insignificant difference in scores between the microneedling side and the PRP with microneedling[10,20] [Table 4]. The differences between these studies and our study could be because of different scoring systems used and the different time of assessment followed.
Table 4.
Similar studies on platelet rich plasma and microneedling
| Sample size | Methodology | Fall in score between two sides | Fall in score after microneedling alone | Fall in score after PRP + microneedling | Patient satisfaction score | Physician satisfaction score | |
|---|---|---|---|---|---|---|---|
| Our study | 64 | Three treatment sessions at an interval of 1 month. Goodman and Baron’s quantitative scale, physician and patient satisfaction score used for the final evaluation of results | Significant | Significant | Significant | Significant | Not significant |
| Asif et al.[1] | 50 | Three treatment sessions at an interval of 1 month. Goodman’s quantitative scale and qualitative scale used for the final evaluation of results | Significant | Significant | Significant | Significant | Significant |
| Fabbrocini G et al.[15] | 12 | Two sessions at an interval of 8 weeks Final follow-up 32 weeks later. Photograph analysis and scar severity score used for the final evaluation of results | Significant | ||||
| Ibrahim et al.[9] | 35 | Topical application of PRP with microneedling compared with micro needling alone Four sessions with 3 weeks interval Goodman’s qualitative grade and patient satisfaction score used for final evaluation | Not significant (qualitative score) | Significant | Significant | Not significant | |
| Patel et al.[11] | 32 | Three sessions at an interval of 1 month. Goodman’s qualitative scar grade and physician score used for the final evaluation of results | Not significant | Not significant | |||
| Gupta et al.[10] | 36 | Topical application of PRP with microneedling compared with micro needling alone Four sessions with 3 weeks interval ECCA score used for final evaluation | Not significant | ||||
| Porwal et al.[14] | 55 | Two groups of patients, one treated with microneedling alone and another treated additionally with PRP were studied Three treatment sessions at an interval of 1 month. Goodman’s quantitative scale, visual analog score, and DLQI used for the final evaluation of results | Significant | Significant | Significant |
PRP – Platelet-rich plasma, DLQI – Dermatology life quality index, ECCA – Echelle d’évaluation clinique des cicatrices d’acné
Similar results on patient satisfaction score were found in studies by Porwal et al.[14] and Asif et al.[1] A lack of difference in physician satisfaction scores was in line with the studies by Ibrahim et al.[20] and Patel et al.,[11] where, similar to our study, photographs were used to assess improvement. This result may be because improvement in milder scars may not be as evident in photographs as it is in person. Split-face trials conducted by Asif et al.,[1] Lee et al.,[19] and Ibrahim et al.,[20] found significantly less erythema and edema and less overall downtime in the side that was treated with microneedling and PRP. This was not noted in our study.
Subgroup analysis based on age, sex, BMI, Fitzpatrick skin type, grade of acne scar, and predominant type of scar at the time of recruitment was done in this study, which has not been done in other similar studies. This analysis has shown that there was no impact of age or sex or scar type, on the improvement of acne scars after treatment. We found that significant improvement was not seen in patients with a mild grade of acne scar, those with Fitzpatrick skin type 6, and patients with a BMI <18.5. This could be because patients in these categories had very mild scars, which were too small to show significant improvement in the quantitative score.
Limitations
Our study had a few limitations. The trial was nonrandomized, and complete blinding was not done. The study had a shorter follow-up interval, while collagen remodeling may take several months to show more visible results. We did not analyze results based on the site of scar.
Conclusions
Despite these limitations, our study provides concrete evidence that addition of PRP to microneedling improves the scar outcome and is safe and effective for South Indian skin types of IV-VI. On subgroup analysis with our small sample size, we also found that mild scars, low BMI, and skin type VI did not show significant improvement with PRP; which is a new finding and must be substantiated with other studies with larger sample sizes.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Conflicts of interest
There are no conflicts of interest.
Use of artificial intelligence (AI)
We have not used artificial intelligence.
Acknowledgements
None.
Funding Statement
IADVL PG Thesis grant 2022.
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