Microneedling cannot match the tissue-tightening effects of lasers, but it addresses issues ranging from stubborn wrinkles to stretch marks, quickly and cost-effectively, said an expert at summer Cosmetic Bootcamp held June 21-24 in Aspen, Colorado. Rather than competing, she added, microneedling and laser treatments often complement each other.
Although fractional ablative lasers have bridged the efficacy-versus-downtime gap between traditional CO2 lasers and nonablative lasers, said Tina S. Alster, M.D., no laser can treat severe perioral rhytides successfully. She is director of the Washington Institute of Dermatologic Laser Surgery and clinical professor of dermatology at Georgetown University in Washington, D.C.
Along with micro-wounding, said Dr. Alster, microneedling creates controlled macro-wounding that spurs healing in the way that tilling a field increases its yield. Microneedling is also inexpensive, combines well with other procedures and incorporates easily into any clinical practice, she said.
Dr. Alster prefers microneedling devices with disposable tips and as many needles as possible. Drum-shaped needle rollers are hard to clean, and their permanent needles dull quickly, she explained.
For perioral rhytides and other indications, Dr. Alster frequently offers what she calls simple microneedling, without radiofrequency assistance, or adjuvant cosmeceuticals delivered through the microscopic channels. Based on a March 2018 Dermatologic Surgery article she co-authored, Dr. Alster offered the following technical tips:
- Don't overdo the gliding gel. "Put just enough on the skin to permit a smooth gliding action of the microneedling tip across the skin, but not so much that excess gel interferes with the device’s motor."
- Use manual traction for smooth needle delivery. "If you're dragging the device over loose skin, the needles can drag or get caught. Your assistant can stretch the skin taut — or you can use your non-dominant hand to do so — during treatment."
- Hold the device perpendicular to the skin so the needles penetrate the surface at 90°.
- Perform multidirectional passes. "I move the microneedling tip back and forth, up and down and diagonally across the treatment area. Some practitioners perform circular motions. It’s important to avoid treatment in the same direction so that patients don’t end up looking like they have stripes."
- Watch for early pinpoint bleeding as a clinical endpoint. “Severely photodamaged skin often bleeds immediately, while fibrotic skin or scars, particularly in non-facial areas, may require several passes to elicit pinpoint bleeding.” Sometimes she treats beyond the pinpoint bleeding, depending on lesional severity. Application of ice water-soaked gauze between passes immediately stops bleeding with minimal pressure. Once bleeding stops, she applies a few drops of Soothe HC Arnica Recovery Balm (A Method).
For patients with minimal perioral rhytides and surrounding photodamage, Dr. Alster frequently performs microneedling followed immediately by full-face nonablative (or, for more extensive photodamage, ablative) fractional resurfacing. To reduce the risk of adverse events, she does not typically perform laser treatment over areas that have been microneedled. She recommends combination microneedling and nonablative laser treatments at monthly time intervals.
"What I like about this combination is that most patients who undergo treatment on a Friday can return to work or their regular activities on Monday. Any residual post-treatment erythema can be easily covered with makeup as early as one day post-treatment,” she said.
However, applying preservative-containing cosmeceuticals too soon after microneedling or nonablative resurfacing can lead to granulomas. Therefore, Dr. Alster advocates waiting until patients have returned to their regular skincare regimen (usually one week post-treatment) before applying additional cosmeceuticals. During that week, patients use her A Method post-care kit, which includes a gentle, nonirritating cleanser, a daytime moisturizer with a nonchemical sunblock and an evening moisturizer.
For atrophic scars, Dr. Alster said, traditional pulsed CO2 lasers can provide significant and lasting improvements with just one treatment. But to avoid post-treatment mismatches in skin color or texture, laser treatment must be delivered to entire cosmetic units. With microneedling, she said, a small area of atrophic scars within a cosmetic unit can be treated without worrying about color mismatches, provided patients do not have pre-existing dyschromias in that location.
For a patient with hypertrophic scars and keloids resulting from CO2 laser burns created by another practitioner, Dr. Alster initially prescribed topical agents in order to improve her dyschromia. "Then I applied the pulsed dye laser on her erythematous, hypertrophic scars, followed immediately by microneedling." The patient achieved very good results with just one treatment, she said. The same was true for a patient whose upper arm Dr. Alster treated for fibrosis following a motor vehicle accident.
To remove a patient's cosmetic lip tattoo, Dr. Alster used a CO2 laser with a 3mm hand piece, tracing the vermilion border to leach out some of the pigment. "I vaporized the area and had a very good result." These days she also uses microneedling for such patients.
Recently, she performed two sessions of microneedling for a patient who had darkening of a flesh-colored camouflage tattoo in a scar that had received prior treatment with a Q-switched laser. "Not only was marked scar improvement seen, but reduction of the darkened tattoo ink was also apparent," she said.
Dr. Alster added that she loves microneedling for enlarged pores, including those created by skin picking or by applying electrodesiccation for telangiectasias around the nose. "Microneedling disrupts the fibrotic pores and induces new collagen formation." For striae that cover large body areas, she said, microneedling can improve both skin texture and tightness.
For periocular treatment, Dr. Alster prefers lasers because their heat provides immediate skin contraction and long-term collagen regeneration. Laser advantages include a proven track record of safety and efficacy, she said, and better collagen contraction than microneedling provides. Laser drawbacks include the fact that they require more money, space and operator training. And their utility in darker skin types is limited.
Microneedling provides modest skin contraction as a result of the wound-healing cascade, Dr. Alster said, but it creates much more bruising around the eyes than lasers do. "In addition to the fact that periocular skin is thin (and therefore more prone to trauma and bruising), it is more difficult to keep the periocular area taut during microneedling." With all forms of microneedling, she added, results are operator- and patient-dependent.