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Received: 10 May 2018    Revised: 7 September 2018    Accepted: 23 October 2018

DOI: 10.1111/jocd.12827

ORIGINAL CONTRIBUTION

Microneedling by dermapen and glycolic acid peel for the

treatment of acne scars: Comparative study

Amr N. Saadawi MD | Abdulla M. Esawy MD  | Abdalla H. Kandeel MD | 

Walaa El‐Sayed MSc

Faculty of Medicine, Zagazig University,

Zagazig, Egypt
Correspondence
Abdulla M. Esawy, Faculty of Medicine,
Zagazig University, Zagazig, Egypt.
Email: abdesawy@hotmail.com
Summary
Background: Many methods have been performed to achieve a satisfying outcome in
acne scars but some of them were high cost and also were associated with low results
and some complications.
Objectives: To evaluate and compare the efficacy and safety therapy of glycolic acid
(GA) peel, microneedling with dermapen and a combination of both procedures in
treatment of atrophic acne scars.
Patents and methods: This study was conducted on 30 patients suffering from acne
scars. They were randomly assigned into three groups, each group included 10 patients;
group I was treated with GA peel, group II treated was with microneedling. Group III re‐
ceived a combination of both procedures. All patients received six sessions with 2‐week
intervals. The clinical assessment was based on the qualitative global scar grading system
before and after treatment, quartile grading scale, and degree of patient satisfaction.
Results: There was a statistically significant decrease in acne scars grade after treat‐
ment among the studied groups (P = 0.04) but it was higher in group III. There was
improvement in boxcar, ice pick, and rolling scars in all groups, respectively (P = 0.03,
P = 0.04, P = 0.04). Patients’ satisfaction was higher in group III (P = 0.04).
Conclusion: The combination of dermapen and GA peel is more effective than
monotherapy.

KEYWORDS
atrophic acne scars, dermapen, glycolic acid peel, microneedling

1 |  I NTRO D U C TI O N Skin needling is a technique which is predominantly used to im‐

Treatment of acne scars is considered a challenge for both patients
and dermatologists. Many options are available as follows: laser sur‐
gery, radiofrequency intervention, chemical peels, chemical recon‐
struction of skin scars (cross) technique, dermabrasion, needling,
subcision, punch techniques, fat transplantation, and other tissue
augmenting agents. Each scar type has a different structural cause
warranting a personalized approach. Little literature exists about the
safety and efficacy of combining such procedures and devices.1
prove the appearance of cutaneous scarring and photodamage. Fine
needles puncture the skin, resulting in increased dermal elastin and
collagen, collagen remodeling, and thickening of the epidermis and
dermis. 2 Additionally, skin needling creates small channels, which in‐
crease the absorption of topically applied preparations a property
which has been used in various dermatological treatments.3
The technique of microneedling has been shown to increase the
remolding of the skin by creating thousands of microscopic chan‐
nels through the epidermis to the dermis. In response to the multiple

J Cosmet Dermatol. 2019;18:107–114. © 2018 Wiley Periodicals, Inc. |  107

wileyonlinelibrary.com/journal/jocd  
108      | SAADAWI et al.

TA B L E 1   Demographic data and dermatological examination of the studied groups

Group I Group II Group III

Variable (n = 10) (n = 10) (n = 10) F P

Age (years)
Mean ± SD 32.10 ± 5.61 28.6 ± 8.78 26.8 ± 6.07 1.5 0.24
Range 27‐45 19‐42 19‐39 NS

Group I Group II Group III

Variable (n = 10) (n = 10) (n = 10) K P

Duration (years)
Mean ± SD 6.7 ± 3.02 6.7 ± 5.47 4.7 ± 2.75 1.89 0.39
Range 2‐13 1‐20 1‐10 NS
2
Variable No % No % No % χ P

Scar type
Boxcar 5 50 4 40 2 20 2.14 0.71
Ice pick 3 30 3 30 4 40 NS

Rolling 2 20 3 30 4 40
Skin type
II 2 20 0 0 0 0 6.74 0.15
III 6 60 8 80 5 50 NS

IV 2 20 2 20 5 50
Scar grade
Mild 3 30 4 40 3 30 0.38 0.98
Moderate 4 40 3 30 4 40 NS

Severe 3 30 3 30 3 30

There were no statistical significant differences between the groups in age, duration, scar type, or skin type.

TA B L E 2   Degree of improvement
Group III
among the studied groups
Group I (n = 10) Group II (n = 10) (n = 10)

Variable No % No % No % χ2 P

Improvement
No 2 20 3 30 0 0 12.87 0.04*
Mild 4 40 5 50 2 20
Good 4 40 2 20 4 40
V. good 0 0 0 0 4 40

The statistically significant improvement in the degree of acne scars before and after treatment with
the three methods and statistically significant difference between the groups in the degree of im‐
provement. *P < 0.05.

cutaneous injuries and breaking the old collagen strands, a cascade
of growth factors (stimulating, migration, and proliferation of fibro‐
blasts) leads to collagen production. Thus, architectural and histo‐
pathologic changes take place in the lesioned area, and scars are
attenuated.4
Glycolic acid (GA) is an alpha‐hydroxy acid, which decreases cor‐
neocyte cohesion and promotes desquamation and epidermolysis.
Due to its exfoliative properties, it is widely used as a superficial
peeling agent. In addition, a study has shown that GA peel has an
anti‐inflammatory effect on acne through its bactericidal effect on
P. acne.5 In acne scars, GA increases dermal hyaluronic acid and col‐
lagen gene expression by increasing secretion of IL‐6.6 It has been
seen that a combination of various modalities gives better results
than using a single method of treatment. Subcision, fractional laser,
infrared laser, trichloroacetic acid, and GA have been used in combi‐
nation in various studies with good results.7
The aim of this study was to compare between GA 35% peel,
microneedling with dermapen monotherapy, and combined GA 35%
peel and micro needling with dermapen in the treatment of acne
scars.
SAADAWI et al.
F I G U R E 1   A case of 33 years old female with atrophic acne
scar (boxcar type). Preoperative (Goodman and Baron qualitative
grading system) grade was 4; 1 months later after receiving six
sessions of dermapen treatment; the grade was 2 with good
improvement
F I G U R E 2   A case of 27 years old male with atrophic acne
scar (icepick type). Preoperative (Goodman and Baron qualitative
grading system) grade was 4. 1 months later after receiving six
sessions of dermapen treatment; the grade was 3 with mild
improvement
2 | PATI E NT S A N D M E TH O DS
This study was carried out at the Outpatient clinics of
Dermatology, Venereology and Andrology Department, Faculty of
Medicine, Zagazig University Hospitals in the period from March
2017 to August 2017. Thirty patients of both sexes (10 men and
20 women) with ages ranged from 19 to 45 years old with different
types of atrophic acne scars were enrolled in the study. Informed
written consent was taken from all the patients before the study.
The study had the approval of the Institutional Review Board (IRB)
at Zagazig University.
2.1 | Inclusion criteria
Patients with acne scars of any age. Patients of both sexes. Patients
who were willing to sign informed consent.
|
      109
F I G U R E 3   A case of 25 years old female with atrophic acne
scar (boxcar type). Preoperative (Goodman and baron qualitative
grading system) grade was 4. 1 months later after receiving six
sessions of combination treatment; the grade was 2 with very good
improvement
F I G U R E 4   A case of 42 years old female with atrophic acne
scar (rolling type). Preoperative (Goodman and Baron qualitative
grading system) grade was 2. 1 months later after receiving six
sessions of glycolic acid peel treatment; the grade was 1 with good
improvement
2.2 | Exclusion criteria
Patients with the history of glycolate hypersensitivity, contact
dermatitis, bleeding disorder, patients with infectious or inflam‐
matory skin disorders. Acute or chronic anticoagulant therapy, the
presence of skin cancers, pregnancy, patients with herpes simplex
infection, patients with solar keratosis, keloids, uncontrolled dia‐
betes. Patients with collagen vascular disease, neuromuscular dis‐
ease, and keloid prone patients.
The full history was taken from each case including personal his‐
tory, the present history which included onset, course, and duration
of scars, previous acne treatment (eg, systemic retinoids), previous
treatment procedures for acne scars and post‐treatment complica‐
tions as hyperpigmentation or keloid formation. Past history of sys‐
temic diseases (eg, diabetes, coagulopathy, etc).
All patients were subjected to general examination and derma‐
tological examination to assess the skin type, the scar type (ice pick,
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110       SAADAWI et al.
F I G U R E 5   A case of 22 years old male with atrophic acne
scar (icepick type). Preoperative (Goodman and Baron qualitative
grading system) grade was 3. 1 months later after receiving six
sessions of glycolic acid peel treatment; the grade was 2 with mild
improvement
boxcar, and rolling type), and the scar severity (grades 2, 3, or 4 ac‐
cording to the qualitative global acne scar grading system).8
Patients were divided into three groups: Group I: Included 10
patients (four males and six females) aged 27‐45 years, and mi‐
croneedling with dermapen for treatment of the scars was per‐
formed. Group II included 10 patients (four males and six females)
aged 19‐42 years, and they were treated by GA 35% peel. Group III
included 10 patients (two males and eight females) aged 19‐39 years.
They were treated with skin microneedling with dermapen combined
with GA 35% peel. Every patient of the three groups has received six
sessions with 2‐week interval between the sessions. Patients were
observed for 1 month.
We asked the patients about their goals, concerns, and expec‐
tations about the treatment to avoid unrealistic expectations. We
emphasized to the patient the unpredictability of acne scar treat‐
ment and that there was no quick, easy, and permanent fix to the
problem. Possible side effects of each procedure as erythema,
edema, pain, prolonged downtime, and hyperpigmentation were
recorded.
2.3 | Methods
Group I: We primed the patients with topical vitamin A and C formula‐
tions twice a day for 2 weeks to maximize dermal collagen formation.
We adapted the technique described by Ibrahim et al9 Microneedling
treatment was performed with dermapen (Bomtech Electronics,
Seoul, Seocho‐Gu, Korea (34, Hyoryeong‐ro 49‐gil, Seocho‐gu,
Seoul, JX‐120DR). Thick layer of local anesthetic EMLA cream (eu‐
tectic mixture of lidocaine and prilocaine), APP Pharmaceuticals,
Fresenius Kabi, San Francisco, IL, USA) was applied to the face for
approximately 45‐60 minutes before the procedure. The cream was
gently removed. Dermapen was performed every 2 weeks for six
sessions. It was passed in various directions with minimal pressure.
F I G U R E 6   A case of 26 years old female with atrophic acne
scar (rolling type). Preoperative (Goodman and Baron qualitative
grading system) grade was 3. 1 months later after receiving six
sessions of combination treatment; the grade was 1 with very good
improvement
We prescribed topical antibiotic two times per day for 3 days after
treatment as well as a proper sunscreen to be applied daily.
Group II (35% GA): The patients in this group were treated with
GA peel 35% weight/volume, was made to order by Care Mid East
Pharma Company (Elmansoura, Dakhla, Egypt) (for GA). Our patients
were primed at home using mild topical peeling agents (tretinoin
0.025%), for 2 weeks prior to the peel and discontinued it 2 days
before the procedure. Cleansing the skin before a chemical peel is
extremely important to obtain a homogeneous penetration of the
peel and thus a uniform result. We asked the patients to wash their
faces with soap and water and then we cleansed the skin surface
to remove any remaining traces of makeups or oils. We used ethyl
alcohol to clean the skin and acetone for degreasing.
The patients were seated in a comfortable position, wearing a
hair cap, and we asked them to keep their eyes closed during the en‐
tire procedure. We applied the acid with a cotton‐tipped applicator.
We start applying the GA on the forehead and then to the rest of the
face since the forehead is less sensitive and can tolerate a little more
exposure to the acid than other parts of the face can. We protected
very sensitive areas, such as the corners of the nose and lips with
Vaseline.
We neutralized the peel when a uniform erythema (endpoint)
was seen by 3‐5 minutes. If frosting was observed in any area be‐
fore the set time or end point, we neutralized it at the same time by
sodium bicarbonate. Patients were instructed to apply moisturizing
cream, topical antibiotic, and a proper sunscreen daily.
Group III: Patients in this group were treated with dermapen and
GA 35% every 2‐week interval for six sessions alternating with each
other.
Digital color facial photographs were taken using a digital camera
(Nikon Coolpix L340 20.2 Megapixels digital camera; Nikon Corp,
Tokyo, Japan). Left and right profile views were obtained at baseline,
before the session, 2 weeks after the last session and at the end of
follow‐up after 1 month.
SAADAWI et al. |
      111

The results were assessed at the end of treatment using the qualita‐
8
tive global scar grading system by Goodman and Baron and the quartile
grading scale. Degree of pain and patient satisfaction were also assessed,
for independent clinical assessment, two dermatologists evaluated the
photographs taken before treatment and after completion of the treat‐
ment (1 month after the last session). Physicians assessed the results
using quartile grading scale which categorizes the improvement as fol‐
lows: very good improvement >75%; good improvement of 50%‐74%;
mild improvement of 25%‐49%; and poor or no improvement <25%.
Pain during the session was assessed by the participants and
graded as mild, moderate, and severe, and a questionnaire was given
to patients at the end of treatment to assess their degree of improve‐
ment as no, mild, good, and very good. Any side effects observed
such as persistent erythema, post inflammatory hyperpigmentation
(PIH), hypopigmentation, herpes simplex flare‐up, scarring, or ke‐
loids were recorded at each session.
The collected data were computerized and statistically analyzed
using SPSS program (Statistical Package for Social Science, SPSS Inc.,
Chicago, IL, USA) version 18.
3 |  R E S U LT S
The demographic and the clinical data of the three groups are shown
in Table 1. The clinical data include history, general examination, and
dermatological examination.
The response to treatment was assessed using the qualitative
global scar grading system before and after treatment, quartile
grading scale, and degree of patient satisfaction. The three groups
showed statistically significant improvement in the degree of acne
scars before and after treatment with the three methods (P < 0.05).
There was statistically significant difference between the groups in
the degree of improvement (P = 0.04) as shown in Table 2.
A marked increase in the frequency of good and very good im‐
provement in Group III compared to Group I and II. An increase was
also noticed in the frequency of good improvement in Group I com‐
pared to Group II (P = 0.04) as shown in (Table 2 and Figures 1-6.
There was a statistically significant increase in the frequency of im‐
provement in rolling compared to boxcar and ice pick in all groups
and also in boxcar compared to ice pick (P = 0.03, P = 0.04, P = 0.04)
in the three groups, respectively (Table 3). The difference between
the response in the three groups according to patient satisfaction
was statistically significant (P = 0.04) as shown in Table 4. Also, there
was a statistically significant difference between satisfactory and
objective rates as shown in Table 5. Types and incidence of side ef‐
fects in each group are shown in Table 6.
4 | D I S CU S S I O N
The severity of acne scars has reduced after treatment with der‐
mapen in most of the patients of group I, two patients had no im‐
provement with dermapen, and this might be due to long duration
of scar. In parallel with this study, Ibrahim et al9 used dermapen for
treatment of atrophic scars. They conducted a study in which all pa‐
tients in the dermapen group showed improvement; better response
was observed in non‐acne scars than acne scars, although the differ‐
ence was statistically insignificant. Our study agreed with this study
in that the response of rolling acne scars was better than boxcar and
ice pick scars.
Osman et al10 observed that the overall improvement was 70%
in fractional (Er: YAG) laser side and 33% in microneedling side. Our
study gave better results than their study as degree of improvement
in our study was 80% as we used dermapen. It is noteworthy that
they had used derma stamp. Post inflammatory hyperpigmentation

TA B L E 3   Relation between scar type and degree of improvement among the studied groups

Boxcar Ice pick Rolling

Group Variable No % No % No % χ2 P

Group (I) Improvement (n = 5) (n = 3) (n = 2)

No 0 0 2 66.74 0 0 10.90 0.03*
Mild 3 60 1 33.3 0 0
Good 2 40 0 0 2 100
Group (II) Improvement (n = 4) (n = 3) (n = 3)
No 2 50 1 33.3 0 0 8.14 0.04*
Mild 2 50 2 66.7 1 33.3
Good 0 0 0 0 2 66.7
Group (III) Improvement (n = 2) (n = 4) (n = 4)
Mild 0 0 2 50 0 0 9.87 0.04*
Good 1 50 2 50 1 25
V. good 1 50 0 0 3 75

The statistical significant increase in frequency of improvement in rolling compared to boxcar and ice pick in all groups and also in boxcar compared to
ice pick in the three groups. *P < 0.05.
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112       SAADAWI et al.

TA B L E 4   Satisfactory and objective

Group II Group III
rate of the studied groups
Group I (n = 10) (n = 10) (n = 10)

Variable No % No % No % χ2 P

Satisfactory
Mild 2 20 6 60 3 30 11.23 0.04*
Good 6 60 3 30 3 30
Very good 2 20 1 10 4 40
Objective
No 1 10 3 30 0 0 13.83 0.03*
Mild 2 20 5 50 2 20
Good 5 50 2 20 5 50
Very good 2 20 0 0 3 30

There was statistical significant increase in frequency of very good satisfactory and objective rate in
Group III compared to Group I and Group II, and in Group I compared to Group II. *P < 0.05.

TA B L E 5   Relation between
Satisfactory
satisfactory and objective rate of the
Mild Good Very good studied group

Group Variable No % No % No % P

Group I Objective (n = 2) (n = 6) (n = 2) 0.03*

No 1 50 0 0 0 0
Mild 0 0 2 33.3 0 0
Good 1 50 3 50 1 50
Very good 0 0 1 16.7 1 50
Group II Objective (n = 6) (n = 3) (n = 1) 0.04*
No 3 50 0 0 0 0
Mild 3 50 2 66.7 0 0
Good 0 0 1 33.3 1 100
Group III Objective (n = 2) (n = 5) (n = 3) 0.02*
Mild 1 50 2 40 0 0
Good 1 50 1 20 1 33.3
V. good 0 0 2 40 2 66.7

McNamara test: There was statistical significance difference between satisfactory and objective
rate in all studied groups, respectively. *P < 0.05.

TA B L E 6   Complications of treatment
Group I Group II Group III
among the studied groups
(n = 10) (n = 10) (n = 10)

Variable No % No % No % χ2 P

Complication
No 1 10 2 20 1 10 21.89 0.005**
Erythema 3 30 0 0 3 30
Pain 6 60 0 0 5 50
Acne flare 0 0 1 10 0 0
Burning sensation 0 0 7 70 1 10

There was highly statistical significant decrease in frequency of pain and erythema and increase in
burning sensation in Group II compared to Group I and Group III (P = 0.005), **Highly significant.
SAADAWI et al.
was not reported on any sides treated with microneedling. Our study
agreed with this study in that there was no PIH.
Also, our study was in agreement with El‐Domyati et al11 who
conducted a study on 10 patients using dermaroller as they found
that dermaroller gave good results in both rolling and boxcar atro‐
phic acne scars while ice pick and other deep scars showed poor
results.
Puri,12 who conducted a study on 15 patients using dermaroller
disagreed with our study in that his results were marked improve‐
ment in 40%, moderate improvement in 40% of cases, and mild
improvement in 20% of cases. While in our study, the results were
good improvement in 40%, mild improvement in 40%, and no im‐
provement in 20%. This may be due to the low number of cases in
our study, and the session interval in our study was 2 weeks, while
in the other study was 4‐week interval which may lead to more time
for collagen deposition.
Grover and Reddu13 conducted a study of 41 patients with
Fitzpatrick Skin Type III‐V, of whom 16 patients had acne. They
used GA (10%‐30%) for 5 minutes. A significant number of patients
had scarring and pigmentation, and the therapeutic response was
good in 75% of patients. Patients with PIH and scarring showed
excellent improvement. While in our study, patients with acne scar
showed mild and good improvement, this may be due to the low
number of patients in our study. Our results disagreed with Garg
et al,14 and they used GA 35% for six sessions with 2‐week inter‐
val, in that GA gave no results in rolling scar, poor results in ice
pick, and good results in boxcar type. In our study, all patients with
rolling acne scar showed mild and good improvement. Also, boxcar
and ice pick types showed mild improvement. This may be due to
the difference in number of patients between two studies.
In our study, all patients treated with combined treatment of der‐
mapen and GA peel showed improvement in acne scars, the differ‐
ence in the qualitative global score before and after treatment was
significant (P = 0.04). By quartile grading scale, two patients (20.0%)
had mild response, five patients (50%) had good response, and three
patients (30%) had very good response. According to patients’ satis‐
faction, three patients (30.0%) estimated their improvement as mild
response, three patients (30%) as good, and four (40.0%) as very good.
In this group, combination treatment showed improvement in
all 10 patients as four patients (40%) show mild improvement, four
patients (40%) show good improvement, and two patients (20%)
show very good improvement. Also, there was statistically signif‐
icant increase in rolling type compared to other types (P = 0.04).
Sharad, (15) was comparing dermaroller with dermaroller and
GA peel. He reported excellent results in the treatment of post‐
acne scars, especially when associated with PIH, by combining
sequential treatment with microneedling and 35% GA peel with‐
out increasing the adverse effects. There was significant im‐
provement in superficial and moderately deep scars (grade 1‐3).
The mean improvement in microneedling and combination groups
in his study was 31.33% and 62%, respectively. However, in our
study, the mean improvement in microneedling and combination
groups was 80% and 100%, respectively. This may be because we
|
      113
used dermapen in our study while Sharad,15 had used dermaroller.
There was also improvement in skin texture, which made this study
concomitant with our study. Melia occurred in two patients in his
study while in our study no complications occurred except for acne
flare in one patient.
5 | CO N C LU S I O N
Dermapen and GA peel are effective and safe techniques for acne
scars especially (superficial scars). The absence of major compli‐
cations, the simplicity of the technique, and the favorable results
obtained in the present study indicate that this is a valid method
in achieving satisfying results in acne scars. No definite numbers
of sessions or definite intervals between treatment sessions were
established. We preferred to choose the 2‐week interval period to
ensure the patient compliance, a problem we often face with our
Egyptian patients. Noncompliance was the reason for choosing the
follow‐up only for 1 month after treatment.
C O N FL I C T O F I N T E R E S T
No conflict of interest.
ORCID
Abdulla M. Esawy  https://orcid.org/0000-0003-0306-5996
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