| |

Received: 1 July 2019    Revised: 26 September 2019    Accepted: 8 October 2019

DOI: 10.1111/jocd.13206

REVIEW ARTICLE

Radiofrequency therapy in esthetic dermatology: A review of

clinical evidences

Andreia Regina Bonjorno MS1 | Tatiana Bertacin Gomes MS1 |

Marli Crisitna Pereira DDS1 | Camila Miranda de Carvalho MS, PhD1 |
Marilisa Carneiro Leão Gabardo DDS, MS, PhD2 | Marina R. Kaizer DDS, MS, PhD2  |
1,2
João Cesar Zielak DDS, MS, PhD

1
Biotechnology, Positivo University,
Curitiba, Brazil
2
Dentistry, Positivo University, Curitiba,
Brazil
Correspondence
Marina da Rosa Kaizer, Positivo University,
5300 Prof. Pedro Viriato Parigot de Souza
Street, Post‐Graduate building, faculty
office, suite 29, 81280‐330 Curitiba, Brazil.
Email: marinakaizer@gmail.com
Abstract
Background: Chronological skin aging causes the modification of genetic material
through enzymes and proteins changes. The process reduces cellular proliferation,
along with loss of tissue elasticity, reduced ability to regulate aqueous exchanges,
and inefficient tissue replication. Appearance is negatively affected by cumulative
changes in coloration, texture, and elasticity over time. The increase in the popula-
tion's average life expectancy boosts the search for cosmetic therapies that can delay
aging, mostly for the noninvasive modalities. Among the various options, radiofre-
quency therapy is a technique that can help reduce the effects of skin aging.
Aim: Therefore, this study aims to review clinical evidence provided by scientific liter-
ature on the benefits of using radiofrequency therapy in reducing skin aging effects.
Methods: A review of the literature concerning skin aging, characteristics of radi-
ofrequency therapy, and radiofrequency therapy in the treatment of skin laxity and
mechanism of action was conducted using PubMed.
Results: The included studies have suggested that the mechanism of radiofrequency
action is heating the dermis while preserving the epidermis. This heating causes im-
mediate collagen denaturation, which is followed by the formation of new collagen,
naturally providing skin tightening and greater elasticity.
Conclusion: Even when used as single therapeutic modality, radiofrequency seems to
meet the expectations in reducing the effects of skin aging.

KEYWORDS
collagen, cosmetic techniques, radiofrequency therapy, skin, skin aging

1 | I NTRO D U C TI O N
The skin is the largest human organ and is an important marker of
chronological age. Throughout life, the body undergoes several
changes caused by intrinsic and extrinsic factors that dictate the
aging process.1 With time, the skin becomes thinner and loses elas-
ticity. The collagen fibrils gradually become more rigid, and there is
a reduction in the number of elastic fibers and other components
of the conjunctive tissue. 2 Such process happens to all individuals,
boosting concerns about appearance with the marked increase in
population's life expectancy.
Novel technologies and techniques realized several cosmetic al-
ternatives for minimizing the effects of human aging.3-6 Noninvasive
and minimally invasive procedures, such as radiofrequency, laser

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© 2019 Wiley Periodicals, Inc. J Cosmet Dermatol. 2020;19:278–281.
BONJORNO et al.
resurfacing, infrared, and ultrasound techniques, are often preferred
6
for offering good results and short, if any, recovery time. Among
these many, radiofrequency therapy (RFT) has shown excellent re-
sults with versatile applications.5,7,8 Radiofrequency equipment
emits electromagnetic radiation, such radiation needs to interact
with tissue to be able to convert to electrical energy to thermal
energy, generating a controlled heat in the deep skin tissue, while
9
the surface of the skin remains unaffected. This method has been
used for medical treatments for more than 75 years, being an at-
tractive option for various dermatological treatments due to its high
efficiency.10 Clinical studies with RFT observed acute and chronic
changes in the helical structure of collagen. The electron micros-
copy of the skin revealed larger diameter collagen fibrils compared
to what was present before treatment. In addition, there was an in-
crease in collagen expression.11
The energy produced by RFT penetrates the cells in the tissues
of the epidermis, dermis, and hypodermis, even reaching muscle
12
cells. Once the tissues detect an increase in temperature above
physiologically values, vasodilation occurs; consequently, there is an
increase in the resorption of intercellular fluids, improving the drain-
age of cellular waste by the lymphatic system, as well as improving
10,12
circulation. This process also increases the gain of oxygen in the
tissues, as well as nutrients and trace elements.12 In addition, it is
known that controlled heat modifies the elastic properties of the
dermal tissue and increases the extensibility of the fibrous tissue,
12
promoting flexibility of scars and adhesions.
The purpose of this study is to review the basics and benefits of
the use of radiofrequency therapy (RFT) in skin laxity treatment, since
the technique induces the production of collagen, promoting tightness
and elasticity to the skin in a safe way, reducing the effects of aging.
2 | S K I N AG I N G
The aging process of the skin is evidenced by loss of volume, laxity,
and wrinkles. These changes occur due to the combination of intrin-
sic and extrinsic factors. The intrinsic aging process is understood
as natural and inevitable, related to genetic factors and functional
1,13,14
changes accumulated with time. Clinically, the aged skin ap-
pears dry, wrinkled, flaccid, and with the presence of nonmalignant
neoplastic lesions. The extrinsic aging process is determined by
harmful external factors and can be avoided. Examples of such fac-
tors are ultraviolet radiation, pollution, tobacco use, among others.
This process leads to premature signs of aging, such as deep furrows,
thick skin, and accumulation of cutaneous pigmentation.13
The main extrinsic factor associated with accelerated premature
aging is excessive sun exposure. Ultraviolet radiation A (UVA) and B
(UVB) lead to an increase in free radicals, which activate cellular re-
ceptors for cytokines and growth factors located in fibroblasts. 2,13
The activation of these receptors stimulates cellular proteins and
induces the formation of an enzyme known as the transcription
factor AP1 (activating protein‐1). The formation of AP1 leads to a
decrease in gene expression for the formation of collagen types I
|
      279
and III in fibroblasts. In addition to AP1, there is also the formation
of another enzyme known as methyl‐metalloproteinase‐4 (MMP‐4),
which is responsible for the degradation of mature collagen.15
Clinical differences are associated with the two types of aging,
such as cutaneous pigmentation—more evident in extrinsic aging;
ptosis—predominant in intrinsic aging; and wrinkles—present in both
types.16 Therefore, it is important to highlight that the aging of the
skin is associated with various factors, which combined promote
changes such as loss of collagen, elastin, reticular fibers, among oth-
ers. Such changes have consequent effects on the support, elastic-
ity, and tightness of the skin, in the dermal level.13,15
3 | C H A R AC TE R I S TI C S O F
R A D I O FR EQU E N C Y TH E R A PY
Radiofrequency therapy technology has stood out as one of the
most effective and versatile techniques in the treatment of lax-
ity.5,8,17,18 Despite being a resource used since the 19th century
by the French physicist Jacques Arsene D 'Ansorval, who analyzed
tissue responses to currents of different frequencies, it was only in
2002 that the first radiofrequency equipment for wrinkle reduction
was approved by the Food and Drug Administration, in the United
States of America.19 Since then, several types of equipment have
been developed for this purpose.
Radiofrequency therapy is a type of alternating electric current
that creates electric fields between two electrodes, comprised be-
tween frequencies of 30 kHz and 300 MHz, forcing collisions be-
tween charged molecules and ions.9,20 At the surface of the skin, the
charge changes from positive to negative alternately, attracting and
repelling charged electrons and ions. Polar molecules are induced to
move back and forth, vibrating at about six million times a second.
Resistance to this movement generates heat in the tissue, transferring
energy from the electric field to the charged particles in the target
tissue. The transfer can occur in three ways: (a) orientation of electric
dipoles that already exists in the atoms and molecules of the tissue;
(b) polarization of atoms and molecules to produce dipole moments;
and (c) displacement of conduction electrons and ions in the tissue.20
Regarding the type of apparatus, there are two forms of radiofre-
quency equipment, capacitive (CAP), and resistive (RES). The electrode
role is producing and conserving energy when in contact with the skin
promoting the increase in temperature. The electrode of the RFT CAP
has a polyamide coating that acts as a dielectric medium, isolating its
metal body from the surface of the skin, thus forming a capacitor with
the tissues. The RFT RES electrode is not coated and thus passes radiof-
requency energy directly through the body and on the neutral plate.21
Regarding the types of electrodes, these can be classified as
monopolar, bipolar, tripolar, and multipolar.10 The electrodes used
for monopolar RFT application are classified as active and passive.
The active electrode causes a localized thermal effect on the tissue,
generating tissue stimulation. The other electrode, called passive,
consists of a conductive plate for closing the circuit of the current,
returning the energy to the patient.19,22
 |
280       BONJORNO et al.
In the bipolar configuration, the depth of propagation of the elec-
tric current is limited by the distance between the two electrodes,
which are coupled in the same head, fixed at a certain distance. Both
are in contact with the treated skin, because of the greater the dis-
tance between the bipolar terminals, the greater the depth of energy
penetration.10,23 Therefore, with this configuration, the reach is not
24
very deep but offers a greater control of the distribution of energy.
In the tripolar and multipolar configuration, there is a monopolar
electrode associated with a bipolar one, which creates two pairs or
more of bipolar electrodes.
Frequency is another factor that influences the depth of action
of RFT. At high electromagnetic wave frequencies, energy is rapidly
transferred across the surface, the wave being attenuated as it is
dispersed. At low frequencies, the penetration of energy is deeper. 25
A comparative study between RFT CAP and RFT RES found sig-
nificant differences regarding temperature increase and retention
after 45 minutes of application, as measured by a skin thermometer.
According to the authors, although RFT CAP presented faster tempera-
ture gains, RFT RES obtained better temperature retention 45 minutes
after treatment (60.3% RES vs 15.5% CAP). Faster heating and thermal
degradation associated with the CAP mode may be indicative of its
relatively superficial penetration. In the RES mode, the higher heat re-
tention and the fact that there is no sharp drop in the post‐treatment
temperature strongly suggest a higher energy penetration.21
4 |  R A D I O FR EQ U E N C Y TH E R A PY I N
TH E TR E ATM E NT O F S K I N L A X IT Y A N D
M EC H A N I S M O F AC TI O N
The heat generated by RFT can be helpful for various clinical pur-
poses in cosmetic dermatology, such as reducing sagging and im-
proving body contour.5,7,8,23 Literature indicates that the retraction
of the tissue, induced by the heat produced by the RFT, depends on
several factors, including the maximum temperature reached, time
of exposure to heat, hydration of the tissues and age.10,26 For ex-
ample, monopolar RFT resulted in a significant improvement in the
preauricular area of 14 out of 15 patients treated for skin flaccidity,
while also showing that monopolar RFT seems to have lesser effects
17,27
in older patients. However, the relationship between treatment
response and age is not clear.17,27,28
In general, the heating obtained by RFT9 decreases the distension
of the loose connective tissue through the mechanism of collagen
denaturation. Collagen is produced by fibroblasts, which synthesize
three polypeptide chains involved in a triple helix. Tissue retraction
occurs due to the denaturation of the triple helix; because, when
collagen is heated, the protein undergoes a transition from a highly
organized crystalline structure to a random gel state. The heated fi-
broblasts also activate new collagen formation. 29,30 The increase in
collagen types I and III in the dermis occurs in a three‐dimensional
form, with continuity of up to three months after treatment, since the
RFT current causes the positive regulation of certain sirtuin genes
(SIRT), favoring the deposition of new collagen and also increasing
the longevity of fibroblasts.26 In addition to that, the body responds
to elevation in temperature with the formation of a protein called
heat shock protein (HSP). The heat generated by RFT stimulates
HSP synthesis in the fibroblast, causing expression of TGF‐beta1
(TGF‐beta1), which stimulates HSP‐47 and HSP‐72 to induce the
fibroblasts to increase the production of collagen.31,32 HSP‐47 and
HSP‐72 are proteins that protect type I collagen during its synthesis.
The Arrhenius equation, Pennes’ bioheat equation, and the cumu-
lative equivalent minute at 43 are relevant principles related to tissue
ablation and hyperthermia treatment.33,34 The Arrhenius equation
principle can be model collagen heating, indicating that the rates of col-
lagen reactions depend on both time and temperature. If high tempera-
tures are reached, low exposure times are required.35 Temperatures of
85°C for one millisecond or 67°C for three seconds are sufficient to
produce structural changes to collagen.26 Lower temperatures should
be used to prevent skin burn, with longer exposure times for effective
collagen remodeling, such as 43°C for three to five minutes, 35 repeated
four to six times at intervals of seven to ten days between sessions.36
It is also known that the dosimetry of RFT in a nonablative form, for
hyperthermia, a therapeutic range between 40°C and 45°C should be
achieved. During application, the power of the equipment can be regu-
lated by back and forth movements, with the electrode pressed against
the skin in small areas three times the size of the active electrode until
the desired temperature is reached.37 The effects of heat for cellular
apoptosis are prominent over a temperature range from 40°C to 55°C,
with rupture around 43°C.37 It is important to highlight that the elec-
trodes should be moved on the surface of the skin during treatment to
maintain the temperature in the target area. However, it is challenging
to achieve uniform temperatures and keep them steady, what can limit
the effectiveness of such dynamics.29
With regard to RFT results in the treatment of flaccidity, in gen-
eral, a need to reach high temperatures in the dermis to achieve the
therapeutic objectives is reported, although no information is given
on the temperature of the therapeutic target, only the temperature
of the epidermis is described. Nonetheless, in addition to the retrac-
tion of the connective tissue and the formation of new collagen, RFT
heating seems to stimulate fat metabolism, thus allowing esthetic
results of the whole body and face, even when applied as the only
therapeutic modality.17,18,23,38,39
5 | CO N C LU S I O N S
The mechanism of radiofrequency action is heating the dermis, while
safely preserving the epidermis. This heating causes immediate col-
lagen denaturation, which is followed by the formation of new col-
lagen, naturally providing skin tightening and greater elasticity. Even
when used as single therapeutic modality, radiofrequency seems to
meet the expectations in reducing the effects of skin aging.
ORCID
Marina R. Kaizer  https://orcid.org/0000-0002-6308-6089
BONJORNO et al.
REFERENCES
1. Alexis AF, Obioha JO. Ethnicity and aging skin. J Drugs Dermatol.
2017;16(6):s77‐s80.
2. Kammeyer A, Luiten RM. Oxidation events and skin aging. Ageing
Res Rev. 2015;21:16‐29.
3. Juhasz MLW, Levin MK. The role of systemic treatments for skin
lightening. J Cosmet Dermatol. 2018;17(6):1144‐1157.
4. Zhang M, Park G, Zhou B, Luo D. Applications and efficacy of plate-
let‐rich plasma in dermatology: a clinical review. J Cosmet Dermatol.
2018;17(5):660‐665.
5. Augustyniak A, Rotsztejn H. Nonablative radiofrequency treat-
ment for the skin in the eye area ‐ clinical and cutometrical analysis.
J Cosmet Dermatol. 2016;15(4):427‐433.
6. Pritzker RN, Hamilton HK, Dover JS. Comparison of different
technologies for noninvasive skin tightening. J Cosmet Dermatol.
2014;13(4):315‐323.
7. Vale AL, Pereira AS, Morais A, et al. Effects of radiofrequency on
adipose tissue: A systematic review with meta‐analysis. J Cosmet
Dermatol. 2018;17(5):703‐711.
8. Gold M, Andriessen A, Bader A, et al. Review and clinical experi-
ence exploring evidence, clinical efficacy, and safety regarding
nonsurgical treatment of feminine rejuvenation. J Cosmet Dermatol.
2018;17(3):289‐297.
9. Wilczynski S, Stolecka‐Warzecha A, Deda A, et al. In vivo dy-
namic thermal imaging of skin radiofrequency treatment. J Cosmet
Dermatol. 2018;18(5):1307‐1316.
10. Belenky I, Margulis A, Elman M, Bar‐Yosef U, Paun SD. Exploring
channeling optimized radiofrequency energy: A review of radiof-
requency history and applications in esthetic fields. Advn Ther.
2012;29:249‐266.
11. Zelickson BD, Kist D, Bernstein E, et al. Histological and
Ultrastructural Evaluation of the Effects of a Radiofrequency‐
Based Nonablative Dermal Remodeling Device. Arch Dermatol.
2004;140:204‐209.
12. Meyer PF, de Oliveira P, Silva FKBA, et al. Radiofrequency treat-
ment induces fibroblast growth factor 2 expression and subse-
quently promotes neocollagenesis and neoangiogenesis in the skin
tissue. Laser Med Sci. 2017.
13. Vierkötter A, Krutmann J. Environmental influences on skin
aging and ethnic‐specific manifestations. Dermato‐Endocrinology.
2012;4:227‐231.
14. Helbig D, Simon JC, Paasch U. Epidermal and dermal changes in
response to various skin rejuvenation methods. Int J Cosmet Sci.
2010;32:458‐469.
15. Helfrich YR, Sachs DL, Voorhees JJ. Overview of skin aging and
photoaging. Dermatol Nurs. 2008;20:177–183:quiz 184.
16. Flament F, Bazin R, Laquieze S, Rubert V, Simonpietri E, Piot B.
Effect of the sun on visible clinical signs of aging in Caucasian skin.
Clin Cosmet Investig Dermatol. 2013;6:221‐232.
17. Alster TS, Lupton JR. Nonablative cutaneous remodeling using ra-
diofrequency devices. Clin Dermatol. 2007;25:487‐491.
18. Man J, Goldberg DJ. Safety and efficacy of fractional bipolar radiof-
requency treatment in Fitzpatrick skin types V‐VI. J Cosmet Laser
Ther. 2012;87:179‐183.
19. Lolis MS, Goldberg DJ. Radiofrequency in cosmetic dermatology: a
review. Dermatol Surg. 2012;38:1765‐1776.
20. Koch RJ. Radiofrequency nonablative tissue tightening. Facial Plast
Surg Clin North Am. 2004;12:339‐346.
21. Kumaran B, Watson T. Thermal build‐up, decay and reten-
tion responses to local therapeutic application of 448 kHz ca-
pacitive resistive monopolar radiofrequency: A prospective
randomised crossover study in healthy adults. Int J Hyperthermia.
2015;6736:1‐13.
|
      281
22. Ronzio Oa, Froes‐Meyer P, de Medeiros T, De Rezende Brasil
Gurjão J. Efectos de la transferencia eléctrica capacitiva en el tejido
dérmico y adiposo. Fisioterapia. 2009;31:131‐136.
23. Beasley KL, Weiss RA. Radiofrequency in cosmetic dermatology.
Dermatol Clin. 2014;32:79‐90.
24. Bloom BS, Emer J, Goldberg DJ. Assessment of safety and efficacy
of a bipolar fractionated radiofrequency device in the treatment of
photodamaged skin. J Cosmet Laser Ther. 2012;14:208‐211.
25. Franco W, Kothare A, Ronan SJ, Grekin RC, McCalmont TH.
Hyperthermic injury to adipocyte cells by selective heating of sub-
cutaneous fat with a novel radiofrequency device: Feasibility stud-
ies. Lasers Surg Med. 2010;42:361‐370.
26. Sadick NS, Nassar AH, Dorizas AS, Alexiades‐Armenakas M. Bipolar
and Multipolar Radiofrequency. Dermatol Surg. 2014;40:S174‐S179.
27. Ruiz‐Esparza J, Gomez JB. The medical face lift: a noninvasive, non-
surgical approach to tissue tightening in facial skin using nonabla-
tive radiofrequency. Dermatol Surg. 2003;29(4):325‐332; discussion
332.
28. Northington M. Patient selection for skin‐tightening procedures.
J Cosmet Dermatol. 2014;13(3):208‐211.
29. Harth Y, Lischinsky D. A novel method for real‐time skin impedance
measurement during radiofrequency skin tightening treatments.
J Cosmet Dermatol. 2011;10:24‐29.
3 0. Tay YK, Kwok C. A novel radiofrequency device for the treat-
ment of rhytides and lax skin: A pilot study. J Cosmet Laser Ther.
2009;11:25‐28.
31. Emilia del Pino M, Rosado RH, Azuela A, et al. Effect of controlled
volumetric tissue heating with radiofrequency on cellulite and the
subcutaneous tissue of the buttocks and thighs. J Drugs Dermatol.
2006;5:714‐722.
32. Tokalov SV, Gutzeit HO. Weak electromagnetic fields (50 Hz) elicit
a stress response in human cells. Environ Res. 2004;94:145‐151.
33. van Rhoon GC, Samaras T, Yarmolenko PS, Dewhirst MW,
Neufeld E, Kuster N. CEM43 degrees C thermal dose thresholds:
a potential guide for magnetic resonance radiofrequency exposure
levels? Eur Radiol. 2013;23(8):2215‐2227.
3 4. Wu Z, Kumon RE, Laughner JI, Efimov IR, Deng CX.
Electrophysiological changes correlated with temperature in-
creases induced by high‐intensity focused ultrasound ablation.
Ultrasound Med Biol. 2015;41(2):432‐448.
35. Nelson AA, Beynet D, Lask GP. A novel non‐invasive radiofre-
quency dermal heating device for skin tightening of the face and
neck. J Cosmet Laser Ther. 2015;17:307‐312.
36. Carruthers J, Fabi S, Weiss R. Monopolar Radiofrequency for Skin
Tightening. Dermatol Surg. 2014;40:S168‐S173.
37. Hiragami F, Motoda H, Takezawa T, et al. Heat shock‐induced three‐
dimensional‐like proliferation of normal human fibroblasts medi-
ated by pressed silk. Int J Mol Sci. 2009;10:4963‐4976.
38. Levenberg A. Clinical experience with a TriPollar radiofrequency
system for facial and body aesthetic treatments. Eur J Dermatol.
2010;20:615‐619.
39. Shapiro SD, Eros Y, Abrahami Y, Leviav A. Evaluation of safety
and efficacy of the TriPollar technology for treatment of wrinkles.
Lasers Surg Med. 2012;44:453‐458.
How to cite this article: Bonjorno AR, Gomes TB, Pereira
MC, et al. Radiofrequency therapy in esthetic dermatology:
A review of clinical evidences. J Cosmet Dermatol. 2020;19:
278–281. https​://doi.org/10.1111/jocd.13206​