Journal of Dermatological Treatment

ISSN: 0954-6634 (Print) 1471-1753 (Online) Journal homepage: http://www.tandfonline.com/loi/ijdt20

Skin microneedling plus platelet-rich plasma

versus skin microneedling alone in the treatment
of atrophic post acne scars: a split face
comparative study

Mohamed Kotb Ibrahim, Shady Mahmoud Ibrahim & Amany Mohamed

Salem

To cite this article: Mohamed Kotb Ibrahim, Shady Mahmoud Ibrahim & Amany Mohamed
Salem (2018) Skin microneedling plus platelet-rich plasma versus skin microneedling alone in the
treatment of atrophic post acne scars: a split face comparative study, Journal of Dermatological
Treatment, 29:3, 281-286, DOI: 10.1080/09546634.2017.1365111

To link to this article: https://doi.org/10.1080/09546634.2017.1365111

Accepted author version posted online: 07

Aug 2017.
Published online: 26 Sep 2017.

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JOURNAL OF DERMATOLOGICAL TREATMENT, 2018
VOL. 29, NO. 3, 281–286
https://doi.org/10.1080/09546634.2017.1365111

ORIGINAL ARTICLE

Skin microneedling plus platelet-rich plasma versus skin microneedling alone in

the treatment of atrophic post acne scars: a split face comparative study
Mohamed Kotb Ibrahim, Shady Mahmoud Ibrahim and Amany Mohamed Salem
Faculty of Medicine, Al-Azhar University, Cairo, Egypt

ABSTRACT ARTICLE HISTORY

Introduction: Acne scarring is a permanent disfiguring sequel, which can take varied morphological Received 2 June 2017
forms. Many therapeutic measures have been performed to improve acne scarring such as microneedling. Accepted 24 July 2017
Our objective is to evaluate the efficacy and safety of microneedling alone versus microneedling com-
bined with platelet rich plasma in the treatment of post acne.
KEYWORDS
Methods: The study included 35 patients with mild to severe post acne atrophic scar. All the patients Microneedling; PRP; scar
received four sequential treatments of skin microneedling alone on the right side of the face and skin
microneedling followed by topical application of platelet rich plasma (PRP) on the left side of the face
with an interval of 3 weeks. Two blinded dermatologists evaluated the clinical response according to quali-
tative global acne scarring system grading of Goodman & Baron. Patients are queried about their satisfac-
tion with the treatment outcomes.
Results: The study included 35 patients with a mean age of 24.7 ± 6.8 years. There was a significant
improvement in the degree of scar severity before and after treatment on both the sides. Regarding
patient’s satisfaction grades, there was a significant improvement after both treatment modalities with
insignificant differences between both treatment modalities.
Conclusions: Both microneedling and microneedling in combined with PRP showed satisfactory results.

Introduction responsible for attracting macrophages, mesenchymal, stem cell,

Acne vulgaris is a common physiologic skin condition that is likely
to affect up to 80% of people between the ages of 11–30 years. A
significant proportion may eventually result in scarring that is usu-
ally related to the severity of preceding inflammation, stage and
nature of treatment, the nature of local manipulation, as well as
individual predisposition to scarring (1).
Several techniques have been suggested for the treatment of
post acne scars that varies in the efficacy according to the type
and severity of the treated scar. These include surgical techniques,
e.g. dermabrasion, microdermabrasion, punch excision, punch
grafting, punch elevation, and subcision, as well as non-surgical
techniques, e.g. radiofrequency (2) fillers, peeling, laser (3), plasma
skin regeneration (4), and intense pulsed light (5).
Since 1995, skin needling has been used to achieve percutan-
eous collagen induction in order to reduce skin imperfection (6).
Skin needling has mostly been proposed as an effective method
of treating scars and wrinkles (7). Skin needling efficacy depends
on its capacity to induce the neocollagenogenesis and the wound
healing process in the upper dermis (8). Furthermore, skin nee-
dling provides a clear channel for topical agents to be absorbed
more effectively through the top layer of the skin such as the PRP
(9).
Platelet rich plasma (PRP) is defined as an autologous concen-
tration of platelets in a small volume of plasma and it was initially
developed in the 1970 (10). Plasma is rich in platelets, stem cells
and growth factors, and this stimulates the skin to produce more
collagen. Platelets were thought to act exclusively with clotting.
However, platelets also release many bioactive proteins
which not only promotes removal of necrotic tissue, but also
enhances tissue regeneration and healing (11).
Patients and methods
This study was a single-center, split-face, prospective clinical trial
comparing a skin needling followed by platelets rich plasma treat-
ment and skin needling treatment alone in patients with post
acne scarring. Thirty-five patients with post acne scarring were
included in the present study. All the patients were recruited from
the Department of Dermatology and Venereology outpatient
clinic, Faculty of Medicine, Al-Azhar University from Marc 2015 to
January 2016. Inclusion criteria included Fitzpatrick skin type I–IV
and post acne scarring. Exclusion criteria included pregnancy or
lactation, previous or current isotretinoin treatment, active infec-
tion on the face and a history of bleeding disorders.
Ethical consideration
The present study was approved by the institutional review board
of Faculty of Medicine, Al-Azhar University. The written informed
consent was signed by the patients. All patients were given a
detailed description of the purpose and possible outcomes of
treatment.
Treatment
All the patients received four sequential treatments of skin micro-
needling using dermaroller alone on the right side of the face and

CONTACT Shady Mahmoud Ibrahim drshadyaly@yahoo.com Department of Dermatology, Al-Hussein University Hospital, Box 11843, Al-Darasa, Cairo, Egypt
ß 2017 Informa UK Limited, trading as Taylor & Francis Group
282 M. K. IBRAHIM ET AL.
skin microneedling followed by topical application of PRP on the
left side of the face with an interval of 3 weeks. We used derma-
roller with needle lengths 1500 mm, possessing 24 circular arrays
of eight needles each (total 192 needles) in a cylindrical assembly.
The needles were made of titanium, providing advantageous
properties being mechanically strong and nontoxic. The area of
interest was anesthetized using a thick application of topical anes-
thetic cream (EMLA) for about 30–45 min before the procedure.
After preparation of the area with antiseptic and saline, the skin
was stretched with one hand, and perpendicularly, rolling was
done five times each in the horizontal, vertical, and oblique direc-
tions with the other hand. The treatment endpoint was identified
as uniform pin-point bleeding, which was easily controllable. Post-
procedure, the area was cleansed with saline and ice packs was
used for comforting the patient. For PRP, 10 ml of autologous
whole blood was collected into tubes containing acid citrate dex-
trose (ACD) and centrifuged at 2500 rpm for 10 min in order to
get PRP at the top of the test tube. Then, the PRP was further
centrifuged at 3500 rpm for 10 min at room temperature of 22
C
in order to obtain a platelet rich count. Platelet-poor plasma (PPP)
was partly removed and partly used to resuspend the platelets.
Calcium gluconate was added as an activator (1:9), i.e. 1 ml of cal-
cium gluconate in 9 ml of PRP. Thereafter, the patient was advised
to use topical antibiotic, sunscreen regularly, and follow sun-pro-
tective measures.
Evaluation
The final assessment and grading of scars were done 3 months
after the last session. Two blinded dermatologists evaluated the
clinical response to treatment for each patient by commenting
on side-by-side comparison of before and after treatment photos
of both sides of the face. The change in the severity or grading
of scars were assessed photographically also using qualitative
global acne scarring system grading of Goodman & Baron and
compared to baseline conditions. On objective outlines, an
improvement of scarring by two grades or more was labeled as
‘excellent’ response while a ‘good’ response meant an improve-
ment by a single grade only. In those patients where the scar
grading remained the same after the completion of treatment
irrespective of any visible change in the facial scarring, the
response was labeled as ‘poor’. Also, patients’ self-assessment of
the whole procedure was obtained at the final visit and which
technique they preferred. Patient graded their response to treat-
ment as poor, good, very good or excellent with 0–24%,
25–49%, 50–74%, and 75–100% improvement, respectively, in
their acne scars. The patients were followed up for 1 year at two
monthly intervals to observe the sustenance of improvement in
scars. Side effects were reported and assessed, including: infec-
tion, erythema, edema, and pain score according to numerical
pain scale.
Data management and statistical analysis
Data were coded and entered into an Excel spreadsheet, and then
all data were transferred to the statistical package SPSS version 18
(SPSS Inc., Chicago, IL) for analysis. Data were summarized using
mean, standard deviation and range of quantitative variables and
number and percentage for qualitative variables. Comparisons
were done using McNemmar Test and Marginal Homogeneity Test
for qualitative variables while non-parametric Wilcoxon’s Signed
Ranks Test was used for quantitative variables. Correlations were
done to test for linear relations between variables p values equal
or less than .05 were considered statistically significant.
Results
Thirty-five patients completed the treatment sessions. Age of
patients ranged from 18 to 34 years with a mean of
24.7 ± 6.8 years. Out of the 35 patients, 31 achieved reductions in
scoring by one or two grades. Based on qualitative global acne
scarring classification of Goodman & Baron, two independent der-
matologists revealed a significant improvement in the degree of
scar severity before and after treatment on both sides (Figures 1
and 2). Whereas, the mean scores decreased from 3.2 ± 0.7 to
1.8 ± 0.6 on the side treated with skin needling and PRP (p < .001)
and 2.1 ± 1.1 in the side treated with skin needling alone
(p < .001) (Figure 3). There was an insignificant difference in com-
paring both sides after treatment denoting that both treatment
modalities gave the same net results. Regarding patient’s satisfac-
tion grades, there was a significant improvement after both treat-
ment modalities with insignificant differences between both
treatment modalities (p ¼ .73). Whereas, there was an excellent
response in five patients (14.2%), very good response in 17
patients (48.5%), good response in nine patients (25.7%), and
poor in four patients (11.4%) in the side treated with skin nee-
dling alone as compared to the other side treated with skin
needling and PRP, there was an excellent response in eight
patients (22.8%), very good response in 17 patients (48.5%), good
response in six patients (17.4%), and poor in four patients (11.4%)
(Figure 4).
Our patients experienced significantly less erythema and
edema in the side was treated with skin needling followed by PRP
(4.3 days ±1.05) and (1.9 days±), respectively, compared to the
other side that was treated with skin needling alone (6.2 days ±1.7)
and (3.3 days±) (p < .001) (Figure 5).
Discussion
Acne is a common condition seen in up to 80% of young people
and in five percent of older adults. In some patients, the severe
inflammatory response results in a textural change in the superfi-
cial and deep dermis, leading to post-acne scars. Different terms
and surgical techniques have been used to describe the types of
acne and to improve the appearance of scarring (12).
Microneedling is a relatively new minimally invasive procedure
involving superficial and controlled puncturing of the skin by roll-
ing with miniature fine needles to induce a normal wound healing
process with release of several growth factors, including platelet-
derived growth factor, fibroblast growth factor, and transforming
growth factors a and b, which stimulate the migration and prolif-
eration of fibroblasts (13). Another hypothesis has been also
proved by Jaffe, 2007 (14) who mentioned that cell membranes
react to the local change with an electrical potential that creates
increased cell activity and the release of potassium ions, proteins
and growth factors. Over a short period of time, it has gained
mass popularity and acceptance as it is a simple, cheap, safe, and
effective technique requiring minimal training. Traditionally used
as a collagen induction therapy for facial scars and skin rejuven-
ation, it is also widely used now as a transdermal delivery system
for therapeutic drugs and vaccines (15).
PRP is an autologous preparation of platelets in concentrated
plasma. PRP contains a mixture of bioactive agents derived from
both platelets and plasma. Various growth factors, including plate-
let-derived growth factor (PDGF), transforming growth factor
(TGF), vascular endothelial growth factor (VEGF), and insulin-like
growth factor (IGF), are secreted from the a-granules of concen-
trated platelets activated by aggregation inducer which are very
 JOURNAL OF DERMATOLOGICAL TREATMENT 283

Figure 1. 31 years old male patients with atrophic acne scars before and after miconeedling (a, b) and before and after microneedling with PRP (c, d).

Figure 2. 26 years old female patients with atrophic acne scars before and after microneedling (a, b) and before and after microneedling with PRP (c, d).
284 M. K. IBRAHIM ET AL.
Figure 3. Comparison between microneedling before and after treatment in right and microneedling with PRP before and after in left side regarding Goodman and
Barron grading score.
Figure 4. Patient’s satisfaction grades before and after treatment in both sides.
important in tissue remodeling, promoting connective tissue heal-
ing by upregulating collagen and protein synthesis (16).
This study was designed as a comparative split face study of
skin needling versus skin needling followed by topical application
of PRP in the treatment of atrophic acne scars. To our knowledge,
this study was the first to perform such comparison in acne scars.
Our study showed that there was a significant improvement of
atrophic acne scars both on the side treated with skin needling
alone (p values was < .001) as well as side treated with skin nee-
dling with PRP (p values was < .001), however, p values of compar-
ing total results of both sides showed an insignificant difference
denoting that both procedures gave comparably close results.
Regarding patient’s satisfaction grades there was a significant
improvement after both treatment modalities with insignificant
differences between both treatment modalities. Majid (17) studied
the efficacy of PCI through the dermaroller in treatment of atro-
phic facial scars of varying etiology and reported excellent
response in 72.2% of patients, good response in 16.7% of patients,
and failure of improvement in 11.1%. Similar results have been
reported in a study by Alam and Dover (3), where they assessed
the efficacy of PRP in 40 patients with atrophic acne scars and
found a mean improvement of 70% by patients and doctors at six
months post-procedure.
Fabbrocini et al. (9) conducted a study and found that PRP
combined with microneedling was more effective in acne scars
than microneedling alone and showed that the grade of severity
of the acne scars in all patients was greatly reduced after only
four sessions, with 8 weeks interval, without any side effects apart
from redness and swelling which disappeared in 2–3 days.
Fernandes et al. (6) showed that PRP had advantages compared

Figure 5. Comparison between both treatments regarding post treatment erythema and edema in days.
with skin needling the most important is that the epidermis heal- ORCID
ing early because this stimulates the skin to produce more colla-
Shady Mahmoud Ibrahim
gen. The new collagen helps to improve skin texture and acne
scarring, and eliminating most of the risks and side-effects of skin
needling.
In agreement with the study by Chawla (18) who showed that
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Disclosure statement
The authors have no conflict of interest to declare, sources of sup-
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