1. Krishna Deb Barman kdebbarman@yahoo.com
A COMPARATIVE EVALUATION OF MICRONEEDLING ALONE VERSUS COMBINED SUBCISION AND MICRONEEDLING IN POST ACNE SCARS
Krishna Deb Barman

2. Maulana Azad Medical College, New Delhi, India

3. Acne is a common disease with considerable prevalence worldwide
INTRODUCTION
Acne is a common disease with considerable prevalence worldwide
Post acne facial scarring is
Devastating
Psychologically distressing

4. Focal treatment with TCA
Available Treatments
Needling
Laser resurfacing
Chemical peels
Microdermabrasion
Dermal grafting
Dermal fillers
Platelet rich plasma
Subcision
Punch excision
Punch elevation
Fat transfer
Implantation of autologous collagen ; cultured and expanded autologous fibroblasts
Focal treatment with TCA

5. Subcision Safe, easy, well-tolerated and effective technique
Introduction of a hypodermic needle
just under the dermis to release fibrous attachments leading to -
skin elevation
controlled trauma
Initiates wound healing with formation of connective tissue
Augments the depressed site

6. Skin Microneedling
Creates thousands of microclefts in epidermis & papillary dermis leading to :
Zone of superficial bleeding
Initiates wound healing
release of growth factors promote collagen deposition
migration & proliferation of fibroblasts

7. Microneedling has been combined, wit variable success with other modalities like :
Subcision
Chemical peels
100% TCA CROSS

8. Microneedling targets superficial box scars
Subcision targets primarily rolling scars
Combination of the two would give better results.

9. AIMS AND OBJECTIVES
To compare the efficacy of microneedling alone vs microneedling with subcision in the management of post acne scarring.

10. MATERIALS AND METHODS
A total of 40 patients with acne scars were included and alternately labeled either as Group-A or -B.
INCLUSION CRITERIA
Patients with facial acne scars >18 years old 
EXCLUSION CRITERIA
Any skin resurfacing procedures within the preceding 1 year
Systemic retinoids or immunosuppressive drugs during or within 6 months
History of coagulation defects ,bleeding diathesis or keloids
Active acne lesions

11. Detailed clinical history were taken
Thorough general physical and dermatological examination
Details were recorded in preset proforma
Number, distribution and type of scarring noted
Scored based on ECCA (Ecchelle D’ Evaluation Cliniques Des Cicatrices D’Acne)

12. Scars were counted, recorded and classified into icepick, box and round types
To evaluate the improvement VAS (Visual analogue scale) by both physician and patient
Complete blood investigations
Written and informed consent were taken.
Pre and post-treatment photographs were taken
Procedures -performed using the same conditions in every sitting

13. Pre-procedure work up of acne scars

14. Post -Procedure
Broad spectrum sunscreen ; strict avoidance of sun exposure to prevent pigmentation
Details recorded using ECCA and self-devised quantitative grading for individual scars at baseline and in every subsequent visit
Patient’s improvement was recorded on VAS at each visit
Pre-Procedure photographs were taken at each visit

15. Instruments Used Dermaroller NoKoR Admix Needle Drum-shaped roller
20 mm wide studded with 192 fine microneedles in 8 rows of 24 each
with a diameter of 0.25 mm & needle length of 2.0 mm.
NoKoR Admix Needle
A 18-gauge 1.5 inch NoKoR Admix needle
non-coring vented needle with thin wall(Becton, Dickinson and Company, Franklin Lakes, NJ, USA)

16. Microneedling
Topical anesthesia (EMLA cream - lidocaine 2.5% and prilocaine 2.5%)
Patients were placed in a recumbent position ; area - cleaned, draped in a sterile manner.
The dermaroller was rolled over both sides of the face with some pressure
4 times in 4 directions: horizontally, vertically, diagonally right and left.
Appearance of uniform pinpoint bleeding : end point.
Serum and blood -cleaned with saline soaked gauze
Cold saline soaked gauze -applied for 5-10 minutes.

17. Combined Microneedling and Subcision
After subcutaneous anesthesia
Needle was inserted adjacent to a scar, parallel to the skin surface,
just below the dermal-subcutaneous junction.
Needle was advanced until resistance was felt ; then gently swept across
Initial backward and forward motion -used to tunnel beneath the scar.
After resistance started to decline, the needle was passed sideways in sweeping motion to complete the freeing up of the skin from the base.

18. This action - repeated in a fan-like pattern to treat the entire scar.
Direct pressure was applied to prevent excessive bleeding.
Once all the scars were treated with subcision procedure
Skin microneedling was performed on both sides of face.

19. Post Procedure Photo protection ;broad spectrum sunscreens
Reassurance - temporary erythema and edema
Antibiotics and analgesics in group B.
Subsequent sittings at monthly intervals till a total of 4 sittings.
Patients were asked to follow up for another 2 months at monthly interval.

20. STATISTICAL ANALYSIS
Statistical Package for Social Sciences (SPSS Inc.20.)
Variables were analyzed was appropriate statistical tests
P value of ≤ 0.05 was considered as significant.
Continuous data were given as mean±SD, range or as median with interquartile range as appropriate.
Normality of quantitative data : Kolmogorov Smirnov tests of normality
Comparison of outcomes pre and post intervention: Paired-t test
Analysis of Covariance : testing difference among the groups.
Wilcoxon signed rank test : compare non parametric data
Mann Whitney U test : compare the same among the two groups.

21. RESULTS

22. Epidemiological Profile
Out of 40 only 37 patients completed the study
Age ranged from years
Mean years ; SD
Majority (60%) : age group of years.
Sex ratio – equal
Group-A had 11 males (55%)
Group-B which had 9 males (45%)
Majority were unmarried (80%)
All of the patients were educated- 22 patients(55%) were graduate
Thirty six patients (90%)employed

23. Clinical Profile Age of onset of scarring Age of onset of disease:
26 (65%) - ages of years
7 (17.5%) - 14 years of age
Rest 7(17.5%) had after 20 years
Group-A
1 (5%) with onset before 14 yrs
15 (75%) between yrs
4 (20%) onset after 20 yrs of age
Group-B
6 (30%) had onset before 14 years
11 (55%) between yrs
3 (15%) onset after 20 years of age
Age of onset of scarring

24. Clinical Profile Duration varied from 1 to 25 years.
Marjority (50%) had duration <5 yrs
25% with duration of 5-10 yrs
20% are with years
5% had more than 15 years

25. Post surgery results in group A
19 patients completed the 4 sittings and followed up for the next 2 months
Mean number of :
Rolling : 13.65, SD
Icepick : 47.45, SD
Box : 30.20,SD

26. Statistical variable Rolling Icepick Box Total scars 20 13.65 47.45
Number of patients 20
Mean
13.65
47.45
30.20
91.30
Std. Error of Mean
3.282
5.263
3.164
8.562
Median
11.00
43.50
27.00
82.00
Mode 21 33 70
Std. Deviation
14.676
23.536
14.152
38.289
Range 53 99 63
172
Minimum 15 6 32
Maximum
114 69
204

27. Post surgery results group A
Over the treatment periods the mean decreased as follows:
Rolling scars to 12.47
Icepick scars to 45.11
Box scars to 29.32
Total scars to 82.55

28. Improvement in Group-A (Paired-Sample’s t-test)
The reduction in mean count of –
Rolling scars was found to be statistically significant from 4thvisit
(p & between baseline & 4th & 6th visit respectively )
Icepick scars was found to be statistically significant from 4th visit
(p & between baseline & 4th & 6th visit)
Boxcar scars was found to be statistically significant from 4th visit
(p & between baseline & 4th & 6th visit)
Total number of acne scars was found to be statistically significant from 4th visit onwards (p value of and 0.004)

29. ECCA SCORE (sample statistics)
Parameters
95% Confidence Interval of the Difference
No.of patients
Mean
Std. Deviation
Std. Error Mean
Lower
Upper
Baseline 20
142.50
32.261
7.214
143.31
170.19
2nd visit
141.34
167.16
4th visit
138.00
33.182
7.420
140.84
166.16
6th visit 19
135.79
32.543
7.466
120.10
151.47

30. ECCA SCORE (sample statistics)
The mean ECCA score in Group-A decreased from to

31. ECCA scoring (Paired-Sample’s t-test)
Comparison between
Paired Differences t df
Sig.
(2-tailed)
Mean
Std. Deviation
Std. Error Mean
95% Confidence Interval of the Difference
Lower
Upper
Baseline-4th visit
4.500
11.799
2.638
-1.022
10.022
1.706 19
.104
Baseline-6th visit
4.737
12.073
2.770
-1.082
10.556
1.710 18

32. The reduction in mean ECCA scoring could not be calculated for Baseline and 2nd visit as the standard error of difference was 0.
No statistically difference was found in ECCA scoring between baseline and 4th visit (p ) and 6th visit (p )

33. VISUAL ANALOGUE SCALE
The improvement in appearance of the patient with acne scars was evaluated by both the patient and the physician on a 4 point visual analogue scale as follows :
1 point for <25% improvement
2 points for 26-50% improvement
3 points for 51-75% improvement
4 points for >75% improvement

34. Visual Analogue Scale - A
Patients
At the end of the treatment
5% : marked improvement (50-75%)
74% : moderate improvement (25-50%)
21% : minimal improvement
Difference in visual analogue scores was statistically significant from
3rd month onwards (p )
Highly significant in 4th & 5th month (p=.001)
Physician
At the end of the treatment
84% : moderate improvement (25-50%)
16% : minimal improvement (<25%)
Difference in visual analogue scores was statistically significant from
3rd month onwards (p = .005)
Highly significant in 4th and 5th month
(p < .001)

35. Pre-treatment
Post-treatment

36. Combined Subcision And Microneedling Group
Post surgery results in Group -B
Rolling
Icepick
Box
Total scars
Number of patients 20
Mean
21.95
79.65
51.90
153.50
Std. Error of Mean
3.623
8.473
5.149
13.163
Median
18.50
76.00
46.00
124.00
Mode 18 24
124
Std. Deviation
16.204
37.894
23.026
58.868
Range 56
130 72
154
Minimum 85
Maximum
148 96
239

37. Post surgery results in Group -B
18 patients
Completed the 4 sittings
Followed up for 2 months
2 patients
Lost to follow up after 4 sittings
Mean number
Rolling scars , SD
Icepick scars 79.65, SD
Box scars , SD 23.02

38. Post surgery results : Group B
Over the treatment period
the mean decreased as
follows :
Rolling scars : to 15.83
Icepick scars : to 65.11
Box scars : to 42.39
Total scars : to 111

39. 95% Confidence Interval of the Difference
ECCA Score -B
Parameters
95% Confidence Interval of the Difference
No. of patients
Mean
Std. Deviation
Std. Error Mean
Lower
Upper
Baseline 20
156.75
28.713
6.420
143.31
170.19
2nd visit
154.25
27.591
6.169
141.34
167.16
4th visit
153.50
27.053
6.049
140.84
166.16
6th visit 18
150.83
27.667
6.521
137.08
164.59

40. The mean ECCA score decreased from 156. 75 to 150
The mean ECCA score decreased from to over the treatment period

41. Improvement in ECCA scoring in Group-B (Paired-Sample t-test)
Paired Differences t df
Sig.
(2-tailed)
Mean
Std. Deviation
Std. Error Mean
95% Confidence Interval of the Difference
Lower
Upper
Baseline-2nd visit
2.5
7.695
1.721
-1.101
6.101
1.453 19
.163
Baseline-4th visit
3.25
8.156
1.824
-.567
7.067
1.782
.091
Baseline-6th visit
6.111
10.36
2.444
.955
11.267
2.500 17
.061
The reduction in mean ECCA scoring was not statistically different when compared to baseline values (p > .05)

42. Visual Analogue Scale-B
Patients
At the end of the treatment
50% : marked improvement (50-75%)
44% : moderate improvement (25-50%)
6% : minimal improvement (< 25%)
Difference in visual analogue scores was statistically significant from
3rd month onwards (p = .002) and
Highly significant in 4th and 5th month
(p <.001)
Physician
At the end of the treatment
50% : marked improvement (50-75%)
50% : moderate improvement (25-50%)
Difference in visual analogue scoring of patients by physician achieved a statistical significance from
2rd month onwards (p = .014)
Highly significant in 3rd, 4th 5th month
(p < .001)

43. Pre treatment
Post treatment

44. COMPARING THE TWO GROUPS
Group A : Microneedling alone vs
Group B : Microneedling with Subcision

45. Rolling scars
Mean number in Gr-A decreased by 8.6% over 6 months period as compared to 27.9% in Gr-B.
On ANCOVA test, statistically significant difference was achieved starting from 2nd visit onward (p )
Highly significant in 4th & 6th visit (p ).
The mean difference with baseline as covariate in ANCOVA test, between the two groups : positive on 2nd , 4th and 6th visit.
Gr-B having more reduction in number of scars as compared to Group-A.

46. Icepick Scars
Mean number of icepick scars in Gr-A decreased by 4.9% over 6 months as compared to 18.25% in Group-B.
On ANCOVA test, statistical significant difference was not achieved at anytime from baseline.

47. Box Scars
Mean number of box scars in Gr-A decreased by 2.91% over 6 months as compared to 18.32% in Group-B.
On ANCOVA test, statistical significant difference achieved between baseline & 6th visit (p ).
The mean difference was 4.868, implying that Group-B had more reduction as compared to Gr-A.

48. Total scars
The mean number of total acne scars in Group-A decreased by 4.83% over 6 months as compared to 19.65% in Group-B.
On ANCOVA test, no statistical significant difference was achieved.

49. ECCA SCORE
The mean number ECCA score in Group-A decreased by 4.7% over 6 months as compared to 3.7% in Group-B.
On ANCOVA test, no statistical significant difference was achieved anytime during the study period

50. VISUAL ANALOGUE SCALE BY PATIENTS
There was statistical difference in VAS by the patients in the two groups from 2nd visit onwards (p <.05).
The mean percentage improvement was 61% in Group-B as compared to 46% in Group-A at 5th month

51. VISUAL ANALOGUE SCALE BY PHYSICIAN
The physician difference in visual analogue scoring was statistically different, beginning with 3rd visit
(p < 0.05).
The mean percentage improvement was 62.5% in Group-B as compared to 46% in Group-A at 5th month

52. Side effects Post Inflammatory Hyperpigmentation:
4 pts in Gr- A and 3 pts in Gr B developed post inflammatory hyperpigmentation : faded by the end of follow up period
1 patient had post inflammatory hyperpigmentation (also fading over time).
No other significant adverse effects were noted

53. CONCLUSIONS AND RECOMMENDATIONS
After evaluating and analyzing the results, we conclude that
Microneedling is a effective treatment option in management of post acne scars
Combining it with a single session of subcision can give better
outcomes especially in - rolling and box type of scars.
More studies, using larger sample size and more equitable distribution of patients are required to validate the results.