A Study of the Efficacy of Skin Needling and Platelet Rich Plasma in the Treatment of Acne Scars

Introduction: Permanent scars are the major complications of acne. Correction of scars is the priority for acne patients. Platelet-rich plasma (PRP) may be useful in the treatment of atrophic acne scars by promoting collagen deposition. Skin needling also releases growth factors, initiate a cascade of wound healing resulting in collagen production. Hence, skin needling and PRP should act synergistically to improve acne scars. Objective: To assess the effectiveness of the combined use of skin needling and PRP application in acne scar treatment. Material and Methods: The study enrolled 10 patients of acne scars. Platelet rich plasma therapy with needling was given to them at monthly interval for a therapeutic period of 6 months. The effects of therapy were evaluated based on photographic assessment and patient’s satisfaction. Results: Mean age of the patients was 28.10 ± 5.065. Twenty percent of patients showed excellent response, 80% showed good response. The results were found to be significant with p value < 0.014. Pain and edema were major complaints which subsided in 1-2 days. Conclusion: Platelet rich plasma therapy combined with skin needling is a safe and effective treatment for management of acne scars.


Introduction
A cne has a prevalence of over 90% among adolescents 1 and persists into adulthood in approximately 12%-14% of cases. 2,3 Acne scar is a possible outcome of the inflammatory acne lesions. Acne scars are of two types-hypertrophic and atrophic. Atrophic acne scars are by far the most common type. 4 Facial scars not only lead to cosme c problems, but also have psychological eff ects such as emo onal debilita on, embarrassment, poor self-esteem, and social isola on. 5 Many techniques are available for the correc on of atrophic acne scars, including subcision, dermabrasion, chemical peeling, laser technology, fat gra ing, and use of fi llers; however, these techniques have resulted in varying degrees of success and associated adverse eff ects. [5][6][7][8] It has been postulated that autologous platelet-rich plasma (PRP) could be used for the treatment of atrophic facial scars, because it can enhance wound healing, which has been shown to accelerate ssue repair. 5,9 Percutaneous collagen induc on or skin needling has recently been proposed as a simple and eff ec ve therapeu c op on for the management of atrophic scars. 10 Skin needling is a technique that uses a sterile dermaroller to puncture the skin and release growth factors. PRP can be combined with skin needling to enhance the effi cacy of both modali es. Accordingly, this current study was conducted aiming to clarify the effi cacy and safety of each modality.
Platelet-rich plasma (PRP) is an autologous concentra on of human platelets in a small volume of plasma that has a higher platelet concentra on (4-7 mes) above baseline. 11 It contains growth factors (GFs) derived of platelets alone (stored as α granules in platelets) and plasma proteins, namely fi brin, fi bronec n and vitronec n. 12 The membrane bound α-granules are an important intracellular storage pool of growth factors including platelet-derived growth factor (PDGF), transforming growth factor (TGF-α) and insulin-like growth factor (IGF-I) that are vital to wound healing 13,14 whereas the plasma proteins act as a scaff old for the bone, connec ve ssue and epithelial migra on. On ac va on, these α-granules fuse with the platelet cell membrane and ac vate secretory proteins to a bio-ac ve state. These secreted proteins then binds to their transmembrane receptors on the target cells like epidermal cells, mesenchymal stem cells, fi broblasts, osteoblasts, endothelial cells inducing an internal signal transduc on pathway, thereby increasing expression of various gene sequences in cells like cell prolifera on, collagen synthesis, an apoptosis etc. thereby augmen ng natural wound healing process. 4,15

Material and Methods
The study was conducted in the Department of Dermatology, Venereology and Leprology, ASCOMS Hospital, Jammu in collabora on with the department of Blood Transfusion Medicine, ASCOMS Hospital from Jan. 2015 to Dec. 2015. The study was approved from the ethical commi ee of our ins tu on. Pa ents in the age group of 20-40 years with acne scars were selected. Exclusion criteria were pa ents with ac ve acne, ac ve herpes labialis, pa ents on systemic re noids, an coagulant therapy, evidence or history of keloid scars, bleeding disorders, pregnancy or lacta on, history of any facial surgery or procedure for scars and pa ents with unrealis c expecta ons, HIV or Hepa s B or C posi ve pa ents.
Ten pa ents of acne scars were selected on the basis of inclusion and exclusion criteria. Type of acne scars were noted (Table 1 & fi gure 1). 16 Photographs of local site at start, during and end of treatment were taken. The results were assessed using qualita ve global scarring grading system ( Table 2). [17] PROCEDURE: In our ins tu on we adopted the manual double spin method used by Arshdeep et al 18 and Gonshor et al 19 for preparing PRP. A er taking informed wri en consent & with all asep c precau ons, 20 ml of venous blood was withdrawn in vacuum tubes containing an an coagulant-citrate dextrose solu on formula. It was then centrifuged at 160 g for 10 min. at 28 deg. celsius. Plasma and buff y coat were aspirated and again centrifuged at 400 g for 10 min. at 28 deg celsius. Approximatly ¾ of the supernatant was discarded and platelet rich pellet was resuspended in remaining amount of plasma. PRP was thus obtained.
Facial skin was disinfected with spirit swab, then a topical anesthe c cream was applied, le for 60 minutes. The procedure site was ac vated by microneedling technique using a dermaroller (1.5mm). Add ac vator (10% Calcium chloride) to the PRP. Ac vated PRP was collected in 1 ml syringes. The PRP was injected into the ac vated site intradermally and the area was massaged to allow it to percolate through the epidermis. A total of 6 si ngs were given to each pa ent at interval of 1 month over a period of 6 months.
Results were assessed at the end 6 months by evalua on of global photographs and pa ent's self sa sfac on. The improvement was rated as poor, good and excellent depending upon the change in grade of acne scars by two blinded dermatologists (who did not perform the procedures) to evaluate the overall clinical improvement. An improvement by two grades was considered as excellent, 1 grade was rated as good and no upgrada on on assessment was labelled as poor response. Each par cipant was instructed to evaluate his/her overall sa sfac on with the treatment using a quar le grading system which defi nes 0 as unsa sfi ed, 1 as slightly sa sfi ed, 2 as sa sfi ed, or 3 as very sa sfi ed. Side eff ects were recorded at each session. Post procedure, an bio c medica on for 2-3 days, sun protec on and regular usage of sunscreens was advised.
The collected data was entered in excel and analysed using appropriate sta s cal methods with SPSS 16.0.2. The signifi cance of the outcome of the study was assessed by calcula ng the 'P' value and a value less than 0.05 was taken as signifi cant.

Results
All the pa ents completed the study. Age and sex distribu on of pa ents is men oned in Table 3. Mean age of the pa ents was 28.10 ± 5.065. All of the 10 pa ents achieved reduc on in acne scarring by 1 or 2 grades as depicted in Table 4. Excellent response was observed in 20% of the pa ents, good response in 80% (Fig 2). Results were found to be signifi cant with p value <0.014. Boxcar round to oval depressions with sharply demarcated ver cal edges, similar to varicella scars and are clinically wider at the surface than icepick scars and do not taper to a point at the base. They may be shallow (0.1-0.5mm) or deep (≥0.5mm) and are most o en 1.5 to 4.0mm in diameter

Discussion
Acne is one of the leading cause for visits to a dermatologist. 20 Although most cases develop in adolescence, it can frequently con nue into adulthood. In one study almost 18% of women were found to have true late-onset disease, with an onset a er the age of 25 years. 21 Acne causes not only facial scarring but also it leads to signifi cant psychosocial implica ons and emo onal distress more so in adolescents. Many op ons are available for the treatment of acne scarring, including chemical peeling, dermabrasion, laser treatment, punch techniques, fat transplanta on, other ssue augmen ng agents, needling, subcision, and combined therapy. Various modali es have been used to treat scars, but limited effi cacy and problema c side eff ects have restricted their applica on. PRP eff ec veness in wound healing has prompted its use in the treatment of depressed facial scars, along with other available treatment modali es. 22 The possible mechanism of PRP in the reconstruc on of a depressed scar is the induc on of growth factors important in ssue remodeling, which promote connec ve ssue healing by upregula ng collagen and protein synthesis. 9 Growth factors present in PRP promotes recovery of laser-damaged skin & accelerates ssue remodelling with the increased synthesis of collagen. 23,24 So, PRP holds a promising role in so ssue augmenta on. Advantages of Platelet Rich Plasma 25 1. PRP is autologous prepara on, hence its nonan genic. 2. It is also a low-risk op on which won't cause further scarring or damage. 3. The mitogenic eff ects of PRP are only limited to augmenta on of the normal healing process and is theore cally not mutagenic, as the growth factors released do not enter the cell or its nucleus, but only bind to the membrane receptors and induce signal transduc on mechanisms. 4. Economical prepara on.
Skin needling also called collagen induc on therapy 26,27 or needle dermabrasion is the technique of rolling a device comprising a barrel studded with hundreds of needles, which create thousands of micropunctures in the skin to the level of papillary to mid-dermis. 26,28 With this technique, the rolling is usually con nued un l bruising occurs, which ini ates the complex cascade of growth factors that fi nally results in collagen produc on [28][29][30] . Also it provides a clear channel for topical agents to be absorbed more eff ec vely through the top layer of skin. Results generally start to be seen a er about six weeks, but the full eff ects can take at least three months to occur and, as the deposi on of new collagen takes place slowly, the skin texture will con nue to improve over a 12-month period. 30 The op mal scars to treat with skin needling are the rolling acne scars and superfi cial boxcar scars. 26,29 This technique has many advantages: 1. It is safe in all skin types and carry the lowest risk of pos nfl ammatory hyperpigmenta on when compared to laser resurfacing, chemical peels, or dermabrasion. 26,30 2. The treatment does not result in a line of demarca on between treated and untreated skin. 3. The recovery period of 2 to 3 days is signifi cantly shorter than other resurfacing procedures. 4. It is much less expensive 26 In our study, a sta s cally signifi cant improvement was noted by combining PRP with skin needling (p value <0.014). This fi nding could be a ributed to the synergis c eff ects of both modali es on all types of atrophic acne scars. None of our pa ents showed any permanent pigmentary or textural changes. The only side eff ects were redness and swelling of pa ents' facial skin a er each session of treatment, which subsided in 2 to 3 days.
In conclusion, the current study off ers diff erent, eff ec ve and safe therapeu c op on for the treatment of atrophic acne scars. This technique is aff ordable and is most likely useful in areas where there is limited access to laser technology.