Efficacy of Autologous Injectable Platelet Rich Fibrin in Facial Atrophic Acne Scars in Combination with Microneedling: A Randomized Clinical Trial

Introduction: Several modalities for treating acne scars exist. The combination of microneedling and injectable platelet-rich fibrin (i-PRF) is a synergistic approach. Objective: The aim was to compare the efficacy of microneedling alone versus microneedling with iPRF in post acne atrophic scars. Materials and Methods: This study was a hospital-based randomized clinical trial conducted at B P Koirala Institute Health Sciences, Dharan, Nepal. Twenty patients with postacne atrophic scars underwent four sessions of microneedling with-iPRF and microneedling alone, monthly. The Goodman and Baron quantitative score and Goodman and Baron qualitative scores were assessed at zero, four, eight, twelve, and sixteen weeks. The Facial Acne Scar Quality of Life questionnaire (FASQoL) was also evaluated. Result: The Goodman and Baron quantitative score was reduced from 23 to 14 in microneedling + i-PRF group (p=0.005) and from 16 to 11.50 for microneedling only group (p=0.005) The percentage reduction in the Goodman and Baron quantitative score after the 16th week was 39.13% for group A and 28.12 % for group B. There was a statistically significant difference in the net reduction of the Goodman and Baron quantitative score from the baseline to the 16th week between group A and group B (p=0.004). Conclusion: Injectable platelet rich fibrin (i-PRF) in combination with microneedling was found effective in reducing lesion count, Goodman and Baron quantitative score, and qualitative grade.


Introduction
A cne is a common disorder experienced by up to 80% of people between 11 and 30 years of age and by up to 5% of older adults.1 Inflammatory acne lesions can result in permanent scars, the severity of which may depend on delays in treating acne patients.2  The treatment options for atrophic acne scars can be broadly categorized into energy-based and non-energy-based.Commonly used energy-based technologies include ablative and non-ablative lasers, fractional radiofrequency, intense pulsed light, and plasma skin regeneration.Non-energy-based devices include platelet-rich plasma (PRP), subcision, microdermabrasion, microneedling, dermal fillers, and Pandey K, et al.Platelet rich fibrin in acne scars compare it in combination with other popularly sought after methods of microneedling.

Material and methods
This study was a randomized control trial done over a period of one year (April 2022 to April 2023) on twenty patients to compare the efficacy of microneedling alone versus microneedling with i-PRF on post acne atrophic scars.Patients having active inflammatory acne lesions, under oral isotretinoin use within the last 6 months, undergoing ablative or nonablative laser skin resurfacing within the preceding 12 months, history of keloid, autoimmune diseases or immunosuppressive drugs, diabetes mellitus/ medical illness, HIV-seropositive status, collagen vascular disease, pregnancy, lactation, and chronic and granulomatous infectious conditions like tuberculosis were excluded.Patients with platelet dysfunction syndrome, critical thrombocytopenia, hemodynamic instability, septicemia, and patients on anticoagulant therapy or aspirin were also excluded.This study was approved by the institutional review committee of the B. P. Koirala Institute Of Health Sciences, Dharan, Nepal.Informed written consent was obtained from all the participants.A detailed clinical history and examination findings were recorded in preset proforma.An examination of the facial scars was done in terms of their number, type and distribution.The grading of the acne scars was done according to Goodman   4).0.1 ml (4 U) of the distilled water, or i-PRF was administered in each grid.A 40 U insulin syringe with a 27G needle was used for the injection purpose.The treatment was provided by the same dermatologists (specialists in dermatology and aesthetic medicine) as follows: Group A: Injectable PRF+ microneedling These patients received intradermal injections of i-PRF in combination with microneedling.
Group B: Microneedling + distilled water These patients received microneedling with intradermal distilled water.
Prior to microneedling, a thick application of topical anesthesia cream (eutectic mixture of prilocaine 2.5% w/w and lignocaine 2.5% w/w) was applied for 30-45 minutes.Dermarollers with 192 needles with a length of 1.5 mm were used for microneedling.The rolling was done 5 times each in the horizontal, vertical, and oblique directions with the other hand till uniform pinpoint bleeding points were seen all over the scarred area.
For the preparation of i-PRF, 10-40 ml of peripheral venous blood was collected from the antecubital vein, kept in 5 ml sterile plastic centrifuge tubes without added anticoagulants, and centrifuged immediately at room temperature.The centrifuge used was a REMI R-8C, and the centrifugation speed was 800 rpm, 60g RCF for 4 minutes.The upper 0.5-0.75 ml of the preparation tube was removed by an insulin syringe and injected within 5 minutes of extraction.i-PRF injection was done after microneedling in the treatment A group.Whereas in the other group (Group B), intradermal distilled water injection was injected after performing the microneedling.The post procedure area was cleaned with normal saline, and ice packs were kept for 10 minutes to comfort patients.Patients were advised to use sunscreen >30 SPF regularly and to follow sun protective measures.
The treatment was given for a total of 4 sessions, and assessment were done at every visit and 4 weeks after the final session.
An objective assessment was done using the Goodman and Baron qualitative and quantitative global scar grading system by an independent dermatologist.The Goodman qualitative scale is a 4-point objective assessment of patient photographs that incorporates three scar morphologies and areas of involvement.The Goodman quantitative postacne scarring grading system is a photographic assessment that results in a more detailed global severity score ranging from 0 to 84 points.The improvement was rated as poor, good, and excellent depending upon the change in grade of the acne scars.An improvement of two grades was considered excellent; 1 grade was rated as good; and no improvement was labeled as a poor response.
Facial acne scar quality of life (FASQoL) 11 self-reported questionnaires were administered to the patients as a patient reported outcome measure.
The presence or absence of adverse events like postprocedural erythema, edema, pain, pigmentation, etc. was assessed.The down time of the treatment was also recorded at each visit.Data was entered in Microsoft Excel 2019 (Microsoft Corporation, Redmond, Washington, USA), and statistical analysis was done using Statistical Package for the Social Sciences version 25 (Chicago, Inc.).For descriptive statistics, percentage, mean, S.D., and median, were calculated along with graphical and tabular presentation.For inferential statistics, Fischer's exact test, the Paired Wilcoxon signed rank test, and the Mann-Whitney U test were performed.

Results:
The clinical data of the study participants is illustrated in Table 1.The decrease in the Goodman and Baron quantitative score was statistically significant for both groups (p = 0.005) as shown in Table 3 (Figures 5 and 6).The percentage reduction in the Goodman and Baron quantitative score for group A was 39.13%.Whereas, in group B, it was 28.12 %.The percentage reduction in scars has been shown in Figure 1.The difference in numerical score between the pretreatment and 16 th week was calculated for the patients in both groups, and was found to be statistically significant (p = 0.004) between group A and group B as shown in Table 4.  5.The difference between the baseline FASQOL scores between the two groups was statistically significant (p = 0.030).The reduction in the FasQoL score is illustrated in Table 5. @Wilcoxon signed rank test Pain (intraprocedural and post procedural) was the most common adverse event, followed by erythema as shown in Figure 3.The occurrence and severity of the adverse events between the groups were statistically insignificant.

Discussion
Microneedling is a simple and cost-effective technique to treat acne scars where collagen synthesis is achieved by causing a minute injury to the dermis with the use of microneedles. 12Microneedling creates microwounds to induce collagen production and dermal remodeling.13Autologous platelet-rich plasma (PRP) is a plasma fraction that contains a higher concentration of platelets relative to whole blood.PRP contains a-granule, that secretes transforming growth factor-B, platelet derived growth factor, and vascular endothelial growth factor after activation.These growth factors, adhesion molecules, and chemokines interact with the local environment to promote cell differentiation, proliferation, and regeneration. 14he use of PRP associated with microneedling to treat acne scars has been largely studied and reported to have good results.A meta analysis in 2020, compared the effectiveness of PRP in combination with other procedures, combination procedures without PRP, and noninvasive monotherapy without PRP in the treatment of atrophic acne scars and concluded that the mean difference in percentage change in Goodman and Baron qualitative scores was more in combination therapy than monotherapy without PRP. 15o overcome the limitations of PRP, platelet-rich fibrin (PRF), a second-generation platelet concentrate, platelet rich fibrin (PRF), was developed in 2001.16  It is obtained using one-step centrifugation without the use of an anticoagulant and is thereby totally autologous.The fibrin matrix is the main advantage of PRF over PRP.It acts as a 3-dimensional scaffold for the leukocytes and platelets and their release products.Miron et al,.observed that by further reducing the centrifugal force and the time duration of spin, a liquid PRF can be prepared.17 The use of the i-PRF has been published as a case series and a few clinical trials for the treatment of various oral and maxillofacial procedures, alopecia, and aesthetic skin rejuvenation with favorable outcomes and improved patients' satisfaction.ne of the strengths of the study is that it included both male and female participants, and it was a oneof-a-kind study that encompassed a newer therapeutic modality.However, this was a single center study with a small number of participants in each arm, and a longer follow up could not be carried out thus obscuring the long term efficacy.Thus, further multicentered, large sample size and studies with a longer follow up period are required to support the current study and eliminate potential biases.

Conclusion
Injectable platelet rich fibrin (i-PRF) in combination with microneedling was found to be more efficacious in terms of reduction of lesion count, Goodman and Baron quantitative score, and qualitative grade.Also, greater efficacy was seen in the reduction of the patient reported outcome measure; FASQoL as well as a greater reduction in the individual FASQoL parameters.Intraprocedural pain and erythema were the most common adverse events.

Figure 1 :
Figure 1: Percentage reduction in icepick scars (a), rolling scars (b) boxcar scars (c) and reduction in Goodman and Baron quantitative score (d)

Fig 3 :Figure 4 :
Fig 3: Adverse events between group A and group B

Figure 6 :
Figure 6: A 20 year old female with atrophic acne scars before treatment (a,) and after fourth session of treatment with microneedling and distilled water (b)

Figure 5 :
Figure 5: An 18 year old male with atrophic acne scars before treatment (a) and after fourth session of treatment with i-PRF with microneedling (b) and Baron Qualitative grading and quantitative score 9,10 Facial Acne Scar Quality of Life (FASQoL), 11 a self-reported questionnaire, was used as a patient reported outcome measure, which comprises ten questions with the given parameters.

Table 1 :
Baseline characteristics of Group A (i-PRF+ microneedling) and Group B ( microneedling+ distilled water) patients *Mann Whitney U test **Fischer's exact test The baseline Goodman and Baron qualitative grading and quantitative score are illustrated in Table2.The groups were comparable in terms of their lesion count, scores, and grading.

Table 2 :
Goodman and Baron Quantitative score and qualitative grade in both groups prior to treatment *Mann Whitney U test # Fischer's exact test In both groups, there was a statistically significant decrease in the number of icepicks, boxcars, and rolling scars in the 16 th week, as shown in Table3.

Table 3 :
Reduction in the lesion count at the end of the study

Table 3 :
Reduction in Goodman and Baron Quantitative score at the end of assessment

Table 4 :
ComparisonImprovement in the FASQoL score after treatment.For group A, the mean FASQoL 11 score was17.70±3.46 with a range of 11 to 22 (median 18).In group B, the mean FASQoL score was 13.50±3.92with a range of 6 to 19 (median 13.00) as shown in Table of net reductions in Goodman and Baron Quantitative score between both groups ( baseline-16 th week) Net score Group A Group B P value *Mann Whitney U test When comparing the Goodman and Baron qualitative grading, in Group A, 4 patients (40%) had excellent responses as compared to Group B where it was 2 patients (20%) as shown in Figure 2.However, there was no statistically significant difference in responses between the groups (p = 1.00) Figure 2 : Grade of improvement in group A and group B

Table 5 :
Comparison of FASQoL score at baseline and at 16 th week (Group A and Group B) Intra procedural pain was the most common adverse event, followed by erythema, both of which were more common in group A.Ibrahimet al., however, found severe pain in 64.3% of patients in the microneedling Pandey K, et al.Platelet rich fibrin in acne scars only group versus 57.1% in the microneedling + intradermal PRP group. 17Thus, in this study, more pain was seen in the combination of i-PRF and microneedling The percentage of severe erythema was seen in 42.9% of the microneedling + PRP group and in 21.4% in the microneedling only group respectively.Porwal et.al., reported erythema in 23.07% of patients in the intradermal PRP + microneedling group versus 15.38% of patients in the microneedling only group.