Body Language

Microneedling and lasers

Our panel discuss the benefits of microneedling for acne scarring, combination treatments, skin brightening and lasers

Our panel this session comprises:Dr David Eccleston, a general practitioner and clinical director of MediZen Clinic, specialising in lasers and injectables; Dr Stephen Mulholland, a consultant plastic and reconstructive surgeon and owner of SpaMedica Infinite Vitality Clinics in Canada; Dr Moshe Lapidoth, consultant dermatologist. He is also head of the laser unit and senior physician in the Department of Dermatology, Rabin Medical Center in Israel; and Dr Robin Stones, co-medical director of Court House Clinics who has worked in private cosmetic practice for the past 13 years and in NHS dermatology practice for 25 years

Q: Do you have to prepare the skin before microneedling to get optimised results? Can you perform it in a single session?
Dr Robin Stones: It depends on what you’re doing. You don’t have to prep the skin, but you want your clients to be on a good skincare regime. My patients use a lot of tretinoin. Some of my colleagues are actually rolling tretinoin into the skin, but I think this could cause a significant inflammatory reaction. You can combine microneedling with other treatments. But I wouldn’t provide it at the same time as Botox, for example—you need to stretch the skin and apply manual pressure. Obviously, you need to clean and disinfect the skin before a treatment.

Q: Do you prescribe antibiotics or antivirals?
Dr Robin Stones: No, you don’t need to. One exception, perhaps, would be a patient with recurrent herpes simplex in an area that you’re going to roll. Otherwise, no. I have never seen a single infection after this treatment.

Q: It can be difficult to get good bleeding with patients with severe acne scarring. How do you deal with this?
Dr Robin Stones: I use the Genuine Dermaroller for this. It has two widths. The MS4 is a narrow, half-width device which enables the practitioner to angle it and roll into the side walls. This can be helpful in depressed fibrotic scarring.

I don’t expect a deep icepick scar to disappear with micro medical needling. I will treat that in a different way, such as punch excision or subcision. But it’s not difficult to get bleeding with extensive acne scarring, providing you stretch the skin properly and roll it in that way. If you try to roll slack skin, you won’t reach your end point as quickly as you could.

Dermarollers can be used for all skin types. The 1.5mm roller is good for facial work. For thicker skin, such as the very thick dermis on the back, the 1.5mm won’t make much impact. You need to choose the needle length according to the thickness of skin or thickness of scarring.

Q: What are the long-term results of microneedling, particularly on scarring? Do you do long-term follow ups on patients?
Dr Robin Stones: Yes, I’ve been performing these treatments for a few years and I do follow them up. I find patients do get long-term benefits, particularly with acne scarring, which is my favourite application for microneedling. I don’t yet know the long-term benefits for keloid and hypertrophic scarring. But in the other types of scarring, once the skin is remodelled, it is a long-term result.

Q: Microneedling seems to be quite a painful procedure, how do you deal with this issue? Also, I believe that fractional lasers have a role in the treatment of acne scars, mainly because of the coagulation and creation of new collagen afterwards. I don’t think you can get the same amount of neocollagenesis by the microneedle, what are your thoughts?
Dr Robin Stones: Firstly, the treatment is very well-tolerated. While it looks brutal, nobody has ever not been able to tolerate treatment and it’s not painful afterwards. I just use topical anaesthetic and treatment is very quick.
Secondly, I agree. I use lasers as well as microneedling. But this treatment is particularly helpful if cost, lifestyle factors and recovery time are important. We see a huge variation here.

Many of the clients I see are not prepared to have five days’ of down time and and do not want to pay a lot of money for treatment. For those clients, microneedling ideal. If these factors were different, you would achieve more with the fractional C02 laser. I have performed a comparison between microneedling and a fractional ablative Erbium laser. I can get as good a result with this as the Erbium but not as good as a CO2 laser.

Q: I think it’s a bit counterintuitive to use this technique in hypertrophic scars. How exactly does this treatment work?
Dr Robin Stones: It strongly upregulates the TGFβ 3, rather than TGFβ 1 and TGFβ 2. Prolonged upregulation of these allows remodelling with normal collagen formation. This comes from dermal and epidermal damage.

It may be that signalling for keloid scars comes from the epidermis. But quite a few burn scars have been treated by this kind of device and it doesn’t seem to exacerbatie the problem. But I wouldn’t treat an active keloid scar.

Q: What do you use as a dressing?
Dr Robin Stones: Following the procedure, you can apply an antioxidant anti-inflammatory cream. We advise patients not to touch or wash their face until the following morning. They can then revert to their normal skincare regime because the tiny microinjuries have sealed off by then.

Q: Dr Lapidoth, how long do the effects of your depigmenting technique last?
Dr Moshe Lapidoth: It is a reversible process. As long as you are applying the cream, it will be effective. Patients have to use the cream permanently—if they stop using it, the pigmentation will come back. It is not a single-use treatment.

We presented at the American Society of Lasers and Medicine Surgery a combination of fractional laser, fractional ALS with a bleaching agent. This combination seems to work nicely. When you re-create micro-pores, hydroquinone can penetrate much deeper. Penetration is increased by 50–60 times, compared with just topical hydroquinone.

Eventually, you don’t need the pores. The pores created by a laser are being blocked after six to eight hours by blood clots and debris. But you are causing a significant dermal/epidermal barrier disruption which will improve the penetration of any topical product for 3–4 weeks after treatment. Resistant cases of melasma show particularly good results.

Q: I do medico-legal and medical negligence work and see the far end of the spectrum for laser problem cases, particularly with depilation in Asian girls. They can have unusual patterns because of the way the laser is applied, like cat stripes. Using your technique, does it differentially depigment the hyperpigmented areas and leave the non-pigmented areas untouched?
Dr Moshe Lapidoth: For some reason, the treatment works extraordinarily well on post-inflammatory hyperpigmentation. One case involved a woman who had laser treatment for diffused solar lentigines on her upper arms and on her face. Although she had skin type III, she developed post-inflammatory hyperpigmentation and was quite upset with us.

We treated her with hydroquinone which, for some reason, didn’t work very well. And when we shifted to the green perioxidase cream, it worked in days. This is a permanent response—in post-inflammatory hyperpigmentation, you don’t have the creation of new pigmentation after the event.

We also have several cases with lasers and IPL treatment, post-hair removal, and it seems to work nicely. It depends on the severity. The less severe the case, the better it will work, but we can see some good improvement.

Q: There tends to be a number of patients who show little or no response to radiofrequency (RF) treatment. How do you manage patients who, perhaps, have had a fairly expensive treatment option, come back and show very little or no response?
Dr Stephen Mulholland: The question, really, is management of patient expectations with or without RF, because it happens in any sort of situation. So my experience would be Thermage, monopolar, bipolar IR combos, tripolar and octopolar. Expectation management is critical, but I try to always bundle a series of treatments where there is always an upside for the patient.

They don’t always achieve their endpoint. You can’t always predict the outcome. The older patient with photodamage may not have success with transepidermal techniques. In my practice, if patients buy a five pack and are unhappy, we will give them some complimentary treatments. It can sell up to the next stage of invasiveness, such as a subdermal or ablative treatment. They will get a better result and some monetary value against it. Generally, this will recapture most unhappy patients. One unhappy patient will tell 20 people. One happy patient tells 2.8 people. We want to try to recover those people.

Dr David Eccleston: The most important thing is that we need to under-promise and over-deliver. We’re so used to treating with toxins and fillers and getting a rapid response. When you get good at a technique, you know that 95% of your patients will be happy.

With an RF device, there are so many variables. It’s not only technique dependent, but different tissues respond in different ways. You can’t predict the healing process when you don’t know how well the patient’s going to be following the post-operative advice. So under-promise, over-deliver and you will have much happier patients. Now that we have such a big toolbox, bundling is the way forward. If you can provide what the guy down the road doesn’t provide, then they’re not going to go elsewhere unless they’re very unhappy.

Q: Why do you think there is such a low uptake of radiofrequency into clinical practices in the UK?
Dr Stephen Mulholland: The bipolar elos world was purely non-ablative with multiple treatments. Every physician should consider some form of ablative fractional device in their clinic. If you are performing Botox and filler injections, ablative fractional lasers are synergistic with your fillers and your toxin. They need to go together.

There is also still a role for non-ablative RFs, the transepidermals. But if you’re not offering some type of selective fractional ablative or interdermal or subdermal approaches, your patients will go elsewhere. They are not difficult to learn. If you can inject fillers into a patient’s face, you can do these treatments and these techniques.

Dr David Eccleston: The initial problems we had with Thermage were not a good start. Thermage has since picked itself up and developed new techniques, delivering more predictable results. But some of the other devices were very technique dependent. In good hands, you could get fabulous results, but many relied on the ouch factor. Practitioners would keep going until the patient said, “ouch” and then treatment would stop. That’s not particularly well controlled.

With the fractional CO2 laser, you set the parameters according to skin type and the nature of the problem. You know roughly what the result will be. When you’re relying on an individual’s pain tolerance, you hit issues. If you’re treating a man, you will be able to put half as much energy in as a woman. If the woman is being treated at a certain time of the month, she may be more sensitive to pain. There are so many variables which can affect the eventual outcome of treatment. So the honeymoon period was rocky. But now, we have some serious evidence-backed devices that are showing some serious results.

Q: Which types of lasers would you recommend?
Dr Stephen Mulholland: It’s more an approach to what kind of patient you’re treating. If you’re doing fillers and toxins in women between 35–55 years, RF or laser fractional ablation is important. If you wanted to move into tightening, you can learn the hypodermal infiltration technique with a little infiltrator and a 25 or 22 spinal. It depends where your practice is, what kind of patients you have and whether or not you are comfortable with full face and neck hypodermal infiltration.

Q: Why not keep it simple by not spending a huge amount on lasers and just providing microneedling treatment?
Dr Stephen Mulholland: While microneedling has an important role, deeper dermatological issues require the application of energy. Does mechanical epidermal dermis disruption work? It does. It has limits, but it’s an affordable way to get a decent result in some patients. But you won’t be able to get all the results in all the patients.

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