An extract from the book THE MAGIC NEEDLE

Written by Horst Liebl. ©Copyright 2011 Horst Liebl, all rights reserved!

Dear Reader,

If you suffer from scars you will find it worthwhile to continue reading. The following is a must reading for those with significant visible scars. As I prepared this article I have done my best to guide you through the medical jargon and to make it easy to understand.

Keywords: Treatment possibilities, Micro needle, Genes, atrophic scars, hypertrophic scars, keloids, burn scars, stretch marks.

It is rare to find a person that does not have some type of scar be it from chickenpox, an injury or as a result of a major operation. Nobody ever says that they like their scar(s) especially when visible and when it cannot be hidden. But first, consider this absurd sounding figure.

Let us assume that every day one in one thousand (1/1000) individuals in the Western World experiences a wound 6 centimeters (2.4 inches) in average length needing to be sutured and dressed. As all of these wounds transform into scars, when strung together, the result would be a linear scar measuring 45,000 kilometers or 28,000 miles. This scar would be longer than the globe’s circumference. Imagine this occurring every day. What an amazing figure!

Scars are the result of protective and lifesaving wound closures formed by the body’s production of new parallel-arranged collagen bundles. Some are elevated (hypertrophic) and some are depressed (atrophic). Scars can be either pale or flamingly red. They can be small or cover a large area of skin. They can itch and burn. They can reduce mobility and can cause functional disabilities. Whatever their form, no one likes them! For many a disfiguring scar can be a stigma, and for others it becomes a source of lifelong psychological pain.

Scars are the visible final state of a skin healing process. For physicians, scars are a source of frustration since in most cases little or nothing can be done to improve them. Compared with all the technical and medical advances, when it comes to scar therapy, medicine is more or less helpless and impotent. Orthodox medicine usually considers scar treatment to be very difficult! And, if we are honest, once a scar forms, it is the least of concerns for physicians. The surgeon has exercised his skills to save a life by closing a wound. A scar serves as reminder of the surgeon’s intervention. In 2004 Professor Wolf-Ingo Worret and his colleagues wrote about scar therapies in the German Medical Journal Deutsches Aerzteblatt and came right to the point: “…There are a plethora therapeutic options in order to makes scars so that they are less noticeable …however in the future only gene therapy promises to bring a complete recovery…”

In order to answer your questions about the various available current scar therapies, kindly refer to the SCAR-THERAPY-TABLE.

The Microneedle - Does it fix scars?

Micro means small and it seems that this adjective is part of the secret. It is similar to the wise saying of Paracelsus: “the dose makes either the poison or the Cure”. Of course, we have to admit that we do not know each and every detail as to why or how a tiny microneedle with a length of 1.0 or 1.5 mm and a diameter of only 0.1 mm affects and causes changes to occur in the living organism. Over the past 10 years our knowledge has grown, and we have increased and gained in experience and understanding. We have collected sufficient evidence from thousands of doctors and patients which indicates that microneedles can correct and have a modulating effect on skin dysfunctions such as: the flattening of hypertrophic (elevated) scars, raising of atrophic (depressed) scars to normal skin level, and skin hyper-pigmentation is normalized regardless the skin type and colour. Further studies with gene and cell-biology experts will surely uncover more secrets.

The following sections contain descriptions that are based on numerous and thoroughly researched findings in cell biology, and through clinical studies and cases.

What do we know about microneedling with the Dermaroller?

Microneedles (MN) stimulate skin stem cells and cause skin cells to proliferate (cell division). The penetration of MN into the skin are sensed by some 200 nerve receptors per square centimetre (cm²) as a lesion, or better yet, as an injury stimulus. An injury, like a cut, is defined as a disruption of tissue. This is not the case when non-traumatic micro needles puncture and penetrate the dermis without cutting it. Pricking channels are created. This stimulus, which we can also call an alarming signal, is transmitted to the cells around the pricking channel within a distance of not more than 0.5 to 1 mm. Although the non-traumatic needles do not disrupt the tissue (in the sense of creating a wound) the so-called wound-healing process is triggered. This process is possibly slightly altered by the MN. Skin cells communicate by means of electrical signals (electro-taxis) and chemical signals (chemo-taxis). These signals are transmitted by electrical currents (in the range of millivolt) and/or electromagnetic fields and stimulate the cells in their vicinity to multiply and to produce new cells such as fibroblasts, keratinocytes, etc. Fibroblasts are the real architects of skin structure and its repair. Wound closure by fibroblasts as they were stimulated by electrical fields was video-recorded by Min Zhao et al [1].

When the fibroblasts reach the “point of action” (wound or pricking channel) they synthesize a particular type of collagen fibres (type III). This is a one way process which cannot be reversed and which results in the production of additional collagen layers (more density). If at the “point of action” there is “nothing to repair” because there was no real wound or injury as occurs when MN penetrate the dermis, then the new collagen fibres integrate themselves into the existing skin structure. In addition, Tissue-Growth-Factors (TGF) control the integration of new protein-molecules into the tissue. These factors (which act as signals or commands) control the structure of the new collagen fibres either to close (repair) a wound that finally results in a scar (fibrotic tissue), or they settle in the existing cell structure matrix. In the case of microneedling, TGF β3 is the controlling factor for cell integration. It is the same TGF that prevents scar formation when an embryo is injured in the uterus (e.g. after amniocentesis).

Genetics:

We feel that Prof. Worret and his colleagues came quite close to the truth when they speculated in 2004 that gene-therapy has the ultimate effect in scar repair. The science of Epigenetics tells us that nothing in this world is stiff and rigid and lasts forever. In addition, our genes are subject to external and environmental which can be in the form of chemical or electrical stimuli - epigenetics.

From our perspective the magic word is: Gene-Expression by Dermaroller® micro needles. Some genes are pre-programmed e.g. colour of our eyes, body size, etc. while others can be influenced to become either active or inactive. For example, if a person (usually a male) has inherited male pattern baldness (an androgenetic form of hair loss) he’ll lose his hair beginning at a particular age and nothing to date has been developed to reverse this genetically based condition. In this case certain genes have been “switched-off” and therefore the hair production has stopped. Women can also suffer from hair loss. In many cases the cause may be hormonal dysfunction due a particular illness. As a result, the genes that control female hair growth were switched off. But, with the introduction of the right medication these genes can be stimulated (i.e. switched on) to return to normal hair growth.

A practical example of the interaction of micro needles and genes:

We know that as we age the proliferation of the skin stem cells in our dermis and epidermis slows down. The renewal cycle for keratinocytes, normally about 20 - 28 days when we are young, becomes longer and longer with aging. The skin becomes thinner and results in more wrinkles. When the epidermis, the upper skin layer without nerves and blood vessels, is stimulated by MN that are 0.10-0.20 mm in length without any additional active substances, gene-expression is stimulated. This results in a significant increase in the production of keratinocytes and the proliferation of collagen VI and VII. Collagen VI and VII are the anchoring-collagens between dermis and epidermis. Fan and Don Owen (both from Baton Rouge, VA) introduced their findings in the International Congress for Microneedling, 2010 in Atlanta/USA [4].

Mechanism of microneedling in scars

Atrophic (depressed) Scars.

Most of us are familiar with acne scars, a condition that affects young people beginning at puberty. Enclosed blackheads become inflamed and infected. Some assist in spreading this process by squeezing, scratching and other manipulations of the skin. The widespread inflammation destroys healthy tissue frequently resulting in depressed scars. However, acne scars respond very well to microneedling regardless of their appearance (crater-like or like an ice-pick), provided that the physician is well trained and that the treatment is performed under sanitary conditions. After the cicatrical (scar) tissue is sufficiently needled “according to the guidelines”, new fibroblasts migrate into the scar-bed and fill it with new collagen layers. Simultaneously, the cells that line the inner aspect of blood vessels called endothelial cells, proliferate creating new blood vessels. New tiny blood vessels (capillaries) migrate into the (old) perforated scar tissue and provide the newly formed tissue with nutrition, oxygen and blood pigments (haemoglobin). In this case the haemoglobin acts like a cosmetic pigment, and the former pale scar adopts the coloration of the surrounding healthy skin.

A scar caused by a drinking glass. 2 Dermastam® sessions, 3 months post-op

Hypertrophic (elevated) scars

In contrast to keloids (see below) and depressed scars, this scar type is caused by exaggerated fibroblast activity that remains within the boundaries of the scar edges. Usually hypertrophic scars mature (final state) after 4 to 6 months. Although a scar therapist might be tempted to use longer needles (i.e. 2.5 to 3.0 mm) to treat this scar type, it would be the wrong decision. Longer and bigger is not always to right choice – why? The first target should be to initiate a scar degradation or thinning process triggered by microneedles.

We have well documented scientific proof that microneedling stimulates cell proliferation. In the case of excessive (fibrotic) scar formation different cells are stimulated to degrade old collagen strands. It is surprising and disappointing at the same time that medicine has not seen fit to focus on this subject. However, we have two hypothesises: Either microneedling stimulates enzymes (proteinases) to degrade scar tissue or fibroblasts and fibrocytes are stimulated to transform into fibroclasts. The reason might be that the organism somehow registers the “too much” (or what is not used/needed) and starts the collagen degradation process. This latter is very likely because scars are degraded over time. Another indication is the spontaneous regression of hypertrophic scars and keloids – but we still don’t know the cause. Since exaggerated or hypertrophic tissue growth needs time to degrade, a patient should bring a lot of patience until fibroclasts and/or enzymes or both do their job. It often takes many months until a positive result can be achieved.

Keloid

It is considered as a benign, non-contagious skin tumour. It is caused by an uncontrolled and unregulated production by enlarged fibroblasts. Compared with hypertrophic scars, the keloid extends well beyond the borders of the scar edges. It can also be massively raised and elevated. A genetic disposition is very likely. Black skin is more susceptible than the Caucasian skin type. For the possible currently available keloid therapies, please refer to our SCAR-THERAPY-TABLE.

Ivan Safonov, a dermatologist from Kiev/Ukraine, is highly specialised in scar treatments and has used the Dermaroller® for years in the treatment of hypertrophic scars and keloids. In his latest article he pointed out that he successfully treats keloids at “a certain stage of development” by microneedling. However, he also stated that the risk of recurrence is possible, although he has not experience any.

Practical experience tells us that microneedles have a “compensatory” effect on skin. In other words, the “Too Much” is decomposed i.e. hyper-pigmentation and the “Too Little” is complemented (collagen addition). Therefore, the conclusions we can gather from Igor Safonov’s work and case studies is that microneedling stimulates increased activity of enzymes or fibloclasts - or both. We shall intensify our research support to concentrate on this phenomenon.

Burn Scars

An upfront remark: In all modesty, we are very proud that the Dermaroller® begot a real and dramatic therapeutic breakthrough for the successful treatment and improvement of burn scars that was not possible until three years ago. In all cases a significant aesthetic improvement could be achieved. In addition it also resulted in improved mobility of burned extremities and neck. Concurrently, it also reduced longstanding pain. Although it may sound a little bit absurd, we can say that microneedling of burn scars is an act of kindness which benefits the spirit and psyche.

In most patients with burn scars they have a mixed form of all above-mentioned scar types. The real problem that patients face later on is that these thermally damaged and charred proteins in the skin transform to sclerotic (hardened) scars. This leads to limited mobility and can be the source of permanent long lasting pain, that which an outsider cannot even begin to imagine. Quite often these scars form hard and elevated strands which often are several millimetres elevated above the normal skin level.

Safonov [7] and Aust et al. [3] published convincing results that burn scars respond outstandingly to microneedling. Safonov produced impressive photographic images that even burn induced hyper-pigmentation (high concentration of skin pigments) is reduced to almost “normal” by microneedling. Even long standing erythema (inflammatory redness) that occurs after a burn is reduced to “normal appearing” skin pigmentation. It is most likely that the erythema is caused by the extreme thermal environment in such a way that the supporting collagen structure and the small vessels found therein reacted by expanding. But, after the structural vessel damage the degraded proteins caused by the heat can’t normally contract and therefore cannot control the blood flow/volume any more. Safonov speculated that the microneedles stimulate the decomposition of the denatured collagen fibres, and at the same time stimulate the sprouting of new capillaries.

Aust et al. reported in their articles that they used rollers with 3 mm microneedles for burn scars. From where we stand and with all the knowledge we have gathered, such needle lengths are not required any more except in some rare cases. Such long needles require that a general anaesthetic be administered and face the potential of side effects. We favour more measured microneedling in hyper-trophic and burn scars. The treatment of burn scars, with the exception of isolated, smaller scars, belong in the hand of “specialists”, and it should be acknowledged  that good results need a lot of time – 4 to 8 months in most cases. This is self-explanatory because needled scar tissue needs many months for transformation – to the better.

Stretch marks (striae gravidarum)

Most stretch marks occur during pregnancy. In some, the influence of certain hormones has a negative impact on fibroblast proliferation impeding the otherwise normal and fast repair of stretching skin. Our statistical experience shows that about 70% of all female patients respond very well to microneedling. Why the remaining 30% do not respond well is unknown. Stretch marks should be treated as early as possible, but not earlier than 3 months after pregnancy. Since stretch marks can cover quite a large skin area. And, since numbing creams last for a finite period of time, they should be limited in volume applied. We recommend that in order to treat an abdominal area that it be divided into several sessions. We recommend the numbing cream LMX4 also sold under the brand name Dolocupin® in Germany.

Treatment intervals

After tissue is microneedled, the body needs time to produce, organize and transform into new collagen and new blood vessels. This process takes some months. Atrophic scars can be retreated after 10 to 12 weeks. Hypertrophic and burn scars require intervals between 4 and 8 months. It is most important to know that the first treatment brings a significant change (and visible improvement) in the range of 40 to 50%, provided the procedure is done lege artis (according to medical rules). Follow-up treatment may bring another 10 to 20% improvement. Short intervals (weekly or monthly) will result in adverse effects, often with an overshoot of healthy tissue around the scar and chronic inflammation.

Copies of the Original Dermaroller

Success causes envy - and triggers copies! This is a sad chapter of the west-east economic dialog, a human weakness that people from Asia are very proud of – Copy the Master! At the first glance even medical practitioners are fooled and they grab for the cheapest copy. But this is very short sighted: When they want to pay with peanuts they should not be surprised to be served by a monkey! Laypersons go in the Internet and look for the cheapest needle roller copy which is usually non- sterile and bacteria contaminated. Then they self-treat with poor needle quality.

Copies often are only identified on the “second glance” – under the microscope. Many copiers bluff with “long” needles, others come up with 500 or more needles per roller, and people forget that impostors in India use the same trick with their nail beds. None of the imitators can produce a single scientific paper on their product and they definitely do not have liability insurance in case “something goes wrong”! They use non-CE marked products or non-FDA listed products but print everything on their packing they can get hold of. The fool saves some bucks and the lawmaker counters with vigorous monetary punishment or jail time. Copying is not profitable!

Self Treatment

No doubt the Internet has in general many positive aspects, but it also harbors deep dark shady sides. One of them is the illegal sales of forged medical devices. In addition they steal intellectual properties by offering their copy products under the name of registered Trademarks. Ruthless traders offer their wares for a few Dollars and encourage naïve consumers to treat themselves often in combination of highly dangerous numbing creams that can lead to fatal shock. In all cases they use second and third class steel pins that easily bend, and that results in skin lesions, infections, bruising and additional scars. Copies from back yard productions often are contaminated with Staphylococcus and E. Coli bacteria that may lead to severe life-threatening infections, blood poisoning and possibly lead to death. These Internet vendors, often without a posted address or location, encourage the consumer to re-use their needle roller repeatedly and offer their own disinfection solution. Even alcohol is not a sterilizer. At most alcohol can reduce but not eliminate bacterial contamination. Teenagers lend their needle roller and forget that this is the easiest way to transfer HIV and hepatitis viruses. Most people do not know that the skin is our biggest organ and it is as vital as our heart, liver and other organs. Many don’t care and treat their precious skin like a cleaning rag.

Medical devices in the hands of professionals can be a blessing. Medical devices (especially forged ones) in the hands of a layperson can have deadly consequences.

Sincerely Yours

Horst Liebl

Last Change: September 2011

Literature

[1] Min Zhao, Electrical signals control wound healing through phosphatidylinositol-3-OH  kinase-_ϒ and PTEN, Nature Vol 442/27 July 2006

[1] Min Zhao, Electrical fields in wound healing—An overriding signal that directs cell migration,  Department of Dermatology, 2008, Seminars in Cell & Developmental Biology 20  (2009) 674–682

[2] Schwarz, A Prospective Controlled Assessment of Microneedling with the Dermaroller  Device, Plastic and reconstructive Surgery, June 2011

[3] Aust et al., Medical needling: improving the appearance of hyperthrophic burn-scars,  GMS Verbrennungsmedizin 2009, Vol. 3, ISSN 1869-1412

[4] Lilli Fan, Don Owen, DNA Microarray Analysis of Microneedle Effects on MatTek FT  Skin Equivalent, 2010 Baton Rouge

[5] Gary W. Cleary, Microneedles for Drug Delivery, 17 November 2010, © Springer Science  + Business Media

[6] Kalluri et al. Characterization of Microchannels Created by Metal Microneedles: Formation  and Closure, The AAPS Journal (# 2011) DOI: 10.1208/s12248-011-9288-3

[7] Safonov, Percutaneous Collagen Induction in correction of post-burn, scars. Translation article  FACE 1/2011