Does Microneedling Help With Melasma

Does microneedling help with melasma? The answer is yes! Microneedling can be used to treat melasma by increasing the penetration of topical ingredients into the skin, as well as by reducing inflammation and redness. It’s important to note that this treatment will take time before you see results; however, if you have tried other methods unsuccessfully then it may be worth trying out microneedling because there are fewer side effects than traditional laser treatments.

In this post, we find out the following: Does Microneedling Help With Melasma, how many microneedling sessions for melasma, melasma microneedling tranexamic acid, and Does microneedling help hyperpigmentation?

Does Microneedling Help With Melasma

Melasma can be frustratingly difficult to treat for all the reasons I highlighted in my last blog post. But there’s growing optimism that that might not always be the case.

New research indicates that energy-free microneedling, typically in conjunction with potent fade creams and strict sun avoidance, can be an effective treatment for melasma across all skin tones. Let’s get into how it works and why.

How it works

Lasers are generally great for eviscerating excess melanin. But the heat they generate can make melasma worse, triggering the formation of even more discoloration in the weeks following treatment. By contrast, mechanical microneedling generates no such heat.

Through a series of clean, controlled punctures, microneedling is able to reach the deeper dermis that’s often affected by melasma. There, via its healing mechanisms, we’re essentially forcing the surrounding skin to make brand-new skin that hasn’t yet been agitated by hormones or the sun.

Exactly how deep the punctures are will depend on a few factors: the location of the pigment, the patient’s susceptibility to creating more melanin as a result of inflammation (also known as post-inflammatory hyperpigmentation, or PIH), the overall sensitivity of the skin, and the amount of downtime a patient’s willing to endure.

That said, the greatest improvement generally results from varying the depth of the punctures across the face, based on the depth of the pigment that’s being targeted and the thickness of the skin (the cheeks can tolerate a deeper puncture than the nose or around the eyes).

In a new study – a review of 459 melasma patients from seven different countries – researchers found that “topical therapy with microneedling improved melasma severity with a large effect,” with the best results seen at 12 weeks. The key phrase is “topical therapy with melasma.” On its own, said one of the study’s coauthors, microneedling doesn’t help.

The other part of the equation

Lighteners enter the equation at different phases. First, dermatologists will usually have patients “pretreat” their skin for two weeks prior to microneedling with a bleaching cream – either a prescription-strength hydroquinone or a formula that contains hydroquinone plus a retinoid and low-dose corticosteroid.

Then, during the microneedling, active ingredients are inserted into the punctures as soon as they’re made or slathered on the treated skin right after. Every dermatologist has their own preferred formulation, but most include some combination of tranexamic acid, glutathione, vitamin C, and niacinamide, most of which are traditionally administered intravenously. Platelet-rich plasma is also popular.

Most patients will undergo several sessions, spaced four to six weeks apart. For the first few days after each treatment, it’s a good idea to use only gentle cleansers, healing ointments, and mineral sunscreens. 

As with most medical procedures – and this should certainly be considered one – there is the potential for complications, which makes it all the more important to seek out a board-certified dermatologist with extensive experience administering topical therapy with microneedling.

how many microneedling sessions for melasma

How many microneedling sessions you need ranges anywhere from 4-8 treatments depending on the patient and other varying factors. Through each microneedling treatment, you’ll see that the appearance of your skin is improving and your confidence will increase as a result. This increasingly popular cosmetic skin procedure uses tiny sterilized needles that can treat a variety of skin flaws including acne scars, fine lines, and wrinkles. It’s suitable for nearly any skin type and has helped countless patients feel more comfortable in their skin. Let’s get into more details surrounding this treatment so you can determine if you’re a candidate. Of course, our team is happy to answer your questions along the way.

How Often Should You Do Microneedling Treatments?

As a general guideline, it is safe to receive microneedling treatments once every 4-6 weeks. The majority of patients opt for this frequency to see the best results, however, some patients may go more or less frequently depending on their skin.

In terms of how many microneedling sessions to see results, patients usually need 4-8 treatments. If you’re looking to improve scar reduction, you’ll likely need 3-6 treatments and collagen induction usually requires 3 treatments as a starting point. Keep in mind that the number of treatments that you need depends on how your skin responds to microneedling. Part of our skincare process at the Metropolitan Skin Clinic is taking the time to sit down with you to understand your skin concerns. From there, we will be able to put together a treatment plan that yields the best results for you.

First Round of Treatments

If this is your first time getting microneedling, you will need to receive multiple “rounds” of treatments to see your desired results. Due to the nature of the treatment, you need to allow your skin ample time to heal and recover between treatments. The average person needs about one month to recover. In terms of microneedling and when to see results, you will likely see some results after the initial session with optimal results taking multiple rounds to achieve.

Treatments to Maintain Results

Once you’ve gotten your first treatment and your skin has been able to fully recover, it’s time to schedule your next microneedling treatment. You’ll notice that your microneedling results will gradually build with each session. This means that you’ll be able to take more time between your regular maintenance appointments than you did with the initial round. Many patients opt to receive treatments 3 months apart after their first round is completed.

Why Does the Time Between Treatments Matter?

The time between your microneedling sessions matters due to the nature of the treatment. Because the average turnover time for dead skin cells and healing is 3-4 weeks for the majority of people, your body needs time to process the treatment.

How quickly your body turns over dead skin cells is dependent on your age and genetics; younger patients may heal faster while older patients might need more time between sessions. If you have questions about the time between sessions, we’re happy to help you!

How Long Does It Take to See Results?

Many patients begin to see results after their initial session is over and they have fully healed. Within 1-3 days following your treatment, you will likely notice an improvement in the texture and tone of your skin. Different results take different times to emerge.

For Anti-Aging

How many microneedling sessions are needed for aging concerns such as dark spots and skin laxity? These results typically become apparent after the third or fourth microneedling treatment. Patients have reported results 3-4 weeks after their appointment. The tightness of your skin will continue to improve as long as you keep up with regular treatments.

For Scar Reduction

Microneedling for acne scars or facial scars, in general, is another popular use case. This process will take longer than smoothing other areas of the skin because it takes the body more effort to do so. Most patients report needing 4-8 sessions to see a full reduction of scarring. You’ll likely notice a gradual improvement of the scar’s texture after every treatment, with scarring fading significantly over time.

For Deep Wrinkles

What about how many microneedling sessions for wrinkles? After all, wrinkles are a top aging concern for many men and women. Most patients need at least 5-6 treatments to see a reduction in the appearance of fine lines and wrinkles. We recommend a consultation to determine the best course of action.

In addition, due to the fact that many seeking wrinkle treatments are on the older side, it may be helpful to space out treatments more to allow your skin plenty of time to heal between treatments. We’re happy to guide you in the right direction in terms of treatment volume and timing and various microneedling packages.

For General Skin Health

Microneedling results for general skin health are the fastest to appear. Once your first appointment is over, you’ll begin to see improvements in your skin. Over the next 7-14 days once your appointment is over, you’ll notice an improvement in the tone and texture of your skin.

melasma microneedling tranexamic acid

 Despite all the existing therapeutic tools, melasma continues to be a dermatological challenge. Therefore, the search for new treatment modalities aims to optimize results and reduce systemic side effects. OBJECTIVE: Evaluate the clinical improvement of patients with melasma treated with robotic micro-needling associated to drug delivery of tranexamic acid. MATERIAL AND METHODS: Seventeen women with melasma were selected to be treated during eight weeks with four fortnightly sessions of robotic microneedling associated to drug delivery of 1.0ml of 4mg/ml tranexamic acid. The group was evaluated before and after the treatment with the following parameters: photographic evolution evaluated by three examiners, self-evaluation with Melasma QoL and MASI improvement. RESULTS: Fifteen Fitzpatrick phototype II to VI patients completed the study. Of those, 31.11% showed little or no improvement; 24.45% moderate to intermediate improvement; 33.33% significant improvement and 11.11% improved almost to resolution. In regards to MASI, there was a significant improvement, with a reduction from 21.33% to 11.19%. CONCLUSIONS: The proposed association showed satisfactory results, constituting an innovative, replicable and safe therapeutic modality for the treatment of melasma.

Keywords: Combined modality therapy; Hyperpigmentation; Tranexamic acid

INTRODUCTION

Melasma is an acquired chronic hyperpigmentation that affects areas of the skin that are exposed to the sun. It occurs in all ethnicities and in both genders, predominating in women of childbearing age and higher skin phototypes.1 Its prevalence in the population is of 1% to 50% and the explanation for this variation lies in the ethnicity and the ultraviolet radiation index of each of the geographic locations studied.2

It is clinically manifested by brownish, asymptomatic, generally symmetrical macules, distributed on the face in three main clinical patterns: centrofacial, malar and mandibular. The centrofacial pattern is the most prevalent, affecting approximately 50% to 80% of cases.3

Its etiology is multifactorial and the exact pathogenesis remains unknown, however it is known that ultraviolet radiation is a major factor. Other conditions are the use of oral contraceptives, hormonal treatment, pregnancy 4 and family history1. Recent studies indicate that 55%-64% of the cases have a positive family history, suggesting the existence of genetic predisposition to melasma.4 Less commonly observed factors are thyroid dysfunction, phototoxic medications, anticonvulsants and contact dermatitis due to the use of cosmetics.5 Nevertheless, most of the cases in men and a third of cases in women are idiopathic.6

The following therapies are used in the treatments of melasma: topical and oral depigmenting and antioxidant agents, chemical peels, and technologies such as robotic microneedling and 1,064nm Q-Swchited laser. More recently, studies have demonstrated that pulsed dye laser can be an option for melasma with predominance of vascular component.7

The most used drug delivery method in dermatology is the topical route. It has many advantages when compared to systemic pathways regarding side effects and patient adherence. However, the epidermis’ barrier function is ensured by the stratum corneums lipid bilayer, which is the main limiting factor for the delivery of drugs that have to be applied to the skin. The drug delivery technique consists of optimizing this penetration into the skin, using chemical, physical and mechanical methods.8

In spite of all existing therapeutic armamentarium, controlling melasma still remains a dermatological challenge, mainly due to its recurrence, refractoriness and aesthetic impairment to the patient. In this manner, the search for new therapeutic modalities — and even combinations of them — are aimed at potentiating the beneficial effects and minimize undesirable systemic effects, maintaining efficacy and safety.

In this context, robotic microneedling combined with drug delivery arises as a minimally invasive method that is safe in all skin types, and can be performed at a medical practice under topical anesthesia. Its main objective is to induce the process of dermal remodeling, including neocollagenesis and neoelas-togenesis, leaving the epidermal layer virtually untouched. It is effective in reducing epidermal melanic pigmentation,9 as well as allowing the delivery of depigmenting skin agents.

As a depigmenting agent, the authors of the present study propose the use of tranexamic acid, since it is a compound approved by the US FDA for the treatment of hypermenorrhea, epistaxis, hematuria, hereditary angioedema and bleeding prevention in major surgeries.10 In addition it has been used in the treatment of melasma since Nijor first reported its effectiveness in Japan, in 1979.11

It is a systemic analogue of lysine and an antifibrinolytic agent, since it blocks the conversion of plasminogen (present in the epidermal basal cells) into plasmin by inhibiting the plasminogen activator.1,4 It also acts by blocking the interaction between melanocytes and keratinocytes, resulting in inhibition of melanin synthesis.6

Plasmin activates the secretion of phospholipase A2 precursors, which act in the production of arachidonic acid and induce the release of fibroblast growth factor (bFGF) .12

It is a potent melanocyte growth factor.13 On the other hand, arachidonic acid is the precursor of melanogenic factors, such as prostaglandins and leukotrienes.14

The plasminogen activator is generated by keratinocytes and increases the in vitro activity of melanocytes. Its serum levels increase with the use of oral contraceptive and during pregnancy. The blocking of this substance may be the paracrine mechanism by which tranexamic acid reduces hyperpigmentation of melasma.14

It is already widely used clinically, through oral and par-aenteral routes, in tablets and injectable solution. A safe dose is deemed to be that of 25 to 50 mg/kg/day — generally 1,000 mg three times a day.10,15 Allowed pediatric use is 10 mg/kg, three times a day. In melasma, 250 mg twice a day is used, corresponding to one-sixth of the conventional hemostatic dose. The most commonly reported adverse effects in the literature are dizziness, tinnitus, headache, menstrual irregularity, hypotension, abdominal distension and pain, heartburn, nausea, vomiting and diarrhea.3,6 Thromboembolism, pulmonary embolism and acute myocardial infarction are rarely reported.13 Therefore, concern about prescribing tranexamic oral acid for patients is indisputable. It is considered as Category B in pregnancy and ofvery low risk during lactation.

In order to maintain and possibly improve the therapeutic efficacy with the decrease of the side effects of the systemic treatment, the authors of the present study used for drug delivery sterile vials of 4mg/ml tranexamic acid — a dose that is well below the one recommended for antifibrinolytic effect.

The objective of the authors of the present study was to evaluate the effectiveness of the robotic microneedling technology associated to drug delivery of tranexamic acid, a compound that has already been studied and established as a depigmenting agent and a safe alternative, with a low complication rate, and which can be applied in all skin types with a minimum period of downtime.

METHODS

An interventionist, open-ended, prospective study was carried out at the Laser Sector of Instituto de Dermatologia Professor Rubem David Azulay of the Santa Casa de Misericórdia do Rio de Janeiro (RJ, Brazil), where seventeen volunteer patients bearers of facial melasma in the age group from 18 to 70 years, with all skin phototypes, were selected (Table 1).

The selection process was based on the referral of specialist physicians from the Cosmiatry and General Dermatology Sector and the Laser Sector of Instituto de Dermatologia Professor Rubem David Azulay. The study was approved by the Research Ethics Committee (90268418600005239).

Inclusion criteria were: patients of both genders and all races, aged over 18 years, presence of clinical diagnosis of facial melasma; not to be in use of topical or oral treatment for melasma for a minimum of one month from the start of the study and no use of other medications for melasma during the proposed treatment.

Exclusion criteria were: pregnancy or lactancy; allergy to topical anesthetics; previous personal history of hypersensitivity to the study medication; patients with thromboembolic disease, active intravascular coagulation and acute occlusive vasculopathy; recent exposure to sunlight; previous use of tetracycline or other photosensitizing medication; use of oral tranexamic acid or oral anticoagulant; and presence of active dermatological lesion.

Patients underwent photographic documentation, MASI (Melasma Area and Severity Index) calculation, and Melasma QUOL (Melasma Quality of Life Scale) questioning before and four weeks after the end of the study protocol.

The procedure was carried out with patients under topical anesthesia with 4% lidocaine fro at least 30 minutes before the session. Robotic microneedling was performed (Eletroderme, Solon, LMG, ANVISA 80520090012) with a 2mm tip, without using radiofrequency, up until the end point was reached (light pinpoint bleeding on the skin). Subsequently, 1ml of 4mg/ml tranexamic acid was dripped (0.5 ml on each hemiface), in the area affected by melasma, with contact maintained for 6 hours. The interval between each of the 8 proposed sessions was 15 days.

An objective clinical evaluation was performed at the end of the study period by three “blind / hidden” dermatologist physicians who assessed the photographs taken in chronological order using an improvement scale graded with quartiles: Grade 1 (<25% = minimum improvement / absence of improvement); Grade 2 (26-50% = (moderate-intermediate improvement); Grade 3 (51-75% = important / marked improvement); Grade 4 (> 75% = improvement close to resolution).

In order to obtain comparative images, the photographs were standardized using the Magic Mirror softwares camera under conventional and UV lighting — a valuable tool that heightens pigmentation visualization.

RESULTS

Of the seventeen patients selected for the study, 2 lost continuity, therefore, only fifteen reached the end of the treatment. They were all female, with a mean age of 42 years and mean duration of melasma development of 8.65 years.

Table 2 shows the distribution of results and percentage participations according to the photographic analysis carried out by the “blind / hidden” evaluators (I, II and III) on the 15 patients.

Regarding the MASI index, there was significant improvement (on average from 21.33 to 11.9) (Table 3).

In most patients, the clinical response was already perceptible from the third session, nevertheless photographic documentation was performed only 30 days after the end of the last session (Fig 1, 2 and 3).

DISCUSSION

Tranexamic acid has been used in dermatology since 1979, when Nijor first reported its efficacy in the treatment of melasma.11 Since then, some studies have compared its efficacy across different routes of administration. Oral, intravenous, topical and intradermal (by microinjection and microneedling) uses have been described in the literature.

Its oral use has been widely reported in the literature. A study carried out by Na et al. demonstrated improvement in 22 women treated for eight weeks with 250 mg, three times per day, in combination with topical medication. In addition to the clinical improvement, there was evidence of reversal of the histological findings of melasma; reduction of epidermal pigmentation, and reduction of vascular proliferation, which correspond to the antiangiogenic effect of tranexamic acid.16 A Chinese study with 74 patients under oral treatment (twice per day for six months) observed improvement in 82.4% of patients, with responses observed in the first two months, and no significant side effects.6 In another Pakistani clinical trial carried out with 65 patients, 86% experienced clinical improvement (at the 6-month follow up 87% did not present recurrence), with absence of significant side effects.17 Another retrospective analysis carried out from January 2010 to June 2014, studied 561 patients using tranexamic acid as an adjuvant to the use of lasers or topical therapy, with improvement in 89.7% of patients, and first clinical signs appearing at 2 months. In this series, however, one patient had deep venous thrombosis 6 weeks after starting treatment.13

These and other studies prove the effectiveness of the oral use of tranexamic acid for the treatment of melasma. Not-withstanding, in a recent 2017 study by Sharm et al., 100 patients were divided into two groups: one group used oral 250mg tranexamic acid twice a day for 12 weeks, while the other used 4 mg/ml intradermal tranexamic acid monthly. The results showed that the difference between the two methods was not significant, however, the oral treatment took longer to yield perceivable clinical results. It was concluded, therefore, that the administration of tranexamic acid is effective and safe, independently of the route of administration.12 For this reason, the authors of the present study chose not to use the systemic route.

In addition, in 2009, Steiner et al. have demonstrated that tranexamic acid is a promising depigmenting agent in the treatment of melasma, even if it is not administered orally. Seventeen women were selected and treated for 12 weeks. One group used topical 3% tranexamic acid twice a day while another under-went weekly intradermal injections of 0.05 ml. The groups were compared before and after the treatment based on photographs, the MASI index, self-assessment and colorimetry. The MASI evaluation showed that the group using topical treatment saw improvement in only 12.5% of patients, while in the group un-dergoing injections that percentage was 66.7%, meaning that the therapeutic effect of tranexamic acid is enhanced when it crosses the bilipidic layer barrier of the cell membrane.1,18 Furthermore, in another study with the isolated use of topical treatment with tranexamic acid, twice a day for 12 weeks, in 21 patients with epidermal and mixed melasma, led to results similar to those of the placebo group, with worsening of erythema on the treated side.19

The first pilot study using pure microneedling in melasma was published in 2011, on the International Journal of Plastic Surgery. It assessed 20 patients whose one of the hemifaces was treated with an isolated whitening formulation, while the other underwent microneedling associated with the same substance. The photographic comparison showed that the hemiface with microneedling had an expressive improvement as compared with that was isolatedly treated with the whitening formulation (MASI: from 19.1 to 9.2 vs. from 20.4 to 13.3),5 demonstrating the importance of the drug delivery method. Aligned with this view, Budamakuntha et al. compared the efficacies of intradermal and microneedling based administration of tranexamic acid in a group of 30 patients. Although the results were not statistically significant, MASI improvement was greater in the microneedling group (44.41% vs. 35.72%),20 which is in line with the expressive results that the authors of the present study obtained with this treatment technique (also evidenced by the reduction of the MASI indices).

According to the studied literature, the results obtained do not show significant differences in the degree of improvement of melasma when comparing the oral and intradermal routes of administration.

Therefore, the authors of the present studys proposal to combine the depigmenting effect of tranexamic acid with robotic microneedling in order to minimize undesirable systemic effects led to results similar to those of the reviewed literature, since this technology allows to potentiate the local effect of the medication, given that it is delivered at a 2mm depth in the skin.

The side effects verified in the present study were minimal. Two patients noticed an initial worsening after the second session — especially of the vascular component, which improved with subsequent sessions.

One patient observed the emergence of erythematous papules, which were linked to the use of the healing cream and have been resolved after the product was replaced by a diverse one.

There was only one patient who had an increase in MASI after the end of treatment, with the worsening of the clinical picture having been observed and attributed to a trip to Bahia (Northeast Brazilian State), with frequent exposure to the sunlight for 14 days (Fig. 4).

Despite the algic component during the procedure, all patients found it tolerable and none decided to drop out of the study for this reason.

It should be noted that the study was limited to a small number of patients, with no control group, with a short duration and possible evaluation bias, given the MASI index is a subjective method of analysis of results. On the other hand, it is the most widely used, thus contributing to validate the results obtained.

The therapeutic response was considered very satisfactory, since the patients did not use any other treatment during the period of the clinical trial and obtained results that were already visible on the forty-fifth day of treatment, with good tolerability and absence of adverse effects, even when carried out in high skin phototypes.

Does microneedling help hyperpigmentation

First it is important to understand that there are several types of pigmentation that can appear in the skin. The most common pigmentation is that which is darker in color called hyperpigmentation and can be caused by the sun, aging, hormonal changes and from taking medication. The second type is hypo-pigmentation, which is a lightening of the skin. We will discuss if micro needling can help with these different types of pigmentation and how best to treat.

What Treatments Can Help With These Pigmentation Issues?

There are many procedures available to treat pigmentation issues. Microneedling, IPL, Laser Genesis and Fractional CO2 Laser, in conjunction with chemical peels and home care products can tackle this problem.

But one of these treatments, skin needling with the MD Needle Pen can successfully resolve these issues with reduced risk and cost.

Micro Needling for Melasma

Melasma, sometimes called pregnancy mask, is common in Fitzpatrick 4-6 and even seen in 10% of men. This has been a difficult condition to treat and sometimes results in more post traumatic hyperpigmentation.

Micro needling creates less risk of complications, and is generally more cost-effective than comparable laser therapy treatments for melasma. However, the micro needle pen creates minor trauma to the skin, that can still trigger an inflammatory response, leading to a worsening of the pigmentation. It is best to use a finer needle gauge (31) and limit the depth of penetration (0.5-1.0mm) to decrease the risk of further pigmentation.

Can Micro needling Reduce Hyper-Pigmentation?

Unfortunately melanin is not always produced evenly throughout the skin, especially in individuals with darker complexions. Uneven/excessive melanin production can also be the result of skin trauma – sunburns, acne, cuts, bug bites etc.

This is where collagen induction therapy (CID) another word for microneedling therapy, can easily aid the skin without removing or damaging the epidermis. Several treatments are required to even out skin tone and get rid of hyper-pigmentation.

If the hyperpigmentation resides in the epidermis, it responds very well to microneedling and other treatments available. However, if the pigmentation is in the dermis, it is to deep for acid peels but not to deep for microneedling. Expect the skin to respond but it can take more skin needling treatments to see results. It is sometimes best to use combination therapy using microneedle therapy with chemical peels to boost the effectiveness of the procedure.

It is best that patients avoid excessive sun exposure and ALWAYS wear sunscreen when going through skin needling treatment for hyper pigmentation. Ignoring this advice my lead to a reappearance of the pigmentation.

Other Micro Needling Combination Therapies

Micro needling treatments with the MD Needle Pen in combination with lightening/brightening creams can boost results for persistent or deep hyperpigmentation (melasma). These ingredients lighten the skin and inhibit melanin production: Hydroquinone , Kojic Acid and Arbutin. Other ingredients that brighten your skin are: Vitamin-A in all forms (Retin-A, Retinol), C-Vitamin, Licorice, Alpha Hydroxyacids and other plant based extracts.

It is best to not apply high concentrations of hydroquinone for long periods of time. Studies have shown that long-term use in combination with sun exposure can cause dark pigmentation. To avoid this, it is best to switch out to other lighteners like Arbutin and Kojic acid every 6 months and then circle back to hydroquinone.

Can Micro Needling Cause Hyper-Pigmentation?

Discoloration caused by skin needling is rare, but can occur if the needle depth is 1.5 mm or deeper, and the procedure is done too frequently. This negligence can cause irritation in the skin which can be one possible cause to post inflammatory hyper-pigmentation.

It is best to do micro needling therapy 4-6 weeks apart and always use Vitamin C based or other lightning products to lighten the skin and reduce the risk.

Micro Needling and Hypo-Pigmentation

Hypo-pigmentation is when the skin is lighter, sometimes looking like white spots on the face or body. Hypo pigmented skin has malfunctions in or absent melanocytes, the melanin producing cells. Skin needling triggers melanocytes production and enables migration of melanocytes from the surrounding skin into the hypo-pigmented area. Treating hypopigmentation with micro needling has shown promising results.