The Combination Therapy of Microneedling and Subcision with

Platelet Rich Plasma (PRP) versus Platelet Rich Fibrin Matrix

(PRFM) on Rolling and Boxscar Type Acne Scar: Case Series

Ance Imelda Betaubun, Etty Farida, Anggana Rafika Paramitasari,Willa Damayanti,

Susanti Rosmala Dewi, Moerbono Mochtar, Indah Julianto

Department of Dermatovenereology, Faculty of Medicine, Sebelas Maret University, Dr.Moewardi general Hospital,

Surakarta, Indonesia

Keywords: Boxscar, Platelet Rich Plasma, Rolling Scar, Scar Acne.

Abstract: Background: Scarring is an unfortunate and frequent complication of acne vulgaris, resulting in significant

psychological distress for patients. They have been subclassified into ice pick, boxcar, and rolling scars.

Subcision and microneedling are some of therapeutic modalities in the form of acne scar. Platelet-rich

plasma (PRP) has been evaluated for its potential benefits in the treatment of acne scars. In addition to

platelets and their products, the presence of a fibrin matrix (PRFM) can enhances the delivery of growth

factors. Objectives: investigate the efficacy of combination therapy using subcision, microneedling with

application of PRP and PRFM in rolling and box acne scars. Methods: To observed the case reports from

patients admitted to the hospital until patient returns. Case: 2 male patients, 28 and 30 years old, having

acne scars in their faces since 5 years ago. They had no previous treatment until they came to dr.Moewardi

general hospital a few months ago. After physical examination, we diagnosed them with box and rolling

scars. We applied PRFM in their scars, followed by microneedling and subcision. Then, we injected PRP in

that region. Conclusions: Giving injury to the dermis by microneedling acts in synergy with act of PRP and

PRFM, which will modify healing response by releasing cytokines and growth factors, thus will induce

remodeling of acne scars.

1 INTRODUCTION

Acne scars can be classified into three different

types : atrophic, hypertrophic, or keloidal.(1)

Atrophic acne scars are the most common type.The

most basic and practical system divides atrophic

acne scars into three main types: ice pick, rolling,

and boxcar scars.A number of treatments are

available to reduce the appearance of scars.(Gozali

MV et al, 2015) There are no methods of completely

removing acne scarring, hence everything is a

compromise, and often multiple techniques are

combined. Many newer treatments offering the twin

hopes of efficacy and safety.(Goodman GJ, 2011)

Subcision is a procedure in which a needle is

inserted under the skin and passed in multiple

directions. Subcision is best utilized for rolling acne

scars.(Gozali MV et al, 2015) Although subcision is

adequate as a stand-alone treatment, improved

results are achieved when it is combined with other

modalities.(Hession MT et al, 2015) Microneedling

with dermaroller is a simple and cheap procedure for

atrophic scar remodulation. However, there is little

published data about its efficacy and safety when

used in patients with dark color Asian skin

type.(Dogra S et al, 2014)

Platelet-rich plasma (PRP) has been evaluated

for its potential benefits in the treatment of acne

scars.(Leo MS et al, 2015) In addition to platelets

and their products, the natural wound response

requires the presence of a fibrin matrix, which

enhances the delivery of growth factors.Fibrin

mediates the adhesion of fibroblasts and other cells

to the injured site. Animal studies have also

suggested improved wound healing when Platelet

Rich Fibrin Matrix (PRFM) is used. (Sclafani AP et

al, 2012)

This case series aimed to investigate the efficacy

of combination therapy using subcision,

microneedling with application of PRP and PRFM in

rolling and box acne scars.

Betaubun, A., Farida, E., Paramitasari, A., Damayanti, W., Dewi, S., Mochtar, M. and Julianto, I.

The Combination Therapy of Microneedling and Subcision with Platelet Rich Plasma (PRP) versus Platelet Rich Fibrin Matrix (PRFM) on Rolling and Boxscar Type Acne Scar: Case Series.

DOI: 10.5220/0008157703730376

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 373-376

ISBN: 978-989-758-494-7

373

2 CASE

We reported 2 male patients, 28 and 30 years old,

having acne scars in their faces since 5 years ago.

They had no previous treatment until they came to

dr.Moewardi general hospital a few months ago.

After physical examination, we diagnosed them with

box and rolling scars. We applied PRFM in their

scars, followed by microneedling and subcision.

After that, we injected PRP in that region.

To make PRP and PRFM, Peripheral blood was

drawn from the patient into two vacuum collection

tubes, the first tubes contained anti coagulants

CAPD to be processed into PRP and the other tube

was without anticoagulants for making PRFM.

The first tube was prepared by double-spin

method for each session. Seventeen milliliters of

blood was withdrawn in a 20-mL syringe prefilled

with 3 mL of acid-citrate-dextrose anticoagulant.

First centrifugation was performed at 293.88 g for 5

min (soft spin). Both buffy coat and plasma layer

were taken for further centrifugation and red cell

sediments were discarded. Second centrifugation

was performed at 690.94 g for 17 min (hard spin)

resulting in the formation of platelet-poor plasma

above and platelet-rich zone at the bottom. Platelet-

poor plasma (PPP) was removed and discarded

leaving behind a solution of 2 mL PRP.

The second tube is centrifuged for 6 minutes at

1100 rpm, which yields a supernatant plasma/

platelet suspension and the cellular components

(erythrocytes and leukocytes) below the separator

gel. The plasma/platelet suspension is transferred to

a second vacuum tube containing calcium chloride

and was ready for use.

First we cleaned patients’ face with milk cleanser

and toner, then we applied topical anesthesia with

EMLA ® for one hour. We applied PRFM topically,

then we did microneedling 1.0 mm in acne scar

region. After that, we did subcision in their rolling

scars and injected them with autologous PRP, 0.1-

0.2 ml per lesion. We applied antioxidant gel after

procedure and patient were not allowed to wash their

face for a while. They should apply antioxidant gel

in their faces twice daily. We did this treatment once

in 4-6 weeks, and re applied this treatment twice.

Clinical improvement in these two patients was

assessed with photography and Global Acne

Scarring (GAS) Grading System. There were

improvements in their acne scars. The first patients

who previously had moderate score becamemild.

The second patient who had severe classification

and after procedure, he had moderate score.

Table 1. Global Acne Scarring Grading System

assessment in our patients. There is improvement in their

score before and after procedure.

GAS

Patient 1 Before Moderate

After Mild

Patient 2 Before Severe

after Moderate

3 DISCUSSION

Procedures such as dermal and subcutaneous

autologous and non-autologous fillers and subcision

carry no further risk and are independent of

photoreactive skin type. Some procedures, such as

light skin peels, microdermabrasion, skin rolling,

and fractional resurfacing, carry minimally more

risk.(Goodman GJ, 2011) This is usually required

when scars occur on the forehead, chin, and lower

jaw line and is due to excessive muscle activity on a

scarred, atrophic, compliant area of skin.(Goodman

GJ, 2011) This case series included two patients

with atrophic scars, mostly rolling and box scars,

predominantly in malar region.

A qualitative global acne scarring system is

presented by Goodman and Baron in 2006 facilitate

the relatively simple grading of a patient with

postacne scarring and allow the rational description

of that patient.(Goodman GJ et al, 2006) This

description may allow better communication of

disease severity between practitioners and give a

lead to the most appropriate treatments for patients.(

Goodman GJ et al, 2006)

Table 2. Grades and examples of post acne scarring

Gra

Level of

disease

Characteristics Exam

ple of

scars

1 Macular

disease

Erythematous,

hyper- or hypopig-

mented flat marks

visible to patient or

observer

irrespective of

distance.

Erythe

matou

hyper-

hypop

igmen

ted

flat

marks

2 Mild

disease

Mild atrophy or

hypertrophy that

may not be obvious

at social distances

Mild

rolling

, small

soft

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374

of 50 cm or greater

and may be covered

adequately by

makeup or the

normal shadow of

shaved beard hair in

males or normal

body hair if

extrafacial.

papula

3 Moderate

disease

Moderate atrophic

or hypertrophic

scarring that is

obvious at social

distances of 50 cm

or greater and is not

covered easily by

makeup or the

normal shadow of

shaved beard hair in

males or body hair

if extrafacial, but is

still able to be

flattened by manual

stretching of the

skin.

signifi

cant

rolling

shallo

‘‘box

car,’’

mild

moder

ate

hypert

rophic

papula

r scars

4 Severe

disease

Severe atrophic or

hypertrophic

scarring that is

obvious at social

distances of 50 cm

or greater and is not

covered easily by

makeup or the

normal shadow of

shaved beard hair in

males or body hair

(if extrafacial) and

is not able to be

flattened by manual

stretching of the

skin.

Punch

ed out

atroph

(deep

‘‘box

car’’),

‘‘ice

pick’’,

bridge

s and

tunnel

gross

atroph

dystro

phic

scars

signifi

cant

hypert

rophy

keloid

Subcutaneous incisionless surgery (subcision)

was first introduced in 1995 as an effective

treatment for rolling scars.In this procedure, a

hypodermic, tribevelled, or filter needle is

introduced into the subdermal plane to undermine

the scar through a series of backward and forward

motions, followed by horizontally rotating the

needle in a fanning motion.These motions loosen the

fibrotic adhesions that cause the bound-down

appearance of rolling scars and create a wound

environment amenable to collagen deposition. The

bleeding and subsequent clot formation that result

from the procedure aid in elevating the skin from the

underlying scar tissue, generating a potential space

for neocollagenesis.(Hession et al, 2015)

“Scar needling” as a means of new collagen

deposition was first introduced by Orentreich and

Orentreich in 1995 in the form of

subcision.Fernandes described percutaneous

collagen induction (PCI) therapy performed with a

self-designed microneedling device, as an alternative

to lasers for skin rejuvenation.Multiple skin

punctures were made with a drum-shaped device

which had multiple fine protruding needles.Basic

contention behind this technique was that the

epidermis need not be damaged to make the skin

smoother. He popularized this technique for

combating photoaging, laxity and for skin

rejuvenation.Later PCI technique has been used for

the treatment of scars of varied etiology like acne,

postburn, postvaricella etc.With this technique, the

rolling is usually continued until bruising occurs,

which initiates the complex cascade of growth

factors that finally results in collagen

production.(Gozali et al, 2015)

We combined microneedling and subcision

technique in our patients, so percutaneous collagen

will be induced so that atrophic scar in these patients

can be elevated. To enhance this elevation effect, we

also used autologous PRP and PRFM that contains

high concentrations of platelet growth factors such

as platelet-derived growth factors (PDGF),

transforming growth factors (TGF), vascular

endothelial growth factor (VEGF), insulin-like

growth factor (IGF), epidermal growth factor (EGF),

and interleukin (IL)-1.

The optimal PRP platelet concentration should

be more than 10 lakhs platelets/lL having 300–700%

enrichment. PDGF in PRP improves dermal

regeneration and acts locally to promote protein and

collagen synthesis, causes endothelial migration or

angiogenesis, and induces the expression of TGF-

beta. TGF-beta activates fibroblasts causing it to

undergo cell division and produce collagen. This

collagen deposition is responsible for reducing the

scars.(Asif et al, 2016)

The Combination Therapy of Microneedling and Subcision with Platelet Rich Plasma (PRP) versus Platelet Rich Fibrin Matrix (PRFM) on

Rolling and Boxscar Type Acne Scar: Case Series

375

Sclafani et al described in their study that the

action of PRFM is more steady and sustained,

yielding increased and sustained concentrations of

growth factors during the crucial wound healing

period after the initial acute inflammatory

phase.(Sclafani et al, 2012)

4 CONCLUSION

Scarring is an unfortunate and frequent complication

of acne, resulting in significant psychosocial distress

for many patients. In this report, we suggested that

injury to the dermis by microneedling acts in

synergy with act of PRP and PRFM, will modify the

natural healing response from the beginning of

inflammation to the initiation of collagen induction

by releasing cytokines and growth factors, thus will

induce remodeling of acne scars.

REFERENCES

Gozali MV, Zhou B., 2015. Effective treatments of

atrophic acne scars. The Journal of Clinical and

Aesthetic Dermatology. PMID: 26029333.

Goodman GJ., 2011. Treatment of acne scarring.

International Journal of Dermatology. doi:

10.1111/j.1365-4362.2011.05029.x

Hession MT, Graber EM., 2015. Atrophic acne scarring: a

review of treatment options. The Journal of Clinical

and Aesthetic Dermatology. PMID: 25610524.

Dogra S, Yadav S, Sarangal R., 2014. Microneedling for

acne scars in Asian skin type: an effective low cost

treatment modality. Journal of Cosmetic Dermatology.

doi: 10.1111/jocd, 12095.

Leo MS, Kumar AS, Kirit R, Konathan R, Sivamani RK.,

2015. Systematic review of the use of platelet-rich

plasma in aesthetic dermatology. Journal of Cosmetic

Dermatology. doi: 10.1111/jocd.12167.

Sclafani AP, Saman M., 2012. Platelet-rich fibrin matrix

for facial plastic surgery. Facial Plastic Surgery

Clinics of North America. doi:

10.1016/j.fsc.2012.02.004.

Goodman GJ, Baron JA., 2006. Postacne scarring: a

qualitative global scarring grading system.

Dermatologic Surgery. PMID: 17199653.

Asif M, Kanodia S, Singh K., 2016. Combined autologous

platelet-rich plasma with microneedling verses

microneedling with distilled water in the treatment of

atrophic acne scars: a concurrent split-face study.

Journal of Cosmetic Dermatology. doi:

10.1111/jocd.12207.

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