Primum Non Nocere. First, do no Harm.
It is the first rule of medicine; should we not extend this to skincare, too?
Because of the overwhelming response I received after writing the article, “Microneedling, Beware”, I wanted to address the topic of side effects further, and look at what is really happening from a medical perspective.
If you’re not immersed in the sometimes-bizarre world of beauty trends, the practice of skin needling – also known as micro-needling or dermarolling – may sound strange, to say the least. However, using a device on your face that looks similar to a tiny lawn aerator is a craze sweeping the nation, and becoming extremely popular amongst skincare fanatics.
With an exhaustive list of claims of how it can improve the skin, why is it that the conditions listed below are all very real, very frightening side effects that many of my readers have experienced as a result of the treatment?
- Tram-track marks
- Accelerated ageing
- Erythematous papules
- Skin pigment changes
- Permanent indentations
- Systemic hypersensitivity
- Granulomatous dermatitis
- Possible tumour formation
- Indurated erythematous plaques
- Post-inflammatory hyperpigmentation
Is it because it allows you to “take skincare into your own hands”? Is it due to incorrect treatment protocol? Or the very real dangers that occur when you deliberately create a wound in the skin?
If you think your skin has been compromised by a skin needling treatment, read below to discover my advice on how to care for and repair the damage that may have been done.
What is Skin Needling?
A medical microneedling treatment involves the use of fine, sterile needles that vibrate at a high power repeatedly: thousands of times over a few seconds. The needles pierce microscopic ‘holes’ into the superficial layer of your skin. These small and controlled piercings create channels, or micro-wounds, which lead to the release of growth factors and instigate the healing response in your skin. The body’s response is to stimulate the formation of new collagen and elastin, and encourage neovascularisation – the natural formation of new blood vessels in the dermis.
In technical terms, skin needling takes advantage of your skin’s response to any kind of inflammatory wound. For example, if you cut your skin, the body’s first line of defence is to deploy white blood cells; these release chemicals that increase the production of components comprising the intercellular matrix of your skin tissue. Basically, they tell your body to patch the hole by creating new cells at the site of the wound.
A classical wound may be defined as a disruption of tissue integrity; any wounds, whether caused by injury or remodelling, rely on the biological phases of healing: inflammation, proliferation, and remodelling.
The 3 Stages of Wound Healing
In this first phase, the blood vessels dilate, allowing white blood cells, nutrients, and antibodies to flood the wounded area. Healing enzymes encourage fibroblasts to divide and create new epithelial cells, whilst foreign pathogens are destroyed; promoting wound healing and staving off infection.
It is during this time that the physical effects of inflammation are experienced, such as redness, heat, and swelling.
In the second phase, the wounded area starts to get rebuilt. Immature granulation tissue moves like a wave from the border of the injury towards the centre, allowing for a new network of blood vessels to replace the damaged one. The colour of the granulation tissue is a good indicator of how healthy the wound is; red or pink generally means that it is healthy, whilst darker tissue may indicate inadequate blood supply or infection.
It is in the proliferative phase that active fibroblasts also form – these cells produce plump, abundant, type III collagen. In a healthy wound, the internal scaffolding of collagen grows stronger as the fibroblasts reorganise themselves; aiding in the development of new tissue, whilst also strengthening the wound.
Maturation is the last phase and is often referred to as remodelling. After the wound has closed up, dermal tissues are overhauled to enhance their strength, and non-functional fibroblasts are replaced by functional ones. Cellular activity declines with time and the number of blood vessels in the affected area decreases.
This phase can take as long as 24 months. It is important to note that whilst the wound-healing process may appear to be over when maturation begins, this is not the case. If the wound is not treated, there is a very HIGH RISK that it could deteriorate, as it is not at its optimal strength. This is why it is so important to keep up the aftercare treatment plan. Even after the maturation phase is over, wounded areas can remain up to 20% weaker than other areas.
The big question: Does microneedling actually work?
#1. Skin inflammation – is it a good thing or is it a bad thing?
Acute and chronic inflammation within the skin are both extremely damaging. By its very design, microneedling causes a measured degree of skin inflammation, depending on the depth of the needling and other treatment parameters. This is a normal, physiological response to the damage, which brings about the desired aesthetic result.
The Naked Truth: As a rule of thumb, inflammation should calm down within a few days. In some cases, it doesn’t; this inflammation could be from something more insidious and pathological. Most allergic reactions or inflammations are mild and go away after a matter of days. However, acute inflammatory responses – such as granulomatous dermatoses – can last for years. This is when the immune system tries to block a substance that it perceives to be a foreign body, but is unable to eliminate. This can be a response to the presence of microorganisms, chemicals, or organic and inorganic materials.
The appearance of redness and swelling may not be visible, which can be misleading. However, below the surface, inflammation begins to take its toll on structural cells and matrix proteins found within the dermis. Because of its resemblance to skin changes associated with accelerated skin ageing, it’s referred to in the industry as “skinflamm’ageing”. Granulomas can be infectious or sterile and become apparent as localised lesions that inflame and distort nearby tissues. These can take weeks or months to develop.
#2. Does needling reduce wrinkles and tighten sagging skin, or does it cause premature ageing?
Skin needling on the face penetrates the upper levels of the dermis, causing inflammation which, in turn, increases the production of fibronectin. This special glycoprotein creates a type of ‘scaffolding’ onto which the newly inducted collagen is deposited. Over time, this collagen undergoes a conversion process where it naturally tightens up, which reduces wrinkles and helps resurface scars.
The Naked Truth: Microneedling may cause collagen breakdown and premature ageing. The minute you puncture the skin, mechanical damage is caused. Dermarolling rips at the collagen fibres already present, causing degradation and desensitising the receptors responsible for signalling collagen synthesis. With constant destruction of collagen, the body is forced to keep producing new collagen fibres to replace it; over time, this natural ability becomes depleted, thus accelerating the ageing process.
It is important to note that collagen formation from skin needling is created by a stress response from the body. Much like when our skin is overexposed to UV rays – another stressor that destroys collagen – the body quickly tries to replace the collagen lost. Whilst the collagen made from exposure to a stressor may give the appearance of plump skin, the reality is, any underlying damage done to the internal scaffolding may take years to manifest, by which time the damage is already done.
#3. Is the efficacy of topical medicines improved or is the barrier function impaired?
Microneedling is performed in the presence of a substance applied to the skin before, during, or soon after treatment. Microneedling helps important ingredients penetrate further, reaching areas beyond the skin’s natural protective surface.
The Naked Truth: Microneedling dramatically disrupts the skin’s protective function. The impermeable barrier that protects the deeper, living cells is made up of multiple layers of ‘dead’, keratinised cells. Skin needling pierces through these layers, creating many thousands of channels which enable topically-applied substances to penetrate easily into the skin. The flip-side is that until these channels form effective plugs and initiate the healing process, the skin is left open and vulnerable to anything it may come into contact with. You can read more about how the protective barrier is formed here.
Many of the major risks associated with skin needling are often not related to the actual needling procedure itself, but adverse reactions to topical solutions which are applied to the skin during a time of maximal barrier function disruption. Substances that are part of one’s normal physiology and found naturally within the skin are safe; substances that are not should be avoided.
#4. Are scars and stretch marks reduced or does microscopic scar tissue form?
When you have any sort of scarring, your body naturally undergoes a process known as fibrosis, which makes the skin clump together. This pulls the skin inwards and down, creating pockmarks or scarring on the surface of the skin. Microneedling is said to break up these fibrosis adhesions underneath the skin, releasing the puckering and smoothing the surface.
The Naked Truth: Scarring from face needling happens at the microscopic level and is not visible like a regular scar; such scarring may show up years later in the form of sagging, thin skin – in some extreme cases, I have had clients referred to me where this has happened within a matter of weeks of hundergoing skin needling treatment. The dermis is comprised of an extracellular matrix made up of collagen and elastin fibres that form a framework, inside which sit all the other important skin molecules, such as proteins, glycans, blood vessels, and cells.
In healthy skin, the fibres of collagen grow in different directions and intertwine with elastin fibres, creating a mesh that allows stretch and movement in the skin. When the skin is injured, the body responds by overproducing collagen in one direction only, forming a thick bundle of fibrous scar tissue that cannot stretch due to the lack of elastin fibres. Without the original formation, even if new collagen is made, it has nowhere to go and instead of becoming part of the skin, it is destroyed by the body.
It’s a vicious cycle; the more skin needling that is carried out, the more scar tissue is formed, and more scar tissue present in the skin means less elastin, collagen, and other proteins associated with healthy skin. The reality is that although some slight changes may occur from microneedling on superficial scars, the treatment does not penetrate deeply enough to break down the thick bands of fibrous tissue in deep scars, nor can it raise the skin or replace the scar with normal tissue.
#5. Is skin health improved or do healthy skin cells die off?
When the skin is punctured with needles, extracellular matrix components such as elastin, which keeps skin firm and taut, and hyaluronic acid, which keeps skin hydrated, are degraded.
The Naked Truth: When collagen, elastin, and extracellular components that are involved in maintaining the structural integrity of the cell are destroyed, you are on the path to cell death, which accelerates the ageing process.
Cellular turnover occurs when skin cells are replaced by another live skin cell via cellular division. When this happens, the end of the chromosome within the cell’s nucleus is cut off, known as the telomere. After some 60 divisions, the telomere becomes completely cut off and ageing begins. Skin needling accelerates the rate at which cellular division occurs, speeding up telomere depletion and accelerating the ageing process.
#6. Does microneedling reduce hyperpigmentation and even out skin tone or cause pigmentation issues?
Microneedling can reduce hyperpigmentation as it increases the expression of matrix metalloproteinases – enzymes that break down fibrous scar tissue.
The Naked Truth: Trauma to the skin can cause melanin – the pigment in the skin that causes colour changes – to rush to the site of the injury. Those with a darker skin type also have a propensity for hyperpigmentation in response to inflammation, many inexperienced practitioners don’t look at the fitzpatrick scale of the clients skin and treat regardless, which can result in changes in pigmentation on the skin.
#7. Can it trigger tumour formation?
For many years, it was thought that skin wounds were benign; however, research is now suggesting that skin wounds may cause basal cell carcinoma. This link becomes even more alarming if you are making lots of wounds through needling the skin.
Basal cell carcinoma is the most common type of skin cancer. Its origins start in the basal cell layer, in the lower part of the epidermis, and the cells of hair follicles. The formation of tumours occurs when errors in the DNA of the follicular cells cause unregulated cellular division, which can lead to tumorous growth.
It is understood that a wide range of wound-type injuries, even small wounds like paper cuts, can activate cancer-provoking genes in the skin as it heals. Reiter & Wong hypothesised that skin wounds may promote basal cell carcinoma; their research showed how stem cells in hair follicles can transform into cancerous cells while helping to heal an injury.
The skin mobilises cells from the hair follicles to heal injuries, if you mobilise these cells into the epidermis, they can produce tumors. Reiter states that scientists are now believing that cancers are wounds gone awry. Usually, the hair follicle represses the tumor-generating potential of the stem cells, he says, but when these cells become unstable, trouble begins.
The findings mentioned above are important because Reiter & Wong found that the development of basal cell carcinomas is not just exclusive to large wounds: even minor incisions could possibly induce carcinomas – such as those created by micro-needling.
After a microneedling treatment, your skin is highly vulnerable to whatever may come in contact with it. Therefore, I advise using only products that are high in molecular weight, which is what our H₂O Hydrating Complex was specifically formulated for. Then, introduce very gentle, non-irritating products, which contain skin-identical ingredients that will help repair the barrier. Fortify, Ceramide, Quench, Bio Lipid, and DNA will all help to redensify the skin – please, use absolutely no actives such as Vitamin C.
Once repaired, you can think about using Vitamin A and other peptides to re-texturise the skin and help with age-related issues, but nothing too strong yet – especially not Vitamin C, research is beginning to show, that it may contribute to granulomatous reactions.
Should You or Shouldn’t You?
To conclude, the answer is that there are just too many shortcomings surrounding this treatment. Through my own research, the available information is either poorly skewed by badly-controlled or non-randomised studies, or delivered by people selling the devices. So, it isn’t easy to get to the truth about what it can and can’t do.
I am getting more and more readers writing to me about complications arising as a result of skin needling. Some are simple, but there is a growing number of reports of devastating skin problems such as granulomas. I feel the industry requires a mutual “call to arms” to try and curb this practice, and certainly implement correct legislation around the treatment, be it with derma rollers or with a derma pen.
So much needs to be taken into consideration, both before and after microneedling, including the brand of needle involved. Some needles have a “dragging” effect during treatment, which distorts the skin and amplifies needle puncture injury. The client’s skin characteristics must also be taken into consideration; the older we are, the less able we are to heal quickly and correctly. Those with a darker skin type have a propensity for post-inflammatory hyperpigmentation (PIH). The depth of needling, medical history, skin preparation, and topicals used are all critical factors that need to be considered.
My suggestion? If you want to ward off premature ageing, increase collagen production, and encourage cellular turnover, why not select any one of the actives from the Naked Chemist skin shot range instead? Each one is designed to target specific conditions safely and effectively – without accelerating the ageing process or putting yourself at risk of cancer.
If you’re feeling a bit apprehensive after reading this article, but still want to bite the bullet and go ahead and have the treatment anyway, you can read all about dermarolling in my article, “Dermapen: The Dangers of Incorrect Treatment Protocol“. This will arm you with all the basics of what you need to know; helping you make an educated decision about whether skin needling is for you, whilst ensuring you have the safest treatment possible.
The Naked Truth
If after reading this, you are still committed to having the treatment, I would like to share the following with you. Dr Lance Setterfield, one of the leading authorities in skin needling, recently wrote to one of my customers as follows:
Dr Fernandes (Environ) and I disagree on needle size, I recommends 0.5 mm, which in practice means you’re going not through, but to the dermal-epidermal junction, he recommends this being carried out every 28 days due to the inflammatory response which can result in hyperpigmentation and scarring if done at deeper levels and more frequent intervals, and combined with things like chemicals peels, it can create infection. Dr Fernandes feels that needle depth should be longer, this way inflammation is provoked and prolonged to get best results, it is difficult to then blame doctors and practitioners who are following his protocol when things go wrong.