Response to “Microneedling with autologous platelet-rich plasma versus microneedling with topical insulin in the treatment of postacne atrophic scars: A simultaneous split-face comparative study”
2021; Elsevier BV; Volume: 85; Issue: 6 Linguagem: Inglês
10.1016/j.jaad.2021.05.070
ISSN1097-6787
AutoresSoha Ghanian, Carlos Gustavo Wambier,
Tópico(s)Bee Products Chemical Analysis
ResumoTo the Editor: Drs Pawar and Singh1Pawar M. Singh M. Microneedling with autologous platelet-rich plasma versus microneedling with topical insulin in the treatment of postacne atrophic scars: a simultaneous split-face comparative study.J Am Acad Dermatol. 2021; 84: 810-811Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar presented interesting findings from a split-face study of microneedling followed by the administration of either topical platelet-rich plasma (PRP) or topical fast-acting insulin (40 IU/mL of human insulin and 0.3% metacresol) for the treatment of postacne atrophic scars. The study concluded that microneedling with topical insulin or PRP was associated with statistically significant improvement in postacne atrophic scars.1Pawar M. Singh M. Microneedling with autologous platelet-rich plasma versus microneedling with topical insulin in the treatment of postacne atrophic scars: a simultaneous split-face comparative study.J Am Acad Dermatol. 2021; 84: 810-811Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar The objective of this letter is to express our concerns about the study design, guide future interventional studies, and discuss the mechanisms of action of topical agents. The study could have been more informative with the inclusion of a sham control group instead of comparing topical PRP with insulin. A control group consisting of microneedling alone would have served as a better comparison in order to determine whether the effects of microneedling are augmented by topical protein-rich preparations. Furthermore, split-face studies are more informative under side randomization because a laterality bias, such as that caused by a more vigorous procedure on the right side of the face based on the dominant hand of the clinician or more chronic sun exposure related to the side of a vehicle's steering wheel, might have been at play. Regarding the mechanism of action, it is expected that the topical application of protein preparations or growth factors cannot achieve dermal delivery after microneedling. In a previous study, "rubbing" black ink after microneedling did not achieve dermal delivery in a proof-of-concept experiment because topical penetration beyond the corneal layer does not occur with molecules larger than 500 Da.2Dhurat R. Sharma A. Goren A. Daruwalla S. Situm M. Kovacevic M. Mission impossible: dermal delivery of growth factors via microneedling.Dermatol Ther. 2019; 32: e12897Crossref PubMed Scopus (10) Google Scholar Insulin weighs over 5000 Da; therefore, the size of the molecule prevents dermal absorption. The millenary needling technique intentionally developed to deliver liquids rich in color pigments to the dermis is called the tattooing technique, and sterile suspensions and solutions may be delivered with a tattoo machine using the right technique.3Wambier C.G. de Farias Wambier S.P. Soares M.T. Breunig J. Cappel M.A. Landau M. 5-Fluorouracil tattooing for idiopathic guttate hypomelanosis.J Am Acad Dermatol. 2018; 78: e81-e82https://doi.org/10.1016/j.jaad.2017.10.033Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar The tattooing technique relies on creating a negative dermal pressure in order to deliver fluids (Fig 1) in a way similar to that of the hydrodynamics of venom inoculation during snake bites.4Young B.A. Herzog F. Friedel P. Rammensee S. Bausch A. van Hemmen J.L. Tears of venom: hydrodynamics of reptilian envenomation.Phys Rev Lett. 2011; 106: 198103Crossref PubMed Scopus (24) Google Scholar When dry needles are used during microneedling, the after-procedure pressure gradient does not allow the dermal delivery of liquids to previously made injury columns.2Dhurat R. Sharma A. Goren A. Daruwalla S. Situm M. Kovacevic M. Mission impossible: dermal delivery of growth factors via microneedling.Dermatol Ther. 2019; 32: e12897Crossref PubMed Scopus (10) Google Scholar Otherwise, while exposed to normal air pressure, pinpoint bleeding would flow back from the epidermis to the dermis. We question whether by using the tattooing technique3Wambier C.G. de Farias Wambier S.P. Soares M.T. Breunig J. Cappel M.A. Landau M. 5-Fluorouracil tattooing for idiopathic guttate hypomelanosis.J Am Acad Dermatol. 2018; 78: e81-e82https://doi.org/10.1016/j.jaad.2017.10.033Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar as opposed to simple dry needle microneedling plus topical application (Fig 1), there would be a difference in efficacy between the therapeutic groups. As shown in a study of dermal delivery of black ink with a tattoo machine versus a handheld needle, needles in a tattoo machine's disposable cartridge create more uniform dermal deposits.5Arbache S. de Mendonca M.T. Arbache S.T. Hirata S.H. Treatment of idiopathic guttate hypomelanosis with a tattoo device versus a handheld needle.JAAD Int. 2021; 3: 14-16https://doi.org/10.1016/j.jdin.2021.01.005Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar It is important to bring about an open scientific discussion of the topic since many practitioners are adopting the topical use of products, such as PRP, over microneedling. However, this might be an impossible mission.2Dhurat R. Sharma A. Goren A. Daruwalla S. Situm M. Kovacevic M. Mission impossible: dermal delivery of growth factors via microneedling.Dermatol Ther. 2019; 32: e12897Crossref PubMed Scopus (10) Google Scholar Drug tattooing is a new concept, and double-blinded, sham-controlled studies need to be carried out to further substantiate the efficacy of this technique. We look forward to attempting the use of fast-acting insulin to verify its effects as another inexpensive sterile injectable drug of easy access worldwide in the armamentarium of drug tattooing. None disclosed. Microneedling with autologous platelet-rich plasma versus microneedling with topical insulin in the treatment of postacne atrophic scars: A simultaneous split-face comparative studyJournal of the American Academy of DermatologyVol. 84Issue 3PreviewTo the Editor: Postacne atrophic scars (PAS) are common sequelae of acne.1 Peels, platelet-rich plasma (PRP), subcision, dermabrasion, lasers, punch techniques, and fillers are useful in PAS; however, many of them are associated with dyspigmentation and scarring, limiting their widespread use, especially in skin-of-color populations.1 Microneedling is safer in skin-of-color populations and is often combined with PRP for enhanced efficacy.2,3 However, PRP therapy is costly and not readily available. Full-Text PDF Reply to comments on "Microneedling with autologous platelet-rich plasma versus microneedling with topical insulin in the treatment of post-acne atrophic scars: A simultaneous split-face comparative study"Journal of the American Academy of DermatologyVol. 85Issue 6PreviewTo the Editor: We read with admiration the comments by Ghanian and Wambier.1 Treatment with platelet-rich plasma (PRP) therapy is already an established and proven modality for postacne scars; hence, we thought of comparing the results of microneedling with topical insulin with those of PRP therapy, the benchmark therapy, for postacne scars. We have already admitted the shortcomings of the study in the penultimate paragraph stating "lack of separate assessment of each treatment modality."2 We agree with the idea of "side randomization"; however, to maintain uniformity in the procedure, we used the same treatment protocol in all the patients. Full-Text PDF
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