Skin Needling: to the point
What is skin needling?
Skin needling, also known as collagen induction therapy or micro-needling therapy, is a minimally invasive non-surgical and non-ablative procedure that involves the use of a sterile roller with needles. The needles are rolled over the skin, which creates many microscopic channels deep into the dermis, stimulating the body to produce the skin’s natural support protein – collagen, in order to facilitate natural repair and make the skin stronger and thicker. Theoretically, the increased levels of collagen fill depressed scars and wrinkles from the bottom up, lifting the depression so they are level with the surrounding skin. 
How skin needling works
As the skin is needled, proliferated skin cells, such as fibroblasts, migrate to the point of injury and transform into collagen fibers, resulting in increased fiber strength and elasticity. The process takes two to three months to produce visible results, however, one recent study, published in the journal Plastic and Reconstructive Surgery, found a considerable deposit of collagen and elastin in the skin six months post skin needling treatment, as well as a 40 percent increase in the thickness of the epidermis. Each successive treatment triggers the production and deposition of new collagen and elastin that progressively in-fill (collagen induction) scars and wrinkles. Collagen induction is said to continue for up to 12 months after a treatment. Advocates of skin needling say that with successive treatments the skin should become firmer, smoother and more elastic, and the complexion more even toned. In addition, the hundreds of tiny dermal channels increase the absorption of skincare creams, theoretically enhancing their efficacy. 
Skin needling is used for:
• Pharmaceutical or cosmetic product infusion.
• Anti-ageing / wrinkles.
• Pigmentation / sun damage.
• Acne / pimples / blackheads.
• Scarring.
• Enlarged pores / seborrhea.
• Stretch marks.
• Melanocyte restoration (the process of regenerating the skin’s melanin production in white spots, age spots and hypo-pigmented areas by stimulating the melanocyte cells in the epidermis).  
A History of skin needling
Skin needling was developed in the 1990s by a team of European plastic surgeons and dermatologists. Dr Philippe Simonin, a Swiss French dermatologist, published his results in Baran’s Cosmetic Dermatology 1994, but his technique called Electroridopuncture (ERP), remained largely unknown to the wider medical community. His study examined 600 patients, split into two patient groups – Skin Ageing and Old Scars.  After 10 treatments on all patients, 40 percent of the Skin Ageing group showed significant improvement, 22 percent moderate improvement and 13 percent some improvement – as measured by comparative skin imprints. In the patient group with Old Scars, 60 percent improved with 5–6 treatments.  Best results were obtained for old fibrous and depressed scars.
Canadian Plastic Surgeon Dr Andre Camirand is another skin needling pioneer. He experimented with tattooing his patients’ facelift scars without pigment and noted improvement in texture and colour. Dr Camirand postulated that hypochromic (depigmented) skin repigmented through the transplantation of melanocytes (pigment producing skin cells) from normal skin into the hypochromic skin during the needling procedure. He also reported flattening of hypertrophic (overgrown) scars.  
In 1997, South African plastic surgeon Des Fernandes, MD, began to explore the idea of increasing collagen production by inducing bleeding in the skin via hundreds of tiny pricks. A study conducted in South Africa and Germany and published in 2008 evaluated its effects on 480 people. Each participant first applied topical vitamin A and C creams, then each was treated with a derma roller up to four times weekly for four weeks. Scientists evaluated tissue samples from 20 participants and found a “considerable increase in collagen and elastin,” according to the report.
How safe is skin needling?
In contrast to all ablative techniques like laser and Fractional Laser treatments, skin needling is said to be safe as it stimulates new tissue formation while maintaining the skin intact. While skin trauma can induce pigmentary changes, some studies are showing that collagen induction therapy doesn’t activate the melanocytes responsible for hyper-pigmentation. In fact, unlike lasers or chemical peels, skin needling can treat all skin types – even sensitive. However, what must be taken into account is that the effects of skin needling differ according to needle gauge, length and the manual pressure used with the roller. Therefore the level of skin invasion and subsequent inflammation on the skin can vary from gentle stimulation to piercing the skin and drawing fluids, i.e. blood and lymph. For this reason, most skin needling devices are disposed of in the appropriate biohazard container or are properly sanitised and reused on the same client. Either way, it is critical that correct sanitation measures are followed to prevent cross contamination. In New Zealand the Health and Hygiene Code of Practice 2013 states that any derma rollers or dermastamps of 0.5mm and below may be re-used on the same customer only if stored in a manner as to prevent contamination from any other item and the client must sign a disclaimer that the derma roller / stamp is only to be used on them. All reused derma rollers / stamps must be disposed of within six months of opening;
Different devices equal different results 
There are various skin needling devices including Dermaroller (Dermaroller GmbH); Dermapen (Equipmed Pty Ltd; Australia) Derma-Stamps (Dermaroller USA). The needles range from 0.13mm to 3mm in length and different lengths must be used to treat different areas of skin. Needling should target the intermediate reticular dermis (a layer in the upper dermis), which contains the highest number of stem cells, which are able to produce new collagen. The epidermis varies in depth from .05mm on the eyelids to 1.5mm on the soles of the feet. The epidermis of the face (other than the eyelids) varies from 0.3mm to 1mm in depth and therefore a 0.75mm to 2mm needle length is more than adequate to reach the intermediate reticular dermis. 
The longer, thinner needles around 1.0mm or 1.5mm in length are more likely to break the skin and draw fluids, so subsequent risk of infection is much higher and extreme caution must be used and this procedure is best conducted under medical supervision due to the risk of adverse reactions and post-procedure complications. When the barrier of the skin is compromised to this degree, bacterial skin infections, adverse skin reactions, as well as post inflammatory hyperpigmentation and premature ageing (due to inflammatory mediators being drawn to the area) can result. In the past, professional needling was done with a 3.0mm needle length, but this is now considered unnecessary. Biopsies of needled skin show that new matrix formation only occurs in the upper papillary dermis and no deeper than 0.6mm below the epidermis. Needling deeper is likely unnecessary to stimulate skin matrix production. In fact, some therapists believe that 0.25mm needle diameter is the maximum that can be used without causing a new scar in the skin. However, as smaller diameter needles do not maximise the dermal injury they will therefore be slower to produce results.
Needle length is also a critical issue. The target when we needle the dermis is a layer in the upper dermis called the intermediate reticular dermis. This dermal layer contains the highest number of stem cells, which are able to produce new collagen. The epidermis (the outer layer of the skin) varies in depth from .05mm on the eyelids to 1.5mm on the soles of the feet. The epidermis of the face (other than the eyelids) varies from 0.3mm to 1mm in depth and therefore a 0.75mm to 2mm needle length is more than adequate to reach the intermediate reticular dermis. 
Skin needling at home
At home dermal rollers have shorter needles (under 0.25mm) than those used by physicians and in theory cannot cause trauma to the skin. Rather, at home rolling is designed to be stimulating and gently exfoliating and enhances the penetration and absorption of active ingredients into the deeper layers of the skin, so is ideally combined with products that contain collagen boosting and skin fortifying ingredients like retinol, vitamin C and peptides. 
However, sanitising the roller is one of the biggest safety concerns when clients are responsible for their own skin needling tools. Manufacturers recommend using the device only once, but due to the cost of the device many consumers try to sterilise it at home meaning infection may be a possibility. Clients that are seeking advice on home dermal rolling should be warned of the risks and advised to sterilise their device after each use. 
Home rolling clients should also be made aware that sanitation concerns are not the only caution. It is best to ensure that their home needling is monitored by a professional skin therapist, so they would be advised to seek professional advice with regards to the length of the needle used and the serums used in conjunction with the treatment. The ultimate care would be to have their skin monitored regularly for adverse reactions as well as progress. 
Clients should also be informed that many copycat devices are available for sale on Internet sites, such as eBay or less reputable online pharmacy sites. Often these include the sale of medical grade rollers which should not be used by the home user due to the potential for harm and risk of infection if the proper precautions are not followed. As skin therapists, we would always recommend that consumers visit a clinic for aggressive medical skin needling treatments and appropriate home care programmes, however if they insist on trying this treatment at home it is important to urge consumers to purchase the devices through reputable online sellers, clinics or direct from manufacturers or distributors.
How frequently should skin needling be performed? 
Like many skin treatments, you can get too much of a good thing. Needling too often will stimulate collagenase, a protein that attacks the bonds of collagen and destroys the newly formed collagen bundles. The skin needs adequate time between needling treatments to heal and start producing more components of the skin matrix. In the first week or two after needling, the skin produces type III collagen, which is weaker and more fragile than the type I collagen that replaces it later in the tissue remodeling process. Needling while there is still a lot of type III collagen in the skin can destroy it and undo the benefits of the previous needling treatment. Many experienced skin therapists prefer a 6 to 12 week recovery period, which allows progress to be evaluated. The amount of needling done is also relevant. If working on multiple areas, take care to treat them one by one to help ensure the client’s healing mechanisms are not overwhelmed. For best results, it is usually recommended that clients commit to completing one to three treatments, although as the skin condition and individual expectations will differ the required number of treatments may vary. In the case of wrinkles associated with ageing skin, one or two refresher skin needling treatments are recommended every year.
Are the results permanent?
Skin needling results may last for several years, however due to a combination of factors such as lifestyle and free radical damage, maintenance treatments may be suggested to the client. As with any treatments, it is important that clients are made aware that to prevent further damage they must avoid excessive sun exposure and apply SPF 30+ sunscreen daily during and post treatments.
Preparing clients for skin needling
To minimise the possibility of adverse skin effects, clients should be advised to avoid the following activities for at least two to four weeks prior to a treatment:
• Sun exposure (apply SPF 30 + sunscreen daily).
• Solariums (professional spray tanning)
• Topical fake tans.
• Prescription strength exfoliates.
• AHAs (Glycolic Acid), Retinol, acidic or ‘active’ ingredients.
• Dermal fillers and/or cosmetic injectables.
• Thick or clogging cosmetic products.
• Accutane (one year prior).
Post treatment care
While skin needling is usually well tolerated by patients, the skin reddens and swells immediately after the treatment and dryness, scaling, redness and swelling may last for several days or longer, depending on the depth of penetration of the needles. For treatment with longer needles it may take up to four to five days for the skin to return to a moderate pink flush which is usually easily covered with mineral makeup and the swelling to decrease. After a skin needling treatment the client’s skin will be flushed and warm – much like a sun burn – so clients are advised to treat the skin gently, just as they would a sunburn. Mineral make-up may be worn the day after treatment. The client should be advised to avoid:
• Prescription strength exfoliant creams.
• AHAs, retinol, acidic or active ingredients.
• Chlorinated swimming pools and spas.
• Activities that cause excessive perspiration.
• Dermal fillers and/or cosmetic injectables (three months post).
• Sun exposure (SPF 30 + sunscreen should be applied daily).
Contraindications of skin needling 
As with any professional treatment, ascertaining the client’s medical history is important. Certain medications may affect the treatment. For example, if the client’s skin is photosensitive due to the use of Roaccutane and Retin A, this could result in pigmentation, so clients should be asked to inform the therapist of any medications and confirm the dates when they were last taken. 
Other contraindications and precautions include: keloid or raised scarring; history of eczema, psoriasis and other chronic conditions; history of actinic (solar) keratosis; history of Herpes Simplex infections; history of diabetes; presence of raised moles, warts or any raised lesions on targeted area. Absolute contraindications include; scleroderma, collagen vascular diseases or cardiac abnormalities; rosacea and blood clotting problems; active bacterial or fungal infection; immuno-suppression; scars less than six months old; and facial fillers in the past six months.
Complementary skin products 
If clients are topically using Retin A, they must not use it for one week leading up to their treatment. After a skin needling it is important that clients treat the skin under your guidance. This ensures they will get the best results with their healing and with the effects of the procedure. Initially, your goal will be to soothe their skin and enhance their confidence by reducing visible redness. Paramedical skin care may be used to treat the skin. Products that are calming and anti-inflammatory would be ideal to soothe any inflammation post needling, in particular a gentle, calming cleanser is recommended for two to three days after needling to ensure that the skin is kept clean, thereby minimising bacterial infection. Some therapists recommend that for the first few days after a professional skin needling, clients keep the skin covered with a very light coat of petroleum jelly to keep the area from scabbing and keep the skin soft and supple. No harsh skin care, including retinol or exfoliants are permitted for 72 hours. Cosmecutical skin care should also be avoided for 48 hours. Pure mineral make-up (no talc powders) may be worn to cover the redness and also to assist healing and this can be applied as early as the day after. No standard chemical or highly fragranced SPFs products are to be used, only physical SPF (ideally zinc based) so as to avoid adverse reactions or irritations. 
As product penetration is enhanced after a skin needling session, daily use of products with antioxidant protection vitamin C will enhance sunblock protection as well as help to even out the skin tone. Hyaluronic acid products can also be used as they are gentle and soothing, while plumping and hydrating the skin and minimising post needling dryness and flakiness. 
Products containing healing ingredients such as copper and zinc will also be beneficial in calming and healing the skin. 
After the skin has healed, clients should be advised to continue at home skin care using products that enhance the process of, and the requirements for, collagen synthesis.
These include products which feature in the ingredients: vitamin A, vitamin C, growth factors, copper peptides, bioflavinoids, iron, zinc and amino acids. 
New Zealand regulations
The Health and Hygiene Code of Practice 2013 states that all commercial services that pierce the skin are required to comply with the general standards for piercing the skin (Minimum Standard 3). The minimum standards contained in this part of the code are in addition to Part 3 and aim to ensure that operators who are undertaking electrolysis, red vein treatment or derma rolling / stamping conduct their operations in a safe and hygienic manner so as to reduce risks to public health.
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