Does PRP Enhance Microneedling Results?

On today's episode of AP Class, we're reviewing a split-face comparison study examining whether platelet-rich plasma combined with microneedling offers meaningful advantages over microneedling alone in the treatment of post-acne scarring. We already know that microneedling alone is an effective intervention, but does adding PRP enhance outcomes or simply add complexity?

Episode participants:
Radiance Wellness | @radiance.well
Megan Ucich | @the.skin.practitioner
Aayesha Patel | @aaestheticsbyaayesha
Sarah Pertschuk | @beautyinjectorsarah

Episode show notes / blog: Link

Disclaimers & disclosures: Link

Transcript

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I actually read somewhere that acne is like one of the top runners that causes depression in a lot of adolescents and young adults. Totally. I believe it makes complete sense. And I think I mean personally I don't know about you guys but back when I had acne when I went to the dermatologist their main priority was just controlling the acne which is great but they don't really do anything after that. Like these scars stick around for so long and it still contributes to the self-esteem issue. And they don't really address how to fix that. Exactly. Um, so that's kind of where we come in. Yeah. Yeah. We're here for you. We feel you. Yeah. Welcome to AP Class, your virtual journal club for all things aesthetic medicine. Created by injectors for injectors, this is where we take a clear evidence-first look at the research shaping modern aesthetics. Each episode we'll unpack a study. What's solid? What's questionable? And how the evidence informs natural refined results in real practice. Class is now in session. On today's episode of AP Class, we're reviewing a split-face comparison study examining whether platelet rich plasma combined with microneedling offers meaningful advantages over microneedling alone in the treatment of post-acne scarring. We already know that microneedling alone is an effective intervention, but does adding PRP enhance outcomes or simply add complexity. Let's take a look into the research and dive in. Welcome back to AP Class. I'm Megan Ucich, nurse practitioner. I'm Aayesha Patel, PA, and I'm Sarah Pertschuck, physician associate. We are the providers here at Radiance Wellness, and we are coming to you with AP Class. So, today we're diving into one that's near and dear to our hearts. It is microneedling over acne scars. This one I think really resonates for a lot of people especially in aesthetics. I know we've all talked about it. We all struggled with acne. Some of us acne scarring. I know I had to go on Accutane when I was a kid. Did you guys do Accutane? I had to go on Accutane. You did? I asked for it and then the dermatologist was like, "No." Oh, no. Yeah. But acne, right? I I honestly like for so many people, I feel like my threshold now is low to be like,"Maybe you need Accutane." Yeah, because it has such a profound impact on your self-esteem. Acne is especially at that age when you're young in your teens and 20s and it really can change the trajectory of your life. And for us, I know that it did like we got into aesthetics because of that passion because it was something that was near and dear to us. So, I love that we now can help treat people that are going through similar situations and help improve their quality of life. So yeah, I went to PA school because the nurse practitioner that treated my acne when I was younger changed the trajectory of my life and I was like, that's what I want to do. Yeah. I want to help kids with acne. And I actually did my thesis in PA school about Accutane. That's amazing. I actually had a similar story. I found the PA profession because I went to the doctors looking to treat my acne and the provider was a PA and I was like, "Oh, wow." Like, "That's cool. Oh my gosh, I love that." Yeah. Yeah. My first taste into aesthetics was my nurse practitioner, primary care, um, NP was like,"I think you should go get microdermmaabbrasions for your acne." Oh my gosh. And so I went to like a cosmetic place to get microdermabbrasions and I was like this is a cool world. I like this. I want more of this. But you know for so many people even after the acne has cleared there's still this whole other realm of acne scarring which still can have a profound impact on people that lasts for years. So this study is really looking at that. We know that microneedling is incredible for the skin. We know it's incredible for for acne scars. But now we want to look at adding in PRP. How does that change the efficacy of microneedling? Can we see better results for our acne patients by adding adding in some PRP to their to their treatment? And we'll go over what PRP is. But so this study is called a split phase comparative study of efficacy of platelet rich plasma combined with micro needling versus micro needling alone in treatment of post acne scars. Yes, it's a mouthful, but you have, you know, they should really try to like cut down the title. Just keep it concise. Yeah. All right. Well, I guess we can't really speak. We don't write research studies, so we should probably just, you know, stick to our lane. Stick to analyzing. Stick to analyzing. So, let's get into it. What did they do? What did they find? Most importantly, how does this change the way you treat patients or as a patient? Yeah. So let's first talk a little bit about acne vulgaris and how it's more than just a skin condition. It is very volatile skin condition and scarring afterwards and during is very very common and it's not just physical, it's emotional. There's a huge psychological effect on patients that have this. So, it affects their, you know, how they feel every day, what they look like, their self-esteem, depression, and it's really lowers their quality of life, especially since it hits in those transformative years when you're young, you know, 14 to 20 or even longer. And a lot of people don't even know that there's treatments. Yeah. So that's it's really important that we find a treatment for our patients that are suffering with these acne scars um to help them through that difficult time. And so talking about treatments a little bit, there's a lot of treatments out there for acne scars. There's chemical peels and lasers, microdermmaabbrasion. there's, you know, resurfacing agents, but microneedling time and time again has been a go-to for a lot of patients because it's accessible, it's affordable, and it has, you know, really great results when it comes to resurfacing the skin and helping build collagen. Yeah. And I think what's so tricky about it is that collagen is so compromised. Right. Right. And that's why micro needling is so amazing because you really need to kind of reorganize that very disorganized collagen that's under the surface of the skin and you need to kind of break it up and lay a new foundation and that's hard to do. Yeah. There's also minimal adverse effects after this. And in this study, I'm glad they treated patients with a slightly darker Fitzpatrick because it shows that there's limited um or minimal post inflammatory hyperpigmentation with this treatment. Back to the depression part. I actually read somewhere that acne is like one of the top runners that causes depression in a lot of adolescents and young adults. Totally. I believe it makes complete sense. And I think I mean personally, I don't know about you guys, but back when I had acne, when I went to the dermatologist, their main priority was just controlling the acne, which is great, but they don't really do anything after that. like these scars stick around for so long and it still contributes to the self-esteem issue and they don't really address how to fix that. Exactly. Um so that's kind of where we come in. Yeah. Yeah. We're here for you. We feel you. Yeah. So this study is primarily um looking into PRP with microneedling. So we know PRP is an autologous um preparation of platelets that release growth factors like PDGF, VEGF. Um these are your intrinsic growth factors. Your body creates them. So that means your body is making them for people or auto selfmade is what I learned. Um so it's not your PVGF that's made outside of your body, right? Um, and the theory here is that it creates um, it releases these growth factors that work synergistically with the wound healing cascade that's triggered by microneedling and that's what's creating that collagen and tissue um, regeneration. So, I think this is a huge thing to kind of look into when we are treating our acne patients. You know, whether there's a missed opportunity if we're not treating them with that PRP or just doing microneedling alone. Yeah. And now people hear differences like we use PRF, right? So there's like PRP, PRF, they're both coming from the same place. Just boils down to the concentration of those growth factors. So PRF has that higher concentration of fibrin which is that protein that you know gets that collagen going. So they're both great. Um, PRP or PRF is a little bit better in a sense just because it's a higher concentration. Yeah. Yeah. And this is stuff that's used in orthopedics all the time too, right? I have some patients that tell me all the time they, you know, knee injections into bad joints. One of my patients was saying um, in infertility, they injected PRP or PRF into her fallopian tubes. After like failed and failed IVF treatments, they did PRF and she got pregnant. Wow. Yeah, I think we're starting to realize that it's used for a lot of things. Um, you know, joints, aesthetics, infertility, there's just it's endless. Yeah. When we were looking for papers to do for this class, I kept coming up on these oral papers with, you know, gingivvil things for their gums and teeth. And I was like, that is great, but that's not what I'm looking for here. Can you imagine how much that must hurt? No, I don't. I try not to think about the dentist. Yeah, my teeth hurt just thinking about that. But I I saw that, too. There's a lot in the dental field with injecting that. Mhm. Cool. All right. Well, let's go over where the study lands in the hierarchy of evidence. So, thinking about that pyramid again, that kind of helps us determine like how much weight are we giving these findings. This is a comparative study. It lands in the category three or four. So, it's below a meta analysis. it's below a randomized control trial. Um, but it's above an observational or an expert opinion. So, there is some sort of comparison happening in this study and we'll get into the details of that. Um, but you know, there is always room for a little bit of bias. Um, they may be underpowered because it's not a randomized control trial. Um, and so those are just things to to take into consideration. It is great that they did a split face comparison. That's really helpful in dermatology when you're trying to assess because it takes away some of the noise, which Sarah, I think you explained that really well. Like, you know, when when you have two people, it's like, well, our skin could heal differently. Uh maybe I have more acne than you have, but when you're doing it to yourself on both sides, it takes away a lot of that noise. So, it was great that they were able to do that. Yeah. It's like the same skin, same scars, same healing capacity for the patients that they picked. So, that was really cool. Um, so kind of getting getting into the design of the study, this actually really matters when we're kind of breaking up that evidence. So to start with the population, they picked 30 patients um with Fitzpatrick's 2 to 4 um sourced from a dermatology clinic in Bangalore, India. So this was kind of cool being brown. Yeah. Myself and having acne and scarring. And it was kind of interesting to see what the results that they found. Um the patients were aged between 19 through 35. So the mean age was around 25 and 60% of them were male. So all the patients had atrophy acne scars. So there were either rolling scars or box cars box. Say it 10 times fast. Box scar. Box scar. Box scar. And our ice pick scars. Um, what did you call it earlier, Sarah? Pick axe. Pick axe and then axe pick and then axe pick. Just couldn't get it right. I mean, that's what I would imagine if someone came out of me with a tiny little axe stick. That's what it would leave it behind. Yeah, exactly. Yep. Um, so there were all scars that were moderate to severe in severity. So that was the inclusion criteria and so there was a lot of exclusion criteria as well. They wanted to make sure that none of the patients had any tendencies towards keloid scars. And they also wanted to make sure that patients didn't have any active acne. It was just scarring. And that's not to say that active acne is a contraindication for microneedling. That's just not what they looked at in this study. The other things that they wanted to avoid were obviously anybody that was pregnant or lactating and anybody with bleeding disorders. So basically anything that could inhibit healing or results. And the way that they looked at the results, they started with a scar grading scale called the Goodman Baron scale and that basically stages the scars from one to four. And so they didn't include anybody with a one. Those are like macular scars that aren't raised and don't have any depth. And they took people with scars that were a two to a four. So the two are atrophic scars, hypertrophic scars, the rolling scars, right? And then three is the box scar plus the rolling scars, atrophic scars, hypertrophic scars. And then four is the ice pick scars, the box scars, rolling scars, and tunneling. So the four is obviously the worst level to have. Yeah. So, when they were choosing what scar types to let in to the study, they chose types two through four and those are the people that they decided to do the microneedling on. Right. So, microneedling, the way that they did the treatment was I thought it was super interesting. They used a derma roller which we don't use often in our professional practices but that but it was interesting because the needles were at 1.5 mm. Yeah. Which I think is an important call out so people aren't like going on Amazon like I could get the derma roller. This was a very deep dermar roller. But it's interesting because that's probably what they have the most access to there. Whereas we have Skin Pen and other apparatuses like that, you know, they used a derma roller with 1.5 mm needles and there were like 192 needles on each drum. Yep. And the practitioners who applied the treatment went uh vertically back and forth, horizontally back and forth, and then diagonally in each direction to make sure they really covered all of the surface. Yeah. And then the right side of the face was the face that was the face. The right side of the face was the side of the face that received the PRP and it was applied topically after the procedure but also injected intradermally in the superficial layers which I thought was really interesting because we microneedle our PRF into the skin when we're doing it and apply it afterwards. But I thought it was cool that they didn't do it until afterwards and then they also injected it. I know. I thought that was an interesting take, too, is to maybe go in after you've microneedled or before and inject into the scars a little bit with some of that PRP or PRF. Yeah. So, that's how they divvied up the face. So, the right side got the PRP and the left side just received the microneedling. Perfect. Oh, they also the way that they did the microneedling was they did four sessions one month apart and then they had a six-month follow-up. And after each session, they did follow up after a week just to make sure that there were no adverse events. They wanted to make sure people were wearing sunscreen, covering their faces, things like that. Um, and then the last after the last treatment, they followed up six months later. Right, and then they used those two scales. So there was the Goodman and Baron qualitative scar. So poor was there was no change. Good one great improvement. Excellent two great improvement. And then there was also the visual analog scale. Yes. That was the 0 to 25% improvement, 25 to 50% improvement, 51 to 75% improvement, or 75% improvement and more. And that was the one that they asked patients to kind of point to on the scale. like where do you feel like you are after these treatments? Um so then what did they actually find? So okay, we've got 30 patients. We split their face in half. Right side micro split their face sounds aggressive. Right side you microneedle it with PRP. Left side you microneedle it alone. They found that 80% of patients showed some reduction in scar severity on at least one side of their face. But what's interesting is 93% showed improvement on the PRP plus microneedling side where only 73% showed improvement on the microneedling alone side. So they definitely noticed that there was an improvement in their skin more I was going to say statistically more but or significantly more but we actually don't know that. Um but they did show some sort of improvement on the on the PRP microneedling side. Yeah. And so when they looked at the degree of improvement like you were saying with the two score change they found that 43% of patients achieved an excellent score on the PRP side of their face. And what that means is for example they went from a grade four scar down to a grade two. So there was a two level change in the type of scarring that they had. So it improved. So it's a decline in the number scarring but it's an improvement in their overall scarring because it went from a four to a two. Right? So patient satisfaction also had a similar result. They said that on the PRP side 37% of patients found a 75% improvement and on the micro needling alone side only 3% reported a level improvement. a big difference just on patient satisfaction on the surface level, it does seem like adding PRP um to microneedling is compelling. Yeah. Yeah. Yeah. So, let's pump the brakes a little bit. I feel like when we were reading the study and analyzing it, we're just saying like there was this buildup like, "Oh my god, this is amazing and then we're like where is all the statistical analysis?" So unfortunately they weren't really clear on any statistical analysis that they used here. We really didn't get any p values to tell us was this a statistically significant finding. So again that means for us can you generalize this? Like can we go out to our patients tomorrow and say with some sort of certainty that we can reproduce this over and over again. Um on this study we can't because we didn't get that. We know and we'll talk about there's a lot of other randomized control trials that have looked at micro needling with PRP that that do show that. But it was just a little bit of a bummer that um that we didn't get that here. Especially when they went through all of the work to do a split face comparison. Like you're setting yourself up for so much success there. You're controlling for so much of the noise by doing a split face, but then if you don't analyze it correctly, unfortunately, it can fall flat. This is why it's so important, especially for us as providers, too, to go back to reading research and to not just look at the headline because sometimes the headline can be misleading. To actually dig in a little bit deeper and analyze it and look to see, does the statistical analysis make sense? Is it actually is there actually something reproducible for me here? Um, so it's just a little bit of a bummer because it it was so close and then it just kind of fell flat. I know. Yeah. So they they kind of threw a lot of percentages at us without without any like confidence intervals or like formal hypothesis, right? And they were just there was nothing that kind of showed statistical significance. And they also had they were analyzing so many different outcomes like patient satisfaction uh physician grading different scar types and they weren't adjusting for the multi multiplic multiplicity um multiplicity multi multiplicity is that a word I think it is yeah multiplicity yeah so there were so many things that they were analyzing but it kind of created like a false positive because there was no consensus. Yeah. Yeah. Um so I mean overall though the sentiment is that the PRP side definitely had an improved response. Yeah. And but it's interesting because when you have doctors evaluating the patient and then patients evaluating themselves, there's a big difference in the scoring there. So it looks like that there's only 17 to 27% of the cases showed agreement between the physicians and the patients on their score. What they refer to that as is the flawless bias and that really means that patients had these expectations of being flawless after the fourth treatment. And so even though most of them received an excellent score for reduction in their scar size and type, they themselves didn't see it as excellent because they had this expectation that their skin would be completely renewed and refreshed. Right? So the doctors are looking at him from an objective standpoint and the patients are looking at themselves from a subjective standpoint. And so there was a big difference there and they didn't really make any room for or a basis for any of that to make it statistical. Yeah. Well, this proves that we are our worst critics kind of matches there. Um there were obviously limitations in this study. Um one being that the patients or the providers were not blinded. So the physicians performing the procedure knew which side was getting treatment or which side was getting PRP as well as the patient. So that kind of scales or creates bias for the performance and the detect detectation detection detection detection. I should just make it up words today. I know I love it. Yeah. So there was bias for the performance and detection especially for the subjective outcomes like patient satisfaction. Yeah. Um that's just going to be a harder scale. Isn't that so true though? Like even with our own patients, you find that happens too. They walk in and I'm like, "Oh my god, you look I you look so good." And they're like, "Oh, I feel like I look like shit." Or, you know, we are our own worst critics. Always. For sure. Yeah. And so while it wasn't blinded, it also wasn't randomized. So the right side of the face for everybody received the PRP and the left side received the micro needling only. So true randomization of the sides would have controlled for any asymmetry in the scar distribution. Totally. Yeah. And then that statistical analysis. So when you're doing a comparative study like that with that split face, you should be using a paired t test, not an unpaired t test. The reason being is it takes out that noise we kind of talked about. So it's kind of like an analogy of like if you have 30 people that you want to see who likes chocolate ice cream and who likes vanilla ice cream and you give one half 15 people vanilla ice cream and one half chocolate ice cream. Well, Sarah maybe just loves all ice cream and so she like rates all of the all chocolate ice cream or vanilla whatever I gave you the same, right? But so you have noise in there because you have people's preferences. Instead, it would be like giving everyone chocolate ice cream and vanilla ice cream and then asking them which one do they like better. That's like a paired t test. So, that helps to take out the noise and make sure that the data you're getting to actually is meaningful to what you're trying to achieve. Yeah. I was wondering how I could be in both of the I like all ice cream. I like all ice cream. So, I mean the swirl. Yeah. Can I'll be in the swirl group. Yeah. What's your favorite ice cream? Mine's cherry Garcia. Oh, mine's okay. Don't judge. I'm already. But every time I tell people it's mint chocolate chip and they're like,"That tastes like toothpaste." No. No. I like mint chocolate chip. Okay. Right. Yeah. So good. Little chips, not big chips. You like big chips? I like big chips. Okay. Or like a mint Oreo. Oh, love a mint Oreo. Ben and Jerry's has a good one. Mmm. Um, I like a double chocolate with peanut butter in it. They're full chocolate base. Yeah. Yeah. Just full full chocolate and add that peanut butter in and you won't hear me talk for hours, man. All we had to do was give one ice cream analogy and we just went completely off course. Yeah. Love it. All right. Reel us back in. Reel us back in. The one other limitation would be PRP preparation is so variable and in aesthetics and actually I think in medicine in general when using PRP there is no standardized preparation for that. So they talk about their centrifuge time was 15 minutes very different than what we do in office. Some people are using PRP and they have that additive that's kind of part of the tube so that doesn't coagulate some don't. So it's also like my chicken soup might be different than your chicken soup and your chicken soup. Why do I keep bringing up food? I don't know. But I we are very food centric. Yeah. But you know so the PRP changes too, right? Depending on where you go. So those are other variables to take into consideration as well. Yeah. I think the overarching sentiment of this paper to kind of bring it all together was that PRP added on to microneedling is improving the procedure for patients with acne scars. Yeah, it's in it's increasing the effectiveness. And this study isn't in a vacuum, right? So, this was one study. There's a lot out there on microneedling with and without PRP. There's actually a metanalysis that looked at 14 controlled studies. There was over 470 patients in that study that showed PRP with microneedling was associated with significantly higher odds, greater than 50% clinical improvement. So, there's a lot of strong data out there. Um, again, it just goes back to, you know, each research study and really looking at the quality of the evidence. Yeah. Yeah. And I think what this means for our patients when they come in for acne scars, it doesn't say that, okay, micro microneedling alone, you know, shouldn't be done anymore. We're still doing it. It still gives great results. But if we can boost that and give optimal results, then we are offering that PRP or PRF in our practice. Yeah. Yeah. And I think too we always kind of counsel our patients. The quality of your blood matters so much, right? So back to that PRP prep, but like are you on anti-coagulants? Are you eating a healthy diet? Are you well hydrated? All of that affects your healing response and therefore your growth factors and what kind of treatment you'll get. That's something I want to look into though because I want to be able to advise my patients on what type of diet to eat and it's been difficult to find information on that. So, if anybody listening has specific ideas, specific ideas that they can send over to us, that would be great because improve your improve and improve your yield. You know, how much you yield because, you know, I'll have a patient that's the spinning image of health and and granted, I'm going to talk about PRF here, but they yield such little PRF, whereas another patient that I just don't think is as healthy or doesn't look as healthy or whatever, they yield so much PRF and I just can't figure out the difference. So, yeah, I'd like to look more into that. Yeah. All right. Anyone have anything else? I feel like this was a good study. Again, a little bit of a lead-up and then a little bit of a but we know the evidence is there. We know there's there's strong evidence. But I think this was a good learning lesson too for everyone listening why we read research and analyze it and critique it because there are flaws. There are limitations. So it's just more than just more than just what the title is. More than just what the title is. So this is true. I think also at the end of the paper it basically says that microneedling with or without PRP is helpful for all of the types of scars. It wasn't just specific to one type of scar. It's specific to all of the different types of scars. So, I think anybody with acne scars is going to benefit from either or of these procedures. Yeah. Yeah. I also love that it was done on darker Fitzpatrick's too because there's always that risk of, oh my god, am I going to hyperpigment because I'm more at risk for that. So that was really reassuring too to see that that wasn't an issue. I really liked that part. Yeah, I was interested to find how they found a Fitzpatrick 2 in Bangalore, India, which is South India. I was like, okay, that's interesting. Yeah, good point. Yeah. Yeah, if they're all Indian, you literally cannot be a fits too. That's what I was thinking. I was like, oh, that's really interesting. Ethnicity wise, how is that possible? Like, you're definitely a four or above. Yeah. Okay. So, got some expats in there, maybe. Yeah. I don't know. Something's going on. Um, I also love that it was a lot of males. Shout out to our our men that want to take care of their skin, right? Like, I love this. We need more didn't I like that it didn't even reveal that until later. I know. Oh my god. 60% males. Oh my gosh. We love that. So surprising. Yeah. So also great and I and I do think for a lot of men that come into our practice, this is a common one, acne scarring, microneedling, like what do I do? What do I do about this? So love that for them, too. Yeah. Awesome. Thank you guys so much for joining us on another episode of AP Class and we will see you next time. You've been listening to AP Class, your virtual journal club for all things aesthetic medicine. If you found today's episode helpful, like and subscribe, share it with a colleague, and join us next time as we break down more evidence that helps elevate your practice.