Wishing all our valued patients a happy Christmas, relaxing holidays, and a prosperous 2018.
The Dermatologic Surgery journal has just published a literature review of microneedling including all references to skin scarring and rejuvenation. The article conclusion was "Microneedling is a safe, minimally invasive, and effective aesthetic treatment for several different dermatologic conditions including acne and other scars, rhytids, and striae. Given its expedient post-treatment recovery, limited side-effect profile, and significant clinical results, microneedling is a valuable alternative to more invasive procedures such as laser skin resurfacing and deep chemical peeling."
They refer to the studies that hypothesise the mode of action is that the creation of numerous microchannels physically breaks up compact scar tissue in the superficial dermis, while spontaneously inducing the production of new collagen and elastin underneath. The same production of new but native components of the dermis works to elevate existing furrows and wrinkles, and tighten and rejuvenate the skin. The microchannels represent tiny wounds which also stimulate the release of various growth factors such as platelet-derived growth factor, fibroblast growth factor, and transforming growth factor (TGF) alpha and beta. Perhaps most exciting is that the data shows up-regulation of TGF-B3 over TGF-B2. TGF-B2 is associated with fibrotic scarring in most wounds, but TGF-B3 promotes regeneration without scarring (scarless healing). A direct demonstration of this phenomenon is seen in foetal wounds that heal without scarring because of the predominance of TGF-B3 over TGF-B2 in the foetus.
While there is nothing particularly new in this article, it summarises well the advantages of this minimally invasive but effective treatment. We have been consistently very pleased with the results in our own patients. It is worth noting that the collagen induction and skin improvement is not immediate and the beneficial effects of each treatment can continue to work for up to 12 months. Treatment intervals are usually between two to four week to allow time for the cumulative effect to take place. There are a myriad of products and procedures advertised to treat scarring and skin rejuvenation. The benefits of skin microneedling are that it is promoting your own skin to rejuvenate itself with your body's own growth factors and dermal components rather than applying these or injecting them. The effects are therefore likely to last much longer and are much safer.
The authors indicated they had no significant interest with commercial supporters.
Reference: Microneedling: A review and practical guide. Alster TS, Graham PM. Dermatol Surg 2017;0:1-8.
A recent small study published in The Journal of the European Academy of Dermatology and Venereology confirms what we know of the benefits of good treatment early in acne using topical retinoids (vitamin A analogues). 31 adults with moderate acne and atrophic (sunken) facial acne scars were treated on one side of the face with a combination cream (adapalene and benzoyl peroxide) and the other side treated with a placebo cream. The duration of the study was six months.
Scarring increased over the study period on the placebo side, but did not on the active side. There was also a significant reduction in the severity of existing scarring on the treatment side, but not on the placebo side.
Dermatologists have long understood the value of early topical retinoid use in acne for improving control without contributing to antibiotic resistance. Prevention of acne scarring is far preferable to treatment. Topical retinoids also have a significant role in improving existing scarring.
It is of critical importance to have a confident diagnosis of a coloured skin lesion prior to laser being performed. A study published recently in The Journal of Dermatology reported 11 patients with a melanoma diagnosed in a region previously treated with laser therapy. In 9 cases, no biopsy was taken prior to laser. In the other two, pre-laser biopsy had shown a benign lesion. Four of the 11 patients progressed to stage IV disease and at least one died of melanoma.
This emphasises the very real difficulty in the diagnosis and treatment of pigmented skin lesions. It is imperative that a reliable diagnosis is established prior to any laser treatment. Each case is different, but a biopsy should be considered. As demonstrated with this series however, a partial biopsy of a pigmented lesion is not always representative of the lesion as a whole.
A high level of suspicion and caution should be exercised before making the decision to have a brown mark lasered off. We see cases, not infrequently, where the laser has removed the pigment but not the melanoma cells themselves. This can delay the subsequent diagnosis and treatment of the melanoma - with potentially fatal consequences. Pigmented skin lesions are not necessarily a mere cosmetic issue, and must be treated with the respect they deserve.
You read statements like this all the time. Often, you end up reading a contradictory article on the same topic not long after. You then choose to believe the one that suits best!
Here's a meta-analysis study (a study looking at all the previous smaller studies on the topic) published in the European Journal of Cancer Prevention. If you like your coffee, the news is all good. It states that there is a statistically significant reduction in the risk of basal cell carcinoma (our most common skin cancer) which increases with the more coffee you drink. The relative risk at one cup per day was 0.96 (a 4% reduction in risk) and this increased steadily to 0.81 (a 19% reduction in risk) for more than three cups of coffee per day.
Go and grab yourself a coffee - you've got the justification, if you need it!
The debate regarding the benefits of sun-exposure with respect to vitamin D production, versus the risk of skin cancer has been prolonged and confusing. An increasing list of the virtues of a healthy vitamin D level to our bodies is evolving. Against this; the production of vitamin D relies on the exposure of our skin to ultraviolet light (UV) which is well known as a human carcinogen. Mixed messages are sent, leaving the public unsure and distrusting of the advice received. One minute we are told to cover-up. The next report tells us there is a vitamin D deficiency epidemic and we must all get more sun-exposure to help our bones, our immune system, and prevent cancer. While media reports favour dramatic and sweeping statements, it is difficult to give general advice when each person's genetic and environmental make-up is so varied. Dark-skinned people living in areas of low UV-exposure are far more at risk of vitamin D deficiency than skin cancer. The opposite is true for fair-skinned people living in a high UV environment.
A 2014 study in fair-skinned Danish people proved that exposure to high UV levels while on holiday in the Canary Islands unfortunately not only led to an increase in vitamin D levels, but also to a significant increase in known biological markers of skin cell DNA damage. So what do we do? We need sun-exposure to make vitamin D, but as soon as we try to get it, we induce skin cancer??
As with most debates, a degree of moderation often ends up the best conclusion. With this in mind, a recent study performed by Felton et al. was reported in the British Journal of Dermatology. Our natural skin pigmentation level is measured by the Fitzpatrick Skin Type Scale. Fitzpatrick skin type I through to type VI document extremely fair skin that always burns and never tans (pale peach, blond or red hair, blue eyes, freckles) through to very dark skin that never burns, and always tans.
In the latest study, Felton et al. compared the results of people of Type V skin (dark brown) to Type II skin (fair) to simulated UK-latitude sun-exposure. The UV-exposure was equivalent to 13-17 minutes of exposure to the UK June midday sun, six times per week for a six-week period. They confirmed what we know: Type II skin demonstrated more DNA damage, and Type V skin less serum vitamin D production following sun-exposure.
However, interestingly they also found that mechanisms within our skin are present to respond to gentle sun-exposure by repairing sun-damaged DNA, and therefore reducing the risk of UVB-induced skin cancer. 24-hours after the six-week exposure period, the urine levels of CPD (a surrogate marker of skin DNA damage) and another DNA-damage marker (8-oxo-dG) were undetectable in both groups. This strongly suggests that fair skin can adapt to gentle sun-exposure, protecting itself against damage while allowing the production of vitamin D.
The important difference between the Danish study results and Felton's study is the level of UV exposure. The Danish study involved high-intensity UV levels. Felton's study involved longer, lower level exposures. Clearly, the summer-time UV levels in New Zealand and Australia are intense, and 13-17 minutes in the midday sun is likely to yield very different and detrimental results. However, gentle low-level exposure (e.g early mornings and late evenings, non-summertime etc) may mean we can get the best of both worlds. This also sits nicely with advice to use sunscreen during times of high exposure. Sunscreen filters out a proportion of UV radiation (rather than completely blocking it) reducing the dose reaching your skin and therefore should help achieve the effect seen in Felton's study rather than that seen in the Danish study. A number of studies have shown that the use of sunscreen does not reduce vitamin D levels in subjects exposed to the sun. Again, generalised advice is difficult. We need to take into consideration our skin type, our individual risk-factors for skin cancer (past exposure, family history etc), and our geographic location to strike a balance that will work well for our own situation.
We have known from previous studies that the high-intensity UV-exposure is not needed for efficient vitamin D production. In fact, vitamin D begins to be degraded at high UV exposure levels. While the relationship between increasing UV exposure and DNA damage is linear, the relationship between UV exposure and vitamin D production is non-linear. Maximum vitamin D production is seen at around 1/3 of the UV dose that induces a slight sunburn. Clearly, the advice never to allow yourself to get sun-burnt stands strong. The body's homeostatic and protective mechanisms are incredible, but can be overcome but extreme exposure (common during Australasian summertime sunlight exposure). However, we don't need to completely avoid all sun-exposure and risk vitamin D deficiency either. The benefits of sunlight (independent of vitamin D) as well as regular outdoor physical activity are well known. This study helps us to understand that with moderation, the clever machine that is our body, may well be able to manage the balance between optimal vitamin D level and skin cancer risk.
A word of caution however, Felton's study was performed on subjects aged 23-59 years old. Whether the same results would be found in older subjects is unknown. Prior studies demonstrate older skin lacks the same ability to repair skin DNA damage due to reduced IGF-1 production by the skins fibroblasts. Interestingly, anti-ageing resurfacing procedures such as micro-needling, dermabrasion, and lasers appear not only to improve the skin's appearance, but to rejuvenate the dermal fibroblasts protective IGF-1 production. Studies on this topic are ongoing to determine if skin resurfacing procedures do indeed produce a lasting preventative effect against skin cancer - rejuvenating not only the skin's appearance, but it's function as well.