“Tram Track Effect” After Treatment of Acne Scars Using a

Microneedling Device
MANISH PAHWA, MD, DNB,* POOJA PAHWA, MD, DNB,† AND AHMED ZAHEER, MD, DVD, PHD*

The authors have indicated no significant interest with commercial supporters.

S kin needling or percutaneous collagen induction

(PCI) suing a dermal rolling device (a needling
tool) is an office procedure used for managing
postacne scars. The treatment of postvaricella scars
and postacne scars usually requires multiple ses-
sions. We would hereby like to report the undesir-
able effect of “tram tracking” with the use of this
microneedling technique.
A 25-year-old woman with a history of varicella
3 years before and acne vulgaris for 6 years pre-
sented with multiple hyperpigmented scars on her
face. The scars were predominantly depressed and
rolled out; there were also some ice pick and boxcar
scars. She did not have a personal or family history
of keloids or hypertrophic scars.
zygomatic arch, and the forehead (Figures 1 and 2).
She was prescribed topical silicone gel, and after
6 months, there was slight improvement in the scars
Microneedling involves a hand-held instrument
consisting of a handle with a cylinder studded with
0.5- to 2-mm long stainless steel needles all around.
The cylinder is rolled on the skin in multiple
directions.1 During the process of microneedling,
tiny wounds are created in the papillary dermis,
leading to release of growth factors, which stimulate
the formation of new collagen.2 The effect of
microneedling has recently been explained on the
basis of a demarcation current produced amongst
cells when microneedles penetrate the skin, which
triggers a cascade of growth factors that stimulate

Two sessions of microneedling were performed

using a 2.0-mm long microneedling device (Derma-
roller; Dermaindia, Chennai, India). The second
session was done 5 weeks after the first session. Both
sessions were uneventful, and the patient had no
postsession problems. She was prescribed topical
mupirocin cream and sunscreen for 7 days.

One month after her second visit, she had multiple

discrete papular scars in a linear pattern in the
horizontal and vertical direction similar to a tram Figure 1. Multiple discrete scars in a linear array on the
track, predominantly over the temporal area, the cheek.

*Max Hospitals, New Delhi, India; †Department of Dermatology, All India Institute of Medical Sciences,
New Delhi, India

© 2012 by the American Society for Dermatologic Surgery, Inc.  Published by Wiley Periodicals, Inc. 
ISSN: 1076-0512  Dermatol Surg 2012;38:1107–1108  DOI: 10.1111/j.1524-4725.2012.02441.x

1107
 TRAM TRACK EFFECT AFTER MICRONEEDLING
Figure 2. Multiple discrete scars on the forehead.
the healing phase.3,4 We had used a microneedling
device weighing 18 g with 192 needles. The needles
were 2 mm long and spaced 2 mm apart. The
second session was more aggressive than the first.
The adverse effects reported included pain during
the procedure, transient erythema and edema, and
postinflammatory hyperpigmentation.3 The patient
had regular patterned scarring, like tracks of criss-
crossing trams.
This kind of scarring has not been reported previ-
ously. The authors believe that this scarring could
have occurred because of the use of a larger needling
1108 DERMATOLOGIC SURGERY
device or strong pressure while using the micronee-
dling device. Hypertrophic scars and keloids are
more often seen over bony prominences such as the
presternal area and shoulder than other areas. Thus,
the authors express caution when using micronee-
dling devices over bony prominences and would
recommend the use of needles smaller than 2.0 mm
over the same.
References
1. Majid I. Microneedling therapy in atrophic facial scars: an
objective assessment. J Cutan Aesthet Surg 2009;2:26–30.
2. Fabbrocini G, Fardella N, Monfrecola A, Proietti I, et al. Acne
scarring treatment using skin needling. Clin Exp Dermatol
2009;34:874–83.
3. Leheta T, Tawdy AE, Abdel Hay R, Farid S. Percutaneous collagen
induction versus full-concentration trichloroacetic acid in the
treatment of atrophic acne scars. Dermatol Surg 2011;37:207–16.
4. Jaffe L. Control of development by steady ionic currents. Fed Proc
1981;40:125–32.
Address corresponding and reprint requests to: Manish
Pahwa, MD, DNB, Department of Dermatology, Max
Hospital, N-110 Panchsheel Park, New Delhi, India,
or e-mail: drmanishpahwa@gmail.com