Journal of Cosmetic and Laser Therapy

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Confocal microscopy can assess the efficacy of

combined microneedling and skinbooster for
striae rubrae

Caterina Mazzella, Mariateresa Cantelli, Paola Nappa, Maria Carmela

Annunziata, Mario Delfino & Gabriella Fabbrocini

To cite this article: Caterina Mazzella, Mariateresa Cantelli, Paola Nappa, Maria Carmela
Annunziata, Mario Delfino & Gabriella Fabbrocini (2018): Confocal microscopy can assess the
efficacy of combined microneedling and skinbooster for striae rubrae, Journal of Cosmetic and
Laser Therapy, DOI: 10.1080/14764172.2018.1511913

To link to this article: https://doi.org/10.1080/14764172.2018.1511913

Published online: 21 Aug 2018.

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JOURNAL OF COSMETIC AND LASER THERAPY
https://doi.org/10.1080/14764172.2018.1511913

Confocal microscopy can assess the efficacy of combined microneedling and

skinbooster for striae rubrae
Caterina Mazzella, Mariateresa Cantelli, Paola Nappa, Maria Carmela Annunziata, Mario Delfino,
and Gabriella Fabbrocini
Department of Clinical Medicine and Surgery, Section of Dermatology, University of Naples Federico II, Naples, Italy

ABSTRACT ARTICLE HISTORY

Striae distensae or stretch marks are dermal scars characterized by flattening and atrophy of the epidermis. Received 19 March 2018
They develop particularly during adolescence but they can also appear in other situations such as pregnancy, Accepted 7 August 2018
the use of prolonged therapies with topical or systemic corticosteroids, Cushing’s syndrome, Marfan’s syn- KEYWORDS
drome, prolonged use of lightening creams, cachexia, rapid weight loss or the use of androgenic and anabolic Skin needling; skin booster;
substances. Treatment options often take a long time, and the results are often disappointing, causing confocal microscopy; striae
significant psychological distress in patients. rubra
We propose a completely innovative approach, combining the skinbooster technique with the microneed-
ling technique. These minivasive methods work by inducing tissue remodeling and stimulating the synthesis
of new collagen. Confocal microscopy can show and follow the skin changes made by these therapies, thus
becoming an important and valid therapeutic monitoring tool for aesthetic dermatology.

Introduction microdermabrasion. No single therapy has been supported

to totally eradicate these lesions (9). Our study is the first to
Striae distensae (SD) or stretch marks is a common condition,
evaluate the combination of two innovative treatment techni-
whose prevalence is 80% in the general population (1). There
ques for SD: microneedling and skinbooster.
are two forms of SD: striae rubra characterized by erythema-
Besides to evaluate the improvements made by these two
tous and stretched lesions and striae alba characterized by
methods, we used confocal microscopy that can be used for
atrophic, wrinkled, and hypopigmented lesions (2).
non-invasive, real-time evaluation of inflammatory condi-
The histological changes of SD are elastolysis of the mid
tions. The hand-held model (VivaScope 3000, Caliber I.D.,
dermis with mastcell degranulation and stimulation of macro-
Rochester, NY) has enabled imaging of small and difficult
phages, perivascular lymphocytic cuffing, increased presence
cutaneous areas.
of glycosaminoglycan, sporadic presence of lymphocytes and
oedema in the dermis (3).
In striae rubra, vascular changes can contribute to the red Material and methods
appearance of the striae, besides collagen fibres become
Ten women patients with striae rubra (average age: 20.5) were
thicker, densely packed, arranged in a parallel pattern with a
enrolled in this study, and they signed informed consent prior to
reduction in elastic fibres. Striae alba are characterized by a
treatment. This study was designed following the 2000
less important vascular change so they are very pale in colour
Edinburgh revision of the Declaration of Helsinki and the
and are similar to stretched dermal scars (4). The pathogen-
applicable ICH guidelines, as well as the Guidelines on
esis of striae remains unclear but a genetic predisposition has
Research Practice. The tested product, used in order to perform
been noted previously (5). Risk factors associated with SD are
the treatment, was stabilized 12 mg/mL hyaluronic acid NASHA
ethnicity, chronic steroid use, pregnancy, Cushings syndrome,
(non-animal stabilized hyaluronic acid) technology with lido-
obesity, adolescence, family history (6). The most frequent
caine. It is commercially available with the trademark Restylane
locations of SD, especially in women, are: breasts, abdomen,
Skinboosters Vital Light and distributed by GALDERMA. The
buttocks, thighs, knees, calves (7).
injection can be made thin wall 29 g needle. Microneedling has
The treatment can be difficult because it reduces only
been practiced using Dermapen ®, an ergonomic device makes
symptoms and improves appearance (8). The most common
use of disposable needles and guides to adjust needle length for
method for treating SD is the use of topicals such as tretinoin,
fractional mechanical resurfacing. The tip has 9–12 needles
cocoa butter, olive oil, silicone gel etc, but different techniques
arranged in rows. The advantage is that it is possible regulate
exist: laser therapy, light therapy, acid peel treatments, laser
the depth of penetration of the needles.
lipolysis, radiofrequency techniques, skin needling and

CONTACT Caterina Mazzella caterinamazzella@libero.it Section of Dermatology, Department of Clinical Medicine and Surgery, University Federico II of
Naples, Via Pansini 5, Naples 80131, Italy
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/ijcl.
© 2018 Taylor & Francis Group, LLC
2 C. MAZZELLA ET AL.

Figure 1. combined treatment: the injection of the hyaluronic acid for the deepest striae (a); microneedling for the less deep striae (b).

In our study, it is preceded by the application of topical Results

anesthesia 20 min before the treatment on the areas, with the
In this study, all patients demonstrated aesthetic improvements
depth of penetration of the needles of 1 mm.
well documented by the photographs taken before and after
Inclusion criterion for this study was the clinical evidence of
60 days (T2) from combined approach. So, the photographs
striae rubrae. Exclusion criteria were history of severe allergic
collected showed a good durability of the aesthetic results even
disorders, known hypersensitivity to HA, history of autoim-
2 months after the treatment (Figures 2, 3a-b). Moreover, confocal
mune disease, pregnancy, lactation and history of skin cancer;
microscopy showed, before the treatment, a pattern characterized
use of anticoagulant therapy such as aspirin or warfarin, use of
by parallel collagen fiber bundles running along the tension lines
retinoid medications or peeling agents in the 4 weeks previous
of the skin perpendicular to the major axis of the lesions, while
the treatment; microdermabrasion or use of fillers in the
after 60 days from treatment, confocal microscopy revealed col-
24 weeks before the treatment. The combined treatment was
lagen bundles that appeared strongly refracting in the dermis and
performed by a dermatologist: the injection of the hyaluronic
that were arranged in a cross-linked network without any obvious
acid was reserved to the deepest striae and microneedling by
precise direction (Figure 4, 5a-b).
Dermapen® for the less deep striae in the same cutaneous area
All the patients were satisfied both immediately after the
affected by SD (Figure 1a-b). Patients received an injection of
procedures and after 2 months and no side effects were
0.5 ml of the product for each SD, and the injections were
reported during the observation period beyond mild symp-
performed with a linear retrograde technique. Once the proce-
toms (pain, sensation of heat, reddening in the injection site).
dure was completed, the injection site was manually massaged
to allow the implanted material to adapt to the tissues.
Dermapen® was carried out by rolling the needling tool over Discussion and conclusion
the areas affected by SD in four different directions: horizon-
tally, vertically, and diagonally right and left. Microneedling is a very simple, safe, effective and minimally
The two treatments were always performed together in 3 invasive procedure that uses fine needles to puncture the epider-
sessions: 1 session every 4 weeks. Visits were planned at mis. It stimulates the release of growth factors and induces col-
30 days (T1) and 60 days (T2) after the last treatment. lagen production (10). The epidermis remains relatively intact,
Patients were photographed at T0, T1 and T2. Another der- limiting adverse events, especially in dark skintypes, in which risk
matologist expert in confocal microscopy, who did not know of post inflammatory pigmentation is very high with other aes-
the type of treatment in the patients, practiced confocal thetic techniques (10). It is used specially for the treatment of
microscopy at the time T0 and at T2. facial scars and skin rejuvenation, but it is very promising for the

Figure 2. clinical results (thighs): before the treatment (T0) (a); after the treatment (T2) (b).

Figure 3. clinical results (abdomen): before the treatment (T0) (a); after the treatment (T2) (b).
Figure 4. confocal microscopy results (thighs): refracting parallel collagen fibres bundles runningalong the tension lines of the skin perpendicular to the major axis of
the lesions before treatment (T0) (a); refracting collagen bundles in the dermis arranged in a cross-linked network without any obvious precise direction after
treatment and new papillae in the context of cross-linked network (T2) (b).
Figure 5. confocal microscopy results (abdomen): refracting parallel collagen
fibres bundles running along the tension lines of the skin perpendicular to the
major axis of the lesions before treatment (T0) (a); refracting collagen bundles in
the dermis arranged in a cross-linked network without any obvious precise
direction after treatment and new papillae in the context of cross-linked net-
work (T2) (b).
treatment of androgenic alopecia, cellulite, alopecia areata, hyper-
hidrosis, melasma and periorbital hypermelanosis (11).
Microneedling may also be combined with topical treatments,
like platelet rich plasma (PRP) or another vitamin-rich serum
(12). Skinboosters are based on stabilized hyaluronic acid of
non-animal origin technology, called NASHA™ (13). Injection of
cross-linked hyaluronic acid stimulates collagen synthesis, par-
tially restoring dermal matrix components that are lost in
JOURNAL OF COSMETIC AND LASER THERAPY 3
photodamaged skin. This stimulatory effect may be induced by
mechanical stretching of the dermis, which in turn leads to
stretching and activation of dermal fibroblasts. Wang et al. studied
the effect of non-animal origin stabilized HA on human skin in
vivo injecting 0.7 mL of Restylane or normal saline into photo-
damaged skin of the arm of 11 volunteers. The injected sites were
biopsied and followed 4 and 13 weeks after the injection. The
results showed increased intracellular and extracellular dermal
marking for collagen I in NASHA-treated samples, particularly
in the skin areas adjacent to the filler. This increase in collagen
production was caused by increased levels of transforming growth
factor-β as well as increased expression of tissue inhibitors of
collagen degrading enzymes. Besides fibroblasts surrounded
NASHA appeared different morphologically from fibroblasts in
saline-treated skin. So the authors proposed that the mechanism
of collagen stimulation was not a direct effect of HA on fibroblasts
but rather indirect mechanical phenomenon. NASHA-mediated
hydration of extracellular matrix induces mechanical stretching of
fibroblasts, thus, initiating production of connective tissue com-
ponents, such as collagen type I (14). Quan et al. showed that
injectable HA caused fibroblasts elongation with subsequent
increase in procollagen I and collagens I and III production for
at least 12 weeks after HA injection. This stimulation is mediated
by up-regulation of type II transforming growth factor-β receptor
and connective tissue growth factor (15).
4 C. MAZZELLA ET AL.
SD are hypothesized to form in patients where the cross-
linked collagen is “overstretched” and rupture of this collagen
matrix causes the striae (15), therefore increasing collagen
production could be a mechanism by which to repair or
treat SD and before today no study has used the injection of
hyaluronic acid for their treatment. In our study using RCM,
we found that striae exhibited parallel collagen bundles run-
ning in the direction of the presumed skin tension while after
treatment collagen bundles are finer than those found before
treatment, and they are arranged as typical randomly oriented
cross-linked collagen similar to those present in the normal
dermis. This evidences show that the treatment has caused
dissolution of parallel collagen bundles and the appearance of
new papillae in the context of the treated area. These changes
could support both stretching and activation of dermal fibro-
blasts and clinical improvement.
Treatments for SD are usually not very satisfactory, so we
believe that by combining these two innovative methods we can
obtain excellent results as demonstrated by photographs and
confocal microscopy. We believe that the combined approach
is useful: needling, as other studies have already shown (16,17),
determines a remarkable improvement for striae by neovascu-
larization and neocollagenesis with migration and proliferation
of fibroblasts that determines the deposition of collagen, while
stabilized hyaluronic acid of non-animal origin stimulates col-
lagen synthesis, partially restoring dermal matrix components,
inducing mechanical stretching of fibroblasts and initiating pro-
duction of connective tissue components, such as collagen type I,
so it is important for the treatment of the deepest SD. The utility
of RCM as complementary tool for the evaluation of inflamma-
tory diseases and skin cancer has been well demonstrated
(18,19). We believe that it can be used as new non-invasive
guide for aesthetic procedures to optimize the choice of treat-
ments and to better monitoring therapeutic response, without
resorting to invasive cutaneous biopsies to have scientifically
valid results.
Disclosure statement
The authors report no conflict of interest
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