Spectacular before and after photos of treatment with our Derminator device:

https://owndoc.com/dermarolling/alopecia-dermaneedling-before-after/

In this document I introduce the theory of microneedling before transitioning into the protocol as seen in the scientific literature. I then answer a few tangential questions and end with a summary of twenty studies dealing with the treatment of alopecia via microneedling. This document is an introduction to a larger, considerably more complex issue, and it accordingly contains a high degree of uncertainty. To the best of my knowledge, the information presented is accurate, and not motivated by ulterior motives.

1. What is the mechanism of action?

1. Microneedling, when applied to the skin, creates microinjuries and stimulates “demarcation currents” (i.e. depolarizations) that occur in a standard bodily response to trauma. Because of the transitory and calculated nature of the needle penetration, this trauma response results without the formation of damaged (fibrotic or necrotic) tissue. Instead, the body is locally stimulated to release various platelets, proteins, growth factors and stem cells which promote hair growth (amongst other things), along with the breakdown of scar tissue and the formation of new vasculature (both of which are suggested to promote hair growth), while promoting the formation of healthy collagen. Furthermore, it is believed that the resulting microscopic breaches of the epidermis (“micropunctures”) are conducive towards a more efficient delivery of topicals, which can work synergistically with the natural body response (in that they address different etiologies).

2.     Are there side-effects?

1. Yes. The “end-point” (visible-indicator) of sufficient treatment is the appearance of erythema or “pin-point” bleeding (lasting approximately half a minute to two minutes) on the applied areas. These symptoms, along with facial swelling (unusual), generally appear immediately, and decrease rapidly (50% reduction within 4-6 hours, disappearing completely in almost all cases within two days). Along with other symptoms, such as flaking, these are generally considered minor issues. However, there are also much rarer, but much more serious symptoms. Some studies record a handful of incidences of “tram-track” scarring, breakage of needles in the skin (from overused or poor products), and the resurgence of residual viruses (i.e. herpes simplex labialis). Several other studies report systemic effects from the over-penetration of applied substances, and allergic reactions to either the microneedles (particularly those containing nickel) or topical substances (i.e., Vitamin C creams), resulting in the latter case, in the formation of resilient granulomas. Fortunately, it is believed that the most serious side effects (scarring, topical overdoses, allergic reactions, and the granulomas) can probably be avoided with proper precautions and protocol (see below). Long term animal or human trials are limited, and it is not a stretch to believe that other symptoms (such as fibrosis) may occur with prolonged or thorough use. I cover this aspect somewhat throughout the thread. User caution is advised.

3. What devices exist on the public market?

1. “Rollers”

1. These are manual devices with 192 to 540 needles that one rolls over the skin. They are often quite affordable, at least initially, and able to quickly cover large areas. Unfortunately, hair does seem to interfere with roller movement. Worries inherent to the roller design involve unequal pressure application causing unequal depth penetration and increased trauma from the forward pushing movement (resulting in angular instead of perpendicular force). The enlarged craters from this angular pushing movement, as well as the repeated usage of rollers (generally meant to be disposable), may also increase the risk of infection. Lastly, poor quality rollers may have needles that contain nickel, are actually blades (not needles), or break off easily. Many users report that these factors contribute to the increased pain experienced with rollers.

2. “Stamps”

1. These are manual devices, generally with 40 to 140 needles, that one presses up and down against the target areas. Stamps are similarly priced to rollers and generally used for localized (small) areas. Because stamps do not use a “rolling motion” they eliminate the worries about excessive angular-trauma seen in dermarollers, but they still suffer from user variations in force, making depth penetration haphazard. Accordingly, stamps can be clunky and painful to use over larger body surfaces, while also risking needle quality issues.

3. “Pens”

1. These are automatic machines that eliminate user pressure variations while also accurately achieving desired depths up to 1mm (sufficient for most operations). Pens are capable of covering large areas quickly and superior to other options for covering small or hairy areas. Conceptually pens are capable of minimizing trauma from both the perpendicular application of the needles to the skin and the rapid entry/exit. Disposable needles cartridges generally contain one to thirty-six needles, targeting various user needs, and allowing for sterile protocol to be observed. Importantly the disposable nature of the pen cartridges allows for needles to be rotated when damaged or worn down. From a psychological perspective, most users report that pens are quicker and noticeably less painful than manual devices. Practically speaking, pens are the best “all-around” option, but they are also generally the most expensive of the three options in the short-term.

4. Perioperative technique

1. Pre-operative

1. Patch testing (performed several days before procedure)

1. Needle allergies

1. Prior to microneedling, individuals may want to consider performing a preliminary “patch-test” (on a out-of-the-way sensitive and hairless piece of skin like inside the elbow or possibly under the forearm) or having a lab-test done to determine whether they are allergic to metals -- particularly nickel. If the user has experienced reactions to jewelry usage, this is especially relevant.
2. Users are cautioned that many needles may claim to be stainless steel or titanium and still use some tiny but significant amount of nickel throughout (“alloys”). Needles may also simply be “metal-plated,” and with increased use or needle depth may still expose a user to nickel. This should inform a buyers purchase decision.

2. Topical allergies

1. Many serums or topical agents contain ingredients that users may be allergic too, which risk being potentiated when used in conjunction with microneedling, even resulting in systemic side effects. A reaction may occur both on application contact, or only after transdermal application (after microneedling). It may also take several days to appear; Hence, patch tests done with both microneedling alone and microneedling with topicals is advised.  

2. Sanitation

1. Every therapeutic study observed (even in usage of microneedling for applications extraneous to alopecia) utilized some form of sanitizing agent on the skin (saline, betadine, 70% rubbing alcohol) prior to microneedling.

1. Despite this, all of the experimental studies I have read which focused on the mechanism of bacterial infiltration demonstrated that the risk of infections from bacteria present on the skin is minimal, indicating that usage of a sanitizing agent on the skin may be unnecessary in most cases.

1. This is suggested to be because the bacterial populations are relatively small on the skin (the skin has antimicrobial properties) and the micropenetrations formed recovering barrier properties, in most cases, within fifteen minutes to two hours (depending on the needle size), maximum. The exception to this is when the affected area is occluded (i.e., covered with a transdermal patch), which can slow closure to forty-eight hours.

1. One study records that the barrier resealing kinetics (related to infections) were negatively affected by increased needle length, increased needle quantity, and larger areas of microneedling.

2. Make-up should be thoroughly removed prior to the procedure
3. Blood-borne transference of disease is possible between shared-needles.  
4. Re-used needles should be disinfected.

3. Anesthetic

1. It is suggested in the literature that many local anesthetics inhibit production of prostaglandin E2 (PGE2), which is known to promote hair growth.
2. Use of an anesthetic increases the risk of an allergic response
3. With the use of an automated pen and a reasonable needle depth, most of the research indicates that microneedling without a topical anesthetic should be quite tolerable for most users.

2. Intraoperative

1. Needle quantity

1. The quantity of needles depends on the area you want to cover. In theory, more localized areas (i.e. small scars) are better addressed by more precise application (smaller quantity needle devices). Conversely, large quantity needle devices may better address large surface areas (particularly in regards to time consumption). Generally, all of the scientific studies utilize either 192 needle rollers or ~12 needle pen cartridges.  

2. Needle length

1. This is largely contingent on the area of the body you needling (i.e., what part of the face), what skin type you are needling (healthy or scar tissue), as well as sex-specific and individual-specific qualities. As the theory is understood currently, the “end-point” of most applications is mild erythema or pinpoint bleeding.

1. Pinpoint bleeding occurs at the following needle depths: forehead 0.7 to 1.0mm; cheek 0.9 to 1.5mm; eye area 0.5 to 0.8mm; chin 0.9 to 1.3mm; glabella and jawline 0.7 to 1.3mm; upper lip 0.7 to 1.0mm.

1. The variation is largely due to age differences (epidermis gets thinner with age), sexual differences (men are believed to have thicker skin, in general), and environmental differences (exposure to various factors thickens and thins the skin). Additionally, fibrotic tissue often necessitates longer needle depth.  
2. As mentioned previously, using any needle length above 1mm in pens tends to very poorly correlate with mean achieved depth, and results in a wide variation in actual depth. As mentioned, needle depth is unfortunately very difficult to control or ascertain precisely with manual devices (rollers and stamps), with one study suggesting that 1.5mm rollers penetrated 1.2mm.  

2. Some of the literature seems to indicate that the results achieved in certain aspects (i.e., microneedling on anti-aging) with a 1mm needle are nearly identical to those with 3mm needles. If extrapolated for alopecia, penetration deeper than 1mm increases risks (scarring, slower barrier recovery kinetics, etc), pain, and instrument wear with probably no additional benefit, and potentially (according to several studies) actually causing worse results.

3. Movement pattern

1. Star-shape: The vast majority of studies performed a “star-shaped” pattern, dividing the target area into horizontal, vertical, and two seperate, perpendicular to each other, oblique passes. Some suggest that this system results in the unequal confluence of micropunctures in the stars center, but this is not the case in situations where the user properly spaces the subsequent passes to the width of the instrument (ensuring no gaps between treatment passes). This pattern is possible on all devices and allows for an easier micropuncture count calculation (see Cycles section).    
2. Spiral: Alternatively some advocate a spiral pattern, whereby one starts at a point and spirals outwards. This system, while theoretically sound, can be difficult from a practical perspective to implement more effectively than a proper star-shaped pattern, even when guided by visual aids (i.e., erythema), because it is difficult to ascertain micropuncture count (see Cycles section). Furthermore, this method does not seem viable when using roller devices.

4. Cycles

1. After deciding upon a movement pattern it is necessary to determine how many cycles or “passes” one takes. Most studies recommend users aim for 200 to 250 micropunctures per cm2 of skin.

1. Roller: With a 192 needle roller this takes approximately fifteen passes over an area of skin, with most studies falling within a range of twelve to twenty passes per area total. If using a star pattern this translates to approximately three to five passes in each of the four directions (vertical, horizontal, and both oblique directions).
2. Stamp: No scientific data
3. Pen: Contingent on pen speed, hand movement speed and needle length, but most studies seem to recommend approximately three passes (range one to six) in each of the four aforementioned directions, or until uniform pinpoint bleeding is observed. Given that pens often result in rapid creation of micropunctures, it is advised to follow the lower estimate of this suggestion (two to three passes) or the visual aid (i.e., pinpoint bleeding).

3. Post-operative

1. Cleaning your face:

1. Some studies suggest that rinsing with tap-water increases the risk of infections, and encourage the use of sterile alternatives (such as boiled water or a dry sterile gauze). As covered above, the risk of infection seems unlikely, but user discretion is advised.  

2. Icing

1. May be recommended to users who desire to more rapidly reduce any inflammatory responses.

1. However, users must remember that the inflammatory stage is characterized by the release of histamine, resulting in a vasodilatory response which facilitates the permeation of growth factors, platelets, etc into the wounded area. Accordingly, it may not be wise to curtail this stage.

3. Sun-exposure

1. Limited exposure to sunlight is advised for a week following the microneedling session. Many studies recommend the application of a non-chemical sunblock or physical occluders to users whose lifestyle inevitably brings them into prolonged contact with the sunlight.

4. Make-up

1. Make up is not recommended for two days following the procedure. This seems to be on the higher end of caution (even occluded micropunctures generally close by 48 hours), but is probably a good suggestion.

5. Antibiotic application

1. Many studies recommend the addition of a topical antibiotic after microneedling, on the exposed areas (twice daily for two days). As covered above, this may be an excessive addition, and expose one to unnecessary risks.

4. Other considerations relating to procedure

1. Many studies recommended that users stretch the skin tight (if applicable) prior to performing microneedling. This allows for the smooth passage of instruments and more equal spread of micropunctures.

1. Additionally, prior to microneedling, many studies apply a lubricant such as hyaluronic acid gel to facilitate the smooth gliding of pens. The user will have to determine whether he considers this necessary or prudent.

2. After performing a pass in one direction, it is strongly recommended that users raise the device off of the skin before restarting the action, as opposed to simply rolling back-and-forth. This, particularly in the case of rollers, is suggested to preclude one of two suspected factors in the pathogenesis of “tram-track” scarring (the other being excessive-force microneedling over bony protuberances). Furthermore, performing this maneuver is suggested to reduce the likelihood of inducing additional trauma in already created micropunctures.  
3. It is recommended that users exercise caution when microneedling around bony protuberances,. Some studies suggest that overzealous microneedling of such areas leads to increased risk of tram-track scars, hematomas (bruises) and too-deep needling.

5. Usage of topicals

1. If patch testing returned negative, topicals can be considered at any of the perioperative stages (post or pre-operative). This is probably the most dangerous consideration in microneedling, as reactions and symptoms are individual-specific.
2. I will briefly cover the two most relevant drugs for alopecia:

1. Minoxidil

1. All studies (that I remember) testing true microneedling with minoxidil for alopecia indicate that it works synergistically in promoting the growth of denser and stronger hair (through different mechanisms of action).
2. Most studies recommend applying minoxidil no earlier than twenty-four hours post-session. Given that most non-occluded micropunctures should sufficiently close within two hours, and that several studies utilized direct and immediate minoxidil application following microneedling, this may be unnecessary. However, user caution seems prudent given the uncertainty reigning in the literature.
3. Wrinkles: see section 9a.

2. PRP

1. All studies that I read testing microneedling with PRP for alopecia indicate that it works synergistically in promoting the growth of denser and stronger hair. Unfortunately, these studies were generally animal studies or mixed with minoxidil, so the results may not be applicable to human individuals.
2. If PRP does work in conjunction with microneedling, application is probably best either during microneedling (as with the fancier tattoo guns being converted into drug-delivery systems), or immediately after microneedling. Because PRP is drawn from the individual, any serious adverse reaction to its application on the wounded areas seems quite unlikely.  

6. Regularity of microneedling sessions

1. As mentioned previously, the mechanism by which microneedling is suspected to work on alopecia is multifold. The bodies wound-response mechanism unfolds as follows:

1. Hemostasis stage: Epithelial barrier is compromised, causing the initiation of a trauma response which occurs almost immediately following injury. This response is characterized by the accumulation of platelets (one of the main constituents of PRP, “platelet-rich plasma”) to the affected site, which release growth factors and begin the clotting and signalling mechanism. The role of this mechanism is to immediately protect the epidermal breach (via clotting) and initiate the future permanent healing process (via a signalling process). During this stage in particular, and up to approximately forty-eight hours later, topical absorption is increased.  
2. Inflammatory stage: Immune cells heed the platelet signals and arrive en force, peaking forty-eight hours after injury. These cells clean the area and secrete platelet derived growth factors and proteins that facilitate tissue repair (especially on days three to four), lasting approximately one week.  
3. Proliferation stage: This stage begins approximately day three following the injury and is characterized by angiogenesis (formation of new blood vessels), migration of stem cells, and the release of growth factors. Furthermore, fibrotic tissue is broken down and an intermediary type III collagen product is instead laid down (neocollagenesis), and peaks at around three weeks to two months. For patients using this for anti-aging purposes, skin becomes noticeably more aesthetic around three to four weeks.
4. Maturation stage: Type III collagen is replaced by the more elastic type I collagen beginning day three to twenty one, and lasting approximately a year. The end result is a thicker and healthier collagen deposition, with increased blood supply.  

2. Furthermore, the recommendations for the minimal recovery time an individual should allow is contingent upon the needle penetration depth:

1. <0.15mm: intervals every two to three days
2. 1 to 1.5mm: A wide variation exists ranging from one week to one month
3. 2.5 to 3.0mm (scars): approximately six to eight weeks

3. Accordingly, general guidelines can tentatively be established as such for alopecia:

1. Breakdown of scar tissue: Occurs during the proliferation stage via the invasion of MMP’s into perforated scars

1. Hypotrophic scars: Degrade ten to twenty weeks after one to three microneedling sessions

1. If alopecia is caused by hypotropic scarring, this is the mechanism to focus on.

2. Angiogenesis: After trauma or scars are broken down, capillaries start to migrate into the affected areas. Capillaries begin to show at three to five days and become well-established, non-leaky capillary beds similar to those in non-injured surrounding tissue by fourteen to twenty-eight days. Prior to this, the capillaries are highly permeable and not necessary for proper wound healing.  

1. While some research suggests the role of proper blood supply to hair-growth, other research also suggests that excessive angiogenesis can stimulate scar formation.

1. If alopecia is caused by poor blood supply, this is the mechanism to focus on.

3. Release of platelets, growth factors, stem cells

1. Occurs at practically every stage, but is probably peaks within one to two weeks.

1. If alopecia is treated by the release of these substances, this is the mechanism to focus on.

4. While the approach to this conundrum is the individuals decision, one solution may be to utilize microneedling from both a micro and macro perspective:

1. Performing a 1.0mm microneedling session once per month to achieve most of the relevant wound-healing benefits.
2. Using a 0.15 to 0.25 microneedling device in conjunction with topicals to maximize absorption benefits.  

7. Contraindications

1. Failing the patch test.
2. If someone has an acute or chronic condition, they should consider the implications it may have on microneedling

1. For instance, if someone has:

1. An autoimmune disease, they should consider sanitation more seriously, and understand that should something happen, their immune system is compromised.
2. Acne on their face, they should not microneedle in the area.
3. Botox injections in the area, microneedling should be avoided to exclude the possibility of spreading toxins.
4. Neoplasms, cancers, or other growths, they probably should not microneedle at all.
5. A skin condition (predisposition to keloids, bleeding, etc), they should probably exercise caution microneedling.
6. A heart condition, they should probably exercise additional caution when microneedling with cardiac-affecting drugs, such as minoxidil.

8. How to approach purchases

1. Ultimately, this will be up to the users means, goals and understanding of how much the potential benefits are worth it for him. From both my understanding of the available literature and from my personal experience, I firmly believe that pens are the best options for users who can afford them. Even overcoming the difficulties inherent to roller and stamp designs, needle quality is a decisive factor for me. The vast majority of rollers appear to be equipped with “knives,” not “needles,” and the needle durability and above all, composition, of the needles is difficult to ascertain. Some of the quality issues also bleed over to pens (engine motor strength and needle composition), but at length, I was satisfied that the Derminator brand pen fulfilled my quality requirements (primarily nickel-free surgical steel cartridges and a strong pen motor to minimize tearing). Out of all the resources I have seen, their manual is the most intelligent and thorough at addressing protocol, although as Derminator users will tell, I still deviate from them in a few aspects (pattern shape, needle depth, antiseptic protocol, etc). I have to add that from my experience with the company of the Derminator, they have excellent customer service.    

9. Questions that may pop up:

1. What about wrinkles from minoxidil?

1. I could find no such results in the scientific literature that reported such symptoms in humans, but there is plausible evidence from animal or cell culture studies that this may occur.

1. For the affirmative, see:

1. One, two and three

2. For the rebuttal, see:

1. Here

2. It is possible that microneedling counteracts the collagen breakdown in humans (if it occurs) contemporaneously. If it doesn’t counteract such an effect in real-time, it is likely that prior (several months to a year prior) microneedling could preclude the formation of wrinkles via the well established and considerable neocollagenesis mechanism. Even, however, if prior microneedling does not preclude the formation of wrinkles there is a very extensive scientific literature that microneedling helps resolve wrinkles.  

2. How does one get PRP?

1. From ones blood. Blood is drawn, centrifuged, separated, centrifuged again, and then removed. For those of you interested in a more in-depth analysis, there are quite a few studies, even videos, detailing the step-by-step process. It appears to theoretically be possible to perform at home, relatively easily and affordably.

3. Does microneedling alone cause hair gain?

1. Conceptually, it seems likely and animal studies seem to indicate strongly in the affirmative. However, in human studies, there is disagreement: Lee et al 2009 found inconclusive results, Lee et al 2013 found a non-significant (~4%) decrease in hair density, whereas Contin (2016) reported positive results.  

4. Does microneedling lead to scar tissue?

1. Not in normal circumstances. While skin cuts deeper than approximately 0.5mm tend to close by a skin-repair processing involving the formation of scar tissue, the extensive literature behind microneedling indicates conclusively that there is no formation of scar tissue from proper microneedling. Rather, the collagen deposited from microneedling retains a healthy lattice structure, unlike the parallel fibre bundles seen in fibrotic tissue. This may be because of the minimal environmental exposure (UV, pathogens, etc) and epidermal disturbance innate to microneedling. With that being said, excessive microneedling (force, depth) or poor technique (back-and-forth rolling or rolling protuberances), may lead to scarring in a few select cases. Given the length of human trials, it is also possible that repeated and prolonged microneedling may lead to scar tissue formation.

5. Should there be considerable bleeding?

1. No. In classical wound situations, bleeding is the result of punctured or cut vessels. In contrast, during microneedling cells are generally “pushed aside,” and only capillaries are punctured (from which the pin-point bleeding occurs). Erythema is probably the result of an expected inflammatory response (mast cells secreting histamine and bradykinins).

6. Does microneedling injure nerves?

1. Unlikely. Microneedling, which penetrates into the superficial reticular dermis, should not reach deep enough to hit nerve bundles. It may, however, hit some free nerve endings (which exist in the epidermis), depending on the thickness of the individuals skin (covered above).

10. Summarization of twenty studies dealing with microneedling as it regards specifically to alopecia:

1. [31]Dhurat et al, 2013: A Randomized Evaluator Blinded Study of Effect of Microneedling in Androgenetic Alopecia: A Pilot Study

1. “Dhurat et al found that combination treatment of MN with minoxidil was statistically superior to minoxidil alone in the treatment of 100 male patients with AGA. Over 12 weeks, Dermaroller treatment combined with 5% minoxidil lotion was administered to half of the participants, with 80% showing moderately or greatly increased hair regrowth per the investigators. Of the same subset, 82% of the patients reported subjective improvement greater than 50% in their hair growth. In the arm receiving 5% minoxidil alone, only 4.5% of patients reported greater than 50% improvement. By the end of the study, mean change in hair count was significantly greater for the MN group (91.4 vs. 22.2, p = 0.039). Additionally, the initiation of new hair growth was first noticeable at 6 weeks in the MN group compared to 10 weeks in the minoxidil alone group. No adverse effects were noted by any of the participants.” [4] 
2. “In the Microneedling group, patients received a weekly Microneedling procedure on the scalp with 1 ml of 5% Minoxidil lotion applied twice daily. In Minoxidil group, patient applied only 1 ml of 5% Minoxidil lotion twice daily.”
3. “The shaven scalp was prepared with betadine and normal saline. A dermaroller of 1.5 mm sized needles was rolled over the affected areas of the scalp in a longitudinal, vertical, and diagonal directions until mild erythema was noted.”

2. [32]Dhurat and Mathapati, (2015): Response to Microneedling Treatment in Men with Androgenetic Alopecia Who Failed to Respond to Conventional Therapy

1. “Dhurat and Mathapati then published a follow-up case series of four men with AGA unresponsive to conventional treatments. Combination therapy was administered to participants with their prior treatment regimen (either topical minoxidil or oral finasteride) and Dermaroller over a course of 6 months. All four patients had moderately or greatly increased hair regrowth and reported subjective increases in hair thickness after 1 month of treatment.” [4] 
2. “The scalp was surgically cleansed with betadine and normal saline. A dermaroller of 1.5 mm sized needles was gently rolled over the affected areas of the scalp in longitudinal, vertical, and diagonal directions until mild erythema was noted.”
3. “All the patients were subjected to microneedling procedure weekly for 4 sessions initially and then fortnightly for subsequent 11 sessions. The total duration of microneedling treatment lasted for 24 weeks.”

3. [33]Chandrashekar et al, (2014): Alopecia Areata—Successful Outcome with Microneedling and Triamcinolone Acetonide

1. “Chandrashekar et al analyzed outcomes from treating resistant AA with MN and topical corticosteroids. Two adult patients with AA recalcitrant to ILK, topical steroids, and minoxidil 5% lotion received topical triamcinolone applied before and after Dermaroller. Both patients graded hair regrowth as “excellent” and had no recurrence at 3-month follow-up. The ability to assess for common adverse effects of steroid treatment such as atrophy, scarring, and increased susceptibility to infection were limited in this study.”[4] 
2. “Both  of  them  were  treated  with  microneedling  using  a  derma  roller  having  192  needles  of  1.5-mm  length  each  followed  by  topical  application  of  triamcinolone  acetonide.  Triamcinolone  acetonide  in  concentration  of 10 mg/ml (0.1 ml containing 1 mg of triamcinolone) was  applied  on  each  lesion  twice,  before  and  after  performing dermaroller. Under aseptic precautions, the dermaroller was moved on the scalp patches diagonally, vertically and horizontally 4 to 5 times in each direction after  applying  triamcinolone  acetonide.  This  created  pinpoint  bleeding  which  was  taken  as  an  end  point,  following  which  triamcinolone  was  applied  topically.  No anaesthesia was used as the procedure was relatively painless.  A  total  of  three  sessions  were  done  for  both  patients  at  3  weeks  interval.” [33]

4. [34]Lee et al. (2013): Effects of topical application of growth factors followed by microneedle therapy in women with female pattern hair loss: a pilot study.

1. Covered the treatment of eleven women (mean age ~41) with female pattern hair loss. The researchers randomly treated one side of the scalp of each patient with growth factor prior to microneedling, and the other with microneedling alone. Each session was performed once a week, for five weeks, for a total of five sessions. By the end of the five week benchmark, the control (microneedling-only) side recorded a total hair-loss of approximately 4%, whereas the treated side experienced an increase in hair shafts of approximately 14%. There were no negative side effects from the microneedling or growth factor application recorded.

5. [35]L.A. Contin (2016): Male androgenetic alopecia treated with microneedling alone or associated with injectable minoxidil by microinfusion of drugs into the skin

1. Covered the treatment of two males (ages 30 and 44, respectively) with androgenetic alopecia using an automated tattoo device, set to 1.5mm penetration. In the first case (P1), the researchers performed four microneedling sessions, each one month apart. The tattoo gun was loaded with 0.5% injectable minoxidil, and a back-and-forth movements seems to have been used until pinpoint bleeding was observed. In the second case, the patient underwent three microneedling sessions (also until pinpoint bleeding), one month apart apiece, without the use of injectable minoxidil. From the before and after pictures provided, both patients seemed to have gained noticeable hair-growth (density) and thickening of hair-shafts, but the analysis appears to be limited to qualitative observation rather than quantitative data.

6. [37]Kumar et. al. (2018): A Randomized Controlled, Single-Observer Blinded Study to Determine the Efficacy of Topical Minoxidil plus Microneedling versus Topical Minoxidil Alone in the Treatment of Androgenetic Alopecia.

1. Covered the treatment of sixty-eight men with grade III and IV AGA, ranging from the ages of 18 to 40. The subjects were evenly split into two groups with 34 patients apiece, who received either (A) microneedling + minoxidil treatment  or (B) minoxidil alone treatment, over twelve weeks. In both cases, the minoxidil was 5% strength, and 1mL was applied twice daily. In case A, dermaroller with 1.5mm needles was applied in a star formation until pinpoint bleeding was observed; For the first four sessions the dermaroller was used once a week, followed by once every other week for the remaining 8 weeks (8 sessions total in 12 weeks).
2. “The mean increase in hair count in the targeted area of one square inch at the end of the treatment was significantly greater for the combination treatment group (12.52/inch²) compared to that for the minoxidil alone group (1.89/inch²). Four patients in the “microneedling plus topical minoxidil” group reported a 50% improvement versus none in the “minoxidil alone” group. “
3. The authors suggest that shaving ones’ head, as done in Dhurat et al. may improve results, and that constant minoxidil application is necessary to maintain results in both subgroups.    

7. [38]Jha et al. (2019): Platelet-rich plasma and microneedling improves hair growth in patients of androgenetic alopecia when used as an adjuvant to minoxidil.

1. Covered the treatment of 93 AGA (Norwood 1-5) patients split equally into three groups: (A) topical 5% minoxidil alone; (B) topical 5% minoxidil and PRP; (C) topical 5% minoxidil, PRP and microneedling. Minoxidil was applied twice daily in each case, whereas microneedling was done using a 1.5mm roller until pin-point bleeding occurred. Treatment was performed in the PRP groups at three week intervals for a total of four sessions. The results indicated that there “was a statistically significant difference between the three groups as confirmed by the hair pull test, terminal-to-vellus hair ratio, and patient satisfaction score as determined by one-way ANOVA,with group C > group B > group A, in terms of results.

8. [39]Jha et al. (2018): Platelet-rich plasma with microneedling in androgenetic alopecia along with dermoscopic pre- and post-treatment evaluation

1. Covered the treatment of 20 patients, Norwood I - V, with AGA. Microneedling with a 1.5mm dermaroller (pattern unclear) along with PRP treatment was performed every three weeks, for three total sessions. At the twelve week mark there was an “increase in the number of vellus and total hairs, increased hair shaft diameter, dramatic reduction or disappearance of black/yellow dots, and reduction in hair pull test. High patient satisfaction was recorded (70%+), and the pictures provided indicate noticeable results.

1. Some of these patients were on minoxidil / finasteride

9. [40]Shah et al. (2017): A Comparative Study of Microneedling with Platelet-rich Plasma Plus Topical Minoxidil (5%) and Topical Minoxidil (5%) Alone in Androgenetic Alopecia

1. Covered the treatment of fifty patients with grade III to V AGA. The study was evenly split into two groups: (A) 5% topical minoxidil and (B) 5% topical minoxidil + PRP + microneedling. In group B, a 1.5mm Dermaroller was utilized in a star pattern “8 times in each direction or until mild erythema was noted,” once a month for six months, for a total of six sessions. At the end of six months, the study noted “ a significant improvement (P < 0.05) in patients' assessment in Group B as compared to Group A at the end of 6 months...significant improvement (P < 0.05) in investigator's assessment in Group B as compared to Group A at the end of 6 months.”

10. [41]Gajjar et al. (2019): Comparative Study between Mesotherapy and Topical 5% Minoxidil by Dermoscopic Evaluation for Androgenic Alopecia in Male: A Randomized Controlled Trial.

1. Covered the treatment of forty-nine males, with grade II-V AGA over four months. The subjects were split into two groups: (A) 25 subjects were allocated to the microneedling with a “mesohair” solution and (B) 24 patients were allocated to group using 2-3mL of 5% topical minoxidil twice daily. The mesosolution in Group A “contained 56 ingredients including 24 amino acids, 13 vitamins, 4 coenzymes, 4 nucleic acids, 5 minerals, and 2 reducing agents. The active ingredient was decapeptide 4, acetyl decapeptide, and copper tripeptide.” It was applied with microneedling once a week for one month, followed by once every other week for another month, followed by once a month for two months, totaling eight sessions.
2. The results indicated that the mesotherapy was approximately as effective as the topical minoxidil application: “Twenty‑three males under mesotherapy group experienced up to 25% improvement in hair loss and hair growth while 2 males noticed hair growth of about 25%–50%...Whereas all the males applying minoxidil solution felt improvement only up to 25% in hair loss and hair growth . In few males (4) having AGA involving vertex area, mesotherapy was more effective than frontal region.”

11. [42]Rodrigues et al. (2019): Treatment of male pattern alopecia with platelet-rich plasma: A double-blind controlled study with analysis of platelet number and growth factor levels

1. Covered twenty-six patients with scale III AGA, who were given 20 subcutaneous injections with either PRP (n=15) or saline (n=11) per treatment, every fifteen days, for a total of four treatments. Don’t ask me how the patient count math works. The PRP group saw “significant increase when the counts before application and 3 months after the last application were compared...significant increase [in hair density] between the baseline and follow-up values,” and a significant increase in anagen percentage, whereas the control saline group saw no significant differences. The authors posit that this discredits the idea that microneedling has a significant impact on hair growth. See Jha 2019 “Every needling is not microneedling”
2. [43]Jha, A. K., & Vinay, K. (2019). Androgenetic alopecia and microneedling: Every needling is not microneedling.

1. A response to Rodrigues et al 2019 where they expounded on the differences between needling and microneedling, namely, the two mechanisms being quantitatively different on several orders of magnitude (n=20 vs n=2000).

12. [44]Kim et al (2016). Repeated Microneedle Stimulation Induces Enhanced Hair Growth in a Murine Model.

1. An interesting study that attempted to explore the role that different length needles and cycles (roller repetitions) had on hair growth in rodent models. They used a “disk microneedle roller” with “microneedles of lengths of 0.15 mm, 0.25 mm, 0.5 mm, and 1 mm and cycles of 3, 6, 10, and 13.” Each group of mice were subjected to microneedling “five times a week for three weeks.” Additionally, they performed tests to ascertain whether certain growth factors or gene activation pathways were modified by the use of needles. They found that “the optimal length and cycle of microneedle treatment on hair growth was 0.25 mm/10 cycles and 0.5 mm/10 cycles. Repeated microneedle stimulation promoted hair growth, and it also induced the enhanced expression of Wnt3a, β-catenin, VEGF, and Wnt10b.” The authors worried that “increased collagen and elastin deposition was shown after microneedle on human...Therefore, when it applied to scalp, perifollicular fibrosis could be evoked, and extensive fibrosis could hinder hair growth. When combined with minoxidil, microneedle could cause [an] overdose of minoxidil which can increase [the] possibility of irritant reaction or cardiovascular side effect.”

1. It is possible I misunderstand the literature, yet it seems as if Aust and colleagues demonstrated that microneedling promotes the up-regulation of TGF-b3 which is responsible for regeneration and scarless wound healing. Aust et al reported that following microneedling there was an increased ratio “of TGF-b3 over TGF-b1 and TGF-b2 (the latter being responsible for fibrotic scarring).”
2. It is important to remember that rodents have thinner skin than humans!

13. [45]Starace et al. (2019): Preliminary results of the use of scalp microneedling in different types of alopecia.

1. Covered fifty patients (36 women and 14 males) with either AGA (n=43) or TE (n=7). The researchers “performed three treatments of microneedling at an interval of 4 weeks, over a total period of 6 months” using a 1.5mm dermaroller in a star fashion, eight times in each direction, or until mild erythema/pin-point bleeding was observed. “All the patients were taking topical or systemic treatments for AGA or TE lasting for at least 1 year.”
2. “After the 6 months treatment, all the patients reported a partial or complete reduction in hair loss, confirmed by a negative pull test...Based on trichoscopical examination, all patients showed an increased frontal and vertex median density over time, respectively, of 36.64% and 35.10%.” Furthermore, “The vellus relative change showed a decrease since the beginning of the procedure in both areas, −9.54% in the frontal area and −9.96% in the central area. The measurements of the medium hair diameter in frontal and vertex area showed important increase after 6 months, with a gain of 9.75% (from 0.057 to 0.062 mm) in the front and 9.08% at the vertex.”

14. [46]Kim et al (2012): Hair follicle regeneration in mice after wounding by microneedle roller

1. Divided mice into seven groups:  namely, a “negative control group, positive control group (50% ethanol), 3% minoxidil group, horizontal wound group, vertical wound group, 0.25-mm-sized microneedle roller group, and 0.5-mm sized microneedle roller group.” There was no description of frequency of rolling performed. Out of these groups, the two microneedling groups showed the earliest and fastest hair growth, and the hair from microneedling was recorded to be shinier than the hair grown from the minoxidil group.

15. [49]Lee et al. (2009): Photodynamic therapy with methyl 5-aminolevulinate acid combined with microneedle treatment in patients with extensive alopecia areata.

1. Covered six patients with alopecia areata (AA), who were on no other treatment at the time. Each patient's scalp was split into a control and treatment side, with the treatment protocol involving the use of a 1mm dermaroller to prepare the control side prior to application of a photosensitizer (used in photodynamic therapy). This treatment was done three times at four week intervals. No hair regrowth was observed in either the control or treatment side. The proposed explanations for lack of any results included a failure for the photosensitizer to absorb properly, despite microneedling (potentially from the bleeding occluding the absorption), or simply that the photosensitizers conceptual mechanism does not work in practice.

16. [50]Sasaki, G. H. (2017). Micro-Needling Depth Penetration, Presence of Pigment Particles, and Fluorescein-Stained Platelets: Clinical Usage for Aesthetic Concerns.

1. The number of subjects is not articulated, nor is the needle depth specified more than with a range of 0.5mm to 2.5mm, but he records that “the average hair count in a 10 mm spot size at baseline (88.3 ± 22.5) increased at the 12 month evaluation period (133.6 ± 13.8).” Furthermore, it should be noted that Sasaki used a Dermapen.

17. [48]Farid et al (2016): Platelet-rich plasma microneedling versus 5% topical minoxidil in the treatment of patterned hair loss.

1. This study covered forty subjects (35 women, 5 men) with patterned hair loss. It began by dividing the subjects into two equal groups: The first group received 2mL of 5% minoxidil daily, whereas the other group had monthly sessions of microneedling (0.5mm roller, probably star pattern) with PRP until erythema was noted. Treatment lasted for twenty-eight weeks (six total sessions), with a benchmark occurring at 12 weeks. After 28 weeks, the minoxidil group saw an increase in hair count from 16.05±11.83, whereas the microneedling + PRP group saw an increase in hair count from 5.05±27.95, both being statistically significant, with the minoxidil application being superior, albeit not significantly.

18. [51]Diamond et al. (2019): A small scale study to evaluate the efficacy of microneedling in the presence or absence of platelet-rich plasma in the treatment of post-clipping alopecia in dogs.

1. This study covered four dogs who were experiencing “post-clipping alopecia,” or a genetically linked failure of hair to grow back after being trimmed. In each dog, the affected area was split into two treatment modalities: (A) microneedling alone and (B) microneedling with PRP. In treatment group B, a 2.5mm Dermaroller was applied in a star pattern until erythema/pin-point bleeding was noted followed by manual addition of the PRP (spread over the surface of the wounded area). During the monthly assessments following this treatment, group B regained the hair growth faster, but by the twelfth month assessment both of the treatment modalities were equalized in terms of treatment outcomes, with three of the four dogs achieving 76-100% improvement, and one dog achieved achieving 51-75% improvement.  

19. [55]Jeong et al. (2012): Repeated Microneedle Stimulation Induce the Enhanced Expression of Hair-Growth-Related Genes

1. The English used in this study is very poor. I interpret it as such: The researchers divided ten mice into five groups (0.15mm, 0.25mm, 0.5mm, 1.0mm and probably a control group). The researchers then somehow subdivided these mice into “rolling cycle” (passes/rotations) of “3, 6, 10, 13 cycles” using a “disk-type microneedle roller” to wound the mice five times a week for four weeks. They determined that the most effective combination in the murine models was the 0.5mm needles with 6 and 10 passes, and observed that the biopsies of these mice showed the “most valuable hair growing effect. VEGF, β-catenin, Wnt3a, and Wnt10b were strongly stained, increased in the 0.5mm microneedle and 10 rolling cycle samples and their gene expression was remarkable in the RT-PCR.”

1. It is important to remember that rodents have thinner skin than humans!

20. [60]Yu et al. (2018). A pilot split-scalp study of combined fractional radiofrequency microneedling and 5% topical minoxidil in treating male pattern hair loss

1. Nineteen Chinese men had the bald areas of their scalp delineated into two segments: Both of the segments were treated with 1mL of 5% minoxidil twice daily, while one segment additionally received fractional radiofrequency microneedling (1.5mm needle; 12W power) once every four weeks for a total of five sessions. For the combined treatment group, minoxidil was applied immediately after microneedling, with no adverse effects. At the end of the trial, both groups experienced hair growth and increases in mean hair thickness:

1. Monotherapy side:

1. Mean hair count:  46.22 ±18.77 to 63.21±19.22
2. Mean hair thickness: 52 ±16 μm to 66 ±14 μm

2. Combined-therapy side:

1. Mean hair count:  44.12 ±21.58 to 73.14 ±25.45
2. Mean hair thickness:  53±13 μm to 71±15 μm

References

[1] Agarwal M. (2012) Dermaroller: The Transepidermal Delivery System. In: Prendergast P., Shiffman M. (eds) Aesthetic Medicine. Springer, Berlin, Heidelberg

[2] Liebl, Horst, and Luther C Kloth. “Skin cell proliferation stimulated by microneedles.” The journal of the American College of Clinical Wound Specialists vol. 4,1 2-6. 25 Dec. 2012, doi:10.1016/j.jccw.2012.11.001

[3] Singh, Aashim, and Savita Yadav. “Microneedling: Advances and widening horizons.” Indian dermatology online journal vol. 7,4 (2016): 244-54. doi:10.4103/2229-5178.185468

[4] Iriarte, Christopher et al. “Review of applications of microneedling in dermatology.” Clinical, cosmetic and investigational dermatology vol. 10 289-298. 8 Aug. 2017, doi:10.2147/CCID.S142450

[5] Ablon, Glynis. “Safety and Effectiveness of an Automated Microneedling Device in Improving the Signs of Aging Skin.” The Journal Of Clinical And Aesthetic Dermatology, vol. 11, no. 8, Aug. 2018, pp. 29–34. EBSCOhost, search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=30214664&site=eds-live.

[6] Lisa Ramaut, Henk Hoeksema, Ali Pirayesh, Filip Stillaert, Stan Monstrey. Microneedling: Where do we stand now? A systematic review of the literature. Journal of Plastic, Reconstructive & Aesthetic Surgery,Volume 71, Issue 1, 2018, Pages 1-14.  ISSN 1748-6815. https://doi.org/10.1016/j.bjps.2017.06.006. (http://www.sciencedirect.com/science/article/pii/S1748681517302504)

[7]Aust MC, Reimers K, Gohritz A, et al. Percutaneous collagen induction. Scarless skin rejuvenation: fact or fiction? Clinical & Experimental Dermatology. 2010;35(4):437-439. doi:10.1111/j.1365-2230.2010.03779.x.

[8]Leheta T, El Tawdy A, Hay RA, Farid S. Percutaneous Collagen Induction Versus Full-Concentration Trichloroacetic Acid in the Treatment of Atrophic Acne Scars.

[9]DERMATOLOGIC SURGERY, 2011. 37(2):207-216. doi:10.1111/j.1524-4725.2010.01854.x.

Aust MC, Reimers K, Kaplan HM, et al. Percutaneous collagen induction–regeneration in place of cicatrisation? Journal of Plastic, Reconstructive & Aesthetic Surgery. 2011;64(1):97. http://search.ebscohost.com.proxy-remote.galib.uga.edu/login.aspx?direct=true&db=edo&AN=56494295&site=eds-live. Accessed October 29, 2019.

[10]Alster TS, Graham PM. Microneedling: A Review and Practical Guide. DERMATOLOGIC SURGERY. 44(3):397-404. doi:10.1097/DSS.0000000000001248.

Available here

[11] Hou A, Cohen B, Haimovic A, Elbuluk N. Microneedling: A Comprehensive Review. DERMATOLOGIC SURGERY. 43(3):321-339. doi:10.1097/DSS.0000000000000924.

Available here

[12] Pratsou, Penelope. "Severe Systemic Reaction Associated with Skin Microneedling Therapy in 2 Sisters: A Previously Unrecognized Potential for Complications?" Journal of the American Academy of Dermatology. 68.4 (2013): AB219. Web.

[13] Soltani-Arabshahi, Razieh. "Facial Allergic Granulomatous Reaction and Systemic Hypersensitivity Associated with Microneedle Therapy for Skin Rejuvenation." JAMA Dermatology. 150.1 (2014): 68-72. Web.

[14] El-Domyati M, Barakat M, Awad S, Medhat W, El-Fakahany H, Farag H. Multiple microneedling sessions for minimally invasive facial rejuvenation: an objective assessment. INTERNATIONAL JOURNAL OF DERMATOLOGY. 2015;(12):1361. http://search.ebscohost.com.proxy-remote.galib.uga.edu/login.aspx?direct=true&db=edsbl&AN=RN381762750&site=eds-live. Accessed October 30, 2019.

[15]Fernandes, D. "Percutaneous Collagen Induction: An Alternative to Laser Resurfacing." Aesthetic Surgery Journal. 22.3 (2002): 307-310. Web.

[16]Fernandes, D. “Minimally Invasive Percutaneous Collagen Induction.” ORAL AND MAXILLOFACIAL SURGERY CLINICS OF NORTH AMERICA, no. 1, 2005, p. 51. EBSCOhost, search.ebscohost.com/login.aspx?direct=true&db=edsbl&AN=RN164440908&site=eds-live.

[17]“Percutaneous Collagen Induction Therapy: An Alternative Treatment for Burn Scars.” Burns, no. 6, 2010, p. 836. EBSCOhost, search.ebscohost.com/login.aspx?direct=true&db=edsgao&AN=edsgcl.233515728&site=eds-live.

[18]Aust, Matthias C., et al. “Percutaneous Collagen Induction Therapy: An Alternative Treatment for Scars, Wrinkles, and Skin Laxity.” PLASTIC AND RECONSTRUCTIVE SURGERY, vol. 121, no. 4, pp. 1421–1429. EBSCOhost, doi:10.1097/01.prs.0000304612.72899.02. Accessed 30 Oct. 2019.

[19]Amer, Mohamed. "Dermapen in the Treatment of Wrinkles in Cigarette Smokers and Skin Aging Effectively." Journal of Cosmetic Dermatology. 17.6 (2018): 1200-1204. Web.

[20]Hogan, Sara, et al. “Microneedling: A New Approach for Treating Textural Abnormalities and Scars.” SEMINARS IN CUTANEOUS MEDICINE AND SURGERY, vol. 36, no. 4, pp. 155–163. EBSCOhost, doi:10.12788/j.sder.2017.042. Accessed 30 Oct. 2019.

Read here

[21]Bhatnagar, Shubhmita. "Microneedles in the Clinic." Journal of Controlled Release : Official Journal of the Controlled Release Society. 260 (2017): 164-182. Web.

[22]McCrudden, Maeliosa T. C., et al. “Microneedle Applications in Improving Skin Appearance.” EXPERIMENTAL DERMATOLOGY, vol. 24, no. 8, pp. 561–566. EBSCOhost, doi:10.1111/exd.12723. Accessed 30 Oct. 2019.

[23]Donnelly, Ryan F., et al. “Hydrogel-Forming Microneedle Arrays Exhibit Antimicrobial Properties: Potential for Enhanced Patient Safety.” International Journal of Pharmaceutics, vol. 451, no. 1–2, July 2013, pp. 76–91. EBSCOhost, doi:10.1016/j.ijpharm.2013.04.045.

[24]Harris, Adam G et al. “Skin needling as a treatment for acne scarring: An up-to-date review of the literature.” International journal of women's dermatology vol. 1,2 77-81. 10 Apr. 2015, doi:10.1016/j.ijwd.2015.03.004

[25]Cohen, Brandon E., and Nada Elbuluk. “Microneedling in Skin of Color: A Review of Uses and Efficacy.” Journal of the American Academy of Dermatology, vol. 74, no. 2, Feb. 2016, pp. 348–355. EBSCOhost, doi:10.1016/j.jaad.2015.09.024.

[26]D. Fernandes, M. Signorini. “Combating photoaging with percutaneous collagen induction.”

Clin Dermatol, 26 (2) (2008), pp. 192-199

[27]Zeitter, S., Sikora, Z., Jahn, S., Stahl, F., Strausz, S., Lazaridis, A., … Aust, M. C. (2014). Microneedling: Matching the results of medical needling and repetitive treatments to maximize potential for skin regeneration. BURNS -OXFORD-, (5), 966. Retrieved from http://search.ebscohost.com.proxy-remote.galib.uga.edu/login.aspx?direct=true&db=edsbl&AN=RN354118109&site=eds-live

[28]Gupta J. (2011). Kinetics of skin resealing after insertion of microneedles in human subjects. Journal of Controlled Release : Official Journal of the Controlled Release Society., 154(2), 148-55.

[29]Yadav, S., & Dogra, S. (2016). A Cutaneous Reaction to Microneedling for Postacne Scarring Caused by Nickel Hypersensitivity. AESTHETIC SURGERY JOURNAL, (4), NP168. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=edsbl&AN=RN377860906&site=eds-live

[30]Pahwa, M., Pahwa, P., & Zaheer, A. (2012). -Tram Track Effect- After Treatment of Acne Scars Using a Microneedling Device. DERMATOLOGIC SURGERY, (7), 1107. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=edsbl&AN=RN314726337&site=eds-live

[31]Dhurat, R., Sukesh, M., Avhad, G., Dandale, A., Pal, A., & Pund, P. (2013). A randomized evaluator blinded study of effect of microneedling in androgenetic alopecia: a pilot study. International journal of trichology, 5(1), 6–11. doi:10.4103/0974-7753.114700

[32]Dhurat, R., & Mathapati, S. (2015). Response to Microneedling Treatment in Men with Androgenetic Alopecia Who Failed to Respond to Conventional Therapy. Indian journal of dermatology, 60(3), 260–263. doi:10.4103/0019-5154.156361

[33]Chandrashekar, B., Yepuri, V., & Mysore, V. (2014). Alopecia areata-successful outcome with microneedling and triamcinolone acetonide. Journal of cutaneous and aesthetic surgery, 7(1), 63–64. doi:10.4103/0974-2077.129989

[34]Lee, Y. B., Eun, Y. S., Lee, J. H., Cheon, M. S., Park, Y. G., Cho, B. K., & Park, H. J. (2013). Effects of topical application of growth factors followed by microneedle therapy in women with female pattern hair loss: a pilot study. The Journal Of Dermatology, 40(1), 81–83. https://doi.org/10.1111/j.1346-8138.2012.01680.x

[35]Contin, L.A. (2016). Male androgenetic alopecia treated with microneedling alone or associated with injectable minoxidil by microinfusion of drugs into the skin.

[36]Katzer, Tatiele & Carvalho Leite júnior, Ademir & Beck, Ruy & Silva, C.. (2019). Physiopathology and current treatments of androgenetic alopecia: Going beyond androgens and anti-androgens. Dermatologic Therapy. 32. 10.1111/dth.13059.

[37]Kumar, Muriki K & Inamadar, Arun & Palit, Aparna. (2018). A Randomized Controlled, Single-Observer Blinded Study to Determine the Efficacy of Topical Minoxidil plus Microneedling versus Topical Minoxidil Alone in the Treatment of Androgenetic Alopecia. Journal of Cutaneous and Aesthetic Surgery. 11. 211. 10.4103/JCAS.JCAS_130_17.

[38]Jha, Abhijeet Kumar. (2019). Platelet-rich plasma and microneedling improves hair growth in patients of androgenetic alopecia when used as an adjuvant to minoxidil. Journal of Cosmetic Dermatology., 18(5), 1330-1335.

[39]Jha, A. K., Udayan, U. K., Roy, P. K., Amar, A. K. J., & Chaudhary, R. K. P. (2018). Original article: Platelet-rich plasma with microneedling in androgenetic alopecia along with dermoscopic pre- and post-treatment evaluation. Journal Of Cosmetic Dermatology, 17(3), 313–318. https://doi-org.proxy-remote.galib.uga.edu/10.1111/jocd.12394

[40]Shah, K. B., Shah, A. N., Solanki, R. B., & Raval, R. C. (2017). A Comparative Study of Microneedling with Platelet-rich Plasma Plus Topical Minoxidil (5%) and Topical Minoxidil (5%) Alone in Androgenetic Alopecia. International journal of trichology, 9(1), 14–18. doi:10.4103/ijt.ijt_75_16

[41]Gajjar, Prachi Chetankumar & Mehta, Hita & Barvaliya, Manish & Sonagra, Bhavesh. (2019). Comparative Study between Mesotherapy and Topical 5% Minoxidil by Dermoscopic Evaluation for Androgenic Alopecia in Male: A Randomized Controlled Trial. International Journal of Trichology. 11. 58. 10.4103/ijt.ijt_89_18.

[42]Rodrigues, B. L., Montalvão, S. A. L., Cancela, R. B. B., Silva, F. A. R., Urban, A., Huber, S. C., … Annichinno-Bizzacchi, J. M. (2019). Treatment of male pattern alopecia with platelet-rich plasma: A double-blind controlled study with analysis of platelet number and growth factor levels. Journal of the American Academy of Dermatology, (3), 694. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=edsbl&AN=vdc.100076026692.0x000001&site=eds-live

[43]Jha, A. K., & Vinay, K. (2019). Androgenetic alopecia and microneedling: Every needling is not microneedling. Journal Of The American Academy Of Dermatology, 81(2), e43–e44. https://doi.org/10.1016/j.jaad.2019.02.070

[44]Kim, Y. S., Jeong, K. H., Kim, J. E., Woo, Y. J., Kim, B. J., & Kang, H. (2016). Repeated Microneedle Stimulation Induces Enhanced Hair Growth in a Murine Model. Annals of dermatology, 28(5), 586–592. doi:10.5021/ad.2016.28.5.586

[45]Starace, M., Alessandrini, A., Brandi, N., & Piraccini, B. M. (n.d.). Preliminary results of the use of scalp microneedling in different types of alopecia. JOURNAL OF COSMETIC DERMATOLOGY. https://doi.org/10.1111/jocd.13061

[46]Kim BJ, Lim YY, Kim HM, Lee YW, Won CH, Huh CH, et al. Hair follicle regeneration in mice after wounding by microneedle roller. Int J Trichology. 2012;4:117.

[47]Fertig, R. M., Gamret, A. C., Cervantes, J., & Tosti, A. (n.d.). Microneedling for the treatment of hair loss? JOURNAL OF THE EUROPEAN ACADEMY OF DERMATOLOGY AND VENEREOLOGY, 32(4), 564–569. https://doi-org.proxy-remote.galib.uga.edu/10.1111/jdv.14722

[48]Farid, C. I., & Abdelmaksoud, R. A. (2016). Platelet-rich plasma microneedling versus 5% topical minoxidil in the treatment of patterned hair loss. Journal of the Egyptian Women’s Dermatologic Society, (1), 29. Retrieved from http://search.ebscohost.com.proxy-remote.galib.uga.edu/login.aspx?direct=true&db=edsbl&AN=vdc.100050747637.0x000001&site=eds-live

[49]Lee, J. W., Yoo, K. H., Kim, B. J., & Kim, M. N. (n.d.). Photodynamic therapy with methyl 5-aminolevulinate acid combined with microneedle treatment in patients with extensive alopecia areata. CLINICAL AND EXPERIMENTAL DERMATOLOGY, 35(5), 548–549. https://doi-org.proxy-remote.galib.uga.edu/10.1111/j.1365-2230.2009.03695.x

[50]Sasaki, G. H. (2017). Micro-Needling Depth Penetration, Presence of Pigment Particles, and Fluorescein-Stained Platelets: Clinical Usage for Aesthetic Concerns. Aesthetic Surgery Journal, 37(1), 71–83. Retrieved from http://search.ebscohost.com.proxy-remote.galib.uga.edu/login.aspx?direct=true&db=mnh&AN=27530764&site=eds-live

[51]Diamond, J. C., Schick, R. O., Savage, M. Y., & Fadok, V. A. (2019). A small scale study to evaluate the efficacy of microneedling in the presence or absence of platelet-rich plasma in the treatment of post-clipping alopecia in dogs. Veterinary Dermatology. https://doi-org.proxy-remote.galib.uga.edu/10.1111/vde.12821

[52]Branchet M, C, Boisnic S, Frances C, Robert A, M: Skin Thickness Changes in Normal Aging Skin. Gerontology 1990;36:28-35. doi: 10.1159/000213172

[53]S. Arora, & P. Bhandaree Gupta. (2012). Automated microneedling device - a new tool in dermatologist’s kit - a review. Journal of Pakistan Association of Dermatologists, 22(4), 354–357. Retrieved from http://search.ebscohost.com.proxy-remote.galib.uga.edu/login.aspx?direct=true&db=a9h&AN=90580732&site=eds-live

[54]Yoo, Hyeon & Kim, Jin & Lee, Se & Pyo, Hyun & Moon, Hyung & Lee, Jong & Kwon, Ohsang & Chung, Jin & Kim, Kyu Han & Eun, Hee & Cho, Kwang. (2006). Perifollicular Fibrosis: Pathogenetic Role in Androgenetic Alopecia. Biological & pharmaceutical bulletin. 29. 1246-50. 10.1248/bpb.29.1246.

[55]Kwanho Jeong, Ye Jin Lee, Jung Eun Kim, Young Min Park, Beom Joon Kim, Hoon Kang. (2012). Repeated Microneedle Stimulation Induce the Enhanced Expression of Hair-Growth-Related Genes International Journal of Trichology 4, no. 2 (April 2012): 117–30. http://search.ebscohost.com.proxy-remote.galib.uga.edu/login.aspx?direct=true&db=a9h&AN=76973118&site=eds-live.

[56]Tonnesen MG, Feng X, Clark RA. Angiogenesis in wound healing. J Investig Dermatol Symp Proc 2000;5:40-6.

[57]DiPietro LA: Angiogenesis and wound repair: when enough is enough. J Leukoc Biol 2016;100:979-984.

[58]Shaterian, A., Borboa, A., Sawada, R., Costantini, T., Potenza, B., Coimbra, R., … Eliceiri, B. P. (2009). Real-time analysis of the kinetics of angiogenesis and vascular permeability in an animal model of wound healing. Burns : journal of the International Society for Burn Injuries, 35(6), 811–817. doi:10.1016/j.burns.2008.12.012

[59]Steed, D. L. (1997). The Role of Growth Factors in Wound Healing. SURGICAL CLINICS OF NORTH AMERICA, (3), 575. Retrieved from http://search.ebscohost.com.proxy-remote.galib.uga.edu/login.aspx?direct=true

[60]Yu, A.-J., Luo, Y.-J., Xu, X.-G., Bao, L.-L., Tian, T., Li, Z.-X., … Li, Y.-H. (2018). A pilot split-scalp study of combined fractional radiofrequency microneedling and 5% topical minoxidil in treating male pattern hair loss. Clinical and Experimental Dermatology, (7), 775. https://doi-org.proxy-remote.galib.uga.edu/10.1111/ced.13551

Disclaimer

This is not meant to be medical advice, which I am not competent under the law to give you. Rather, it is a synopsis of the medical literature as it relates to the application of microneedling in the treatment of alopecia. It is my hope that this compilation will make you more informed in deciding whether to or how-to pursue medical treatment.

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