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BREAKING THE BARRIER "This is literally a new method of drug delivery, versus oral or intravenous," says Jill S. Waibel, MD, medical director and owner, Miami Dermatology and Laser Institute, Miami, who specializes in the treatment of scars, especially burn scars. "Without exception thus far, laser-assisted transepidermal delivery (TED) has been found to enhance the local uptake of any drug or substance applied to skin. Among the hundreds of topical and systemic drugs used in medicine, it remains to be determined which formulations are specifi cally appropriate or inappropriate for laser-assisted delivery, and why. As a treatment paradigm, the implications for laser-assisted TED are potentially vast and could signifi cantly impact the specialty of dermatology as well as other fi elds of medicine." While dermatologists generally agree that fractional lasers are the best method of creating conduits for TED, they disagree on the merits of microneedling as a means of enhancing topical preparations. "Microneedling has been around for a long time," says Macrene Alexiades-Armenakas, MD, PhD, associate clinical professor, Yale University School of Medicine and director and founder of Dermatology & Laser Surgery Center of New York. "If it worked, dermatologists would not have spent so much time, effort and fi nances developing and purchasing resurfacing lasers." She has had some success combining microneedling with TED. "I have conducted microneedling prior to PDT and have seen reasonable improvements in effi cacy for nonmucosal actinic keratoses. However, it has not been successful in my hands for actinic cheilitis. Well-designed studies are critical here. In contrast, we already have several well-designed and well-executed studies on fractional CO 2 and PDT," says Dr. Alexiades-Armenakas. Alternately, Vivian Bucay, MD, founder of the Bucay Center for Dermatology and Aesthetics in San Antonio, Texas, is a proponent of micronee- dling, particularly for patients who may experience complications with fractional laser technologies. "We do a lot of microneedling procedures," she says. "I have a large number of Hispanic patients and I prefer devices like microneedling and radiofrequency that are colorblind and less likely to cause postprocedure hyperpigmentation. I don't think microneedling poses any danger if you prep the skin thoroughly." According to Dr. Bucay, without proper cleansing prior to breaking the skin barrier, any injection—in- cluding those introduced through microneedling or fractional laser—can drive biofi lm or foreign bodies into the skin, leading to poor healing and possible granulomas. Dr. Waibel sees different roles for fractional lasers and microneedle devices when it comes to TED. "While the effects of laser settings on delivery need further study, lasers are tunable and the depth can be precisely controlled from 10µ to 4,000µ, whereas the microneedle systems are not tunable." Therefore, she feels that microneedle devices are more suitable for use with topical anesthesia and to enhance pen- etration of cosmetic and cosmeceutical preparations. Nonphysicians can use microneedle devices in many states, but the depth of needle penetration is limited to 0.5mm or less, while medical microneedle devices can penetrate 2.5mm or more. ADVANCES IN MICRONEEDLING Microneedling devices have been used in dermatol- ogy and aesthetics for more than 20 years, but newer devices and positive research outcomes have fueled interest in the past few years. "I had tried earlier manual microneedling devices but didn't like them," says Dr. Bucay. "I found there was too much variation in results. It was diffi cult to control the angle of entry and depth, and there was too much pain for the patient. Newer automatic devices, like the Eclipse Micropen, move so rapidly patients barely have time to feel the tiny pin pricks. Most patients report pain of 1 or 2 on a scale of 10, even when I go as deep as 2.5mm." The Eclipse Micropen is a cordless device that gives Microneedling is becoming increasingly prevalent due, in part, to improvements in device design. 48 SEPTEMBER 2014 | MedEsthetics © GETTY IMAGES