European Journal of Cardiovascular Medicine

Acne is a chronic inflammatory disease of pilosebaceous units characterized by seborrhoea, the formation of open and closed comedones, erythematous papules, pustules and in more severe cases nodules, deep pustules, and pseudocysts and a degree of scarring ensue in many cases¹.

Various factors like androgen-induced increased sebum production, alteration in quality of sebum lipids, inflammation, altered keratinization and colonization of hair follicles by bacteria like Cutibacterium acne are contributory to it. Series of events like infra infundibular inflammatory process, follicular rupture, and peri-follicular abscess leads to injury of the skin. This, in turn, initiates the cascade of wound healing through soluble chemical mediators and various inflammatory cells leading to enzymatic degradation of collagen fibers and subcutaneous fat. The result of which is the formation of scar tissue^2,3.

Acne vulgaris occurs in all races worldwide, affecting 90% of people sometime or the other in their life. According to a study it occurs in all races worldwide, affecting 58% of women and 40% of men (Leeds grading technique). The disease usually begins at puberty or a few months earlier. Peak incidence is between 14-17 years in females and 16-19 years in men. The prevalence of acne decreases significantly only after 45 years of age⁴. It is more prevalent among men than women at 18, beyond the age of 23 clinical acne was more prevalent among women as the prevalence in men gradually declined⁵. 95 % of acne patients develop some degree of facial and truncal scarring is more likely in men versus women. There is a positive correlation between the severity of scars.

Design of study: A prospective, analytical, comparative study was conducted on patients with post acne atrophic scars on face, presenting to the department of DVL, Ananthapur, Andhra Pradesh. The study was conducted over a period of 17 months from February 13th, 2024 to 24th July 2025 in the Department of DVL, Ananthapur, Andhra Pradesh. Study population: 32 patients with atrophic acne scar presenting to the outpatient department of DVL between the period February 13th, 2024 to 24th July 2025 were enrolled as study subjects, based on inclusion and exclusion criteria. 2 patients dropped out before completion and could not be evaluated.

Inclusion criteria:

1. Age 20 – 40 yrs
2. Patient willing to give consent for the treatment
3. Patients with Grade 2,3 and 4 post acne atrophic scarring based on Goodman and Baron qualitative system of post acne scarring
4. No active acne
5. Patient not on any other scar treatment

Exclusion criteria:

1. Patient not giving consent
2. Patients with unrealistic expectations
3. Cases with inflammatory active acne
4. Active infection of adjacent skin
5. Acute illness in past 4 weeks
6. Keloidal tendency
7. History of usage of retinoids oral/topical retinoids or undergone any treatment for scars in the past 6 months
8. Bleeding disorders
9. Cold urticaria, cryoglobulinemia, Raynaud’s disease, multiple myeloma, concurrent treatment with immunosuppressants, renal dialysis
10. Pregnancy
11. History of thyroid, diabetes, hypertension, asthma

METHODOLOGY:

The study was conducted after taking approval from the institutional ethics committee. The patients were explained in detail about the benefits, duration of the treatment, possible side effects and the prognosis of the treatment and written informed consent was obtained. Detailed history and clinical examination were done for all patients. Standardized Digital Photography was done using a camera. The arbitrary distance between the subject and the camera was 15 cm and the pictures were taken in the well-illuminated area keeping the camera parallel to face to avoid any artifacts due to shadowing. The acne scars are graded by a blinded observer using Goodman and Baron Qualitative and Quantitative grading. Subjective evaluation grading was taken based on patients own perception scale of 0-10. The patients were then randomized into two groups Microneedling and Cryoroller.

For microneedling the area to be treated is anesthetized with topical anaesthesia for 45 minutes to 1 hour. Microneedling was done with a dermaroller having 192 needles each having a length of 1.5 mm (Figure no. 1 & 2). After preparation of the area with antiseptic and saline, the skin was stretched with one hand, and perpendicularly, rolling was done five times each in the horizontal, vertical, and oblique directions with the other hand. The treatment endpoint was identified as uniform pin-point bleeding, which was easily controllable. Post procedure, the area was cleaned with saline and ice packs was used for comforting the patient. (Figure no. 4)

Cryoroller therapy was done with a Cryoroller using Liquid nitrogen (Temp – 196 degrees Celsius) as cryogen (Figure no. 2 & 3). To prevent sticking of the roller over the face, acetone was applied prior to rolling the cryoroller over that segment. Liquid nitrogen was poured in a plastic cup. The roller was dipped in the cup and rapidly rolled over the face in a sequential manner (approx. 5 times), covering a segment of face each time to produce mild erythema, which was considered an endpoint of treatment. (Figure no. 5)

Post procedure the patient was prescribed oral and topical antibiotics and anti-inflammatory drugs for 5 days. Strict photoprotection in the form of sunscreen having a SPF of >30 was advised for the whole study period. Avoidance of application of any cosmetics for a period of 7 weeks was advised. 6 sessions were performed at an interval of 3 weeks.

The patients were followed up for a period of 6 months, after completion of 6 sessions. Digital photographic evaluation and grading were done by the blind observer using the Goodman and Baron qualitative and quantitative grading scale. A subjective improvement as per patient’s assessment on a scale of 0-10.

Data analysis:

The data obtained from all the patients were tabulated on MS excel program. Data were summarized using means standard deviations for quantitative variables and percentages for qualitative variables. Mean acne scar scores were computed for patients, both at the time of presentation and at end of 6 months. Statistical significance of the difference in acne scar scores was estimated using a paired t-test. Clinical improvement in scar score was also analysed by initial severity status. P ≤ .05 was considered statistically significant and P ≤ .01 considered highly significant.

A total of 30 patients were enrolled in the study with 15 patients in each group. Overall maximum number of patients in this study 66.66% (n=20) were in the age group of 23-32 years, the minimum age was 20 years and maximum 37 years.43.33% (13) were males and 56.66% (17) were females. 33.33% of males and 66.66 % of females were in Microneedling group and 53.33% of males and 46.66 % females were in Cryoroller group.

Among the participants 33.3% have used oral retinoids in the past and 66.7% did not.

Out of total subjects 20% (6) patients were Grade 2, 46.66% (14) were Grade 3, 33.33% (10) were Grade 4 scarring on Goodman and Baron Qualitative Scale. Grade 2,3,4 on Goodman and Baron Qualitative scale were taken and were allocated equally into microneedling and cryoroller groups i.e. 3 Patients with Grade-2 in each and 7 patients with Grade-3 in each, 5 patients with Grade 4 in each group. The mean time since onset of acne was 7.73 years with a minimum of 2 years and maximum 20 years.

Fig.no. 1 Materials required for microneedling

CHANGE IN GOODMAN AND BARON QUALITATIVE GRADE FOR MICRONEEDLING GROUP:

Table No. 1

COMPARISON OF PRE AND POST VALUES OF VARIOUS VARIABLES IN MICRONEEDLING GROUP

Table No. 2

PERCENTAGE IMPROVEMENT USING THE GOODMAN AND BARON QUANTITATIVE GRADING SCALE FOR MICRONEEDLING GROUP

Table No.3

CHANGE IN GOODMAN AND BARON QUALITATIVE GRADE FOR CRYOROLLER GROUP:

Table No. 18

COMPARISON OF PRE AND POST VALUES OF VARIOUS VARIABLES IN

CRYOROLLER GROUP                     

Table No.5

PERCENTAGE IMPROVEMENT USING THE GOODMAN AND BARON

QUANTITATIVE GRADING SCALE IN CRYOROLLER GROUP

Table No.6

Table No. 7

Chart no :1

Chart No.2

Comparison of microneedling vs cryoroller on quantitative scaling

Chart no: 3

A statistically significant difference was found between the pre and post procedure values of various grading scale of assessment in microneedling group and cryoroller group.

Microneedling group - Mean percentage of improvement was 40 .69 %. Maximum 80% of patients having a percentage of improvement on the Quantitative scale of >30 %. 60% had improvement between 31-50%. Change in Goodman and Baron Qualitative grading was seen in 13/15 patients. A significant change was found from grade 4 to 2 in two patients, grade 3 to 1 in two patients. No change of grade in two patients. Mean percentage of improvement on subjective evaluation was 31.81% with 53% showed >30% improvement. (Table no. 1, 2 & 3) (Fig 6 & 7)

Cryoroller group - Mean percentage of improvement was 51.20%. Maximum 93% of patients have improvement >30%. Change in Goodman and Baron Qualitative grading was seen in 13/15 patients. A significant change was found in 3 patients from grade 4 to 2 in 3 patients, grade 3 to 1 in 2 patients. No change of grade in 2 patients. Mean percentage of improvement on subjective evaluation was 39.42 % with 74% percentage showing improvement of >30% on a subjective scale. (Table no. 4, 5 & 6) (Fig 8 & 9)

Difference on comparing microneedling and cryoroller was statistically significant on a Quantitative scale and Subjective evaluation but not on Qualitative scale (Table no. 7). On comparing microneedling vs cryoroller on a quantitative scale, the cryoroller indicating a greater mean percentage of improvement. (Chart no.1,2 &3)

Post inflammatory hyperpigmentation took longer duration to resolve in cryoroller group than microneedling group.

ADVERSE EVENTS

Post-procedure erythema found in all 30 (100%) patients in both cryoroller and microneedling groups. It was resolved completely within 5 days (2.5 days).

Post procedural edema found in all microneedling groups. It was resolved completely within 2 days.

Procedural mild to moderate pain was found in microneedling group.

Post microneedling hyperpigmentation was observed in 20% (3) of patients which were subsided in all 10-15 days. (mean duration – 11.7 days).

Post cryoroller hyperpigmentation was observed in 20 % (3) of patients which resolved in 2-5 months (mean duration – 3 months).

A prospective, analytical comparative study was conducted on 30 patients, assigning 15 to each group i.e. microneedling and cryoroller to evaluate the efficacy of each modality in the management of post acne atrophic scars on the face. The study was conducted over a period of 17 months from February 13th, 2024 to 24th July 2025 in the Department of DVL, Ananthapur, Andhra Pradesh.

The study was conducted to compare the efficacy of microneedling against cryoroller in the management of post acne atrophic scars using Goodman and Baron qualitative and quantitative grading system also including a subjective evaluation scale and to assess the efficacy of each modality of treatment in the management of acne scars. The present study compares the efficacy of microneedling against cryoroller in treatment post acne atrophic scars. On review of the literature, no comparative studies have been carried out between above modalities of treatments.

In the present study the mean percentage of improvement using Goodman and Baron Quantitative grading scale was 40.69 % in the microneedling group, change in Qualitative grading was seen in 13/15 patients. A significant change of 2 grades was found from Grade 4 to 2 in two patients, 3 to 1 in two patients. Whereas, the mean scores decreased from 3.13 with SD 0.743 to 2 with SD 0.654 (P<0.00001). This finding was similar to the following studies.

A study conducted by S Porwal et al¹ on Combined Dermaroller and Platelet-Rich Plasma Versus Dermaroller Alone in Acne Scars, 55 patients were included, and patients evaluated based on Goodman and Baron’s quantitative scale, 43.03% improvement showed among the dermaroller alone group.

In a study by Mohamed Kotb et al² on skin microneedling plus PRP vs skin microneedling alone in the treatment of atrophic post acne scars. Patient graded their response to treatment as poor, good, very good or excellent with 0–24%, 25–49%, 50– 74%, and 75–100% improvement, respectively. Out of the 35 patients, 31 achieve reductions in scoring by one or two grades. Based on qualitative global acne scarring classification of Goodman & Baron, two independent dermatologists revealed a significant improvement in the degree of scar severity before and after treatment on both sides. Whereas, the mean scores decreased from 3.2 ± 0.7 to 1.8 ± 0.6 on the side treated with skin needling and PRP (P<.001) and 2.1 ± 1.1 in the side treated with skin needling alone (P<.001)⁴

Whereas there was an excellent response in five patients (14.2%), very good response in 17 patients (48.5%), good response in 9 patients (25.7%), and poor in 4 patients (11.4%) in the side treated with skin needling alone.

In the present study 60% of patients had improvement between 30 – 50% in the microneedling group on a quantitative scale

A study conducted by Puri et al³ on atrophic acne scars, 30 patients were included. The grading of acne scars was done clinically and by serial photographs. The improvement of the patients was categorized as follows: excellent, improvement greater than 70%; good, improvement of 50-70%; fair, improvement of 30-50%; poor, improvement less than 30%. Patients were also asked to fill a questionnaire based on a 10-point scale starting from 0-10. After four sessions of microneedling, marked improvement was seen in 40% patients in the dermaroller group, the moderate improvement was seen in 40% mild improvement was noticed in 20%.

In the present study, efficacy was present in 13 patients (86.67%) on quantitative grading in the microneedling group. This finding coincides with following studies.

In a study conducted by Hassan et al⁵ on Comparison of Efficacy of Micro needling for the Treatment of Acne Scars in Asian Skin with and without Subcision, a simple 5-grade scoring system was used. Efficacy was present in 27 patients (77.1%) in microneedling group.

In the present study according to quantitative scaling, 20% showed a good response, 60% showed fair response and 20% showed a poor response.

In a study by Badheka et al⁶, for treatment of acne scars at the end of 3 sessions, according to physician’s evaluation, microneedling group 6.67% (n=1), 20% (n=3), 46.67% (n=7), 26.67% (n=4) patients showed excellent, good, fair, and poor response respectively⁶. According to self-evaluation by the patient at the end of 3 sittings, overall, 44.44% (n=20) patients showed an excellent response (score of 8-10).

An Egyptian group Leheta et al⁷., 2011 randomized 30 participants to receive either microneedling or the focal application of 100% trichloroacetic acid (TCA) using the CROSS (chemical reconstruction of skin        scars) method. A blinded investigator scored a 68% mean improvement in the microneedling group and a 75% improvement in the TCA group, with no statistically significant difference between groups.

An Italian study Fabbrocini et al.,2011c⁴ compared microneedling to microneedling combined with the topical application of platelet-rich plasma (PRP) in a split-face trial of 12 patients. Photographic data were analyzed using the Sign Test (α<.05). The study showed that the scars severity grade in all patients was greatly reduced on all the faces, but the improvement was more efficient on the side treated with both microneedling and PRP.

A study by Sharad et al⁸ on microneedling alone and the combination of microneedling and glycolic acid peels for the treatment of acne scars in dark skin. Thirty patients in the age group of 20–40 years with atrophic box type or rolling scars with post inflammatory hyperpigmentation were chosen for the study. Two groups were made. Patients from both groups were evaluated based on Echelle d’Evaluation clinique des Cicatrices d’acne´ classification. Based on the objective scoring and its statistical analysis, there was a significant improvement in superficial and moderately deep scars (grade 1–3). The mean improvement in scars with microneedling alone was 31.33%.

Evaluating the efficacy of skin needling in conjunction with other treatments for acne scarring:

In the present study on cryoroller group mean percentage of improvement was 51.20 %. Maximum 93% of patients have improvement >30%. 46.6% have a mean percentage of improvement. Change in Qualitative grading was seen in 13/15 patients. A significant change of 2 grades was found from grade 4 to 2 in two patients, 3 to 1 in two patients. Mean percentage of improvement on subjective evaluation was 39.42% (SD—10.54) with 74% percentage showing improvement of >30% on a subjective scale.

In present study on microneedling group mean percentage of improvement on was 40.60%. Maximum 80% of patients having a percentage of improvement on a Quantitative scale of >30 %. 60% had improvement between 31-50%. Change in Qualitative grading was seen in 13/15 patients. Mean percentage of improvement on subjective evaluation was 31.81% (SD—10.542) and 53% showed >30% improvement.

In a study by Gadkari et al⁹, a split-face comparative study to evaluate efficacy of combined subcision and dermaroller against combined subcision and cryoroller in treatment of acne scars assessment using the Goodman and Baron quantitative grading scale showed, a 57% improvement using combined subcision and cryoroller against 40% improvement with combined subcision and dermaroller, with maximum patients (60%) having 50–69% improvement. Change in Goodman and Baron qualitative grading was seen in only 12 of 30 patients. But, a significant change from grade 4 to grade 2 was seen in two patients⁹.

On the subcision and dermaroller side, using the Goodman and Baron Quantitative grading scale, mean percentage improvement was 40% (SD—0.17) with maximum patients (43%) having 30–49% improvement. Change in Goodman and Baron qualitative grading was seen in only nine of 30 patients.

On the subjective evaluation of cryoroller, mean percentage improvement noticed by the patient was 61% (SD—0.14) with maximum patients (63%) reporting improvement between 50 and 69%. Whereas in microneedling, mean percentage improvement noticed by the patient was 45% (SD—0.09) with maximum patients (90%) reporting improvement between 30 and 69%.

Savant SS¹⁰ on his textbook of Dermatosurgery and Cosmetology mentioned cryotherapy as a safe procedure on Indian skin type for acne and post acne extensive scarring.

In the present study group out of 10 patients in grade 4, four (40%) patients improved to grade 2 and 6(60%) patients improved to grade 3. Out of 14 patients in grade 3 scars, four patients improved to grade 1 (28.6%) and ten patients improved to grade 2 (71.4%). And 86.66% show change in grading.

In a study conducted by Chawla S et al¹¹, a split face comparative study of microneedling with PRP vs microneedling with vitamin C in treating atrophic post-acne scars, out of 30 patients, 23 achieved a reduction in scarring by one or two grade.

LIMITATIONS:

There were no side-to-side studies in the literature which compared microneedling with cryoroller in the treatment of atrophic acne scars.

There were few studies using Goodman and Baron system of grading acne scars and therefore it is difficult to compare the results of various studies on a common ground.

Microneedling was shown to work well in combination with other treatments for acne scarring, but the results of each study were specific for each treatment and lacked external validity.

The study population was less and there was no control group

Lack of blinded evaluator and subjective way of evaluating acne scars. There is a need for larger, double-blinded RCT's in order to provide further insight.

Thirty patients with Grade 2,3,4 post acne atrophic scars were included in the study. The patients were randomized into two groups microneedling was done in 15 subjects and cryo-roller was done in 15 patients.

A statistically significant difference was found in pre and post procedure values on 3 different scales in both the groups, proving microneedling with dermaroller and cryoroller as an effective modality of treatment for post acne atrophic scars.

Statistical analysis of the mean improvement using quantitative grading scale and subject assessment proved that cryoroller is a better technique than microneedling in the treatment of atrophic acne scars. But the difference in mean improvement values using the qualitative grading scale was not found to be significant.

Both microneedling and cryoroller were an effective modality of treatment for post acne atrophic scars on face. Cryoroller was more effective in an atrophic scars and boxcar scars compared to microneedling. Cryoroller was a better technique and much more cost effective than microneedling in the treatment of post acne atrophic scars on face. Microneedling was effective for icepick scars than cryoroller.

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