Since it’s development in Italy in 1985, microdermabrasion has become an increasingly popular non-invasive procedure used for skin rejuvenation, and the treatment of acne and certain acne scars. The procedure uses the abrasive qualities of aluminum oxide crystals in conjunction with mild suction, to gently remove dead skin cells and surface debris. It’s a simple, painless and rapid procedure, which can be performed in an office setting, with minimal recovery time. Until recently, there had been a scarcity of peer-reviewed literature published to assess its efficacy. How It Works The mechanical technique of microdermabrasion uses aluminum oxide crystals to gently ablate the skin. The machine used to perform microdermabrasion is a closed loop system that works under vacuum pressure. Particles of aluminum oxide are drawn, under suction, from a container and pass over the skin though a small hole at the end of the hand-piece. At the same time, the skin is sucked into the handpiece under the vacuum pressure while the crystals pass over that area. Most machines use a 4- to 6-mm opening at the tip of the handpiece. The crystals are then collected in a reservoir and discarded. The particle flow rate and vacuum pressure determine the amount of skin contact with the particles. Some have claimed that the vacuum pressure also increases blood flow to the superficial layers of the skin. Partial skin ablation to the level of the stratum corneum is desirable. More aggressive treatments can reach the superficial papillary dermis. The degree of exfoliation is determined by the vacuum pressure, particle flow, the speed and movement of each pass, as well as the number of passes over a given area of skin. Other factors, such as the angle of the handpiece as it contacts the skin, may also dictate the degree of exfoliation. Repeated passes over one area, or excessive contact time on one area, may result in pinpoint bleeding, petechiae and bruising. Vacuum pressure (negative pressure) varies inversely with particle flow, and the pressure varies depending on the manufacturer. As the vacuum pressure increases, so does the risk of bleeding and bruising. Treatments, which should be repeated at 2- to 4-week intervals, usually take about 20 to 30 minutes to perform, and are operator-dependent. Following treatments, patients may experience mild redness and tingling, but discomfort is minimal. Many patients describe a “tightened skin” feeling. Side effects such as bleeding, bruising and even urticaria have been described. Additionally, the safety of aluminum oxide crystals has been controversial. These issues will be addressed later in this article.1 Does It Work? Several recent reports have assessed the histologic skin changes associated with microdermabrasion, as well as patient satisfaction with the procedure. - Tsai et al., published one of the first studies on microdermabrasion in 1995. For 2 years, 41 patients with acne, traumatic chicken pox and burn scars were treated with microdermabrasion to the superficial papillary dermis. “Good to excellent” clinical improvement for these types of scarring required a mean of nine treatments with a pressure setting of –76 mm Hg. Mild post inflammatory hyperpigmentation was the only noted adverse effect. Acne scars required a mean of 15 treatments to achieve improvement.2 - Freedman et al., studied the epidermal and dermal changes associated with microdermabrasion. Ten Caucasian patients aged 31 to 62 years, underwent a series of six microdermabrasion treatments at 7- to 10-day intervals. Pretreatment photographs and 2-mm full-thickness biopsies were obtained from the left and right post auricular areas. The left post auricular area was then treated while the right side was left untreated. Subsequent punch biopsy specimens were obtained 5 cm from the original biopsy sites after three treatments and six treatments. Various histologic parameters were evaluated. Significant epidermal and papillary dermal thickening was noted at both the 3- and 6-week intervals. The rete pegs were flattened with wider spacing in each case after three and six treatments as compared to the controls. The stratum corneum normalized in each case after three and six treatments. All treated areas showed increased basal cell activity as compared to none in the control areas. Collagen fibers in treated patients showed hyalinization with thicker, more tightly packed, horizontally oriented collagen bundles, compared with controls. Improved appearance of elastic fibers and changes in microcirculation were noted with increased inflammatory activity in the treated group, as compared to controls. The study concluded that microdermabrasion results in histologic changes after three treatments, and that microdermabrasion produces clinical improvement by a mechanism resembling a reparative process at the dermal and epidermal levels.3 - Tan et al., completed a study of 10 patients who underwent one microdermabrasion treatment per week for 5 or 6 weeks. Skin surface roughness, topography, elasticity, stiffness, compliance, temperature, sebum content and histology were analyzed. Seven patients noted a mild improvement. Physician analysis of photographs revealed mild improvement in the majority of patients. Thermography was performed at the first visit before and after the procedure on one patient. Immediately following the procedure, increased skin temperature was noted, suggesting increased blow flow. Sebum analysis showed a dramatic decrease in surface sebum immediately after the procedure, thought this didn’t persist between treatments. The study found statistically significant decrease in skin stiffness and an increase in skin compliance. Skin biopsies were obtained from preauricular skin in two patients, and from volar skin in two patients. Histology showed slight orthokeratosis and flattening of the rete ridges, and a perivascular mononuclear infiltrate, edema and vascular ectasia in the upper reticular dermis 1 week after the series of treatments. No significant change in collagen or elastin content was noted. The authors concluded that immediately after treatment, changes consistent with mild abrasion and increased blood flow could be measured, and that these vascular changes were due to the effects of negative pressure. Although this study noted changes in the skin after microdermabrasion, they were minimal.4 - Shim et al., evaluated microdermabrasion by using self-rated questionnaires, as well by evaluating acute and chronic histologic effects after microdermabrasion treatment sessions in 14 patients. Eleven of these 14 also had comedonal acne or milia, and three had acne scars. For these three patients multiple passes were applied to these patients’ scarred areas, until pinpoint bleeding was seen. Photographs were taken and self-assessment questions were completed before and after treatments. The histologic evaluation was broken down into two parts: acute and chronic effects. Microdermabrasion was done on abdominal skin (20 passes at -12 mm Hg). A 4-mm punch biopsy was performed on treated and untreated skin. The chronic changes of microdermabrasion were evaluated by choosing three volunteer subjects with little to moderate photodamage who underwent a series of six microdermabrasion procedures on the dorsa of the forearm at 2-week intervals. A 4-mm punch biopsy was performed before and after treatments. Results showed significant improvement was achieved with regard to roughness/textural irregularities and mottled pigmentation. Fine wrinkling and acne were not improved. Of the patients with acne scarring, the results varied from moderate to none. The acute histopathologic changes revealed thinning of the stratum corneum with homogenization. Chronically, there was epidermal hyperplasia, decreased melanization and mild increase in elastin. They concluded microdermabrasion improves some aspects of photoaging and select cases of acne scarring, with notable histologic changes after repeated treatments.1 Microdermabrasion Vs. Glycolic Acid Peels It has generally been accepted that microdermabrasion is comparable to superficial chemical peels in its ability to improve photodamaged skin. n Alam et al., in 2002 compared efficacy and patient satisfaction of glycolic acid peels to microdermabrasion. An unblinded, randomized, controlled trial was conducted. Ten patients received paired treatment of 20% glycolic acid peels and microdermabrasion (mild setting) for 6 weeks. The right and left sides of the face were treated with one of the different modalities. Patient ratings, investigator ratings and photographs were obtained before treatment and after the last one. Seven of 10 patients preferred glycolic acid peels, one preferred microdermabrasion, and two had no preference. Investigator ratings and photographic comparisons failed to reveal treatment specific differences or significant improvement from baseline. Overall, the two treatments did not differ in efficacy. Both procedures were well tolerated by patients. It’s important to note that more intense treatment parameters with either modality may have produced different results.5 Adverse Events Side effects of microdermabrasion are limited and predictable. Mild erythema and increased skin sensitivity are common, but resolve quickly. Petechiae, bleeding and purpura may also occur, and usually are due to prolonged contact time or too high a vacuum pressure on one area of skin. Patients who take aspirin or nonsteroidal anti-inflammatory agents may experience an increased incidence of the events. Patients with rosacea should be discouraged from microdermabrasion since the redness from telangiectasia can be enhanced from the negative pressure of the vacuum. Microdermabrasion is contraindicated for patients with active skin infections of all types. Patients with impetigo, warts and other viral infections, such as herpes simplex, should not be treated. If there’s a history of herpetic infections on the face, the patient should be prophylaxed with the appropriate anti-viral medication. Patients who have completed isotretinoin (Accutane, Amnesteem) therapy should wait 1 year before undergoing microdermabrasion, because of abnormal healing and hypertrophic scarring that’s been reported, though not thoroughly studied. Post inflammatory pigmentary changes have been reported so patients should avoid sun exposure and use a broad-spectrum sunblock. Pigmentary changes are more commonly seen with aggressive microdermabrasion. Scarring has yet to be reported in the literature. The risk of scarring would theoretically be increased in patients who receive glycolic acid peels immediately before or after microdermabrasion. The aluminum oxide crystals could be a potential problem because corneal trauma may occur if crystals were to fall onto the eye. Protective eye gear, such as wet gauze or small goggles, should be used to avoid this risk. There’s been great controversy over the potential hazardous nature of aluminum oxide, specifically with regard to respiratory complications and Alzheimer’s disease. Some studies have linked occupational exposure to aluminum oxide to pulmonary fibrosis, pneumonia, lung function changes and chest X-ray abnormalities. These studies weren’t consistent and couldn’t rule out the possibility of mixed dust disease, since workers were exposed to a mixture of heavy metal dusts. Studies have also been published to challenge to link between aluminum and Alzheimer’s disease.1 An acute urticarial response following microdermabrasion was recently reported in the literature. -Farris and Rietschel, described a 52-year-old woman with known latex allergy who was treated with microdermabrasion in an attempt to improve her photodamaged skin as well as her acne. Immediately following the procedure the patient complained of pruritus on the neck and face. The episode was controlled with systemic corticosteroids. She was prick tested to saline and histamine controls, latex and sterile medical grade aluminum oxide crystals, which had passed through the microdermabrader. The test to aluminum was negative, while the latex was strongly positive, making it not likely that the patient was exposed to latex during the procedure. The etiology of the urticaria remains unclear. It’s possible that it was a dermatographic response to the hand-piece, or possibly true pressure-induced urticaria. Physicians and non-physicians should be aware of the potential complications that can occur from microdermabrasion. Detailed medical histories should be obtained and a physician should be present at the facility when microdermabrasion is performed in case of such unexpected complications.6 The Future of Microdermabrasion Clearly there remains controversy as to whether or not microdermabrasion is efficacious. Several factors appear to be important when studying the effects of microdermabrasion. The depth of ablation appears to be an important factor in predicting results. Deeper ablation seems to be associated with improved results according to some authors. Others state that frequent and continual treatments may play an important role. In summary, microdermabrasion offers an alternative approach to treating photodamaged skin, acne and certain types of scars. The recovery time is quick and patient satisfaction is generally positive. Further research is clearly needed, with standardized study designs. Unfortunately, there’s no universal conclusion as to whether microdermabrasion offers any unique benefits over other modalities, such as glycolic acid peels. Still, microdermabrasion remains a popular alternative for many patients.