Continuing Education Activity

Microdermabrasion (MDA) is a minimally invasive epidermal resurfacing procedure used to treat uneven skin tone/texture, photoaging, striae, melasma, and scars, including acne scars. It is widely available and one of the most common nonsurgical cosmetic procedures performed in the United States. This activity describes the technique used to perform microdermabrasion, its indications, contraindications, and complications.

Objectives:

• Explain the difference between crystal and crystal-free microdermabrasion systems.
• Review the contraindications and relative contraindications for the use of microdermabrasion.
• Describe the potential clinical use of microdermabrasion in topical medication delivery.
• Outline the importance of coordination among interprofessional team disciplines to enhance clinical outcomes for patients undergoing microdermabrasion.

Introduction

Microdermabrasion (MDA) is a minimally invasive epidermal resurfacing procedure used to treat uneven skin tone/texture, photoaging, striae, melasma, and scars, including acne scars. It is widely available and one of the most common nonsurgical cosmetic procedures performed in the United States. MDA was first introduced in 1985 by Marini and Lo Brutto as a less aggressive alternative to chemical peels and dermabrasion. The MDA procedure can be performed in the outpatient setting (medical office, medical spa) by a trained clinician, aesthetician, medical assistant, or nurse without the use of anesthesia.

During the procedure, abrasive crystals are propelled against the skin under the control of a handheld vacuum system. The crystals cause gentle mechanical abrasion to the skin, which ultimately removes the stratum corneum layer of the epidermis. As part of the wound healing process, new epidermis forms with enhanced cosmesis. The technique is considered safe for all Fitzpatrick skin types and complications are minimal. In addition to the cosmetic benefits of MDA, studies have also shown improved skin permeability, and enhanced delivery of transdermal medications dosed on an area of the skin treated with MDA.

Anatomy and Physiology

There are five layers of the epidermis, each with different properties. Moving from the most superficial to deep layers, they are as follows: 

• Stratum corneum 
• Stratum lucidum 
• Stratum granulosum 
• Stratum spinosum 
• Stratum basale

Microdermabrasion removes the stratum corneum, the outermost layer of the epidermis.[1][2][3] MDA has also been shown to affect deeper layers of the epidermis and dermis. MDA causes a re-arrangement of melanosomes in the basal layer of the epidermis, flattening of rete ridges at the dermal-epidermal junction, increased collagen fiber density at the dermal-epidermal junction, and vascular ectasia in the reticular dermis.[4] MDA also causes an upregulation of wound healing transcription factors and matrix metalloproteinases in the dermis.[5]

Indications

Cosmetic Indications:[1][4][5][6][7][8]

• Scars, including acne scars
• Acne
• Uneven skin tone/texture
• Striae distensae (stretch marks) 
• Melasma
• Photoaging
• Seborrheic skin
• Fine wrinkles
• Enlarged pores

Patients often report improved skin "glow," softness, texture, and decreased visibility of pores.[1] Decreased sebum levels are noted immediately after the procedure.[8] The biomechanical analysis demonstrates a decrease in skin stiffness, an increase in skin compliance, and an increase in skin thickness.[9] In individuals with melasma, MDA decreases melanization and evenly distributes melanosomes in the epidermis. In individuals with scarring, striae, and photoaging, MDA improves collagen fiber density and distribution. 

Transdermal Drug Delivery

Microdermabrasion has been shown to improve transdermal drug delivery by removing the stratum corneum. Methods to increase transdermal delivery often target the stratum corneum layer of the epidermis, as the stratum corneum is the principal barrier that limits the percutaneous diffusion of molecules.[10] Drugs diffuse more freely in the viable epidermis, directly below the stratum corneum layer. MDA has been shown to improve transdermal insulin delivery, transdermal vitamin C delivery, transdermal lidocaine delivery, and transdermal 5-fluorouracil delivery.[11][12][13] Although there are several ongoing clinical trials with promising results, the feasibility of using MDA in a clinical setting to enhance transdermal drug delivery is still unknown.[12]

Contraindications

Microdermabrasion is contraindicated in an area of active cutaneous infection, such as herpes simplex virus, varicella-zoster virus, human papillomavirus, and impetigo.[14] In individuals with contact allergies to the abrasive crystals (i.e., aluminum allergy), a different crystal or a crystal-free system should be used.[15] MDA should be used cautiously in individuals with a known history of hypertrophic scarring (keloids).[8] Rosacea and telangiectasias are considered relative contraindications.[14]

Equipment

Microdermabrasion devices are categorized as either crystal or crystal-free systems. The crystal-based system propels abrasive crystals at the skin at a predetermined flow rate. The most common crystal used is aluminum oxide. Sodium chloride, magnesium oxide, and sodium bicarbonate crystals are less commonly employed. With the crystal-free systems, diamonds embedded in the handpiece provide the abrasive stimulus. The following equipment is needed to perform the procedure: 

• Microdermabrasion handpiece 
• Disposable handpiece tips or autoclave-safe handpiece tips
• Fresh abrasion crystals (for crystal-based systems)
• Filters (for machines with a closed-loop vacuum system)
• Gentle skin cleanser 
• Protective equipment (eyewear, gloves, mask)

Technique or Treatment

The area of desired treatment should be cleaned with a mild cleanser prior to the start of the procedure. Moist gauze is placed over the eyes to prevent contact with the abrasive crystals. Contact is made between the skin and the device tip. Using negative pressure, the device pulls the skin into the handpiece. The device then releases the abrasive crystals at a controlled flow rate. Surface debris and the stratum corneum layer of cells are removed, and the particles collect in a reservoir. The device is then passed over the skin to target the desired surface area. A single treatment usually requires three passes over the treated area. The remaining crystals and debris are wiped away with a washcloth, and a gentle moisturizer is applied. The entire procedure typically takes 30-60 minutes. Patients often require 4-6 weekly treatments to achieve the desired results. The degree of stratum corneum removal is dependent on the crystal flow rate and procedure exposure time. The pressure generated by the vacuum device has little effect on stratum corneum removal.[2][9]

Complications

Side effects of microdermabrasion are minimal, and most patients experience no adverse events. Common complications include tenderness, swelling, redness, petechiae, and bruising. Eye irritation can occur if the crystals come in contact with the conjunctiva.[4] There is an increased risk of autoinoculation of viral cutaneous lesions (e.g., molluscum contagiosum) and reactivation of latent herpes simplex virus in an affected dermatome.[9] Since stratum corneum removal occurs during MDA, the skin is more sensitive to photodamage for a few days after the treatment.

Clinical Significance

The primary clinical significance of microdermabrasion lies in cosmetic and aesthetic benefits. It is a minimally invasive procedure that can offer evened skin tone, bright complexion, reduced appearance of dark spots, and wrinkles, with cleaned-out pores and improved smoothness of the skin. Microdermabrasion has also been shown to enhance transdermal drug delivery by allowing the drug to diffuse more freely in the viable epidermis. The theoretical benefits of this are thought to include improved transdermal insulin delivery, transdermal vitamin C delivery, transdermal lidocaine delivery, and transdermal 5-fluorouracil delivery. Although there are several ongoing clinical trials with promising results, the feasibility of using microdermabrasion in a clinical setting to enhance transdermal drug delivery is still unknown.

Enhancing Healthcare Team Outcomes

Microdermabrasion may be performed by several types of practitioners in the outpatient setting, including aestheticians, medical assistants, and nurses. Although MDA is a relatively benign procedure with minimal complications, all providers should receive training on the proper technique, benefits, as well as risks of the procedure. A medical history, including allergies, should be documented prior to starting the procedure. Appropriate expectations should be set, and patients should be informed that several treatments might be required to achieve the desired results. As some patients may experience petechiae and redness immediately after the procedure, treatments should be avoided for at least two weeks prior to significant life events (e.g., wedding photography, etc.) Proper sterilization of MDA equipment is essential to prevent infectious disease transmission from one patient to another. Patients should be advised to use sunscreen when outdoors for at least one week following the procedure. For individuals with skin conditions not amenable to MDA, a referral to a dermatologist is warranted.