STUDY
`
`Molecular Analysis of Aggressive
`Microdermabrasion in Photoaged Skin
`
`Darius J. Karimipour, MD; Laure Rittie´, MS, PhD; Craig Hammerberg, MS, PhD; Victoria K. Min, BA;
`John J. Voorhees, MD; Jeffrey S. Orringer, MD; Dana L. Sachs, MD; Ted Hamilton, MS; Gary J. Fisher, PhD
`
`Objective: To investigate dermal remodeling effects of
`crystal-free microdermabrasion on photodamaged skin.
`
`Design: Biochemical analyses of human skin biopsy
`specimens following microdermabrasion treatment
`in vivo.
`
`Setting: Academic referral center.
`
`Participants: Volunteer sample of 40 adults, aged 50
`to 83 years, with clinically photodamaged forearms.
`
`Intervention: Focal microdermabrasion treatment with
`diamond-studded handpieces of varying abrasiveness on
`photodamaged forearms and serial biopsies at baseline
`and various times after treatment.
`
`Main Outcome Measures: Quantitative polymerase
`chain reaction, immunohistochemistry, and enzyme-
`linked immunosorbent assay were used to quantify
`changes in inflammatory, proliferative, and remodeling
`effectors of normal wound healing. Type I and type III
`procollagen served as the main outcome marker of der-
`mal remodeling.
`
`Results: Coarse-grit microdermabrasion induces a wound
`healing response characterized by rapid increase in in-
`
`duction of cytokeratin 16 and activation of the AP-1 tran-
`scription factor in the epidermis. Early inflammation was
`demonstrated by induction of inflammatory cytokines,
`antimicrobial peptides, and neutrophil infiltration in the
`dermis. AP-1 activation was followed by matrix metal-
`loproteinase–mediated degradation of extracellular ma-
`trix. Consistent with this wound-healing response, we
`observed significant remodeling of the dermal compo-
`nent of the skin, highlighted by induction of type I and
`type III procollagen and by induction of collagen pro-
`duction enhancers heat shock protein 47 and prolyl 4-hy-
`droxylase. Dermal remodeling was not achieved when
`microdermabrasion was performed using a medium-
`grit handpiece.
`
`Conclusions: Microdermabrasion using a coarse dia-
`mond-studded handpiece induces a dermal remodeling
`cascade similar to that seen in incisional wound heal-
`ing. Optimization of these molecular effects is likely the
`result of more aggressive treatment with a more abra-
`sive handpiece.
`
`Trial Registration: clinicaltrials.gov Identifier:
`NCT00111254
`
`Arch Dermatol. 2009;145(10):1114-1122
`
`M ICRODERMABRASION IS A
`
`popular procedure for
`skin rejuvenation. It
`has been suggested
`that microdermabra-
`sion can improve the appearance of
`wrinkles,1 atrophic acne scars,2 dyspig-
`mentation,3 and other signs of aging skin.
`The proposed mechanism by which mi-
`crodermabrasion exerts these effects is
`through remodeling the dermis with elabo-
`ration of new collagen and other matrix
`components.1,3,4
`
`Author Affiliations:
`Department of Dermatology,
`University of Michigan
`(Drs Karimipour, Rittie´,
`Hammerberg, Voorhees,
`Orringer, Sachs, and Fisher and
`Mr Hamilton), and University
`of Michigan Medical School
`(Ms Min), Ann Arbor.
`
`CME available online at
`www.jamaarchivescme.com
`
`Karimipour et al5 demonstrated that
`aluminum oxide microdermabrasion ac-
`tivates a dermal remodeling cascade in-
`volving cytokines, transcription factors,
`
`and matrix metalloproteinases (MMPs).
`However, stimulation of new collagen syn-
`thesis occurred in only a few subjects and
`was not statistically significant. A pos-
`sible explanation for the lack of signifi-
`cant collagen production might relate to
`the minimal wounding of microdermabra-
`sion.6 In fact, aggressive ablative resurfac-
`ing procedures characteristically result in
`significant collagen production.7,8
`Hence, the objective of this study was to
`investigate whether microdermabrasion
`could be improved through more aggres-
`sive (but still nonablative) perturbation of
`the epidermis. We hypothesized that in-
`creasing the wounding stimulus might en-
`hance dermal remodeling, as observed with
`other aggressive procedures,7,8 and thereby
`elicit consistent induction of collagen pro-
`duction. To test this hypothesis, we used a
`diamond-studded handpiece with varying
`roughness as a wounding stimulus.
`
`(REPRINTED) ARCH DERMATOL/ VOL 145 (NO. 10), OCT 2009
`1114
`
`WWW.ARCHDERMATOL.COM
`
`©2009 American Medical Association. All rights reserved.
`
`Downloaded From: on 07/18/2018
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`1
`
`Sinclair Pharma et al.
`EUNSUNG-1026
`
`

`

`The microdermabrasion system used (Diamond-
`Tome; Altair Instruments, Camarillo, California) offers
`a unique way to vary the abrasive stimulus. The system
`differs from standard microdermabrasion systems that use
`aluminum oxide crystals as corundum. The system uses
`a handpiece that has diamond fragments embedded in
`the contact point of the wand with the skin. The wand’s
`roughness is controlled by the size of the diamond par-
`ticles at the contact point.
`We assessed the ability of medium-grit and coarse-
`grit handpieces to elicit molecular responses that occur
`during normal wound healing. Collagen production was
`quantified.
`
`METHODS
`
`HUMAN SUBJECT DESCRIPTION, TREATMENT,
`AND TISSUE PROCUREMENT
`
`This study was approved by the University of Michigan Medi-
`cal School Institutional Review Board for Human Subjects
`Research. All subjects provided written informed consent.
`Forty subjects (26 males and 14 females), aged 50 to 83 years,
`received a single microdermabrasion treatment with the
`diamond-studded handpiece to photodamaged forearm skin
`using a medium-grit (100-µm particle size) or coarse-grit
`(125-µm particle size) wand. In each subject, three 2⫻2-cm
`areas of photodamaged forearm skin were treated with micro-
`dermabrasion. The microdermabrasion device was set at −25
`inches mercury, and the microdermabrasion wand was
`applied in horizontal, vertical, and oblique directions for a
`total of 3 passes. For this study, 3 passes represents 1 micro-
`dermabrasion treatment. Each pass was characterized as a
`back-and-forth motion lasting approximately 15 seconds to
`“paint” the test area in sequential rows; the handpiece was not
`lifted off the skin during each pass. This procedure is similar
`to how we perform microdermabrasion on a daily basis in our
`clinic. The treatment resulted in mild erythema in all subjects
`that would typically last less than 2 hours.
`Punch biopsy specimens (4 mm) were obtained from treated
`and untreated (control) skin at different intervals ranging from
`4 hours to 14 days after treatment. Each subject’s baseline (no
`treatment) biopsy specimen served as his or her control. Im-
`mediately after biopsy, skin specimens were embedded in op-
`timal cutting temperature (OCT) embedding medium (Tissue-
`Tek OCT compound; Miles, Naperville, Illinois), frozen in liquid
`nitrogen, and stored at −80°C until processing.
`
`RNA EXTRACTION AND REAL-TIME
`REVERSE TRANSCRIPTION–POLYMERASE
`CHAIN REACTION
`
`RNA extraction from skin biopsy specimens, reverse transcrip-
`tion, and messenger RNA (mRNA) quantification by real-time
`reverse transcription–polymerase chain reaction were per-
`formed as previously described.9 Custom primers and probes
`were used for type I procollagen (COL1A1) (GenBank Z74615),
`type III procollagen (COL3A1) (GenBank X15332), and the
`housekeeping gene 36B4 (GenBank AB007187). All other
`primer-probe sets were validated gene expression assays (Taq-
`Man; Applied Biosystems, Foster City, California). Results are
`presented as fold change in treated vs untreated skin samples
`(normalized to transcript levels of 36B4) or as fold change vs
`36B4 (2−[CTtarget−CT36B4], where CT indicates cycle threshold and
`is the end point of the real-time polymerase chain reaction).
`
`IMMUNOHISTOCHEMISTRY
`
`Frozen tissue embedded in OCT medium was cut into 7-µm-thick
`sections. Immunohistochemical staining was performed using the
`following primary antibodies: cytokeratin 16 (Novocastra; Leica
`Microsystems,Bannockburn,Illinois),cJun(AbtransductionLabo-
`ratories, Lexington, Kentucky), JunB (Santa Cruz Biotechnology,
`SantaCruz,California),MMPtype1(MMP1),prolyl4-hydroxylase,
`type I procollagen (Chemicon, Temecula, California), neutrophil
`elastase (DAKO, Carpinteria, California), heat shock protein 47
`(HSP47; BioGenex, San Ramone, California), and fibroblast acti-
`vationprotein(BenderMedsystems,Burlingame,California).Tissue-
`boundprimaryantibodywasvisualizedwithasecondaryantibody–
`peroxidase complex,10 and the amount of staining was quantified
`using commercially available software (Image-Pro; Media Cyber-
`netics, Inc, Bethesda, Maryland). To assess the specificity of stain-
`ing, substitution of isotype ␥-globulin for the primary antibody was
`used. There was no staining visualized with any isotype ␥-globulin.
`
`PROTEIN EXTRACTION AND TYPE I
`PROCOLLAGEN ENZYME-LINKED
`IMMUNOSORBENT ASSAY
`
`Frozensections(50µmthick)werecollectedfromOCT-embedded
`skinsamplesontopolyethylenenaphthalatefoil-coatedslides(Leica
`Microsystems). For each sample, the dermal area was measured
`using software associated with the laser capture microdissection
`microscope (Leica AS LMD), and skin sections were isolated from
`surrounding OCT by microdissection. Samples were collected into
`ice-cold protein extraction buffer (50mM Tris hydrochloride [pH
`7.4], 0.15M sodium chloride, 1% Triton X-100, and protease in-
`hibitors [Complete Mini; Roche Diagnostics, Indianapolis, Indi-
`ana]).Extractionproductswerecentrifugedfor5minutesat10 000g
`at 4°C, and supernatants were assayed for type I procollagen using
`an enzyme-linked immunosorbent assay kit (Panvera, Madison,
`Wisconsin). Type I procollagen protein concentrations were nor-
`malized to sample volumes.
`
`STATISTICAL ANALYSIS
`
`Changes in biomarkers over time compared with baseline lev-
`els were statistically evaluated using repeated-measures analy-
`sis of variance. Dunnett multiple comparisons procedure was
`used to test the significance of specific comparisons. The type
`I error rate was set at .05 for a 2-tailed hypothesis. Descriptive
`statistics included means, ranges, and standard errors. These
`data were analyzed using commercially available statistical soft-
`ware (SAS; SAS Institute, Inc, Cary, North Carolina).
`
`RESULTS
`
`We demonstrate that aggressive nonablative microderm-
`abrasion is an effective procedure to stimulate collagen
`production in human skin in vivo. The beneficial mo-
`lecular responses, with minimal downtime, suggest that
`aggressive microdermabrasion may be a useful proce-
`dure to stimulate remodeling and to improve the appear-
`ance of aged human skin.
`
`COARSE-GRIT MICRODERMABRASION INDUCES
`EARLY EPIDERMAL INJURY RESPONSE
`
`Induction of cytokeratin 16 by interfollicular keratino-
`cytes is a well-characterized response to epidermal in-
`jury.11 A single microdermabrasion treatment with the
`
`(REPRINTED) ARCH DERMATOL/ VOL 145 (NO. 10), OCT 2009
`1115
`
`WWW.ARCHDERMATOL.COM
`
`©2009 American Medical Association. All rights reserved.
`
`Downloaded From: on 07/18/2018
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`2
`
`

`

`∗
`
`Untreated
`
`6 h
`
`24 h
`
`48 h
`
`14 d
`
`15
`
`12
`
`9
`
`6 3 0
`
`IL-1β mRNA Fold Change
`
`Figure 3. Coarse-grit microdermabrasion induces primary cytokine interleukin
`(IL) 1␤ gene expression in human skin in vivo. Photodamaged forearm skin
`was treated with coarse-grit microdermabrasion. Samples were obtained at the
`indicated times from untreated and treated skin sites. Interleukin 1␤ messenger
`RNA (mRNA) levels were quantified by real-time reverse transcription–
`polymerase chain reaction (n=20).*P⬍.05 vs untreated control.
`
`the ensuing 48 hours (Figure 1A). At the protein level,
`cytokeratin 16 was not detectable at baseline and was
`readily detectable in the suprabasal layers of the epider-
`mis 24 and 48 hours after treatment (Figure 1B).
`JunB and cJun are components of the AP-1 transcrip-
`tion factor complex.12 They control several important gene
`products involved in the regulation of epidermal wound
`response and epidermal differentiation, including MMPs,
`cytokeratin 16, and inflammatory mediators.13,14 JunB and
`cJun protein expression was dramatically induced within
`6 hours after a single coarse-grit microdermabrasion treat-
`ment (Figure 2A and B). JunB and cJun protein expres-
`sion was induced in keratinocytes throughout the epi-
`dermis and localized in cell nuclei. JunB and cJun protein
`expression levels returned to baseline levels 24 hours af-
`ter treatment (data not shown).
`
`COARSE-GRIT MICRODERMABRASION INDUCES
`EARLY INFLAMMATORY CYTOKINES
`INTERLEUKIN 1␤ AND INTERLEUKIN 8
`
`Primary proinflammatory cytokine interleukin (IL) 1␤
`mRNA (GenBank NM00576.2) was induced 10-fold
`(P⬍.05) 6 hours after a single treatment with the coarse-
`grit wand (Figure 3). Microdermabrasion did not in-
`duce gene expression of the primary cytokine tumor ne-
`crosis factor (GenBank NM000594.2) (data not shown).
`Interleukin 1␤ can stimulate induction of other cyto-
`kines that are involved in wound healing. Interleukin 8 is
`one such cytokine and is a potent neutrophil chemoat-
`tractant. A single microdermabrasion treatment using the
`coarse-grit handpiece resulted in statistically significant in-
`creases in IL-8 gene expression (GenBank NM000584.2).
`Interleukin 8 gene expression was maximally induced 64-
`fold 6 hours after a single treatment (P⬍.05) (Figure 4).
`One of the early inflammatory cellular events follow-
`ing epidermal injury is neutrophil infiltration into the
`wound site.15 Neutrophil elastase was used as a marker
`for infiltrating neutrophils. Neutrophil elastase protein
`expression was not detectable at baseline but was readily
`detectable 6 and 24 hours after coarse-grit microderm-
`abrasion treatment (Figure 5). Neutrophil elastase ex-
`pression was induced throughout the reticular dermis.
`Increased neutrophil infiltration into the skin is consis-
`tent with observed elevations in IL-8 level.
`
`∗
`
`∗
`
`∗
`
`Untreated
`
`6 h
`
`24 h
`
`48 h
`
`14 d
`
`CK16 Protein
`
`Untreated
`
`48 h
`
`15
`
`12
`
`9
`
`6 3 0
`
`CK16 mRNA Fold Change
`
`A
`
`B
`
`Figure 1. Coarse-grit microdermabrasion induces cytokeratin 16 (CK16)
`messenger RNA (mRNA) and protein expression in human skin in vivo.
`Photodamaged forearm skin was treated with coarse-grit microdermabra-
`sion. Samples were obtained at the indicated times from untreated and
`treated skin sites. A, Cytokeratin 16 mRNA levels were quantified by real-time
`reverse transcription–polymerase chain reaction. *P ⬍.05 vs untreated
`control. B, Skin samples from untreated sites (left) and from sites 48 hours
`after treatment (right) were immunostained for cytokeratin 16. Positive
`staining appears red, and hematoxylin counterstaining appears blue. Images
`are representative of 20 subjects. Original magnification ⫻120.
`
`A
`
`B
`
`JunB Protein
`
`Untreated
`
`6 h
`
`cJun Protein
`
`Untreated
`
`6 h
`
`Figure 2. Coarse-grit microdermabrasion induces JunB and cJun protein
`expression in human skin in vivo. Photodamaged forearm skin was treated
`with coarse-grit microdermabrasion. Samples were obtained at the indicated
`times from untreated and treated skin sites. Protein expression was
`determined for JunB (A) and cJun (B) by immunohistochemistry. Positive
`staining appears red, and hematoxylin counterstaining appears blue. Images
`are representative of 20 subjects ( JunB) and 4 subjects (cJun). Insets
`represent original magnification ⫻120.
`
`coarse-grit handpiece resulted in 11-fold induction of cy-
`tokeratin 16 gene expression (GenBank NM004084.2)
`6 hours after treatment (P ⬍.05). Cytokeratin gene ex-
`pression was still elevated 24 hours after treatment (10-
`fold vs untreated skin, P⬍.05) and decreased slowly over
`
`(REPRINTED) ARCH DERMATOL/ VOL 145 (NO. 10), OCT 2009
`1116
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`WWW.ARCHDERMATOL.COM
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`©2009 American Medical Association. All rights reserved.
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`

`∗
`
`∗
`
`∗
`
`∗
`
`∗
`
`∗
`
`Untreated
`
`6 h
`
`24 h
`
`1.5
`
`1.2
`
`0.9
`
`0.6
`
`0.3
`
`0.0
`
`12
`
`10
`
`8
`
`6 4 2 0
`
`50
`
`40
`
`30
`
`20
`
`10
`
`0
`
`Relative Levels × 10 – 4
`Defensin α1 mRNA
`
`Relative Levels × 10 – 4
`
`HBD2 mRNA
`
`Relative Levels × 10 – 4
`
`HBD3 mRNA
`
`A
`
`B
`
`C
`
`Figure 6. Coarse-grit microdermabrasion induces antimicrobial peptide gene
`expression in human skin in vivo. Photodamaged forearm skin was treated
`with coarse-grit microdermabrasion. Samples were obtained at the indicated
`times from untreated and treated skin sites. Messenger RNA (mRNA) levels
`for defensin ␣1 (A), HBD2 (B), and HBD3 (C) were quantified by real-time
`reverse transcription–polymerase chain reaction. Images are representative
`of 8 subjects. *P ⬍.05 vs untreated control.
`
`HBD3 mRNA expression was also rapidly induced follow-
`ing a single coarse-grit microdermabrasion treatment. HBD2
`(Figure 6B) and HBD3 (Figure 6C) mRNA levels were el-
`evated 15-fold 6 hours after treatment (P⬍.05); gene ex-
`pression of both antimicrobial peptides remained el-
`evated 24 hours after treatment (76- and 15-fold vs
`untreated skin, respectively; P⬍.05).
`
`COARSE-GRIT MICRODERMABRASION INDUCES
`DERMAL REMODELING MMPs AND FIBROBLAST
`ACTIVATION PROTEIN
`
`Matrix metalloproteinases break down structural pro-
`teins that comprise the dermal extracellular matrix (ECM)
`and are critical for dermal remodeling during wound heal-
`ing.19-21 We examined 3 MMPs that are known to be in-
`ducible in human skin. Interstitial collagenase (MMP1)
`initiates collagen degradation by generating 2 smaller frag-
`ments, which are then further degraded by stromelysin
`1 (MMP3) and gelatinase B (MMP9). A single coarse-
`grit microdermabrasion treatment resulted in 333-fold
`induction of MMP1 mRNA (GenBank NM002421.2) at
`6 hours and 99-fold induction at 24 hours (P ⬍.05) be-
`fore trending toward baseline values (Figure 7A). MMP1
`protein induction was localized in the papillary dermis
`(Figure 7A). Similarly, MMP3 gene expression (GenBank
`NM002422.3) increased 345-fold 6 hours and 39-fold 24
`hours after a single treatment (P⬍.05) (Figure 7B). MMP9
`
`∗
`
`Untreated
`
`6 h
`
`∗
`
`24 h
`
`48 h
`
`14 d
`
`100
`
`80
`
`60
`
`40
`
`20
`
`0
`
`IL-8 mRNA Fold Change
`
`Figure 4. Coarse-grit microdermabrasion induces neutrophil chemoattractant
`interleukin (IL) 8 gene expression in human skin in vivo. Photodamaged
`forearm skin was treated with coarse-grit microdermabrasion. Samples were
`obtained at the indicated times from untreated and treated skin sites, and IL-8
`messenger RNA (mRNA) levels were quantified by real-time reverse
`transcription–polymerase chain reaction (n=20). *P⬍.05 vs untreated control.
`
`∗
`
`Untreated
`
`6 h
`
`24 h
`
`0.30
`
`0.25
`
`0.20
`
`0.15
`
`0.10
`
`0.05
`
`0.00
`
`Neutrophil Elastase mRNA
`
`Arbitrary Units
`
`Neutrophil Elastase Protein
`
`Untreated
`
`6 h
`
`A
`
`B
`
`Figure 5. Coarse-grit microdermabrasion induces infiltration of neutrophils
`in human skin in vivo. Photodamaged forearm skin was treated with
`coarse-grit microdermabrasion. A, Samples were obtained at the indicated
`times from untreated and treated skin sites. *P ⬍.05. B, Neutrophils were
`stained by immunohistochemistry using the marker neutrophil elastase.
`Images are representative of 20 subjects. Insets represent original
`magnification ⫻60. mRNA indicates messenger RNA.
`
`COARSE-GRIT MICRODERMABRASION INDUCES
`ANTIMICROBIAL PEPTIDES
`
`Antimicrobial peptides constitute a large diverse group of
`small-molecular-weight proteins that function in host de-
`fense against infection by directly killing microorgan-
`isms and by modulating innate and adaptive immunity.16
`Recent studies17,18 have demonstrated altered expression
`of antimicrobial peptides in inflammatory skin diseases and
`following skin injury. A single treatment with coarse-grit
`microdermabrasion stimulated gene expression of anti-
`microbial peptides human defensin ␣1 (DEFA1) (GenBank
`NM004084.2), human ␤-defensin 2 (HBD2) (GenBank
`NM004942.2), and human ␤-defensin 3 (HBD3) (GenBank
`NM018661.3). Defensin ␣1 mRNA was near the limit of
`detection in untreated skin and was increased approxi-
`mately 33-fold 6 hours after treatment (P ⬍ .05)
`(Figure 6A). Defensin ␣1 mRNA levels remained el-
`evated 19-fold for at least 24 hours (P⬍.05). HBD2 and
`
`(REPRINTED) ARCH DERMATOL/ VOL 145 (NO. 10), OCT 2009
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`

`gene expression (GenBank NM004994.2) followed a simi-
`lar course, with 27-fold induction 6 hours after treat-
`ment (P⬍.05), dropping close to baseline within 24 hours
`after treatment (Figure 7C).
`Fibroblast activation protein (FAP) is a membrane-
`bound serine protease that can degrade denatured col-
`lagen fragments.22,23 It is involved in matrix remodeling
`and cell motility. A single microdermabrasion treat-
`ment with the coarse-grit handpiece dramatically in-
`duced FAP protein expression 6 hours (3.9-fold) and 24
`hours (4.6-fold) after treatment (Figure 8).
`
`COARSE-GRIT MICRODERMABRASION INDUCES
`COLLAGEN BIOSYNTHETIC PATHWAYS
`
`Microdermabrasion with the coarse-grit wand induced
`collagen biosynthetic pathways. HSP47 is a molecular
`chaperone protein necessary for intracellular transport
`and processing of procollagen within dermal fibro-
`blasts.24 Microdermabrasion with the coarse-grit wand
`resulted in significant increases in HSP47 protein
`expression. HSP47 protein staining was increased 7.5-
`fold (P ⬍.05) throughout the dermis (Figure 9A) 14
`days after microdermabrasion treatment with the
`coarse-grit wand. Prolyl 4-hydroxylase catalyzes
`hydroxylation of proline residues within procollagen.
`Hydroxylation of proline is necessary to stabilize the
`triple helix structure of procollagen. 2 5 Prolyl
`4-hydroxylase protein expression was near the limit of
`detection at baseline but was readily detectable
`throughout the reticular and papillary dermis 14 days
`after treatment (Figure 9B).
`Consistent with elevated expression of HSP47 and pro-
`lyl 4-hydroxylase, coarse-grit microdermabrasion in-
`duced type I and type III procollagen expression. Type I
`and type III procollagen transcripts were induced 3.2-
`fold and 2.6-fold, respectively, 14 days after a single mi-
`crodermabrasion treatment (P ⬍.05) (Figure 10A and
`B). Type I procollagen protein expression was induced
`3.7-fold 14 days after treatment as measured by enzyme-
`linked immunosorbent assay (P⬍.01) (Figure 10C). Type
`I procollagen production was induced throughout the pap-
`illary and deeper dermis 14 days after treatment
`(Figure 10D).
`
`MEDIUM-GRIT MICRODERMABRASION
`FAILS TO STIMULATE
`REPAIR RESPONSES
`
`Microdermabrasion with the medium-grit handpiece did
`not result in statistically significant changes in any of the
`evaluated molecular components of the wound re-
`sponse or dermal remodeling cascade. In untreated and
`medium-grit microdermabrasion–treated forearm skin,
`the transcript level or protein expression was quantified
`at the various times after treatment for the following:
`MMP1, MMP3, MMP9, cytokeratin 16, type I and type III
`procollagen, and cytokines IL-1␤ and tumor necrosis fac-
`tor. Medium-grit microdermabrasion did not result in pro-
`tein production or significantly alter mRNA levels in any
`of these genes (n=20) (data not shown).
`
`A
`
`MMP1 Protein
`
`Untreated
`
`6 h
`
`∗
`
`∗
`
`∗
`
`∗
`
`∗
`
`Untreated
`
`6 h
`
`24 h
`
`48 h
`
`14 d
`
`600
`
`400
`
`200
`
`MP1 mRNA Fold Change
`
`0M
`
`600
`
`400
`
`200
`
`MP3 mRNA Fold Change
`
`0M
`
`60
`
`40
`
`20
`
`MP9 mRNA Fold Change
`
`0M
`
`B
`
`C
`
`Figure 7. Coarse-grit microdermabrasion induces matrix metalloproteinases
`(MMP), messenger RNA (mRNA) and protein expression in human skin in
`vivo. Photodamaged forearm skin was treated with coarse-grit
`microdermabrasion. Samples were obtained at the indicated times from
`untreated and treated skin sites. Messenger RNA levels were quantified by
`real-time reverse transcription–polymerase chain reaction, and protein
`expression was determined by immunohistochemistry. A, MMP1 protein
`expression (original magnification ⫻240) and mRNA levels. B, MMP3 mRNA
`levels. C, MMP9 mRNA levels. Images are representative of 20 subjects.
`*P ⬍.05 vs untreated control.
`
`FAP
`
`Untreated
`
`24 h
`
`Figure 8. Coarse-grit microdermabrasion induces FAP expression in human
`skin in vivo. Photodamaged forearm skin was treated with coarse-grit
`microdermabrasion. Frozen skin sections were stained for FAP protein
`expression by immunohistochemistry. Specimens are representative of
`20 subjects. Insets represent original magnification ⫻120.
`
`(REPRINTED) ARCH DERMATOL/ VOL 145 (NO. 10), OCT 2009
`1118
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`

`∗
`
`∗
`
`∗
`
`Untreated
`
`14 d
`
`Type I Procollagen Protein
`
`Untreated
`
`14 d
`
`4
`
`3
`
`2 1
`
`0
`
`4
`
`3
`
`2 1
`
`4
`
`3
`
`2 1
`
`Type I Procollagen mRNA
`
`Fold Change
`
`ype III Procollagen mRNA
`
`Fold Change
`
`0T
`
`ype I Procollagen Protein
`
`Fold Change
`
`0T
`
`A
`
`B
`
`C
`
`D
`
`A
`
`B
`
`HSP47 Protein
`
`Untreated
`
`14 d
`
`Prolyl 4-Hydroxylase Protein
`
`Untreated
`
`14 d
`
`Figure 9. Coarse-grit microdermabrasion induces expression of HSP47 and
`prolyl 4-hydroxylase proteins involved in collagen synthesis in human skin in
`vivo. Photodamaged forearm skin was treated with coarse-grit
`microdermabrasion, and immunohistochemistry was performed for HSP47
`(n=20) (A) and prolyl 4-hydroxylase (n=10) (B). Insets represent original
`magnification ⫻120.
`
`COMMENT
`
`As the population ages, skin rejuvenation has become an
`area of significant interest. Patients prefer cosmetic pro-
`cedures that require minimal disruption of their normal
`lifestyle.26 Microdermabrasion is a popular method of su-
`perficial skin resurfacing that is used to treat various cos-
`metic ailments, including wrinkles, atrophic scars, and
`dyspigmentation.1-3 It is associated with minimal morbid-
`ity, making it an ideal procedure for patients who want
`treatment that does not require prolonged healing.27 Kari-
`mipour et al5 demonstrated that aluminum oxide micro-
`dermabrasion stimulates a dermal remodeling cascade
`involving AP-1, MMPs, and cytokines; however, the pro-
`cedure failed to consistently induce collagen production.
`Type I collagen is the major structural protein in the der-
`mis, accounting for approximately 90% of dermal mass.25
`Fragmentation of collagen fibrils with concomitant im-
`pairment of structural integrity is a characteristic feature
`of photoaged and aged skin.28,29 In addition, stimulation
`of collagen production seems to be a prerequisite for ef-
`fective treatments that objectively improve the wrinkled ap-
`pearance of skin.7,30 Therefore, the failure of aluminum ox-
`ide microdermabrasion to reliably induce new collagen
`production suggests a minimal clinical effect. We investi-
`gated whether microdermabrasion can be improved to pro-
`vide reliable remodeling with increased collagen produc-
`tion, while retaining the characteristic “minimal downtime.”
`We hypothesized that increasing the wounding stimulus
`might enhance activation of the dermal remodeling cas-
`cade and result in increased collagen generation.
`Wound healing involves several overlapping phases.15
`Microdermabrasion with aluminum oxide crystals or a dia-
`
`Figure 10. Coarse-grit microdermabrasion induces type I and type III
`procollagen expression in human skin in vivo. Photodamaged forearm skin was
`treated with coarse-grit microdermabrasion. Samples were obtained at the
`indicated times from untreated and treated skin sites. A, Type I procollagen
`messenger RNA (mRNA) levels were quantified by real-time reverse
`transcription–polymerase chain reaction. *P⬍.005 vs untreated control.
`B, Type III procollagen mRNA levels were quantified by real-time reverse
`transcription–polymerase chain reaction. *P⬍.01 vs untreated control. C, Type
`I procollagen protein levels were determined by enzyme-linked immunosorbent
`assay. *P⬍.01. D, Type I procollagen protein expression was localized by
`immunohistochemistry. Images are representative of 20 subjects. Insets
`represent original magnification ⫻120.
`
`mond-tipped wand triggers molecular responses that are
`observed during wound healing and should be consid-
`ered a form of superficial wound. In previous work, we sug-
`gested that minimal barrier disruption combined with physi-
`cal movement of the skin by vacuum is likely responsible
`for generating a wound healing response.5,31
`Treatment with coarse-grit microdermabrasion results
`in cytokeratin 16 induction. Cytokeratin 16 is a well-
`characterized marker of injury to the epidermis and epider-
`mal barrier disruption.32 Cytokeratin 16 promotes reorga-
`nization of cytoplasmic keratin filaments that precedes
`keratinocyte migration into a wound site.11 Cytokeratin 16
`induction may serve as a useful marker of sufficient epider-
`mal injury to induce repair pathways in response to regen-
`
`(REPRINTED) ARCH DERMATOL/ VOL 145 (NO. 10), OCT 2009
`1119
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`
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`
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`

`Microdermabrasion
`
`Epidermis
`
`IL-1β
`
`IL-1βR
`
`IL-8
`
`AP-1 (cJun/cFOS)
`
`MMPs
`
`Keratinocyte
`
`PMN
`
`Dermis
`
`CK16
`AMP
`
`Collagen
`repair
`
`Collagen
`degradation
`
`MMPs
`
`(COLase, GELase
`Strom)
`
`Dermis
`
`Figure 11. Schematic of the wound-healing cascade induced by
`microdermabrasion using a coarse-grit diamond-studded handpiece. Stratum
`corneum is preserved, and there is generation of cytokeratin 16 (CK16),
`antimicrobial peptide (AMP), cytokines, and presumed leakage of epidermal
`matrix metalloproteinases (MMPs) into the dermis, with resultant dermal
`remodeling. COLase indicates collagenase; GELase, gelatinase B;
`IL, interleukin; Strom, stromelysin 1; and PMN, polymorphonuclear leukocyte.
`
`erative aesthetic procedures. In our study, medium-grit mi-
`crodermabrasion did not induce cytokeratin 16 expression
`nor did it induce other components of the repair pathways.
`Subjects with the largest increases in cytokeratin 16 expres-
`sion also demonstrated a trend toward some of the largest
`increases in type I collagen expression.
`Keratinocytes may serve as initiators of inflammation be-
`causetheyelaborateproinflammatorycytokinesundermany
`different conditions. Nickoloff and Naidu32 demonstrated
`that injury of the epidermis by tape stripping resulted in cy-
`tokeratin 16 gene expression and the induction of several
`epidermal-derived cytokines. We observed induction of IL-
`1␤ following treatment of the skin with the coarse-grit wand,
`as was also observed with aluminum oxide microdermabra-
`sion.5 Interleukin 1␤ is a primary cytokine that can stimu-
`late the elaboration of other cytokines, including IL-8. In-
`terleukin8isapotentchemoattractantforneutrophils,which
`are important phagocytic cells that participate in the early
`phases of wound healing.15 We found statistically significant
`elevated levels of IL-8 and neutrophil elastase, a marker of
`neutrophilinfiltration,inskinaftermicrodermabrasiontreat-
`ment with the coarse-grit handpiece. Elevation of neutro-
`phil chemoattractants and neutrophil products after coarse-
`grit microdermabrasion suggests a role for neutrophils in
`the wound-healing response after microdermabrasion that
`is similar to the healing response to an incisional wound.
`cJun and JunB components of AP-1 were induced within
`6hoursaftertreatmentwiththecoarse-gritdiamond-studded
`
`handpiece wand. cJun expression is rapidly induced by vari-
`ous injurious stimuli and is a key mediator in a wide array
`of cellular responses.12 cJun is also involved in the regula-
`tion of cytokeratin 16 expression.14 Wang et al13,14 demon-
`strated that epidermal growth factor stimulation of protein
`kinases mediates phosphorylation of the cJun component
`of AP-1, which then stimulates cytokeratin 16 induction.
`In addition to its role in cytokeratin 16 regulation, AP-1 is
`well known to be involved in the induction of inflamma-
`tory cytokines (such as IL-1␤) and MMPs.19,21
`Matrix metalloproteinases are responsible for degrada-
`tion of ECM that comprises the structural material of con-
`nective tissue. The substrates of MMPs are collagens, fi-
`bronectin, proteoglycans, and other ECM proteins.19 We
`measured the effects of microdermabrasion on 3 impor-
`tant MMPs known to be regulated by AP-1, namely, MMP1,
`MMP3, and MMP9. Coarse-grit microdermabrasion in-
`duced expression of all 3. Less aggressive therapy with the
`medium-grit wand failed to induce significant increases in
`the expression of MMPs. Matrix metalloproteinase activ-
`ity is important in wound healing to facilitate the motility
`of inflammatory cells and to enhance the availability of in-
`flammatory mediators to set the stage for healing.19
`FAP is an inducible membrane-bound glycoprotein that
`possesses serine protease activity. FAP is expressed by ac-
`tivated fibroblasts in reactive stroma during wound healing
`andtumorinvasion.FAPhastheuniqueabilitytocleavepro-
`lyl residues in peptide substrates.22,23,33 This activity has led
`to the suggestion that FAP works in concert with MMPs to
`further break down partially degraded collagen, as collagen
`contains a large number of prolyl residues. FAP expression
`was induced after a single microdermabrasion treatment, in-
`dicating activation of dermal fibroblasts. A role for MMPs
`and FAP can be envisioned in cosmetic regenerative proce-
`dures. Photoaged skin is characterized by partially degraded
`cross-linke