Microneedle fractional radiofrequency in the treatment of periorbital dark circles

Periorbital hyperpigmentation (POH) is a common disorder in the patients. Women are more upset with POH in compare to males. Several methods have been used to the POH, with different efficacy and adverse reactions.


| INTRODUC TI ON
Periorbital hyperpigmentation (POH) is a very common trouble among the patients. POH is a disorder that appears as a homogenous, round, bilateral, brownish to black color around the eye. This lead to the look of fatigue in the patients. 1 This disorder can be because of too much pigmentation, glowing and thin lower eyelids, and skin laxity. 2,3 The etiology of POH is multifactorial. Several factors are contribute in POH development including genetic, hormones, skin laxity, prominent vasculature, tear trough and volume loss, excessive pigmentation, atopic dermatitis, and allergy. 4 In some study it is showed that melanin is the main chromophore in POH. 5,6 POH treatment is challenging because of the complex etiology and pathogenesis. 1 Recently, there are some nonsurgical treatment methods for POH like topical treatments, chemical peels and botulinum toxin, fillers, and autologous fat transfer. [7][8][9] currently, laser therapy for skin disorder has received a lot of attention. [10][11][12][13][14][15][16][17][18] Lasers have been commonly used for POH treatment, due to their careful capacity to attack endogenous chromophores. 7,15,19 Laser therapy is generally perfect for deep facial vessels treatment because the laser energy can penetrates superiority. 4 The objective of this study is the treatment and assessment of POH by new therapeutic technique with microneedle radiofrequency (MRF). An MRF method, transports radiofrequency energy via a fractional microneedle electrode. This technique induces the new blood vessels production via increasing the growth factors levels. It can improve the blood flow supplies nutrients and oxygen to the vessels and skin, that finally change the skin look favorably. In our study, the influence of MRF on the around the eye skin-coloring, elasticity, and erythema has been evaluated. Furthermore, we also assessed the decrease in the periorbital wrinkles.

| Participants, Inclusion, and exclusion criteria
In our evaluation, nine patients with the age range of 25-57 years and POH were participated. Patients were treated with MRF laser.
The treatment option was explained to the patients and signed consent was gained from each patient for participate and photography.
Inclusion criteria were age more than18 years with no infections and no untreated comorbidities in the area. Also the informed patient consent was considered.
The local skin disease, pregnancy or lactation, history of cancer, collagen vascular diseases, liver disease, local or systemic infections and patients with laser therapy in the area were considered as exclusion criteria. probe was evaluated the erythema as well.

| Skin ultrasound imaging system
The skin ultrasound imaging system was estimated the diameter and density of the dermis and epidermis. Increase in collagen amount of dermis equals to the increase in the density, and show the skin condition of the patients is improved.

| Digital photographs, patients, and physician assessment
Before and 6 months after last treatment session digital photographs were taken. The physician' opinion according to VAS score, and patient's satisfaction were assessed. The results were evaluated as no satisfaction, slightly, moderately and well satisfied. SPSS 15.0 statistical software (SPSS) was used for statistical analysis. Also, student's t-test or one-way ANOVA were done to analyze the significance of differences in the present study. A p < 0.05 was considered as significant results. Data were demonstrated as mean ± standard deviation (SD).

| Biometric characteristic results
The biometric assessment results are showed in Table 1 (mean ± SD).
The results showed that, the periorbital skin lightness in the patients was 34.15 ± 9.35 and 45.55 ± 7.13, before and after treatment ( Table 1). The results showed that the lightness changed significantly after treatment (p < 0.05) (Figure 1) Figure 1) (p < 0.05), and the change in percentage was evaluated as 49.41 ± 9.12 (p < 0.05) ( Table 1).
Moreover, the results showed that difference in the percentage of change of erythema was not significant after treatment (1.49 ± 0.61) (p > 0.05) ( Table 1 and Figure 1). Also, according to the skin ultrasound outcomes the dermis and the epidermis skin layers become denser after treatment ( Table 1). The results showed significant differences between the percentages of changes in skin thickness and density (p < 0.05) (Table 1, Figure 1 and Figure 2). According to the Cutometer outcomes, the skin elasticity increase significantly (p < 0.05) ( Table 1 and Figure 1). The results of visioface displayed that the color of the periorbital skin before and after treatment was 10.43 ± 1.23 and 8.12 ± 2.30 ( Table 1 and Figure 3). The significant change was seen in the periorbital color after MRF treatment (Figures 1 and 3), p < 0.05. Similarly, the visioface findings displayed the skin wrinkle significantly reduced 6 months after the last treatment session ( Table 1, Figures 1 and 4).

| Patients satisfaction and Physicians assessment results
According to the patient's satisfaction results, 10% of patients attained a fair response, 30% of patients achieved good, and 60% of patients achieved excellent reply (

TA B L E 1
Comparing biometric characteristics of the periorbital dark circles in patients, before and 6 months after last treatment session. The data was shown as Mean ± SD. The p < 0.05 was considered as statistically significant in all the tests.

F I G U R E 2
Skin analysis via ultrasonography. The skin density and thickness, were evaluated before and 6 months after MRF treatment.

F I G U R E 1
Periorbital patient's biometric data: B: Before treatment, A: 6 months after MRF treatment. *p < 0.05; ns, non-significant.
assessments specified a significant difference before and after treatment (p < 0.001) ( Table 3). The clinical photos are shown in the  melanin (non-ablative fractional Erbium laser or ablative fractional carbon dioxide laser) is usually effective and without side effect. [23][24][25][26] Nevertheless, some patients showed some side effects, like postinflammatory hyperpigmentation (PIH) because of higher melanin density. 27,28 Numerous studies informed the reduction of pigmentation resulting RF treatment that can described by hyaluronan increase, dermal and epidermal regeneration, and the effect of inflammation in the process of healing. 29,30 So, the use of MRF technique, could be a more effective and safer technique for treating POH.

| Study Limitation
The study sample size is small so further research with larger sample sizes is required.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.

E TH I C S S TATEM ENT
Informed consent was obtained from all the patients. All patients were provided with a complete description of the study design, purpose, and probable outcomes. All the patients were checked before and 6 months after the last session of treatment.
F I G U R E 5 Study patients before and 6 months after last MRF treatment.
TA B L E 2 Patient satisfaction 6 months after last treatment session. The P < 0.05 was considered as statistically significant.