Microneedling in the nickel-allergic patient

Abstract

Microneedling uses sterilized microneedles to repetitively puncture the skin, inducing a wound-healing cascade, which may improve skin appearance.1Boyd A.H. Hylwa S.A. Nickel release from surgical instruments and operating room equipment.Dermatol Online J. 2018; 24 (13030/qt88q6q97w)Crossref Google Scholar Currently, there are no guidelines regarding prescreening for nickel allergy in patients who undergo microneedling but endorse a possible history of metal allergic contact dermatitis (ACD). Nickel is the most prevalent trigger for ACD, affecting both men and women. Here we present a commentary on the currently available literature regarding nickel ACD and microneedling. Although microneedling has gained popularity in recent years, metal ACD to microneedles is rarely reported. Microneedling devices approved by the US Food and Drug Administration contain needles commonly composed of surgical stainless steel (SS). SS contains varying amounts of nickel, depending on the grade.1Boyd A.H. Hylwa S.A. Nickel release from surgical instruments and operating room equipment.Dermatol Online J. 2018; 24 (13030/qt88q6q97w)Crossref Google Scholar Specifically, the authors’ microneedling device is composed of 316L alloy (Table I), containing 10% to 14% nickel.1Boyd A.H. Hylwa S.A. Nickel release from surgical instruments and operating room equipment.Dermatol Online J. 2018; 24 (13030/qt88q6q97w)Crossref Google Scholar Although some devices have titanium-coated needle tips, it is unclear if there is sufficient nickel exposure to induce ACD in sensitized individuals. When testing the microneedling tips of the SkinPen Precision system (Crown Aesthetics) with 2 dimethylglyoxime tests (Nickel Alert [Athena Allergy] and Chemo Nickel Test [Chemotechnique Diagnostics]), twice each, negative results were noted (Fig 1). Additionally, used microneedles were similarly tested to consider the possibility of microneedle breakdown; however, these tests were negative both times. In contrast, a nickel-containing US minted nickel, used as positive control, tested positive.Table IStainless steel composition of medical grade instrumentsStainless steel gradeComposition304Iron + carbon, 18%-20% chromium, 8%-12% nickel316∗Stainless steel found in the microneedles used by authors.Iron + carbon, 16%-18% chromium, 10%-14% nickel, 2%-3% molybdenum409Iron + carbon, 10.5%-11.75% chromium, 0.5% nickel410Iron + carbon, 11.5%-13.5% chromium, 0.75% nickel420Iron + carbon, 12%-14% chromium, 0% nickel430Iron + carbon, 16%-18% chromium, 0%-0.75% nickel440Iron + carbon, 16%-18% chromium, 0% nickelAdapted from Boyd and Hylwa.1Boyd A.H. Hylwa S.A. Nickel release from surgical instruments and operating room equipment.Dermatol Online J. 2018; 24 (13030/qt88q6q97w)Crossref Google Scholar∗ Stainless steel found in the microneedles used by authors. Open table in a new tab Adapted from Boyd and Hylwa.1Boyd A.H. Hylwa S.A. Nickel release from surgical instruments and operating room equipment.Dermatol Online J. 2018; 24 (13030/qt88q6q97w)Crossref Google Scholar A PubMed literature search for the terms “microneedle,” “allergy,” “allergic contact dermatitis,” and “nickel allergy” was performed, revealing 1 report of skin eruption 6 days after microneedling with a Dermaroller device (Derma India) containing titanium-coated tips of stainless steel needles. Patch testing later revealed a positive nickel reaction.2Yadav S. Dogra S. A cutaneous reaction to microneedling for postacne scarring caused by nickel hypersensitivity.Aesthet Surg J. 2016; 36: NP168-NP170Crossref PubMed Scopus (13) Google Scholar However, this study was limited in that there was no allergy testing to utilized local anesthetics or antiseptics. Similarly, 2 cases of ACD have been reported after exposure to nickel-containing hypodermic needles.3Mehta V. Vasanth V. Balachandran C. Nickel contact dermatitis from hypodermic needles.Indian J Dermatol. 2011; 56: 237-238Crossref PubMed Google Scholar In a test of SS ear piercings, SS (316L alloy) was found to release nickel at a rate of <0.05 μg/cm2/wk and did not elicit ACD in patients with a known nickel allergy.4Ingber A. Hershko K. Horev L. AISI 316L stainless-steel ear piercing post assembly does not cause dermatitis in nickel-sensitive subjects.Exog Dermatol. 2003; 2: 195-200Crossref Scopus (8) Google Scholar As it pertains to microneedles, it is unclear if nickel ions are released with use. Our testing of the SkinPen Precision system suggests either a true negative or that the percentage of nickel is too low to detect with dimethylglyoxime testing, which is only 59.3% sensitive.5Thyssen J.P. Skare L. Lundgren L. et al.Sensitivity and specificity of the nickel spot (dimethylglyoxime) test.Contact Dermatitis. 2010; 62: 279-288Crossref PubMed Scopus (100) Google Scholar Given the high prevalence of nickel ACD, a screening question may be of benefit during cosmetic consultations. Further prospective clinical studies are needed to make discrete recommendations given the scarcity of relevant literature investigating this subject. Another approach may be to perform microneedling test spots in patients with patch test-proven nickel allergy to assess whether a cutaneous reaction occurs, though further research is needed. None disclosed.