Microneedling in Clinical Practice

Microneedling in Clinical Practice
Edited by
Boris Stoeber, PEng, PhD
Faculty of Applied Science, University of British Columbia, Vancouver
Raja K Sivamani, MD, MS (Bioengineering), AP

Department of Dermatology, University of California at Davis
Department of Biological Sciences, California State University, Sacramento
College of Medicine, California Northstate University
Pacific Skin Institute
Zen Dermatology
Howard I. Maibach, MD
School of Medicine, University of California at San Francisco
First edition published 2021
by CRC Press
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Contents
Contributors.............................................................................................................................................. vii
1. Microneedles and Transdermal Transport.................................................................................... 1

Ashley Clark and Raja Sivamani
2. Skin Perforation and Solid Microneedles....................................................................................... 7

Michael L Crichton and Mark Kendall
3. Dissolvable and Coated Microneedle Arrays: Design, Fabrication,

Materials, and Administration Methods...................................................................................... 19
Emrullah Korkmaz and O. Burak Ozdoganlar
4. Hollow Microneedles....................................................................................................................... 35
Iman Mansoor and Boris Stoeber
5. Microneedles vs. Other Transdermal Technologies.................................................................... 49

Yeakuty Jhanker, James H.N. Tran, Tarl W. Prow, and Heather A.E. Benson
6. Combination of Microneedles with Other Methods.................................................................... 65

Sahitya Katikaneni
7. Medical Applications of Microneedles.......................................................................................... 75

Samantha Tran and Raja Sivamani
8. Therapeutic Drug and Biomolecule Monitoring Potential

for Microneedle Technologies........................................................................................................ 81
Sahan A. Ranamukhaarachchi and Urs O. Häfeli
9. Commercialized Microneedles....................................................................................................... 91
KangJu Lee, SeungHyun Park, JiYong Lee, and WonHyoung Ryu
10. Considerations for Clinical Trials Involving Microneedle Devices......................................... 109

Janet Tamada
11. Microneedling in Clinical Practice: Cosmetic applications.......................................................119

Aunna Pourang, MD and Kourosh Beroukhim, MD
12. Dermatotoxicology of Microneedles in Man...............................................................................133

John Havens Cary, Becky S. Li, and Howard I. Maibach
Index........................................................................................................................................................145
v
Contributors
Heather A.E. Benson Yeakuty Jhanker

School of Pharmacy School of Pharmacy
Curtin Health Innovation Research Institute Curtin Health Innovation Research Institute
Curtin University Curtin University
Perth, Western Australia Perth, Western Australia
Kourosh Beroukhim Sahitya Katikaneni

Department of Dermatology Zosano Pharma
University of California, Davis Fremont, California
Sacramento, California
Mark Kendall
John Havens Cary The University of Queensland
Louisiana State University School of Medicine Delivery of Drugs and Genes Group
New Orleans, Louisiana Australia
Australian Institute for Bioengineering and
Ashley Clarke
Nanotechnology (AIBN)
Department of Dermatology
St. Lucia, Australia
University of Pennsylvania Perelman School of
Medicine ARC Centre of Excellence in Convergent
Philadelphia, Pennsylvania Bio-Nano Science and Technology
The University of Queensland
Michael L. Crichton Australia
Heriot-Watt University
School of Engineering and Physical Sciences
Diamantina Institute
(EPS)
Princess Alexandra Hospital
Edinburgh, United Kingdom
St Lucia, Queensland, Australia
Institute of Mechanical, Process and Energy
Engineering (IMPEE)
Faculty of Medicine and Biomedical Sciences
Edinburgh, United Kingdom
Royal Brisbane and Women’s Hospital
The University of Queensland Herston, Queensland, Australia
Delivery of Drugs and Genes Group
Australia Emrullah Korkmaz
Department of Mechanical Engineering
Australian Institute for Bioengineering and
Carnegie Mellon University
Nanotechnology (AIBN)
Pittsburgh, Pennsylvania
St. Lucia, Australia
ARC Centre of Excellence in Convergent JiYong Lee
Bio-Nano Science and Technology School of Mechanical Engineering,
The University of Queensland Yonsei University
Australia Seoul, South Korea
Urs O. Häfeli KangJu Lee

Faculty of Pharmaceutical Sciences School of Mechanical Engineering,
University of British Columbia Yonsei University
Vancouver, British Columbia, Canada Seoul, South Korea
vii
viii Contributors
Becky S. Li Sahan A. Ranamukhaarachchi

Howard University College of Medicine Department of Electrical and Computer
Washington, DC Engineering
University of British Columbia
Howard I. Maibach Vancouver, British Columbia, Canada
Department of Dermatology
University of California WonHyoung Ryu
School of Medicine School of Mechanical Engineering
San Francisco, California Yonsei University
Seoul, South Korea
Iman Mansoor
Department of Electrical and Computer Raja Sivamani
Engineering Department of Dermatology
The University of British Columbia University of California at Davis
Vancouver, British Columbia, Canada
Department of Biological Sciences
California State University
O. Burak Ozdoganlar
Sacramento College of Medicine
Department of Mechanical Engineering
California Northstate University
Pittsburgh, Pennsylvania Pacific Skin Institute
Zen Dermatology
Department of Materials Science and Engineering
Boris Stoeber
Pittsburgh, Pennsylvania
University of British Columbia
Department of Biomedical Engineering Vancouver, British Columbia, Canada
Pittsburgh, Pennsylvania Janet Tamada
Scientia Bioengineering Consulting
SeungHyun Park Stanford, California
School of Mechanical Engineering
Yonsei University James H.N. Tran
Seoul, South Korea School of Pharmacy
Curtin Health Innovation Research Institute
Aunna Pourang Curtin University
Department of Dermatology Perth, Western Australia
University of California, Davis
Sacramento, California Samantha Tran
Stryker School of Medicine
Tarl W. Prow Western Michigan University
Biomaterials Engineering and Nanomedicine Kalamazoo, Michigan
Strand
Future Industries Institute
University of South Australia
Adelaide, South Australia
1
Microneedles and Transdermal Transport
Ashley Clark
University of Pennsylvania Perelman School of Medicine
Raja Sivamani
University of California-Davis
1.1 Anatomy of the Skin

As the outermost layer of the body, the skin serves many roles including protection against UV radiation
and microbes, regulating the movement of substances into and out of the body, and maintaining water
and temperature equilibrium.1 In order to perform its specialized functions, skin is divided into three
layers: the epidermis, the dermis, and the hypodermis.
1.1.1 Stratum Corneum and Epidermis

The epidermis is the outermost layer of the skin and can range from 0.04 mm to 1.5 mm in thickness
(Table 1.1), based on age, gender, ethnicity, and location on the body.2 It is composed of self-regenerating
stratified squamous epithelium, and serves as a protective barrier to the structures underneath. It is fur-
ther separated into four layers: stratum corneum, stratum granulosum, stratum spinosum, and stratum
germinativum. The stratum corneum consists of dead keratinocytes that form a relatively impermeable
barrier to transdermal movement.
1.1.2 Dermis
The dermis is the layer of skin underlying the epidermis, measuring 1–2 mm in thickness.6 It consists
of nerves, vasculature, hair follicles, and glandular structures, held in place by a network of elastin and
collagen fibers embedded in ground substance, which is the gel-like extracellular matrix that exists in
the extracellular spaces.
1.1.3 Hypodermis
The hypodermis, also called the subcutaneous layer, is composed of approximately 3 mm of loose, well-
vascularized connective tissue, and serves as adhesion to the bone and muscle. It also provides additional
cushion and insulation.6
1.2 Modes of Transdermal Delivery

The skin is an appealing target for drug delivery for several reasons. Drug delivery through the skin is
often minimally invasive and allows for more frequent administration. It also provides a larger surface
area for drug absorption. And finally, transdermal drug delivery bypasses hepatic first-pass metabolism
and deactivation through gastric enzymes.7
1
2 Microneedling in Clinical Practice
TABLE 1.1
Epidermal Thickness at Various Anatomical Sites
Mean Epidermal
Body Site Stratum Corneum (µm) Thickness (µm)
Temple 6.3 61.4
Chest 6.5–12.8 56.0
Abdomen 6.3 61.3
Outer forearm 10.9–19.5 60.3
Leg 20.5–22.5 61.8
Dorsum of hand 9.3 84.5
Fingertip 160–209 (palm) 369.0
Adapted from Whitton et al.,3 Robertson et al.,4 and Bohlin et al.5
Unfortunately, the skin’s effectiveness as a barrier makes transdermal drug delivery a difficult task.
The stratum corneum is the primary gatekeeper, preventing the movement of large, polar substances
across the skin. For this reason, a certain amount of creativity is required to purposely bypass the stratum
corneum and deliver drugs directly to the vascular dermis.
Multiple solutions have been attempted to assist in drug delivery across the skin by increasing the
permeability of the stratum corneum. These typically fall into two categories: chemical and physical
enhancers (Table 1.2).
1. Chemical enhancers: Chemical enhancers work by interacting with the lipid bilayer of the
stratum corneum to reversibly compromise the skin barrier, and allow for the penetration of
drugs that would normally have difficulty crossing the stratum corneum. Although they are
minimally invasive, chemical enhancers can cause significant irritation.8 Listed below are vari-
ous types of chemical enhancers.9
a. Solvents (methanol, chloroform, acetone, pyrrolidones, sulphoxides)10
b. Detergents
c. Liposomes
d. Nanoparticles
2. Physical Enhancers:8
a. Iontophoresis: Iontophoresis involves the use of a small electrical current, either directly or
indirectly, to aid in the movement of charged particles across the skin.
b. Electroporation: Electroporation, unlike iontophoresis, uses high-voltage pulses
to create small pathways within the skin’s lipid bilayer, resulting in increased skin
permeability.11
TABLE 1.2
Transdermal Drug Delivery Methods
Method Mechanism Examples
Chemical Reversibly compromises the Solvents
skin barrier when applied to Detergents
the skin Liposomes
Nanoparticles
Physical Current, ultrasound waves, Iontophoresis
and needles are used to Electroporation
create small holes in the Sonophoresis
skin Microneedles
Microneedles and Transdermal Transport 3
c. Sonophoresis: Like electroporation, high-frequency sonophoresis also forms small holes in

the skin to increase drug permeability. However, sonophoresis relies on ultrasound waves.
It has been used to deliver topical steroids and NSAIDs.12
d. Microneedles: Microneedles form small holes in the stratum corneum, allowing for drug
penetration through the least permeable layer of the skin. This method will be discussed
in further detail below.
1.3 Microneedles
Microneedles can be a single microscopic needle or an array of them measuring approximately a few
hundred microns in diameter, and up to 2500 μm in length. The needle’s small size allows it to painlessly
penetrate the epidermis when it is shorter (typically < 700 μm in length), making it incredibly useful for
cosmetic, diagnostic, and therapeutic purposes.13,14 As stated earlier, microneedles are used to form small
conduits in the stratum corneum, allowing topical drugs to efficiently surpass this minimally permeable
barrier.
Microneedles come in many shapes and sizes, and have been fabricated from various materials, includ-
ing silicon, metal, polymer, glass, and ceramic.15 There are generally three forms of microneedles:14,15
1. Solid microneedles are made from silicon, polymers, water-soluble compounds (e.g., maltose),
and metals (e.g., stainless steel, titanium). They can be either uncoated or coated with the drug
of interest. Uncoated solid microneedles can be used to create small holes in the skin before
the application of a topical drug, to allow for more effective drug penetration. The tips of the
microneedles can also be coated with a drug, allowing deposit of the drug into the deeper layers
of the skin.
2. Dissolving microneedles are made from water-soluble materials such as polymers and sugars,
and can dissolve once embedded into the skin. They often contain drugs encapsulated within
the needle, and function similarly to a coated solid microneedle.
3. Hollow microneedles are often fabricated from metals or silicon and come in a variety of
shapes, including cylindrical, conical, rectangular, and pyramidal. There is an opening either
at the tip or on the side allowing liquid to flow into the skin. They are often used with a syringe
or an actuator, for better control of drug flow.
1.4 Microneedles for Transdermal Drug Delivery

The use of microneedles for transdermal delivery of drugs enables circumvention of the thick stra-
tum corneum by creating small conduits in the stratum corneum, allowing deeper penetration of drugs.
Microneedles have been used to deliver desmopressin,16 insulin,17 vaccines,18,19 and more. Differences in
the needle length, width, and number can affect efficacy in drug delivery.
1.4.1 Depth of Microneedle Penetration

The depth of the micropore left by a given microneedle is indicative of the extent of the increase in per-
meability. In one study, using an optical coherence tomography (OCT) system to measure microneedle
skin penetration in vivo, a 10 × 10 arrangement of needles 280 μm in height was measured to penetrate
an average depth of 179 ± 14 μm into the skin. However, the average epidermal thickness measured under
each micropore was 64 ± 19 μm, indicating that a component of the epidermis is compressed, and that
the microneedles penetrate, on average, 61% of the epidermis.20
Another study (Table 1.3) used microscopy to assess the depth of penetration of various needle lengths
and found that the mean depth corresponded well for shorter needle lengths (up to 1000 μm), but less
well for longer needles (> 1500 μm).21
TABLE 1.3
Depth of Tissue Penetration of Various Needle Lengths
Mean Depth of Micro-Channels
Needle Length (μm) (µm ± SD)
250 235 ± 50
500 475 ± 35
1000 920 ± 75
1500 900 ± 500
2000 1275 ± 600
2500 1100 ± 650
Adapted from Sasaki et al.20
1.4.2 Rate of Micropore Closure

The rate of micropore closure is another important factor in determining its efficacy as a drug delivery
mechanism. A slow closure rate provides adequate time for the drug to diffuse across the tissue. OCT
imaging was used to assess changes in micropore depth over time. Again, using a 10 × 10 arrangement
of 280 μm needles, the pore depth was measured to reduce from 158 ± 20 μm to 76 ± 13 μm, while the
epidermal thickness under the micropore increased in thickness from 52 ± 11 μm to 92 ± 11 μm over a
span of 85 minutes.20 This increase might represent the intrinsic elasticity of the tissue, a regenerative
process, or, most likely, a combination of both.
Various factors can slow resealing time, including increased microneedle length, number, and cross-
sectional area, and application of an occlusive barrier (Table 1.4). In fact, one study found that doubling
the length of the microneedle alone (from 750 μm to 1500 μm) can increase the skin resealing time by up
to sixfold.22 However, they also found that increasing the microneedle length, but not the number or cross-
sectional area, resulted in increased pain. The study demonstrated that treatment with microneedles can
increase skin permeability from 2 to 40 hours, depending on the geometry of the needle and the applica-
tion of an occlusive barrier. Factors such as microneedle number, width (the size of the needle’s opening),
length, and spacing density can be adjusted to facilitate drug delivery without unnecessary pain.
1.5 Transdermal Extraction from the Skin

There has also been growing interest in the use of microneedles to painlessly sample from the intersti-
tial fluid. Ideally, a high-density array of silicon-based hollow microneedles would remain in contact
TABLE 1.4
Microneedle Geometry and Corresponding Resealing Time
Skin
Skin Resealing
Resealing Time in
Time in Hours
Thickness Width Number of Minutes (Non-
Treatment Length (l) μm (t) μm (w) μm Microneedles (Occluded) occluded)
A 750 75 200 50 30 2
B 750 75 200 10 3 2
C 500 75 200 50 22 2
D 1500 75 200 10 18 2
E 750 125 500 50 40 2
F Hypodermic needle (26 gauge) N/A 2
Adapted from Gupta et al.22

Microneedles and Transdermal Transport 5
with the skin, allowing for continuous monitoring of the targeted substance.23 The microneedle should
be short enough to avoid penetration into the neurovascular-rich dermis and minimize pain and
bleeding.24
Currently, the focus is on integrating microneedle arrays with sensors to allow for rapid analysis of
the fluid sample. Engineering obstacles include needle mechanics to prevent clogging and buckling, as
well as the creation of accurate micro-sensors.23,25 Successful incorporation of microneedles into sensors
would provide a noninvasive and painless method to measure drugs, electrolytes, and glucose levels,
with minimal risk of infection.
While there are few clinical studies, early animal studies suggest that microneedle-based extraction
may collect enough volume for biochemical analyses.26 More clinical studies are needed to better evalu-
ate small-volume sampling through microneedles.
1.6 Summary
The skin provides an efficient barrier against most compounds. However, its large surface area and
its position as the outermost layer of the body make it a convenient and noninvasive location for drug
delivery and interstitial fluid sampling. Microneedles, of various types, are a promising mechanism for
both transdermal delivery and extraction due to their ability to traverse the mostly impermeable stratum
corneum. Several factors, such as the needles’ type and geometry, are important to keep in mind when
developing and choosing microneedles, as they can influence the efficacy of drug delivery.
REFERENCES
1. Hussain SH, Limthongkul B, Humphreys TR. The biomechanical properties of the skin. Dermatol Surg.
2013;39(2):193–203.
2. June Robinson CWH, Siegel D, Fratila A, Bhatia A, Rohrer T. Surgery of the Skin: Procedural
Dermatology. 3rd ed. London: Saunders; 2014.
3. Whitton JT, Everall JD. The thickness of the epidermis. Br J Dermatol. 1973;89(5):467–476.
4. Robertson K, Rees JL. Variation in epidermal morphology in human skin at different body sites as
measured by reflectance confocal microscopy. Acta Derm Venereol. 2010;90(4):368–373.
5. Bohling A, Bielfeldt S, Himmelmann A, Keskin M, Wilhelm KP. Comparison of the stratum corneum
thickness measured in vivo with confocal Raman spectroscopy and confocal reflectance microscopy.
Skin Res Technol. 2014;20(1):50–57.
6. Washington N, Washington CW, Wilson Clive G. Physiological Pharmaceutics: Barriers to Drug
Absorption. Boca Raton: CRC Press; 2000.
7. Escobar-Chavez JJ, Bonilla-Martinez D, Villegas-Gonzalez MA, Molina-Trinidad E, Casas-Alancaster
N, Revilla-Vazquez AL. Microneedles: a valuable physical enhancer to increase transdermal drug deliv-
ery. J Clin Pharmacol. 2011;51(7):964–977.
8. Naik A, Kalia YN, Guy RH. Transdermal drug delivery: overcoming the skin’s barrier function. Pharm
Sci Technolo Today. 2000;3(9):318–326.
9. Jean L, Bolognia JVS, Cerroni L. Dermatology. 4th ed.: New York: Elsevier; 2018.
10. Lane ME. Skin penetration enhancers. Int J Pharm. 2013;447(1–2):12–21.
11. Brown MB, Martin GP, Jones SA, Akomeah FK. Dermal and transdermal drug delivery systems: cur-
rent and future prospects. Drug Deliv. 2006;13(3):175–187.
12. Rodriguez-Devora JI, Ambure S, Shi ZD, Yuan Y, Sun W, Xui T. Physically facilitating drug-delivery
systems. Ther Deliv. 2012;3(1):125–139.
13. Donnelly RF, Raj Singh TR, Woolfson AD. Microneedle-based drug delivery systems: microfabrica-
tion, drug delivery, and safety. Drug Deliv. 2010;17(4):187–207.
14. Bhatnagar S, Dave K, Venuganti VVK. Microneedles in the clinic. J Control Release. 2017;260:164–182.
15. Kim YC, Park JH, Prausnitz MR. Microneedles for drug and vaccine delivery. Adv Drug Deliv Rev.
2012;64(14):1547–1568.
16. Cormier M, Johnson B, Ameri M, et al. Transdermal delivery of desmopressin using a coated micronee-
dle array patch system. J Control Release. 2004;97(3):503–511.
17. Gupta J, Felner EI, Prausnitz MR. Minimally invasive insulin delivery in subjects with type 1 diabetes
using hollow microneedles. Diabetes Technol Ther. 2009;11(6):329–337.
18. Gill HS, Söderholm J, Prausnitz MR, Sällberg M. Cutaneous vaccination using microneedles coated
with hepatitis C DNA vaccine. Gene Ther. 2010;17(6):811–814.
19. Ding Z, Verbaan FJ, Bivas-Benita M, et al. Microneedle arrays for the transcutaneous immunization of
diphtheria and influenza in BALB/c mice. J Control Release. 2009;136(1):71–78.
20. Enfield JG, O’Connell ML, Lawlor K, Jonathan E, O’Mahony C, Leahy MJ. In-vivo dynamic char-
acterization of microneedle skin penetration using optical coherence tomography. J Biomed Opt.
2010;15(4):046001.
21. Sasaki GH. Micro-needling depth penetration, presence of pigment particles, and fluorescein-stained
platelets: clinical usage for aesthetic concerns. Aesthet Surg J. 2016;37(1):71–83.
22. Gupta J, Gill HS, Andrews SN, Prausnitz MR. Kinetics of skin resealing after insertion of microneedles
in human subjects. J Control Release. 2011;154(2):148–155.
23. Mukerjee EV, Collins SD, Isseroff RR, Smith RL. Microneedle array for transdermal biological fluid
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2
Skin Perforation and Solid Microneedles
Michael L Crichton1,2,3, Mark Kendall2,3,4,5

1 Heriot-Watt University, School of Engineering and Physical Sciences (EPS),
Institute of Mechanical, Process and Energy Engineering (IMPEE)

2 The University of Queensland, Australian Institute for Bioengineering
and Nanotechnology (AIBN)

3 ARC Centre of Excellence in Convergent Bio-Nano Science and Technology,

4 The University of Queensland, Diamantina Institute, Princess Alexandra Hospital
5 The University of Queensland, Faculty of Medicine and Biomedical Sciences,
Royal Brisbane and Women’s Hospital
2.1 Overview/The Goals of Skin Delivery (from a

Medical Device Engineering Perspective)
The ability to place drugs and vaccines into the skin relies on having simple, effective ways to breach
its surface and deliver therein. Achieving this requires the tough outer skin layer, the stratum cor-
neum (SC), to be punctured, and the drug deposited in either the viable epidermis (VE) or the dermis
below (or both). However, breaching skin’s surface on a micro scale presents a challenge not just in
the puncturing but also in how to place the corresponding payload in the vicinity of the cells or ves-
sels we wish to reach. This becomes important when a technology (e.g., microneedles) is employed
whose precise application requires the ability to ensure every dose is the same. For biological systems
(e.g., the human body), this can be a significant challenge due to the biological variability of human
skin. Indeed, the age, weight, sex, and environmental history of individuals will result in differences
that must be overcome with any new technology targeting this area (1). This chapter will discuss the
challenges of the skin’s material properties and one way to achieve this with microneedles: solid
microneedles.
2.2 Skin as an Engineering Material

2.2.1 The Material Composition of Skin
When considering a site for drug or vaccine delivery, its material composition must be considered. For
skin, this means considering the three main constituent layers—the SC, VE, and dermis—and evaluat-
ing their distinct material properties. These have been discussed in the previous chapter, but they are
discussed here with particular reference to their material properties.
2.2.1.1 The Epidermis (Comprising the SC and VE)

The epidermis of the skin represents a cellular epithelial tissue layer which ranges from the basal layer of the
VE, through a process of vertical differentiation, to the tough keratinized cellular layer of the SC. Through
7
this process, the cells’ transition from newly divided to progressively flattened lose their nucleus and then
harden (keratinize), resulting in a gradient of stiffness that increases from the base to the surface (2). The
process takes about 28 days in a human (14 from basal layer to the bottom of the SC and then 14 for desqua-
mation) and ensures the constant regeneration of our skin (3). However, as the thin, tough SC sits atop a soft,
flexible layer of cells, the skin can deflect significantly when a force is applied—a positive, natural way to
limit wounding but a challenge for engineers looking to puncture the skin to reach precisely within.
Potential variabilities in the epidermis relate to the hydration and environmental exposure of the
skin layers, as these can significantly change the ability of layers to deform or puncture. For example,
Wu et al. (4) noted that when human SC was stretched in high humidity, the skin showed corneocytes
sliding over each other prior to the skin breaking. This behavior was not observed at low humidity and
the skin fractured at an earlier point as a result.
The plate-like structure of the SC also presents a challenge for puncture, as it enables surface flex-
ibility which allows deflection, avoiding penetration. While this may not be a problem for large devices
by which very high pressures can be introduced (such as a vaccine syringe), placing smaller doses of
vaccine/drug at precise locations can be a challenge.
2.2.1.2 The Dermis

Below the epidermis sits the dermis—a rich mesh of collagen, blood capillaries, cells, hair/sebum fol-
licles, and nerve endings, embedded in a proteoglycan and hyaluronic acid gel (5). This layer can be fur-
ther split into the papillary dermis (the upper dermis around the base of the epidermis) and the reticular
dermis (the lower dermis). The papillary dermis has a finer mesh of collagen than the reticular dermis
and contains smaller capillary ends; the reticular dermis has larger collagen bundles forming its struc-
ture and large capillaries (6). This composition means that the tissue has a range of properties that can
challenge the engineer looking to deliver drugs or vaccine within. The collagen fibers in particular give
an overall structural strength to the skin that enables it to be flexible but hard to puncture.
2.2.2 The Scale Dependency of Skin

One of the challenges for the development of novel micron-scale devices such as microneedles has been
limited material property knowledge of skin’s layers. Until relatively recently, the primary material prop-
erties of skin available were those that had been identified at the large scale (millimeters and above).
However, recent studies on the micro and nano scale have shown that the tissue behavior is quite differ-
ent at these scales (7). Indeed, as skin is a highly complex composite material, the relative influences of
different physiological features become more significant as the scale decreases. For example, the VE and
dermis may be considered a homogenous structure at the scale of millimeters or above, but on a smaller
scale this is not the case. At the sub-millimeter and micron scales, features such as individual corneo-
cytes, skin topography, collagen bundles, or rete ridges will influence the measured material properties
(8). We have previously observed this, for example, where collagen presence in the dermis resulted in a
bimodal distribution of elastic modulus in microscale testing.
For full-thickness skin, the elastic modulus of skin has been reported to vary from the low kilopascal
range on the millimeter scale (9) up to megapascals at the small micro scale (7). As microneedles span
these scales (from individual needles to full arrays), the designer of an array must consider how the skin’s
material behavior will affect its ability to puncture skin and deliver drug/vaccines.
2.3 Skin Fracture and Puncture

2.3.1 Skin Fracture
The ability to inject into skin has been of interest for hundreds of years with early needles and syringes
using quills and animal bladders for fluid injection (10). In modern use, the conventional needle and
syringe is credited to Dr. Alexander Wood, a Scottish physician, and concurrently Charles Gabriel
Skin Perforation and Solid Microneedles 9
FIGURE 2.1 The mechanisms of puncture of skin as proposed by Shergold and Fleck (11), in which a sharp penetrator
will expand a “crack” in skin to reach depth. (Reproduced with permission from ref. (11).)
Pravaz, a French orthopedic surgeon. Wood attached a graduated cylinder to a hypodermic syringe to
deliver morphine into the veins of his patients, but there have been relatively few advances in the needle
and syringe technology since then. One reason for this may be the complexity of puncturing skin in a
minimally invasive way for fine positioning of a drug/vaccine payload.
The puncture of skin is a complex, multistage process in which a crack must be initiated to allow pro-
gressive entry into skin (Figure 2.1).
Specific aspects of the puncture process of skin relevant to microneedles include:
a. Contact and deflection phase:

i. A sharp object contacts the skin either from directly above or at an angle.
ii. The skin starts to deflect, with the SC distributing the force from the penetrator into and
across the skin.
iii. The stress (pressure) around the penetrator increases as deflection increases. While this
is happening, the skin has deflected to the point where there is significant tension on the
surface of the skin and the area of skin directly beneath the penetrator is being compressed
(strain). The effect of this stress would be felt at a depth ten times the depth of the compres-
sion, reaching into the skin (12).
b. Puncture phase:
i. As the tension on the SC increases and the compressive strain on the epidermis increases,
a combined stress would eventually reach a critical point. This is where the surface fails
and starts to rip/puncture. However, as the SC has a brick-and-mortar structure, this failure
requires either delamination of corneocytes or ripping between them. When this event
happens, the skin will dynamically puncture and the penetrator will progress into the skin.
c. Penetration phase:
i. Beyond this initial puncture point, the progressive puncture of the skin requires the VE to
continue to allow puncture—that is, to allow the penetrator to separate or burst the skin
cells. At the same time, residual tension in the SC will provide friction against the penetra-
tor to slow its entrance into the skin.
ii. Pushing beyond the epidermis and into the dermis, the SC friction force continues, plus
any force required for additional widening of the hole if the penetrator is not a uniform
cylinder. Here, the collagen fiber mesh of the dermis is encountered. If the penetrator has
a very small diameter or sharp conical shape, it may be able to push between the collagen
fibers, through the dermis. However, if it is of a larger scale, then it may encounter signifi-
cant resistance at this point, requiring delamination or breakage of the collagen fibers to
allow penetration.
These stages allow the progressive entrance of a penetrating object to the skin. Figure 2.2 shows a
single microprojection from our work, penetrated into mouse skin tissue. Layer deflection and fracture
are visible.
In studying the mechanisms of puncture, the engineering fracture toughness of a material becomes of
interest. However, the orientation of testing is particularly important, as skin’s high level of anisotropy
(different properties in different testing orientations) results in differences in measured properties, as
do differences in temperature or humidity. For example, in tensile testing of skin’s SC, Koutroupi and
Barbenel (13) measured a work to failure of 3.6 kJ/m2, and a failure stress of ∼60 MPa at around 75%
humidity. However, Wildnauer et al. (14) found that skin failed at around 35 MPa, but with the failure
strain ranging from 35% to 200% as relative humidity increased from 0% to 100%. From this, we can
infer that there may be more challenges in getting microneedles to penetrate skin in high-humidity
environments. This may be a consideration of importance for clinical use in many low-resource settings.
Other studies that have examined the cutting of full-thickness skin have shown lower fracture tough-
ness values of around 2.5 kJ/m2 in trouser tear testing (15). These values are however much lower than
puncture toughness values that were presented by Davis et al. (16), with microneedle puncture giving
around 30 kJ/m2. This difference may be due to the increased complexity of the failure mode, in which
skin has a vertical compressive behavior in addition to the tensile failure stresses present. So, while
Shergold and Fleck suggest that soft solid penetration can be modeled as the opening of a crack, the
actual initiation of this crack can absorb a lot of the applied energy. How this energy is absorbed was
discussed by Yang et al. (17), who note that the skin has an impressive ability to adapt to high forces that
would otherwise tear it.
FIGURE 2.2 A nanopatch projection (original content) in mouse skin, following application at 2.3 m/s. This image was
taken by freeze-fracturing skin with a nanopatch in place, showing the layers of skin (SC: stratum corneum; VE: viable
epidermis) that have been deflected during the penetration process.
2.4 Microneedle Puncture of Skin

A range of designs of microneedles have been developed to place drugs and vaccines directly into precise
locations in skin. These have the benefit of targeting skin layers that are otherwise difficult to reach and
overcome the barrier properties of the SC. Solid microneedles have found widespread use in research
and preclinical studies and are progressing in clinical studies. The concept of this microneedle approach
is to have the simplest physical penetrator for the skin, with a drug/vaccine formulation that either dis-
solves from the surface once within the skin or can be applied after the perforation of skin by the
microneedles. We will discuss microneedle perforation of skin in this chapter and coated microneedles
in later chapters.
2.4.1 Microneedle Patch Manufacture

The manufacturing process of arrays of microneedles is dependent upon the materials to be used in the
device, their strength, and the geometry of individual microneedles. Correspondingly, these then dictate
how well the arrays puncture skin. Microneedle-manufacturing methods have been discussed in detail
elsewhere (18, 19); we will briefly discuss some key approaches below.
a. Silicon manufacturing
Manufacturing from silicon makes use of either dry or wet etching of crystalline silicon
wafers. This starts by defining a mask that is deposited on the surface, often using photoli-
thography, which defines the areas for either anisotropic or isotropic etching. Wet etching
is considered a simpler manufacturing process, as isotropic etching erodes material with
orientation to the crystal structure of the material. This will give microneedle shapes that
are generally blunter than dry etching (20). Dry etching, similar to that used in the micro-
electronic industry, can perform both anisotropic etching (etching vertically downward to
make high aspect ratios) and isotropic etching (removal in all directions simultaneously).
This approach can give some high-aspect-ratio structures with very sharp tips (sub-micron)
(21, 22).
b. Metal manufacturing
Metal microneedles tend to either be based on the traditional needle and syringe, where mul-
tiple sharp tips are mounted upon a base, or make use of laser machining. Both methods have
been used to create simple microneedle arrays. An example of the first is the manufacture of
devices such as the “microneedle roller,” now popular as a cosmetic device, with rows of sharp
microneedles arranged on a roller to apply to the skin (23). Where laser-machined micronee-
dles have been used, either a single row of microneedles has been created, or multiple rows
have been machined and then bent to form the tips that will puncture the skin (24). This tech-
nique is again very good for producing very sharp tips.
c. Polymer manufacturing
Manufacture of polymer microneedles can be done using a variety of molding techniques in
order to generate a range of microneedle profiles. These often require the manufacture of a
“master” mold that can be manufactured from silicon, metal, or another polymer (e.g., PDMS/
PMMA), into which the polymer can be formed (25, 26). Various forming techniques have been
employed, which include direct injection molding, hot embossing, and melt-casting (discussed
in more detail in ref. (27)). These processes enable arrays to be replicated at low cost and with
fixed geometry.
While the manufacture method is unlikely in itself to indicate whether a clinical product will be
achievable, some challenges affect manufacturing methods. For example, the cost of a single patch pro-
duction and the ability to produce continuous production lines for millions of units per year will become
important as such devices become standard in clinical use.
2.4.2 Microneedle Patch Application

Within the field of microneedles, there are significant challenges in getting arrays with large numbers of
microneedles to puncture the skin. Some key points are:
a. High-density arrays—Skin is a topographically varied surface that can withstand large defor-
mations prior to puncture. When there is a high-density array of microneedles (e.g., more than
500/cm2), a large number of discrete punctures must be created. This requires substantial
energy. Naturally, as density and number of microneedles increase, the required force for skin
puncture also increases. This can mean greater sensation for the patient and might require a
larger/stronger device to be used for applications.
b. Tip sharpness—Varying the sharpness of the tips of microneedles can help control the punc-
ture force. Increased tip sharpness not only reduces puncture force but also reduces the struc-
tural strength of the microneedles, leading to increased breakage risk. We have also observed
that the capacity of the skin to distribute force from small penetrators (like microneedles) can
limit the effectiveness of striving for progressively sharper tips, below the diameter of a few
microns (28).
c. Bioactive component application—The location of the drug or vaccine payload is a
significant consideration of microneedle design. If the payload is to be carried on the
microneedle device, then the design must be adapted for this. For example, if this is a sur-
face coating on the microneedles, the design will need to accommodate the extra surface
geometries.
The application of microneedle patches to skin has been used with a variety of patch configu-
rations, often with similar outcomes of the penetration force per microneedle. Roxhed et al. (29)
applied a 25-microneedle array of sharp tip (<100 nm radius) microneedles to skin and measured
penetration to require 10 mN per microneedle. Similarly, O’Mahony (30) found 15–20 mN per
microneedle, and Resnik et al. (31) required around 15–30 mN per microneedle. These forces repre-
sent arrays of 10–100 microneedles, which give a total applicator force of 0.1–3 N. Although these
forces are low, the need for consistent application may necessitate a controlled application approach/
device.
Skin is a highly viscoelastic material, which means that any intention to puncture its surface will
be dependent upon the velocity/strain rate at which puncture happens. If the device contacts slowly, a
large deflection is likely, prior to puncture; if quickly, the deflection will be much lower. This has been
observed when manual (hand) application of microneedle patches has been used for application. For
example, Verbaan et al. (32) observed that with hand application of their patches, there was minimal
increase in dye delivery into skin. However, when an applicator applied these at velocities of 1–3 m/s,
flux increased by an order of magnitude above the manual application. We observed similar effects with
penetration depth and patch surface area penetration doubled when dynamic application was used (33).
An example of the differences observed by applying patches at difference velocities is shown in Figure
2.3. This data demonstrates one of the challenges in perforating skin with an array of microneedles:
ensuring both that the penetration depth of microneedles is sufficient and that all the microneedles
penetrate. As the energy of application decreases, some areas of the patch do not breach the surface
(Figure 2.3).
These differences can be very important when using a device designed to reach into precise locations
of the tissue.
2.4.3 Skin Substrate (Fat/Muscle)

The surface upon which the skin is sitting is one of the key determinants of where puncture will occur.
Even with sharp penetrators, a soft layer underlying the skin may reduce penetration significantly,
especially if there is fat/muscle variation. According to Meliga et al. (35), very sharp microneedles
FIGURE 2.3 Delivery of dye when patches have been applied at increasing velocities. Lighter dye indicates lower deliv-
ered payload. These images are from arrays of 1316 microneedles of length 356 μm, spaced over a 15 mm radius. (a) is
with a 36 g driving mass and (b) is using a 17 g driving mass (i.e., same velocity but half the mass). (Reproduced with
permission from ref. (34).)
applied to mouse ear skin sitting on PDMS required almost 95% of the application energy to compress
the soft substrate, compared to only 5% going to penetrate the mouse skin. While this is at the extreme
ends of the comparison, it does allow us to speculate on how significant a clinical effect adipose tis-
sue may introduce. The effect may be even more pronounced when a slow application is used and the
skin has more time to deflect. In this situation, it is likely that the microneedles to be used will end
up needing to be low-density arrays or have lengths that exceed 1 mm to ensure sufficient penetra-
tion. However, this may not be a problem: an ultrasound examination of skin layer thicknesses (36)
observed that having microneedles of 1.5 mm length should ensure that the payload is always delivered
into the dermis.
2.4.4 Microneedle Perforator/Enhancer Arrays

As discussed above, one of the simplest ways to use microneedles is to apply patches to the skin and
then place a topical formulation on the surface. This then relies on diffusion into the pores created
by the microneedle device to achieve the desired therapeutic outcome. This overcomes the ∼500 Da
cutoff for molecules passing through the surface of the skin (37), and as this is the key goal for this
technology, the microneedles can be short. Correspondingly, this enables a low-pain, low-complexity
approach.
The designs that have been employed for microneedle perforators or MEAs range in length, micronee-
dle number, and shape. In general, these have numbers on the order of 100–1000 microneedles and are
administered either by hand or with an applicator.
Microneedle length can be a strong determinant on their function. For example, Mikszta et al. (38)
found that their 50-μm-long microneedles did not result in increased transdermal permeability, whereas
100-μm-long microneedlees increased permeability by 2800 times. This difference is most likely attrib-
utable to the ability of skin to deflect around short microneedles, but puncture with longer ones. In
array form, Henry et al. (21) (using one of the earliest MEA designs) found that their 20 × 20 array of
150-μm-long, sharp-tipped (<1 μm) microneedles gave a permeability increase of up to 25,000 times.
They observed that leaving the array in place longer (10 minutes–1 hour) resulted in a considerable
increase in the permeability. This may be due to skin relaxing around the microneedles over time and
the passage of the initial wound healing response.
The transport capability of skin once an MEA has been applied will depend upon the perforation
depth of the tissue. If a drug is relatively small with high diffusion capacity, creating surface pores by
microneedle application should be sufficient for therapeutic function. However, if rapid delivery to the
bloodstream is a goal, it may be preferable to create pores that reach to the dermis where capillaries are
located. This may be one reason for the very varied microneedle lengths that have been published to date.
For example, in addition to the shorter microneedles discussed above, there have been many studies with
long microneedles, such as that of Martanto et al. (24), which looked to increase insulin permeability
into skin using 1000-μm-long microneedles.
To attempt to produce a more controlled-release approach to drug delivery once the pores were
created, Pearton et al. used a hydrogel for delivery of plasmid DNA for gene regulation in the skin
following application of 260-μm-long microneedles (4 × 4 array). Their 50–100 μm pores, com-
bined with the hydrogel, allowed more precise gene regulation in the skin. These short conduits
appear to be sufficient to improve drug delivery to a large extent. Wu et al. (39) observed similar-
sized conduits by application of their 150-μm-long microneedles, giving 10 4 - to-105-fold improve-
ment in calcein.
The use of microneedle rollers has recently grown with a wide range of topical applications used.
Enhancements in topical anesthetics (40), antiepileptic drugs (41), hair growth (42), and skin aging (43)
have all been reported with the microneedle roller. However, even with very simple devices like these,
there have been adverse clinical outcomes when used for cosmeceutical purposes. The rapid uptake of
these devices by the cosmetics industry has resulted in some drugs approved for topical use only being
introduced into the body. Clinical presentation with erythema and granulomas in the skin has been
observed (discussed in ref. (44)). This is one problem with the perceived simplicity of these devices and
the ease of obtaining them.
2.4.5 Challenges of MEAs

While MEAs have the potential to overcome the barrier properties of the SC, they rely on passive diffu-
sion of the biological formulation into skin. This can make it difficult to deliver high doses, and a lot of
the dose will be wasted on the surface of the skin.
The time of application and the inability to monitor dose delivery have made this technology less
attractive for certain clinical applications. One example is in the area of vaccine delivery. Recent stud-
ies (e.g., ref. (45)) have noted that delivering vaccine directly to the epidermis and dermis in skin has
the potential to generate immune responses with far less vaccine than traditional intramuscular injection.
However, if only a small percentage of the applied dose reaches the skin, these benefits can be lost. And
while this may not be a complete barrier to this technology, dose consistency is of great importance. For
vaccines in particular, a threshold dose must be delivered to invoke immunity, which can be more difficult
when relying on passive diffusion after microneedle application. However, for cheap compounds or drugs
generally applied in topical form, the increase in dose that can enter the body will represent a significant
advance.
2.4.6 Clinical Use

A key benefit of the solid MEA approach is that the clinical development of the microneedle device can
progress independently of the drug or vaccine formulation. This might considerably simplify any regula-
tory process and might allow more rapid integration of the technology into the supply chain of particular
drugs. However, it becomes important to ensure that the drugs to be used are suitable for internal deliv-
ery and not just as topical carriers.
2.5 Conclusions
Perforating skin on a micro scale remains a significant challenge for devices that aim to enable preci-
sion drug or vaccine delivery. Another complication is introduced when there is a large array of short
microneedles, as this increases the risk of only partial surface puncture across the array. The result of these
challenges is that an applicator of some type is often required to precisely position the microneedles where
the drug should be deposited. Topical drug application to the site following surface puncture (or perfora-
tion) has the potential for simple, effective delivery of large-molecular-weight drugs and vaccines into the
body. Although only a small amount of the molecule may actually reach its desired delivery location, the
simplicity of the approach may reduce the regulatory challenges experienced by other, more complex for-
mulation approaches.
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3
Dissolvable and Coated Microneedle Arrays: Design,
Fabrication, Materials and Administration Methods
Emrullah Korkmaz1 and O. Burak Ozdoganlar1,2,3

1 Department of Mechanical Engineering, Carnegie Mellon University
2 Department of Materials Sci. and Engineering, Carnegie Mellon University
3 Department of Biomedical Engineering, Carnegie Mellon University
3.1 Introduction
Delivering therapeutics and vaccines by cutaneous and transdermal routes offers unique advantages over
prevailing oral and parenteral drug delivery methods [1, 2]. Transdermal systems deliver vaccines and
therapeutics through the skin into the systemic circulation, whereas cutaneous systems deliver drugs into
the skin, targeting certain skin microenvironments (e.g., epidermis and dermis). Both transdermal and
cutaneous routes bypass the gastrointestinal (GI) tract, thereby improving bioavailability and potency
of the delivered drugs, as well as reducing their side effects. Transdermal and cutaneous drug delivery
routes also eliminate needle-stick injuries and needle reuse issues, and increase patient compliance since
they cause little to no pain during administration. Moreover, these routes minimize or eliminate the
need for, and the associated cost of, trained health care professionals for administration of drugs [1–4].
As a result, the number of transdermal and cutaneous drugs in the market and in the regulatory approval
pipeline has been expanding significantly in the past few years [1].
Although many advantages of transdermal and cutaneous (i.e., intradermal) delivery have been well
recognized, they have yet to be fully exploited. Transdermal and cutaneous routes present their own chal-
lenges: delivering drugs through these routes requires overcoming the physical barrier imposed by the
stratum corneum (SC), the top layer of the skin [5]. Without a physical breach or chemical penetration
enhancers, only small molecules (<500 Da molecular weight) can penetrate the SC [6–8]. This puts sig-
nificant limits on the types of proteins, peptides, and genetic materials (i.e., polyplexes and recombinant
viral vectors) that can be directly delivered to or through the skin, thereby hindering the use of trans-
dermal and intradermal routes for a majority of vaccines and therapeutics without the use of specifically
designed delivery systems [9, 10].
To mitigate the limitations associated with the transdermal and cutaneous delivery toward increas-
ing the types of drugs that can be administered through these routes, as well as toward improving
the delivery efficiency, microneedle array (MNA)-based trans/intradermal delivery systems have been
developed in the past decade [2, 4, 11, 26]. These devices include an array of microneedles, each with
dimensions ranging from 50 μm to 1 mm in width, and up to 1.5 mm in height. Microneedle arrays
physically breach the SC layer and enable delivering therapeutics and vaccines to viable epidermis and
dermis in a minimally invasive manner [1, 2]. Pioneering works have demonstrated that trans/intra-
dermal delivery using MNAs can overcome the aforementioned challenges while retaining advantages
of transdermal and cutaneous delivery [12–16, 26]. However, the full potential of MNA-based trans/
intradermal drug delivery has not yet been realized, mainly due to considerable challenges in design,
manufacturing, and administration of MNAs.
Currently, there are four major MNA-based trans/intradermal drug delivery concepts (Figure 3.1). The
first concept is known as the poke-and-patch approach, where solid microneedles made of silicon, met-
als, or non-dissolvable polymers are used to precondition the skin by piercing the SC. The pores created
19
FIGURE 3.1 Microneedle-based trans/intradermal drug delivery concepts. 1. Types: (a) Solid MNA, (b) Coated MNA,
(c) Dissolvable MNA, and (d) Hollow MNA. 2. Methods: (a) Solid microneedles are used to precondition the skin by pierc-
ing the stratum corneum to substantially increase the permeability prior to topical application of drug (poke-and-patch).
(b) Drug-coated solid microneedles are inserted into the skin. Upon insertion of microneedles, the drug coating is dis-
solved into the skin, after which the microneedles are removed (coat-and-poke). (c) Dissolvable microneedles penetrate
the skin, and then dissolve and deliver their cargo to targeted skin microenvironments (poke-and-release). (d) Hollow
microneedles are utilized to deliver liquid drug solutions into the skin (poke-and-flow). SC: stratum corneum; VE: viable
epidermis, D: dermis.
by the MNAs increase the permeability of skin to subsequent topical and transdermal-patch-based
deliveries (Figure 3.1a) [6, 15–17]. However, since this method relies on passive diffusion of the bio-
active cargo, it provides only limited spatial, dosage, and delivery rate control [6]. Furthermore, the
MNA material should be carefully selected to prevent unwanted complications in the event of accidental
breakage of the microneedles in the skin. Therefore, it is important to create these solid MNAs from
biocompatible materials.
The second concept, the coat-and-poke approach, also uses solid microneedles created from silicon,
metals, or non-dissolvable polymers. The microneedles are coated with the aqueous solution contain-
ing the drug to be delivered. Upon insertion, the drug coating is dissolved into the skin, after which
the microneedles are removed (Figure 3.1b) [6, 18]. Although this method provides a better dosage and
spatial control over the poke-and-patch approach, its capacity is limited to small quantities of drugs.
Similarly to the poke-and-patch approach, the MNA materials should be carefully selected to avoid
potential complications.
The third concept is the poke-and-release approach, in which MNAs are made from biodissolvable
materials that encapsulate the drug within the microneedle material. Upon insertion into the skin, the
MNAs dissolve rapidly and deliver their biocargo to targeted skin microenvironments. Dissolvable
MNAs have been demonstrated to have sufficient strength to allow insertion, to dissolve within minutes
in interstitial fluids of the skin, and to effectively release their biocargo [6, 19–21, 26, 67–68]. The dis-
solvable MNAs are made from biocompatible materials, and their full dissolution eliminates sharp or
biohazardous waste (Figure 3.1c) [6, 19–21, 26, 69]. Therefore, dissolvable MNAs combine the physi-
cal toughness of solid microneedles with relatively high bioactive material capacity and controllable
delivery rate, while possessing other desired attributes of simple and low-cost fabrication, storage, and
application.
Dissolvable and Coated Microneedle Arrays 21
The last microneedle concept, the poke-and-flow approach, utilizes hollow microneedles attached
to a reservoir of bioactive cargo [6, 22] (Figure 3.1d). The hollow microneedles and associated design,
manufacturing, and administration aspects will be covered in Chapter 4.
This chapter focuses on design, manufacturing, and administration aspects of the MNAs for the
coat-and-poke and poke-and-release concepts. The following section discusses the geometric design
considerations for both the individual and the array of microneedles. Subsequently, we describe the
prevailing fabrication methods for the MNAs. We then discuss the selection of MNA materials. Next,
we discuss the administration methods, which is critical in realizing precise and reproducible delivery
using MNAs.
3.2 Microneedle and Array Designs

Realizing the true potential of MNAs depends critically upon precise and effective delivery of their
biocargo to targeted skin microenvironments in a minimally invasive manner [23–26]. The MNAs
must penetrate the SC with minimum force and without mechanical failure to deliver their biocargo
to the epidermis and/or dermis. Penetration and cargo delivery performance of MNAs are highly
correlated with the geometry of individual microneedles and the array, MNA materials, the MNA
administration method, and the skin-tissue characteristics [23]. Ideally, the microneedle design and
administration method should maximize the number and portion of the microneedles that penetrate
the skin with low insertion forces to achieve an optimal and precise delivery performance with
minimum tissue damage. Further, clinically relevant microneedle and array designs should enable
controllable and reproducible delivery location and dose. This section focuses on geometric aspects
of microneedle and array designs, and discusses the critical design aspects for successful and repro-
ducible penetration of MNAs into the skin with minimum tissue damage toward optimal biocargo
delivery.
The geometric parameters of the microneedle and array designs (Figure 3.2) include tip radius, apex
shape and dimensions, stem shape and dimensions, bevel angle, fillet radius at the base of the micronee-
dles, tip-to-tip distance of microneedles in the array, and overall array size. These parameters directly
impact the mechanical performance (i.e., penetration and failure characteristics) of MNAs, their bio-
cargo capacity, cargo delivery location, and the tissue damage caused by the MNA insertion [23–26]. In
general, the cutting and deformation of skin tissue arise from the thrust (axial) force at the microneedle
tip and the friction force between the microneedle surface (including that of the stem) and the skin tissue.
FIGURE 3.2 MNA design parameters: (a) A 6 × 6 MNA with negative bevel obelisk microneedles and with a total size
of 8 mm × 8 mm. (b) Microneedle and array geometric parameters indicated on a negative bevel obelisk needle [24, 26].
Tip sharpness, quantified by the tip radius, is a critical factor for skin penetration. Sharper microneedles
can penetrate the skin with low insertion forces [6, 23, 26]. Apex shape and dimensions control the force
distribution during penetration and deeper tissue insertion. Symmetric apex geometries and smooth
edges can provide more uniform force distributions, thereby reducing the possibility of microneedle
failure during insertion. Microneedles with smaller apex angles lead to lower penetration forces. Stem
shape and dimensions not only affect the insertion forces but also dictate the delivery location and depth.
Shorter microneedles (<300 μm in height) may not penetrate the skin at low application force and speed
levels due to the elasticity of skin [27], necessitating larger insertion forces. The stem portion of the
microneedles affects the total insertion forces due to the frictional interactions between the microneedles
and skin tissue. Bevel angle affects both the insertion and retention (i.e., keeping MNAs in place after
inserting into the skin tissue) [26]. Fillet radius at the base of the microneedles help reduce the stress
concentration, thereby increasing the strength of microneedles [24, 26]. Tip-to-tip distance controls the
MNA skin-piercing event. When the microneedles are placed too close to one another, either the piercing
does not occur or high piercing forces are required [23–25]. This is due to what is referred to as the bed
of nails effect. Furthermore, higher needle density may considerably reduce the total penetration volume
(and thus the delivery amount) [23, 25]. In addition to the aforementioned individual effects of each
geometric parameter, the array geometry controls the stress distribution on the MNA, the maximum
deliverable biocargo amount, and the initial tissue damage resulting from the insertion of the MNAs into
the skin.
Apart from the aforementioned geometric aspects of MNAs, innovative microneedle and array
designs may be realized by introducing various advanced features (Figure 3.3), including: (1) conform-
able MNAs: MNAs with a flexible backing layer (Figure 3.3a) that can enable conformal contact between
the MNA and the complex topography of the underlying skin to enhance the penetration and delivery
performance [28]; and (2) layer-loaded MNAs (as opposed to uniformly distributed bioactive cargo; see
Figure 3.3b): MNAs with controlled location of the biocargo within the microneedles and across the
array that can enable improved spatial control and delivery efficiency to targeted skin microenviron-
ments (Figures 3.3c and 3.3d show multilayer-loaded and tip-loaded MNAs, respectively). This selective
layer loading has yet to be exploited in the literature other than localizing the drug at the tip of micronee-
dles [30–32]. Furthermore, multiple bioactive cargoes can be loaded into or onto the MNAs, and then
delivered simultaneously to targeted skin microenvironments for novel skin-targeted immunization and
treatment strategies [33].
Myriad microneedle geometries, comprising cylindrical [34], rectangular [35], pyramidal [26], coni-
cal [19], obelisk [24, 26], and negative bevel obelisk [24, 26], with different microneedle lengths and
widths, have been developed (Figure 3.4) [6]. Typical geometries vary from 100 μm to 1500 μm in
length, from 50 μm to 1000 μm in base width, and from 1 μm to 40 μm in tip diameter [6, 36].
The insertion of a microneedle into a tissue involves six distinct phases: (1) pre-penetration; (2) ini-
tial piercing; (3) progressing head penetration; (4) complete head penetration; (5) stem penetration; and
FIGURE 3.3 Innovative microneedle and array designs toward application-oriented optimization. (a) Conformable
MNAs with a flexible backing layer (reproduced with permission [28]). Selective layer-loaded MNAs: (b) Uniformly loaded
microneedles (reproduced with permission [29]), (c) layer-loaded microneedles (unpublished work from the Ozdoganlar lab
at Carnegie Mellon University), and (d) tip-loaded microneedles (reproduced with permission [30]).
FIGURE 3.4 Different microneedle stem geometries. (a) Cylindrical (reproduced with permission [34]), (b) Rectangular
(reproduced with permission [35]), (c) Conical (reproduced with permission [19]), (d) Pyramidal (reproduced with permis-
sion [26]), (e) Obelisk (reproduced with permission [26]), (f) Negative obelisk (reproduced with permission [26]). Scale
bars correspond to 300 μm.
(6) final tissue relaxation. Depending on the microneedle and array geometries, insertion conditions (e.g.,
insertion speed), and tissue characteristics, some of these phases may not exist or may not be distinguish-
able. For instance, for a pyramidal needle, phases 4 and 5 are not present since the overall geometry
is smooth without a head-stem transition. On the other hand, phase 2 may not be recognizable when a
very sharp (small tip radius) needle penetrates into a very elastic tissue. This dependence on the needle
geometry and tissue properties has led different works in the literature (e.g., ref. [37]) to identify differ-
ent selections of insertion phases. Since an obelisk microneedle shape (see Figure 3.2b) embodies many
of geometric features and could show all different phases, we will consider this shape in describing the
forces.
The forces associated with the six insertion phases are schematically presented in Figure 3.5. The
pre-penetration phase begins when the microneedle tip comes into contact with the skin tissue. As the
microneedle is pushed further, the skin tissue deforms elastically, and an associated increase in forces
is observed. The duration of pre-penetration phase depends on the tip sharpness and tissue properties,
the latter of which might change considerably depending on the penetration speed (viscoelasticity and
dynamic response) and the tissue preparation (e.g., stretching). Commonly, the sharper the microneedle
tip and the lower the effective tissue elasticity, the shorter the pre-penetration phase. This phase will
conclude with the initial piercing phase, when the tissue surface is punctured. In this short phase, the
microneedle tip will penetrate the tissue, and some of the elastic (strain) energy will be released, causing
a drop in the insertion forces.
During the progressing head penetration phase, the forces will steadily increase. These forces include
continued “cutting” force at the microneedle tip and forces caused by the steady expansion of the punc-
tured tissue area due to increasing cross-sectional area of the microneedle head. This increase in forces
continues until the punctured tissue area reaches the area of the stem, that is, when the complete head
penetration phase is reached. In this short phase, another relaxation event will occur, and a sharp drop
in the insertion forces will be recognized.
As the microneedle is further inserted into the tissue, the stem penetration phase marked with a steady
increase in forces is observed. These forces arise from the shear stresses (causing frictional forces on the
microneedle) between the tissue and the microneedle stem. The force will continue to increase with the
increased needle depth, until the penetration is stopped. At this point, the final tissue relaxation phase,
which is characterized by the force relaxation due to strain energy release, will occur [38, 39].
FIGURE 3.5 A typical needle-tissue insertion force diagram [71].
In summary, microneedle and array designs play a crucial role in the tissue penetration and insertion
forces. For instance, blunt and short needles, or needles that are too closely spaced in the array, may cause
the skin to fold around the needles, limiting or hindering the penetration capability. Weaker microneedle
materials, non-optimal MNA designs, and unfavorable insertion conditions might result in excessive
insertion forces, and the associated stress levels might exceed the strength of the microneedle material,
resulting in mechanical failure of the microneedles. This being so, microneedle and array geometries
are critical factors in developing clinically relevant MNA-based drug delivery systems. Comprehensive
models that capture the effects of microneedle and array designs, as well as accurate skin tissue charac-
teristics, could facilitate optimization of MNA-based drug delivery strategies. Developing such models
requires a thorough understanding of the relationships between microneedle/array designs and insertion
forces, and of the key mechanical properties of the skin.
3.3 Microneedle-Manufacturing Techniques

This section summarizes the current fabrication approaches of both the coated and dissolvable MNAs, as
well as the coating methods toward satisfying key requirements in developing clinically relevant MNAs.
Successful manufacturing of MNAs is of utmost importance for their regulatory approval and clinical
adaption. An effective manufacturing technique for both the coated and the dissolvable MNAs should
satisfy certain key requirements, including (1) accuracy and reproducibility, yielding dimensionally
accurate MNAs encapsulating a precise dosage of biocargo; (2) material applicability, which entails
capability to use a broad range of relevant materials for MNAs so that optimal insertion and delivery
performance for different vaccines and therapeutics is obtained without any toxic effects and unwanted
immune response; (3) geometric capability, which enables creating required microneedle and array
geometries toward optimal insertion and delivery performance; (4) benign processing, that is, processing
without toxic chemical solvents or high temperatures that can damage the bioactive cargo; and (5) low
cost and scalability, which is required for the process to be used for commercial applications in terms of
production cost and volume. Furthermore, an ideal fabrication approach should facilitate easy, rapid, and
low-cost changes in geometric and material parameters for optimization.
The existing microneedle manufacturing approaches can be classified into two main categories: (a)
direct fabrication techniques and (b) hybrid fabrication techniques, which involve a direct fabrication
technique followed by the use of a micromolding method [26, 36, 70].
3.3.1 Direct Fabrication Techniques

Direct fabrication techniques used for solid MNAs include photolithography [21], laser cutting [35],
micromachining [26], and additive manufacturing (i.e., 3D printing) [40]. Photolithographic processes
are among the first microneedle manufacturing methods for reproducible fabrication of accurate solid
MNAs. However, the use of photolithography-based approaches for MNA fabrication imposes strict
material (e.g., silicon, silicon-oxides, and a few metals) and geometric limitations, requires a long time
from conception to fabrication, and occasions high production costs for small-to-medium production
volumes. Specialized cleanroom processing, use of hazardous chemicals, and expensive production
equipment are other disadvantages. These requirements and shortcomings hinder rapid and low-cost
fabrication of different MNA designs, limiting the capability to conduct parametric studies for optimiza-
tion of microneedle and array designs [26, 31].
Laser-based approaches (e.g., laser UV cutting) are also used to fabricate the solid MNAs from ther-
moplastic polymers and metals [35]. Even though these methods can effectively create MNAs, they usu-
ally suffer from poor geometric integrity, low dimensional accuracy, low surface quality, and large form
errors (e.g., blunt tips) due to the process generated heat and residual stresses. Laser-based approaches
also impose further geometric restrictions since they are limited to fabricating planar (i.e., 2.5D) features
rather than fully 3D features.
Mechanical micromachining (e.g., micromilling) has recently emerged as an effective manufac-
turing technique for MNAs [26]. An important advantage of this technology is its capacity to gener-
ate any microscale geometry on a range of materials, including polymers, metals, and ceramics, in a
highly reproducible and accurate fashion [26]. The lead time for fabricating new designs is measured
in minutes or hours, and the unit cost of the parts created by micromilling is very low. Most recently,
a diamond micromilling approach has been introduced to further advance micromachining-based solid
MNA (including master mold) fabrication [26, 31]. Therefore, the use of micromilling could address the
aforementioned shortcomings of photolithography- and laser-based microneedle fabrication processes
(especially during the design optimization stages) in geometric and material capability, cost, and ramp-
up time [26].
More recently, additive manufacturing and 3D printing approaches have been adapted for fabricat-
ing MNA-based trans/intradermal drug delivery systems. For example, a two-photon-initiated polymer-
ization method was demonstrated for fabricating MNAs, where a near-infrared ultrashort-pulsed laser
was focused into a photocurable resin to create the 3D microneedles using a layer-by-layer approach
[41]. However, currently, 3D printing brings limitations in material capability, achievable resolution, and
scalability. Further advancements in 3D printing might enable more innovative microneedle and array
designs toward application-oriented optimizations.
The direct fabrication techniques are not restricted by the geometrical constraints arising from the
micromolding step of the hybrid fabrication techniques, and thus are capable of creating more innova-
tive microneedle designs, such as those with undercuts [42–44]. On the other hand, the direct fabrication
techniques suffer from one or more drawbacks that prevent high-throughput industrial manufacturing of
MNAs, including limited production rates and high costs for scaling up to higher production volumes.
3.3.2 Hybrid Fabrication Techniques

Hybrid fabrication techniques can be utilized to create both coated and dissolvable MNAs. The general
approach in hybrid fabrication techniques involves fabrication of a set of master molds using a direct
technique, and subsequently using micromolding to create the final MNAs. The MNAs can be fabricated
using micromolding either directly from the master molds or from production molds obtained from the
master molds. Silicon, metals (e.g., aluminum), and thermoplastic polymers (e.g., poly(methyl methacry-
late), PMMA) have been used as master mold materials [26, 45]. The molds (master or production) are
filled with a molten, dissolved (solvent-based), multi-component (e.g., thermosets) or softened (above
the glass-transition temperature) material to create solid polymer microneedles upon solidification (by
cooling, solvent evaporation, or cross-linking). Similarly, ceramic microneedles have been fabricated by
molding a ceramic-powder slurry (e.g., alumina) onto the MNA molds, and then sintering the molded
slurry [47].
3.3.3 Fabrication of Coated MNAs

Coated MNAs are obtained by coating the solid MNAs, created using either the direct or the hybrid
fabrication techniques, with the desired biocargo (Figure 3.6a) [45–47]. The coating process commonly
involves dipping the non-dissolvable (solid) MNAs into a liquid solution of a bioactive molecules, or
spraying the solution onto the solid MNAs [6, 36]. Alternatively, a layer-by-layer coating approach has
also been demonstrated in the literature [48].
The solution with bioactive molecules is often prepared so that its viscosity is sufficient to conformally
spread onto the microneedles during drying [6, 36, 46]. A biocompatible surfactant is usually added to
the coating formulation to facilitate the wetting of the microneedle surface [6, 49]. A stabilizing poly-
mer may be used to protect the biocargo from damage during drying and storage [6, 49]. The amount of
biocargo that will be coated is adjusted by controlling the initial concentration of the drug solution. For
relatively higher doses, since the coating solution may become too viscous, desired drug dose is obtained
by applying multiple coating steps. The coating solution is formulated for optimal delivery performance,
such as dissolution of coating within the desired time period after penetrating the skin. In addition to
applying them to the entire microneedle, when the required doses are sufficiently low coatings might
be localized just to the microneedle tips, to increase the delivery efficiency. Alternatively, if the coating
makes the tips very blunt, diminishing the insertion performance of MNAs, only the shafts might be
(a) (1) MN fabrication (2) Sucrose and vaccine addition (3) Drying
PLA microneedle array PLA microneedle array PLA microneedle array
(b)
Curing
Peeling off
Master template Pouring PDMS (base and curing agent) PDMS female mold
Pretreatment
(e.g., plasma)
Centrifugation
Peeling off or vacuum
Polymeric microneedles Solidification via drying or photocrosslinking Pouring polymer solution
FIGURE 3.6 Manufacturing of (a) coated (reproduced with permission [45]) and (b) dissolvable MNAs (reproduced with
permission [46]).
coated. Using benign conditions during the coating and drying steps is critical to maintaining the activity
of the biocargo, especially for the heat-sensitive drugs.
3.3.4 Fabrication of Dissolvable MNAs

Dissolvable MNAs are fabricated from biodissolvable materials. The biocargo is incorporated into the
biodissolvable material, dissolution of which within the skin facilitates precise delivery of the biocargo.
Commonly, dissolvable MNAs are created using a hybrid fabrication technique: As depicted in Figure 3.6b,
the general approach involves manufacturing the master molds using a direct fabrication approach, fabricat-
ing the production or female molds with the microneedle-shaped wells using elastomer molding, and creat-
ing the final dissolvable MNAs using a micromolding technique (e.g., injection molding [50], investment
molding [51], spin-casting [21, 26, 67–71], and pouring [52]). In a few studies (e.g., ref. [19]), laser-based tech-
niques were used to directly fabricate the elastomer production molds with the microneedle-shaped wells.
The bioactive cargo incorporated into the hydrogel microneedle matrix is commonly distributed uni-
formly within the entire microneedle (Figure 3.3b). More recently, concentrating the bioactive cargo
only at the tips, or more generally, loading one or more bioactive cargoes in different locations of the
microneedle has been demonstrated (e.g., layer-loaded MNAs in Figure 3.3c) [30, 31]. The tip or layer-
loaded MNAs have potential to bring further advances for effective skin immunization and therapy
strategies. However, there are still important challenges in accurate, reproducible, and controllable fab-
rication of these MNAs, and thus a strong need to further develop effective manufacturing approaches.
The most commonly used micromolding technique for creating dissolvable MNAs has been spin-
casting, since it not only satisfies many of the aforementioned key manufacturing requirements, but also
is relatively simple, low-cost, and scalable. The spin-casting technique has been applied to a broad range
of biodissolvable materials with myriad biocargoes [21, 26]. Importantly, its low-temperature processing
capability enables maintaining the activity of heat-sensitive biologics. The first step in the technique is to
fabricate high-accuracy microneedle molds. This can be done either by directly creating the production
molds [19] or by creating a master mold [21, 26] that can then be replicated to obtain many production
molds. Each production mold can then be used to create a large number of dissolvable MNAs through
the spin-casting approach. Due to the nature of solvent-based casting, a certain amount of shrinkage is
observed in the dissolvable MNAs due to the drying process. However, for a given geometry, the amount
of shrinkage is consistent, resulting in reproducible geometries [26]. Yet prediction of the shrinkage
behavior for different process conditions is critical to fabricating accurate and reproducible MNAs.
For the MNA materials they can produce, the hybrid fabrication techniques can address many of the
drawbacks of the direct fabrication techniques for creating the final MNAs. The hybrid fabrication tech-
niques hold the potential to be a predictable, reproducible, inexpensive, accurate, and scalable approach
for fabricating MNAs. To realize these attractive benefits, further advances are needed to precisely con-
trol geometric and mechanical properties of the MNAs, and to enable fabrication of clinically relevant
MNA designs.
3.4 Microneedle Materials

The microneedle materials are critical for both effective penetration and cargo delivery performance of
MNAs. Furthermore, the effects of microneedle materials on the bioactivity and longevity/stability of the
MNA-embedded biocargo should be carefully considered.
For both the coated and the dissolvable microneedles, the choice of material directly affects the
mechanical strength and biocompatibility [23, 53, 26, 71]. Furthermore, the choice of dissolvable mate-
rial and coating formulation strongly impact the drug delivery profile, including intradermal release
kinetics and intradermal residence of the delivered drugs. Importantly, the microneedle material should
preserve the viability of the incorporated biocargoes, and should enable satisfying the desired storage
duration without affecting the bioactivity of the biocargoes. Therefore, favorable biocompatible materi-
als should be identified or formulated toward optimized clinical applications and long-term stability of
the MNA-integrated biocargoes.
3.4.1 Materials for Coated MNAs

As mentioned above, coated MNAs utilize solid, non-dissolvable microneedles coated by a layer of
aqueous solution incorporating the relevant bioactive cargo. Coated microneedles have been fabri-
cated from a number of materials, including silicon [54]; many metals, such as stainless steel [35] and
titanium [55]; non-dissolvable polymers (e.g., a copolymer of methylvinyl/ether and maleic anhydride
(PMVE/MA) [56], poly-L-lactic acid (PLA) [45], and polymethylmethacrylate (PMMA) [57]); and
ceramics [58]. Despite promising results obtained using those materials, materials with better inert-
ness and biocompatibility are still needed to implement clinically relevant MNA designs. To elabo-
rate, since the coated MNAs utilize non-dissolvable microneedles, it is imperative that the needles
remain fully intact during the insertion and removal to prevent any complications that can arise from
material residue left in the skin. Biocompatibility of the structural material and coating formulation
is also critical to avert any adverse immunologic or toxic effects arising from the dissolution of the
coating layer.
In general, the coating formulations should account for the following considerations:
(1) Controlled spreading of the coating solution onto the microneedles to obtain uniform coating of
the microneedle surfaces. Specifically, the increased viscosity and reduced contact angle between the
aqueous coating solution and the microneedle surfaces can improve the wetting and, in turn,
the coating performance. (2) The coating formulation should be water-soluble to enable the coating
process and to ensure rapid and complete dissolution of the coating in the skin microenvironment.
(3) The mechanical strength of the dried coating on the needle surfaces should be sufficient to keep
the coating adhered to them during insertion. (4) The coating solution should be biologically safe,
and formulated such that the activity of the biocargo is maintained during both drying and storage
[6, 49]. The water-soluble solution of the biocargo is often formulated at a sufficiently high viscosity
to enable better retention on the microneedle surfaces during drying [6, 49]. To further improve the
coating performance, surfactants that facilitate enhanced wetting of the surface may be used [49].
Stabilizing polymers may be added to the coating formulation to protect the biocargo during both
drying and storage [6].
To formulate an effective coating with a broad range of bioactive cargoes, a myriad of water-soluble
biomaterials have been used [6, 49]. The most commonly used biodissolvable polymers include car-
boxymethylcellulose (CMC) [35], sucrose [49], sodium alginate [49], hyaluronic acid (HA) [49], glyc-
erol [49], poly(lactic-co-glycolic acid) (PLGA) [49], and polyvinylpyrrolidone (PVP) [49]. To further
improve the coating performance, surfactants, such as Poloxamer 188 [41], Lutrol F-68 NF [35], and
Quil-A [41] have been used. In addition, stabilizers, such as trehalose, sucrose, glucose, and dextrans
have been used to maintain the biological activity of the drugs during the coating process and sub-
sequent storage [6, 48, 59]. The same stabilizing agents can be added to the materials of dissolvable
materials [60].
3.4.2 Materials for Dissolvable MNAs

Dissolvable MNAs are specifically designed to completely dissolve in the skin, thereby leaving no bio-
hazardous waste or sharps after use. Most dissolving microneedles in the literature need to remain in
skin for at least 5 min to fully dissolve. If controlled-release performance is desired, biodegradable
polymer microneedles might be designed to achieve a defined dissolution profile and remain in the skin
for extended periods (e.g., days). As a general rule, dissolvable MNAs should be fabricated from biologi-
cally safe [69], water-soluble materials that will dissolve in the skin after insertion. While dissolving
microneedles might be used as a skin pretreatment to increase permeability, drugs are often encapsu-
lated inside the needle for release into the skin similarly to coated microneedles.
Biodissolvable and biodegradable MNAs that incorporate the bioactive cargo have been fabricated
using hybrid techniques for a range of biocompatible polymers (singly or in combination), including poly-
L-lactic acid (PLA) [61, 62], poly-glycolic acid (PGA) [61], poly-lactic-co-glycolic acid (PLGA) [14, 61],
poly(vinylpyrrolidone) (PVP) [20, 26], poly(vinyl) alcohol (PVA) [19], CMC [21, 26, 31], and silk [63], as
well as sugars, including galactose [64], dextrin [64], and maltose [26].
FIGURE 3.7 Microneedle administration to living rats: (a) A microneedle array placed on living rat skin; (b) Thumb
insertion; and (c) Device-assisted application [The Ozdoganlar group at Carnegie Mellon University, unpublished].
3.5 MNA Administration Methods

A critical step toward enabling clinical adaptation of MNA-based trans/intradermal delivery systems is
to ensure that each administration of MNAs precisely delivers the required dose in a minimally invasive
manner. Therefore, MNAs should be capable of piercing the SC layer of skin with minimal force and
obtaining the desired penetration depths in a reproducible manner. However, inherent elasticity and com-
plex topography of skin, combined with the micron-scale-size microneedles, pose challenges for precise
and reproducible delivery using MNAs (Figure 3.7a).
Unlike the conventional transdermal patches, MNAs require an external force to facilitate effective and
reproducible penetration of microneedles into the skin [21, 65]. This external force can be provided either by
a manual application method (i.e., thumb insertion, Figure 3.7b) or by using an external application device
(i.e., an applicator, Figure 3.7c). Although it has been demonstrated that long microneedles with sharp tips
can be manually inserted into skin, obtaining uniform insertion forces, achieving consistent penetration
depths is very challenging [50, 65]. On the other hand, an applicator can control the insertion speed (and thus,
the insertion force), thereby enabling reproducible penetration into the skin [53, 65]. For this reason, applica-
tors are preferred over manual application. The devices can be for either single or multiple use.
A few studies have highlighted the necessity of an applicator. Crichton et al. [66] showed that, by varying
the application speed of coated microneedles, the piercing depth and the delivered dose can be increased.
Applicators are especially needed for high-density, short MNAs with blunt microneedles to ensure a suf-
ficient penetration depth [23, 27]. Verbaan et al. [27] showed that although manual application failed to
enable 300-μm-long microneedles to pierce the skin, such needles successfully and reproducibly pierced
the skin when an external applicator was used. Increasing the applicator speed commonly improves pene-
tration (i.e., enables a larger needle portion to penetrate). However, beyond a certain speed, applicators may
increase the chance of damage to the dermal and/or subdermal tissues. Therefore, an optimal penetration
speed should be identified for a given microneedle and array geometry and skin properties.
When designing applicator devices for clinical use, a number of design criteria should be met. Since
a major benefit of MNAs is to improve patient compliance by eliminating pain, the use of the applicator
should be pain-free. Furthermore, the applicator should enable more reproducible and controlled adminis-
tration of MNAs without increasing the risk of mechanical failure of MNAs. Considering the wide range of
microneedle designs and skin conditions, advancing the applicator designs and identifying optimal penetra-
tion conditions through microneedle insertion studies are critical for the clinical adaptation of MNAs.
3.6 Conclusions and Outlook

Microneedle-based drug delivery systems, which are enabled by recent advances in microfabrication
technologies, could bring exciting advances to transdermal drug delivery. Microneedle arrays with
coated or dissolvable needles are among the most popular microneedle concepts developed in recent
years, and pharmaceutical companies have shown a great interest in these technologies. However, the
true potential of coated or dissolvable MNA-based drug delivery has yet to be achieved due to consider-
able challenges in design, manufacturing, and administration of MNAs. Many design, manufacturing,
and administration requirements must be addressed to create clinically applicable MNA-based transder-
mal drug delivery systems.
This chapter presented an overview on the design, fabrication, and administration of the coated and
dissolvable MNAs. The design (i.e., both the geometry and the material) of the needles controls their
skin penetration and biocargo delivery performance. The material also affects the bioactivity and lon-
gevity of the biocargo incorporated into or onto the needles. Further studies are needed to identify opti-
mal geometries and materials for achieving clinically applicable and reproducible delivery of a broad
range of therapeutics and vaccines using MNAs.
The fabrication technique used for creating the MNAs dictates both the attainable geometries and
the utilizable materials for the MNAs. To be effective, a manufacturing technique should be capable of
reproducibly creating MNAs with diverse geometries and from a myriad of biomaterials. In addition, the
scalability of the fabrication technique directly affects the cost of the microneedle-based drug delivery
systems. Moreover, manufacturing conditions could have a strong influence on the stability and viability
of the drugs when they are coated onto or integrated within the MNAs. Therefore, development of scal-
able, controllable, and cost-effective approaches for MNA manufacturing is fundamental to realizing
further advances in MNA-based delivery systems toward their clinical deployment.
Successful MNA administration entails piercing of the SC and achieving the desired penetration
depths in a reproducible manner. To this end, the application method, including manual or device-
assisted approaches, plays a critical role. Further research is needed for identifying application methods
and associated conditions for satisfactory administration of MNAs. When addressing these objectives,
the skin properties, which may vary throughout the body and change from person to person, should also
be considered.
Taken together, MNAs show great promise of significantly advancing the existing administration
techniques for transdermal and intradermal delivery of biocargoes, and of bringing exciting new thera-
pies and immunization strategies. However, further research into MNA design, manufacturing, materi-
als, and administration is needed for realizing clinically applicable MNA-based drug delivery systems.
Effectively addressing those aspects are also prerequisites to regulatory approval of MNAs by various
government agencies.
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4
Hollow Microneedles
Iman Mansoor1, Boris Stoeber1,2

1 Department of Electrical and Computer Engineering
The University of British Columbia

2 Department of Mechanical Engineering
The University of British Columbia
4.1 Introduction
Hollow microneedles are much smaller in size but otherwise similar to the conventional needles that
have been used with syringes since the 1850s. There are several key differences compared to other
microneedles discussed in this book. The hollow lumen with typical inner diameters smaller than 100 µm
represents the main challenge to the manufacturing of hollow microneedles. In principle, injectable drugs
do not require reformulation for injection through hollow microneedles, given that hollow microneedles
provide a conduit for injecting fluids into the body similar to that of conventional hollow needles, pro-
viding a relatively simple regulatory path. In addition to fluid injection into the body, several sensing
concepts have been developed based on hollow microneedles; these will be discussed in Chapter 8. Here
we will focus on the general characteristics of hollow microneedles.
4.2 Fabrication Technology for Hollow Microneedles

Hollow microneedles are fabricated using microelectromechanical systems (MEMS) technology.
Fabrication typically starts from a flat substrate such as a silicon or glass wafer using tools originally
developed for the integrated circuit (IC) industry and additional more specialized tools. This suggests
that hollow microneedles can benefit from the scalability of the underlying technology; however, the long
duration of some process steps performed on investment-intensive equipment can be challenging. Unlike
IC devices, whose feature sizes keep shrinking leading to shorter process steps, hollow microneedles
require large feature sizes due to their application-specific requirements.
The manufacturing strategies for hollow microneedles depend strongly on the orientation of the needle
shaft with respect to the substrate plane. It is therefore common practice to classify microneedles with
respect to their shaft orientation: that is, as in-plane when the shaft orientation is parallel to the substrate
plane and as out-of-plane in the case of a shaft perpendicular to the substrate plane.
4.2.1 In-Plane Microneedles

The earliest hollow microneedles developed in the early 1990s were in-plane designs based on sili-
con developed using MEMS technology available at that time. Surface micromachining had recently
been developed, in which the successive deposition and patterning of thin films of metals, dielectrics,
and semiconductors and the removal of so-called sacrificial layers results in microstructures that reside
in near proximity of the substrate surface. A technique introduced in the late 1960s used for “bulk-
micromachining” takes advantage of the crystal structure of single-crystal silicon wafers through aniso-
tropic etching using etchants such as potassium hydroxide (KOH). The direction-dependent etch rate
results in structures defined by particular crystal planes.
35
Several approaches used silicon as the supporting substrate and provided the flow channel on top or
within the silicon substrate. Lin et al. (1) used a combination of surface micromachining and anisotropic
silicon wet etching to form single microneedles with a shaft length between 1 and 6 mm. The enclosed
flow channel was 9 µm high and 30–50 µm wide. The needles were 70 µm thick and 80–140 µm wide.
Paik et al. (2) used a buried-channel technology in which they etched narrow trenches into a silicon sub-
strate, passivated the trench walls, and then etched the channel starting from the trench bottom. A con-
formally deposited polysilicon layer closed off the trench, followed by a front-side deep reactive ion etch
(DRIE) step to define the needle shape and a back-side DRIE etch to thin the substrate; DRIE permits
etching straight into a silicon substrate, forming trenches with vertical side walls. Their microneedles
had a 100-µm-wide, 100-µm-thick, and 2-mm-long shaft with a microchannel diameter of 20 µm. Lee
et al. (3) developed a fabrication technology based on a combination of DRIE vertically into silicon and
glass bonding and reflow to provide a channel cover. They formed microneedles up to 5.3 mm in length
and 70 µm wide and 40 µm in thickness. These extremely slender and long microneedles were intended
for precise fluid injection into brain tissue. Lee et al. (4) developed a fabrication process for microma-
chining microdialysis probes. A length of 4 mm of their 180-µm-wide and 45-µm-thick silicon probe
was covered with a 5-µm-thick polysilicon membrane with 60–80-nm-wide straight pores etched into it.
The probe contained a 30-µm-deep and 60-µm-wide U-shaped channel.
Other approaches based on surface micromachining were developed by Brazzle et al. (5) and Takeuchi
et al. (6), both forming needle structures around sacrificial photoresist. Brazzle et al. used electroform-
ing of nickel to fabricate microneedles on sacrificial photoresist layers patterned on a silicon membrane.
The microneedle structures were 2 mm long with an inner channel of approximately 30 µm in width and
20 µm in height, and outer dimensions of approximately 80 µm in width and 60 µm in height. Fabrication
of polymer in-plane microneedle neural probes was demonstrated by Takeuchi et al. A flexible needle-
like probe was formed by deposition of parylene beneath and on top of a sacrificial photoresist layer cor-
responding to the inner channel. The resulting probes were several millimeters long with 200-µm-wide
inner channels. As the high flexibility of the parylene structure did not allow penetration into the tissue,
the authors proposed filling the needle channels with polyethylene glycol (PEG) temporarily prior to
tissue penetration, to improve its rigidity. Stupar and Pisano (7) formed similar parylene microneedles
around sacrificial silicon. The outline of a microneedle structure was first patterned, in the in-plane
direction, through a thin silicon wafer using DRIE. A thick parylene layer was then vapor-deposited
as the structural layer. The sacrificial silicon was then etched using KOH to create the hollow parylene
microneedles. By partially etching the silicon, stiffer microneedles were made containing parylene
shafts and single-crystal silicon tips. The resulting microneedles were able to endure very large deflec-
tion angles of up to 180°. A 2.65-mm-long microneedle with a width of 240 μm and wall thickness of
20 μm was measured to have a bending stiffness of 63.5 N/m.
Lippmann et al. (8) demonstrated a different approach for manufacturing polymeric microneedles
involving a combination of injection molding and investment casting performed at micron scale. After
placement of investment wires into silicon micromachined inserts, the inserts were put into an injection
mold assembly. Polymer was then injected into the insert cavity to create needle-like structures. After
releasing the molded structures from the assembly, the hollow core of the needles was formed by dis-
solving the investment wires. Using this process, needles with rectangular cross-sections of 130 µm ×
100 µm were created with lengths of 280 µm and an inner diameter of 35 µm. Tapered needles were also
created with triangular cross-sections, with two sides of 105 µm in width and one of 150 µm; they had a
base-to-tip length of 300 µm and the same inner diameter of 35 µm.
Talbot and Pisano (9) and Zahn et al. (10) developed a molding technique for polysilicon microneedles.
They etched a mold straight into a silicon wafer using DRIE. Through holes were etched from the back-
side using KOH. They then deposited phosphosilicate glass onto this wafer and onto a blank silicon
wafer. Both wafers were pressure-bonded together at 1000°C. During the deposition of 15–20 µm of
polysilicon, the polysilicon entered the mold by the through holes and deposited on the inside wall of the
mold and on the outside. After removal of the polysilicon from the outside using reactive ion etching, a
release etch in concentrated hydrofluoric acid removed the phosphosilicate glass, separated the two mold
wafers, and freed the polysilicon needle structures from the mold. The needles had a thickness of 110 µm,
a width of 160 µm, a wall thickness of 15–20 µm, and a typical length of 4.5 mm.
Hollow Microneedles 37
4.2.2 Out-of-Plane Microneedles

Out-of-plane microneedles with their shafts perpendicular to the base substrate plane allow for two-
dimensional arrangements; they can therefore cover a larger tissue area than in-plane microneedle designs,
which can be advantageous for particular applications. Out-of-plane microneedles are in general formed
either through subtractive manufacturing such as bulk micromachining of silicon or through additive
manufacturing including thin film processing and molding of metals, polymers, ceramics, or polycrystal-
line silicon. In subtractive manufacturing, the needle lumen is etched into the substrate; in additive manu-
facturing, the hollow core emerges as material is deposited around a temporary core structure.
4.2.2.1 Silicon Out-of-Plane Microneedles

Fabrication methods for hollow silicon microneedles have first been presented in 2000 (11), not long after
DRIE was introduced as a new micromachining process. DRIE permits etching straight into silicon,
enabling the formation of channels through a silicon wafer that can form the inner lumens of micronee-
dles; the outer shape of these needles can be achieved through a variety of etching processes that remove
the silicon such that only the silicon forming the needles remains along with a backing plate connecting
the needles of an array. Figure 4.1 shows schematics of representative fabrication processes for hollow
silicon microneedles. In all cases, the needle lumen is formed using DRIE before machining the outer
FIGURE 4.1 Schematic of the fabrication processes of hollow silicon microneedles, based on data in (a) ref. (13),
(b) ref. (14), (c) ref. (16), (d) ref. (17), and (e) ref. (18).
shape of the needles. The needle shape can be created through a combination of isotropic dry etching
and DRIE as shown in Figure 4.1a (12, 13) and Figure 4.1b (14, 15); through anisotropic etching taking
advantage of the crystalline structure of silicon as shown in Figure 4.1c (16) and 4.1d (17); or through a
dicing saw followed by a wet etching process as shown in Figure 4.1e (18).
All the silicon out-of-plane microneedle designs offer the possibility of a side opening where a sharp
needle tip initiates penetration into the target tissue. In addition, the design by Griss and Stemme (14)
positions the tip above the lumen with lumen openings on rather vertical areas of the needle shaft. This
design, which extends the needle length significantly, was intended to prevent coring – that is, the cre-
ation of a tissue plug during insertion, thought to be an issue in other designs.
4.2.2.2 Polymer Out-of-Plane Microneedles

Polymers are attractive materials for microneedle fabrication due to their low material and processing
cost. However, their lower strength compared to silicon and metals imposes limitations on the needle
size. To achieve a strength comparable to that of metal or silicon microneedles, polymer microneedles
require a much greater wall thickness, which often results in devices substantially larger and with a
smaller aspect ratio than other microneedle types.
Plastic injection molding has also been used to manufacture polymer microneedles. The limitations of
computer numerical control (CNC) machining in creating high-aspect-ratio cavities, and the difficulties
of injecting molten plastic through narrow cavities without degradation, lead to constraints on the size
of the manufactured needles.
An example of the result of plastic injection molding is presented by Yung et al. (19). These
microneedles have lengths of 500 µm and tip diameters of 110 µm. However, despite performance of
a preliminary penetration experiment into pig skin samples, sufficient strength of these structures has
not been demonstrated in clinical applications or through bench testing. The Hollow Microstructured
Transdermal System (hMTS) by 3M (St. Paul, MN, US) is another example of an injection-molded
microneedle device consisting of arrays of 500–900 µm microstructures with 10–40 µm lumen
diameters.
Other methods for fabricating polymer microneedles have been proposed. Moon et al. (20, 21)
used a process involving two successive inclined photoresist exposure steps to fabricate polymer
tetrahedral-shaped microneedles with heights in the range 750–1000 µm and lumen diameters of
190–400 µm. The resulting devices have sharp tips but are limited in aspect ratio and array spac-
ing. Huang and Fu (22) proposed a process for making polymer microneedles involving a patterned
polydimethylsiloxane (PDMS) base layer on a patterned glass assembly, followed by forming needle
structures on the PDMS layer from photo-patternable SU-8 epoxy through photolithography. The
resulting needles were 200 µm high; however, their mechanical strength for reliable skin penetration
has not been demonstrated.
A scalable method for producing polymer microneedles presented by Mansoor et al. (23) is shown in
Figure 4.2. This method involves deposition of a thin polydimethylsiloxane (PDMS) layer onto a mold
containing a number of vertical posts, followed by deposition of the microneedle structural polymer
layer using solvent casting. Prior to the casting of the microneedle structural layer, a plasma treatment
step was used to ensure better wetting and adhesion of the microneedle structural layer to the PDMS
substrate. Separation of the array was performed by mechanical force. Opening of the tips was achieved
by a plasma etching step prior to separation from the mold, which removed the structural polymer from
the tip because the structural layer is thin in that region.
Using this process, polyimide microneedles with 2 wt% clay reinforcement were fabricated. The nee-
dles were 280 µm tall, and had tip and base diameters of 65 µm and 115 µm, respectively. The strength
of the structures was evaluated under axial compressive loading with a failure load of about 0.17 N.
Another example of a ceramic-reinforced polymer microneedle was presented by Ovsianikov et al.
(24) who used an optical two-photon polymerization system to manufacture 3D cross-linked structures
from an organically modified ceramic hybrid material (Ormocer®). Hollow microneedles with 800 µm
height and base diameters in the range 150–300 µm were manufactured. The resulting devices were
shown to be capable of puncturing porcine adipose tissue.
FIGURE 4.2 Method for forming hollow polymeric microneedles involving solvent casting on a reusable mold (based
on data in ref. (23)).
4.2.2.3 Metal Out-of-Plane Microneedles

Hollow metallic microneedles offer several advantages over silicon or polymeric microneedles in terms
of fabrication costs and mechanical strength. The most common fabrication technique involves electro-
deposition of metal onto a mold that is later either removed through etching or dissolving in a solvent or
separated from the metallic layer.
Figure 4.3 shows some reported MEMS-based fabrication processes that commonly involve creating
cone-shaped high-aspect-ratio post structures extending from a planar surface, and then using them as
template for subsequent metal electrodeposition. In these processes, the length and diameter of the post
structures control the needle length and lumen size, respectively. The duration of the electrodeposition
step determines the thickness of the structural metal layer, which impacts robustness of the needle shaft.
Several such processes for metal microneedles made using electrodeposition have been developed that
differ in their approach to create the conductive seed layer required for electroplating, the method used
to separate the microneedles from the template, and the method for achieving open needle tips. These
processes allow microneedles to be manufactured in a wide range of dimensions. Outer diameters rang-
ing from 30 µm to 125 µm (at the tip) and lengths ranging from 200 µm to 1800 µm have been reported.
FIGURE 4.3 Methods for forming metal microneedles around posts that (a) and (b) are being dissolved to release the
needles or (c) can be reused for subsequent fabrication processes (a, based on data from ref. (25); b, based on data from refs
(26 and 27); c, based on data from ref. (29)).
After creating template structures from the negative photoresist SU-8 using photolithography, Kim
et al. (25) deposited a Cr-Cu seed metal layer using sputter deposition followed by electroplating of
the structural nickel layer (Figure 4.3a). Next, another SU-8 layer was added that embedded the metal
layer. This temporary support structure facilitated mechanical polishing of the microneedle tips to open
them up. Finally, dry etching of the SU-8 layers was achieved using O2/CF4 plasma, yielding arrays of
hollow metal microneedles. Li et al. (26) used SU-8 drawing lithography to create tall mold structures
(Figure 4.3b). After depositing a silver seed layer, nickel was electroplated to form microneedles. The
tip of the microneedle was removed through laser cutting, followed by dissolving the SU-8 template in
a liquid solvent. Lee et al. (27) used a similar method, but instead of laser cutting the tips, they used
a non-conductive masking layer to coat the top of the conductive seed layer prior to plating, to prevent
metal electroplating in this area and to ensure that the tips of the final device are open. Another method
by Kobayashi and Suzuki (28) created a microneedle by plating on a conductive wire protruding from a
base substrate, and the opened tip of the microneedle was achieved by adding a protective mask to the
tip of the wire prior to plating; the wire was then dissolved leaving the plated metal shell as the needle
structure. Another approach, shown in Figure 4.3c, by Mansoor et al. (29) used solvent casting to coat an
array of SU-8 pillars with a polymer-based conductive sacrificial layer. A plasma etching step was then
used to selectively etch the solvent cast coating covering the tip of the SU-8 pillars. After electroplating
nickel onto the conductive coating, the microneedle array was separated by dissolving the conductive
coating. The SU-8 mold could then be reused for repeated manufacturing of microneedles.
Norman et al. (30) used multiple replica molding steps to create sacrificial replicas of a master mold
containing a cone-shaped pillar structure with a laser-ablated cavity at the tip. After sputtering a seed
layer onto the sacrificial molds, metal was electrodeposited to form microneedles. As the metal did not
coat the deep cavities at the tip, the resulting structures were open at the tip. Microneedles with inner tip
diameters of 20 µm and lengths of 1100 µm were fabricated with this method.
Using silicon as sacrificial substrate in metal microneedle fabrication was demonstrated by McAllister
et al. (31) and Shikida et al. (32). Shikida et al. fabricated silicon structures with hourglass-like shapes
by a combination of dicing and anisotropic etching steps. Next a Cr-Au seed layer was deposited on the
structures. During this step, the top surface of the hourglass-shaped structures acted as shadow mask
preventing metal deposition on side walls of the upper portion of the structures. Nickel was then elec-
troplated to fabricate the microneedle structural layer, and the silicon etched away using anisotropic
etching. Microneedles of various tip-opening shapes were made with heights ranging from 120 µm to
250 µm.
A number of previous studies have formed metallic microneedles on negative molds containing a
cavity on which metal is plated. An overview of such a process is shown in Figure 4.4. McAllister et al.
(31) used solid silicon microneedles (formed by anisotropic SF6/O2 plasma etching of silicon) as a master
to form metallic microneedles using a polymeric mold. After deposition of SU-8 epoxy on the sili-
con structures, a plasma etching step was used to expose their tips. The silicon structures were then
selectively removed by SF6 plasma or HNO3/HF solution, leaving an SU-8 epoxy mold as a negative of
the microneedles. After deposition of a seed layer, a NiFe layer was deposited onto the mold to form
microneedles. Arrays of 20 × 20 were made with 150 µm spacing. The needles were 150 µm in height
with a base diameter of 80 µm and a tip diameter of 10 µm. Davis et al. (33) drilled holes through a
polymer substrate using a laser. The substrate was then coated by a conductive seed layer followed by
electroplating of a nickel layer to form the needles. Next, the polymer substrate was selectively etched
leaving the microneedles behind. As the laser-drilled holes were through holes, the resulting devices
were open at the tip. Microneedles with heights of 50–1000 µm and diameters of 50–400 µm have been
manufactured.
Examples of metallic microneedles made through conventional machining techniques have also
been reported (i.e., Micropoint Technologies Hollow Microneedle Hub or Becton Dickinson Soluvia
FIGURE 4.4 Formation of metal microneedles by metal electrodeposition onto the surface of a laser-drilled through hole.
Microinjection System). Machined microneedles are large in size due to the limitations of the conven-
tional machining tools. The typical lengths are 1–1.5 mm with diameters comparable to those of conven-
tional 31 or 32G hypodermic needles. Due to these lengths, liquid injection occurs in deeper skin layers
or in subcutaneous tissue.
4.2.2.4 Silica and Ceramic Microneedles

Similar to silicon microneedles, devices made from silicon dioxide (SiO2) or ceramics are brittle and thus
prone to fracture inside the skin during application.
One common manufacturing method for SiO2 microneedles uses a combination of etching into the
bulk of the silicon substrate followed by a thermal oxidation step to grow a silicon dioxide layer that will
later form the needle upon subsequent etching of the initial silicon mold. The same process limitations
as for silicon needles also apply to SiO2 needles. In addition, the SiO2 needles are much more brittle than
silicon needles since the thickness of the oxide layer is limited resulting in fragile structures. Khanna
et al. (34) used masking steps and DRIE to create deep channels, which were later coated with SiO2
through thermal oxidation. Similarly, through a combination of DRIE and selective vapor-liquid-solid
growth, Takei et al. (35) created a mold for subsequent SiO2 deposition. Another process presented by
Rodriguez et al. (36) used a similar approach involving multiple silicon substrate etching steps using
tetramethylammonium hydroxide (TMAH) to create deep high-aspect-ratio channels. After growing an
oxide layer on the channel surfaces, buffered HF etching was used to partially remove the oxide layer to
open the needle tips. Another approach has been presented by Rajaraman and Henderson (37) in which
a coherent porous silicon (CPS) etching technology is used to fabricate deep channels that are then used
to grow a structural oxide layer. Strambini et al. (38) used back-side illumination electrochemical etch-
ing (BIEE) to create deep channels in a silicon substrate on which an oxide layer was then formed. In all
these techniques, a process step involves etching of a silicon substrate mold to reveal the oxide structures.
4.3 Mechanical Strength

Microneedle strength is important to avoid breakage during insertion or handling. Many microneedles
have therefore been tested for buckling strength through axial loading and also for shear or bending
breakage due to lateral loads.
Talbot et al. (10) applied a lateral force to their 4.5-mm-long polysilicon microneedles and observed
failure at around 56 mN. The failure load almost doubled for needles that were coated with a 10-µm-
thick layer of platinum or nickel. Paik et al. (2) found that their 2-mm-long silicon needles had a buckling
strength of 3.06 N to 6.28 N depending on the particular shaft design, while the tapered tips broke at loads
between 146 mN and 276 mN. The maximum average bending load of these needles was 124 mN. The
needles were sufficiently strong for insertion into rabbit ear skin. Khanna et al. (39) determined the axial
and shear fracture strength of 200-μm-tall silicon microneedles that had outer diameters from 100 μm
to 200 μm with a wall thickness of 35–50 μm. The needles with 100 µm outer diameter collapsed under
7.4 N of axial load. The shear fracture strength increased from 0.36 N to 2.75 N when increasing the
needle diameter from 100 μm to 200 µm. In all three cases, failure occurred near the fracture strength
of silicon around 700 MPa.
Khanna et al. (34) evaluated the strength of silicon dioxide microneedles with circular and square tip
shapes, formed through silicon thermal oxidation, by measuring the axial and shear fracture strength of
the devices. The axial fracture strength of these microneedles was 30 mN for a circular tip and 20 mN for
a square tip. The shear fracture strength of these microneedles were 22 mN for a circular tip and 6 mN
for a square tip.
Mansoor et al. (23) reported a strength of 320 mN, under axial loading, for clay-reinforced polyimide
microneedles formed through solvent casting. The strength was shown to be sufficient for insertion of
microneedles into excised rabbit ear skin.
Li et al. (26) measured the axial fracture load of 1.8-mm microneedles made from nickel and com-
pared that with the force required to penetrate a polyurethane skin model. The measurements were
performed on microneedles with bevel angles of 15° and 90° (with respect to the axial direction). The
skin penetration forces were measured to be 1.63 ± 0.07 Ν and 0.83 ± 0.05 Ν and the fracture forces 5.97 ±
0.14 Ν and 5.85 ± 0.25 Ν for 15° and 90° bevel angles, respectively. Lee et al. (27) compared axial frac-
ture forces of nickel microneedles of different lengths. The axial load fracture force of a microneedle
with 10-µm wall thickness was 1 ± 0.13 N for a 600-µm length, 0.28 ± 0.4N for a 1200-µm length, and
below 0.1 N for a 1800-µm length. Increasing the wall thickness of an 1800-µm-long microneedle to 20
or 30 µm increased the fracture force to 0.34 ± 0.18 N and 3.16 ± 0.09 N, respectively. Mansoor et al.
(29) measured the fracture force of 500-µm-tall nickel microneedles with tip lumen diameter of 40 µm
and tip wall thickness of 15 µm to be 4.2 ± 0.61 N under axial loading. Another study by Davis et al. (40)
showed a similar fracture force under axial loading for 500-µm-tall metallic nickel microneedles, and
also showed that the fracture force is insensitive to tip radius for radii ranging from 40 µm to 65 µm, and
the fracture force increases significantly with wall thickness from 4 µm to 15 µm and slightly with wall
angle from 60° to 70°. Kim et al. (25) presented an analytical solution for critical buckling of tapered
metallic nickel microneedles, indicating a high sensitivity of the critical buckling force with respect to
the height of the microneedles, and showing that the critical buckling force drops as the height increases.
A direct comparison of the strength of the different microneedles is difficult because of their different
geometries and dimensions. However, if one assumes that considerations for strength were included in
the needle designs and the designs tested were reasonably manufacturable, one can make the following
observations: polymer microneedles are the least robust. Microneedles made from brittle silicon or sili-
con dioxide show very low shear fracture strength and their tapered tip breaks easily under axial load.
The tested silicon and nickel microneedles show a comparable axial robustness, while the tested silicon
structures had mechanically more favorable dimensions. When metal needles collapse under axial load,
they mainly bend without pieces breaking off, while silicon needles disintegrate. The ductility of the
metal therefore reduces the possibility of pieces breaking off in the skin during application under exces-
sive loading. As a result, they are less likely to remain partially in the tissue, which could be a concern
for other materials.
4.4 Needle Integration

Integration methods of hollow microneedle arrays with secondary systems have to take the micronee-
dle material and the intended application into consideration. In intradermal drug delivery systems, the
high liquid pressures involved in intradermal injection (41) settings requires a strong seal between the
microneedle arrays and the supporting structures. For silicon, due to its brittleness, the most common
integration method for this application is adhesive bonding of the array to a rigid backing such as brass
(14) or plastic (13, 42) that provides a support for the majority of the backing plate. In addition, there
exist several direct bonding methods for silicon. The irreversible chemical bonding of plasma surface-
activated PDMS and silicon has been used to bond a chip with a row of in-plane silicon needles to a
PDMS channel system (2) or to generate an integrated MEMS syringe (43); however, the flexibility of
PDMS and the large unsupported area above the fluid reservoir make this silicon-needle-based MEMS
syringe very fragile. Anodic bonding forms an irreversible bond between silicon and Pyrex™ and has
been used to integrate an array of silicon microneedles with a channel system etched into the back side
of the needle backing with a Pyrex™ chip for fluid extraction (18).
Roxhed et al. (15) fabricated silicon microneedles coated with a thin (170–470 nm) layer of gold that
also covered the needle opening. This seal was supposed to prevent liquid leakage before needle inser-
tion into tissue. The 170-nm-thick gold membranes were shown to burst at a pressure of 120 kPa, by
electrochemical means within 2 min, or through full needle insertion into human skin in vivo.
Rodrigues et al. (36) bonded silicon dioxide microneedles to a glass support and then by means of an
epoxy connected the assembly to a flexible tube ending in a syringe. The fixture, though, was not tested
under any high-pressure application to assess the strength of the bonding.
Takei et al. (35) used resin to integrate a silicon dioxide microneedle device, formed on silicon sub-
strate, to a flexible tube connected to a syringe. The setup was then used to deliver DI water to a rat model
using a pressure of about 40 kPa.
Plastic and metallic microneedles have mostly been integrated with polymer support structures using adhe-
sives and sealing materials. For example, Mansoor et al. (23) used adhesives to bond polymeric microneedle
to a plastic Luer fitting that attached to a syringe. Kobayashi et al. (28) integrated a metallic microneedle
into a sampling system by using silicone rubber at the base of the microneedle structure to provide a seal.
4.5 Insertion Methods

The shape of microneedles plays a significant role in the insertion process, in particular for the required
insertion force. Roxhed et al. (44) required 10 mN per needle to insert an array or 25 silicon micronee-
dles with a sharp tip (tip radius below 100 nm) into human skin in vivo. Khanna et al. (45) used silicon
microneedles that were sharpened to different degrees by reducing the width of the ring-shaped tip area.
For slow insertion into skin tissue, the insertion force for a 4 × 4 microneedle array dropped from 4.80 N
to 0.11 N when reducing the ring area per needle from 11,100 μm2 to 186 μm2. Davis et al. (33) deter-
mined that the average force required to insert a 500-µm-long metallic microneedle, with tip diameter
of 75 µm, into human skin is approximately 0.2 N. In another work, Davis et al. (40) presents a theo-
retical model that describes the insertion force of the microneedles (with flat tips) as a function of the
needle tip area. The model assumes a linear relationship between the insertion force and the needle tip
area. Further experimental work done with microneedles of various tip areas (ranging from 2500 µm2
to 20000 µm2) showed results consistent with the theoretical prediction. Li et al. (26) reported that the
average force required for skin penetration by 1800-µm-long metallic microneedles with bevel angles of
90° and 15° (with respect to the axial direction) was 1.63 ± 0.07 Ν and 0.83 ± 0.05 Ν, respectively; the
outer diameter of the microneedles was 120 µm. Khanna et al. (34) measured the forces of penetration
for silicon dioxide microneedles into cadaver human skin. An array of 15 × 15 needles with 1000 µm
pitch penetrated the skin samples at about 20 mN. The microneedles were circular in lumen shape, with
20 µm outer diameter and 100–120 µm height. Stupar and Pisano (7) demonstrated the penetration of
in-plane hollow parylene microneedles into a gelatin membrane. The force required for penetration was
measured at 0.45 N, for 4.5-mm-long, 200-µm-wide needles with 50-µm wall thicknesses.
Verbaan et al. (46) produced 4 × 4 arrays of 300–900-μm-long needles made from commercially available
30G hypodermic needles, and showed that needles of 550 μm length or longer can be manually inserted into
excised human skin, while manual insertion of 300-μm-long needles fails. Several researchers have devel-
oped insertion devices that impart a high velocity onto the needles facilitating tissue penetration. Verbaan
et al. (47) applied arrays of 16–81 245-μm-long silicon microneedles made according to Gardeniers et al.
(16) to excised human skin. Their electric applicator inserted the needles at 1 m/s or 3 m/s into skin while
manual application resulted in only slight piercing of the skin. The depth of nanoparticles deposited follow-
ing insertion was identical for 1 m/s and 3 m/s, while molecular diffusion through the insertion openings in
the skin was slightly higher for the higher velocity. Van der Maaden et al. (48) used an applicator to insert
microneedles, made from fused silica capillaries with an outer diameter of 375 µm, into human skin at a
speed of 1 m/s. Chua et al. (49) applied arrays of about 260 silicon microneedles of 325–350-µm length to
human skin at an impact velocity of 10 m/s. The array of needles that were tapered along the entire shaft
at an angle of about 10° caused mainly mode-I cracks where the needles wedged open the cracks as they
advanced. The array of more blunt needles resulted mainly in mode-II cracks where circular regions of tissue
propagate ahead of the needles. They used both arrays for a glucose sensing application and noticed that the
signal collected with the array of blunt needles was weaker than the signal from the more pointed needles,
indicating a slight obstruction of the blunt needles related to mode-II crack formation.
4.6 Conclusions
A wide variety of hollow microneedle designs have been developed that differ in geometry, manufactur-
ing method, and materials. Many of the manufacturing methods described in this chapter are suitable
for large-scale manufacturing, while some will not go beyond lab scale. In-plane designs are particularly
advantageous for integrating electrodes and flow control elements, while out-of-plane designs can be used
for larger arrays, and they allow more convenient integration with large-scale flow control systems. The
low rigidity of polymers makes it challenging to produce polymeric microneedles with small dimensions
that are capable of penetrating the stratum corneum. Silicon, silicon dioxide, and metals are sufficiently
rigid, but manufacturing silicon dioxide structures with significant wall thicknesses is challenging; both
silicon and silicon dioxide are brittle and risk breaking under shear forces, and microneedles made from
these materials are therefore more difficult to integrate than metal microneedles. These considerations
should guide the choice of a particular design for a given application.
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5
Microneedles vs. Other Transdermal Technologies
Yeakuty Jhanker
James H.N. Tran
Heather A.E. Benson
School of Pharmacy and Biomedical Sciences, Curtin Health Innovation
Research Institute, Curtin University
Tarl W. Prow
Biomaterials Engineering and Nanomedicine Strand, Future Industries Institute,
University of South Australia
5.1 Background
The stratum corneum (SC) is the primary physical barrier to overcome the delivery of active molecules
to therapeutic sites in the skin or underlying tissues, or via the cutaneous circulation for systemic deliv-
ery. The anatomical structure and barrier properties of the skin have been reviewed in Chapter 1. To
successfully achieve transdermal or intracutaneous delivery, the SC barrier must be overcome by either
mechanical or chemical intervention. The focus of the preceding chapters has been the application of
microneedles in a range of fabrications that can overcome the SC barrier. Here we review other approaches
and technologies that have been applied to SC barrier disruption and how they compare to microneedles
(Figure 5.1). Enhancement techniques include vehicle modification to include chemicals capable of enhanc-
ing solute solubility in the SC and directly disordering the SC lipid domains, and nano and microemul-
sion and vesicle formulations. Indirect physical methods involving the application of electrical, acoustic,
laser, and magnetic energy have advanced through experimental evaluation to commercial development.
Most similar to microneedles are the alternative direct penetration methods including microdermabrasion,
biolistic technologies, thermal and laser ablation, and elongated microparticles (EMPs). While formulation-
based modification is an important SC permeation enhancement approach, it is the indirect and direct
physical enhancement methods that are most closely comparable to microneedles and are therefore the
focus of this chapter. However, vehicle/formulation-based approaches are particularly relevant in consider-
ing their potential to enhance delivery in combination with microneedles, both to enhance diffusivity of
solutes within microneedle-generated pores and following microneedle-based deposition in the cutaneous
tissues, and in considering controlled release to optimize therapeutic outcomes following microneedle-
based deposition in the skin. Recent publications utilizing microneedles incorporating smart delivery tech-
nologies to generate combined diagnostic and treatment patches for diabetes highlight the potential role of
this approach in future health care (1, 2). This combination of microneedles with other delivery technolo-
gies offers new therapeutic opportunities, and is reviewed in Chapter 6.
5.2 Indirect Physical Methods

Indirect physical methods involve the application of an energy source to the skin surface to increase dif-
fusivity of an applied solute in the SC. A variety of different energies have been investigated including
electric (iontophoresis and electroporation), magnetic (magnetophoresis), acoustic (sonophoresis), and laser.
49
FIGURE 5.1 Routes of penetration of an API applied topically to the skin surface (appendages including hair follicles and
sweat glands; intercellular and transcellular routes through the SC). Delivery enhancement approaches applied to human
skin categorized as indirect and direct physical methods to enhance transport through the SC barrier.
5.2.1 Iontophoresis
In iontophoresis (Figure 5.2), a mild electric current (typically 0.1 to 1.0 mA/cm2) is applied to increase
skin permeation by three mechanisms: electromigration (the ordered movement of ions within an applied
electric field as described by Faraday’s law), electroosmosis (convective solvent flow in the anode-to-
cathode direction due to the isoelectric point pI of 4–4.5 and negative charge of the skin), and enhanced
passive diffusion (relatively minor role) (3–5). Uncharged molecules can also be delivered by these
mechanisms but flux enhancement is low relative to charged molecules. The intensity of the applied
current, duration of current application, and skin surface area in contact with the electrode determine
iontophoretic molecular transport.
Iontophoresis has been extensively investigated for the delivery of small molecules, peptides, and
proteins, and many review articles have been published (3, 6–8). A number of factors can influence
iontophoretic skin delivery including: the current density and continuous/pulsed waveform, drug
FIGURE 5.2 Iontophoretic drug delivery: a powered device consisting of an anode and a cathode generates a weak
current that repels a charged solute into the skin.
Microneedles vs. Other Transdermal Technologies 51
concentration, vehicle pH (the degree of drug ionization affects mobility and electromigration; the
degree of skin ionization determines the electroosmotic solvent flow) and molecular factors (charge/
molecular mass ratio; and volume, shape, and charge distribution of the molecule) (6). In clinical
use, iontophoresis is generally well tolerated, particularly when applied as a pulsed current profile
that can allow time for the skin to depolarize and return to its resting state prior to initiation of the
next pulse.
A number of transdermal iontophoretic products have received regulatory approval including the
LidoSite™ Topical System (lidocaine and epinephrine for local anaesthesia; Vyteris Inc., Fairlawn, NJ,
USA) and Ionsys™ (fentanyl iontophoretic transdermal system for patient-controlled analgesia; devel-
oped by Alza Corporation, then acquired in sequence by Johnson & Johnson, Incline Therapeutics, and
The Medicines Company and subsequently discontinued in 2017).
5.2.2 Electroporation
Electroporation involves the application of high-voltage (50–1500 V) electrical pulses lasting 10 μs to 10 ms,
to generate transitory pores in the SC lipid bilayers through which applied compounds can diffuse (9).
Electroporation has been shown to enhance the skin penetration of a range of molecules (9–15) but is
reported to cause pain and muscle contraction (16).
5.2.3 Magnetophoresis
Magnetophoresis is the enhancement of drug permeation by the application of a magnetic field (17),
5-amino levulinic acid (18–20). Diamagnetic repulsion of the molecule into the skin is the sug-
gested mechanism of action, although there is also some evidence of potential transient SC barrier
reduction (19). We have shown that pulsed electromagnetic fields (PEMF) increased the permeation
of naltrexone hydrochloride across human epidermis by 6.5× compared to passive administration
(19). Gold-nanoparticle (10 nm)-treated human skin exposed to a PEMF had 200 times more gold-
nanoparticle-positive pixels when visualized by multiphoton microscopy–fluorescence lifetime
imaging microscopy (MPM-FLIM) than skin exposed to gold nanoparticles without PEMF. This
suggests that the PEMF facilitates penetration of the gold nanoparticles through the SC and that
the channels through which the nanoparticles move must be larger than 10 nm in diameter. An
alternative magnetophoresis fabrication has been developed as a thin flexible polymer matrix con-
taining multiple magnetic elements arranged to produce complex three-dimensional (3D) magnetic
gradients (40 mT peak magnetic field strength; 2 T/m 2 total magnetic gradient; OBJ Ltd., Perth,
Australia). This magnetic array effectively enhances flow into microneedle-porated skin to pro-
vide a synergistic permeation enhancement (21). The first commercially available magnetophoresis-
based enhancer consists of the magnetic array housed in a “wand” that is used to enhance skin care
products (Procter & Gamble, Cincinnati, OH).
5.2.4 Sonophoresis
Sonophoresis (phonophoresis) is the application of acoustic waves to facilitate transdermal delivery (22, 23).
The main ultrasonic effects are cavitation (formation and oscillation of microbubbles; Fig. 5.3[b]), acous-
tic streaming, thermal effects, and direct ultrasound pressure effects on the SC bilayers. Polat et al.
proposed that a microjet formed by collapse of the cavitation bubbles in the application medium
generates shock waves in the SC, perturbing the barrier and increasing permeability (22). A further
proposal is that the applied ultrasonic pressure waves oscillate between compression and rarefaction,
transiently interrupting the continuity of the SC lipid bilayers to form pores through which applied
drugs can diffuse (24).
Low-frequency ultrasound (20–100 kHz) is reported to enhance permeation of a range of mol-
ecules including macromolecules such as insulin, interferon-γ, and erythropoietin (5.8, 17, and
48 kDa respectively) across human skin in vitro (25). As low-frequency ultrasound can itself elicit
FIGURE 5.3 Sonophoresis delivery. Two proposed mechanisms of delivery: (a) rapid formation and oscilliation of micro-
bubbles (cavitation) resulting in disruption and deformation of cells; (b) sonically generated microbubbles that rapidly
collapse resulting in a microjet that leads to shockwave-induced cell disruption.
an immune response and activate Langerhans cells of the viable epidermis, it can act as an immuni-
zation adjuvant when coupled with a vaccine. Sonophoretic delivery of tetanus toxoid was reported
to provide equal protection as an intramuscular injection when administered to mice (26, 27).
Commercialized sonophoresis devices are bulky (e.g., Sonoprep®; Sontra Medical) but attempts
have been made to develop wearable sonophoretic devices (28–30). A recent development is the
dual administration of low and high ultrasound frequencies to increase the cavitation effect and
thus skin permeability (31, 32). Schoellhammer et al. reported that a 4-min pretreatment with dual
ultrasound frequencies of 20 kHz and 1 MHz, in combination with 1% SLS, enhanced the perme-
ation of inulin and glucose across porcine skin by 3.81-fold and 13.6-fold respectively, compared to
single-frequency sonophoresis (31).
5.2.5 Laser-Assisted Delivery

A photomechanical wave is generated by laser ablation of a target medium consisting of a polymer
(e.g., black polystyrene) placed on the surface of the skin (33–35). The medium undergoes rapid
phase change (e.g., degradation or plasma formation) resulting in the production of a shockwave
through the skin below, (Figure 5.4) (36). Unlike with sonophoresis that oscillates between positive
and negative pressure, no cavitation is observed. The photomechanical wave is a unipolar compres-
sive one that disrupts the lipid arrangement within the SC intracellular space and also the cellular
membranes.
In one of the earliest reports, Lee and colleagues utilized a single photomechanical wave for the
delivery of nanoparticles in rats. A photomechanical wave, generated via Q-switched ruby laser abla-
tion of black polystyrene resulting in a calculated peak pressure in the skin of 592 ± 23 bar, delivered
40 kDa rhodamine dextran to a 50 µm depth in the skin (37), and the skin remained permeable for
a period after application that varied with drug size and molecular charge (2 and 40 min for 40 kDa
rhodamine and amino levulinic acid, respectively) (33, 38). They also reported a 3.4-fold increase
in 20-nm latex nanoparticle delivery compared to topical alone. Substantial enhancement of skin
FIGURE 5.4 Laser-assisted drug delivery via photomechanical enhancement: laser is applied to a target medium (black
rubber or polystyrene) situated on a reservior containing the active compound in solution. Rapid phase change in the rubber
generates shockwaves through the solution into the skin, disrupting the stratum corneum lipids and facilitating diffusion
of the active compound.
delivery has been reported for a range of compounds and nanoparticles in small-animal models
(34, 35, 39). Laser-generated photomechanical waves do not produce the same degree of delivery
enhancement as laser-based techniques that cause ablation of the SC, as is shown by a comparative
study of aminoleculinic acid with 7-, 41-, and 641-fold delivery with laser-generated photomechanical
wave < fractional ablation < full ablation. The technique has received limited further interest with
few publications in recent years.
5.3 Direct Physical Methods

Microneedles and their various fabrications and applications have been discussed in detail in previous
chapters. While the fabrications vary from the so-called “poke and patch” to the inclusion of their
medication on the surface or within the projections, they have in common the mechanism of poking
an array of small, sharp projections into the skin to breach the SC barrier. Accordingly they are clas-
sified as direct physical enhancement methods. The following section reviews other technologies that
are based on direct physical enhancement and thus most similar to microneedles in their enhancement
mechanism.
5.3.1 Microdermabrasion
Microdermabrasion was initially developed as a technique for skin rejuvenation via superficial disrup-
tion of the skin as is utilized in dermatological and cosmeceutical practices (40, 41). This can be accom-
plished by instruments consisting of air-propelled particles that “sandblast” and simultaneously remove
the skin by vacuum. Simple “sandpaper” approaches that are less controlled, removing larger/deeper
tissue regions are described as “dermabrasion.” “Microdermabrasion” is designed for local disruption of
the SC and superficial viable epidermis (42–45), with minimal to no pain or bleeding and relatively fast
recovery time. It is sometimes applied along with topical cosmetic products such as retinoic acid, vitamin C,
and nicotinamide (46–48).
Microdermabrasion has also been investigated as a tool for enhancing delivery of therapeutic
compounds into the skin. These include locally active ingredients such as 5-fluorouracil, ami-
nolevulinic acid, clobetasol 17-propionate, and systemic drugs such as insulin (44, 49–52). Lee and
colleagues utilized a pressurized microdermabrasion system whereby AL2O3 microcrystals were
propelled onto excised pig skin (49). Lee et al. reported that microdermabrasion by pressurized
AL2O3 microcrystals significantly improved the flux of 5-fluorouracil across excised pig skin from
1.19 ± 0.82 to 13.16 ± 4.23 µg/cm 2/h (an 11.06-fold increase) (49). Microdermabrasion also increased
aminolevulinic acid flux by 39-fold in excised pig skin and 48-fold in nude mouse skin. The dif-
ference is associated with the thinner and less robust skin of the mouse. In contrast, clobetasol
17-propionate permeation decreased following microdermabrasion. Flux across intact skin was 6.99 ±
3.57, as against 0.56 ± 0.15, 0.94 ± 0.30, and 1.64 ± 0.18 µg/cm 2/h following microdermabrasion
of 3, 5, and 10 seconds’ duration, corresponding to a decrease of approximately 4- to 12-fold. This
suggests that while microdermabrasion was an effective skin penetration enhancer for the hydro-
philic compounds aminolevulinic acid and fluorouracil (log partition coefficients of 1.5 and –0.89,
respectively), it reduced penetration of the lipophilic compound clobetasol 17-propionate (logP of
3.50). This suggests that while removal of the lipid-rich SC benefits penetration of hydrophilic
compounds, it reduces penetration of lipophilic compounds. Drugs delivered post-dermabrasion
rely on passive diffusion within the viable skin tissue, potentially excluding lipophilic compounds
that partition into the now-removed SC lipid bilayers. Controlled microdermabrasion (44, 53) and
appropriate vehicle selection tailored to the physicochemistry of the applied compound may allow
the technique to be optimized.
5.3.1.1 Thermal Ablation Technologies

Thermal ablation involves heating the skin surface to vaporize SC tissue. If the heating source is
effectively controlled, the temperature gradient across the SC can allow extreme heat at the skin
surface (≈300°C for microseconds) while there is no significant temperature rise in the underlying
viable epidermis and deeper skin tissues (54, 55). In effect, this removes portions of the SC to create
micron-scale channels similar to those created by a microneedle array. This can be achieved by the
application of arrays of microfabricated-resistive (56) and radiofrequency (57, 58) electrical heat-
ing elements, and by lasers (following section). The ViaDor™ system (developed by TransPharma
Medical, Israel), which creates 144 microchannels in 1 cm 2, is applied followed by patch application.
Histological studies demonstrate that the microchannels reach in to the dermis and are almost com-
pletely healed within 24 h. A similar technology is the PassPort system (developed by Altea, now
owned by Nitto-Denko, Japan and recently spun out as PassPort Technologies Inc, San Diego, CA).
5.3.1.2 Laser Ablation

Laser skin rejuvenation uses devices such as the P.L.E.A.S.E (Painless Laser Epidermal System) for
dermatological (scarring, stretch marks) and cosmetic outcomes that apply laser-generated ablative pho-
tothermal energy to disrupt and remove the superficial skin layers. These devices cause thermal ablation
of the skin using a laser source.
The absorption of laser energy is related to the optical absorbance of water within the skin; thus
the choice of laser can be tailored to the depth of desired tissue ablation. A ruby laser has poor
water absorbance at 694 nm resulting in a minimally ablative technique, while a CO2 laser is highly
absorbed at 10,600 nm resulting in strong ablation but also more extensive photothermal tissue dam-
age. Erbium:yttrium-gallium-garnet (Er:YAG) and yttrium scandium gallium garnet (YSGG) lasers,
emitting at 2790 nm and 2940 nm respectively, offer effective ablation of the SC with reduced thermal
damage to the underlying viable tissue (60).
Rather than affect the entire skin surface, fractional laser ablation (59, 61) ablates sub-millimeter
regions (spots) within a treatment area interspaced with undamaged tissue, mimicking a microneedle
array-type pattern. Average spot size ranges of 40–300 µm with densities between 50 cm−2 and 600 cm−2
(59, 61–63) correspond to approximately 5% to 30% of disrupted epidermis evenly spaced within a treat-
ment area. The overall effect is minimal photothermal damage and faster healing times due to migration
of neighboring viable keratinocytes into the ablated cavities.
Laser ablation has been investigated for delivery of a range of compounds such as imiquimod,
5-aminolevulinic acid, minoxidil, hydro-quinone, nanoparticles, and antigens (59, 61, 62, 64–69).
As with all techniques that act by creating pores in the SC, an important consideration is how the
properties of the drug and vehicle applied within those pores influence passive diffusion within the
skin. Lee et al. (66) reported that penetration enhancement of the relatively lipophilic imiquimod
(logP 2.7) of 18.45-fold was achieved when formulated in 40% PEG400 in conjunction with 5 J/cm 2
fluence full skin ablation (ER:YAG). The same formulation applied with a fractional ablation tech-
nique (4 J/cm 2 fluence) resulted in a 8.83-fold enhancement. Greater enhancement was achieved with
the hydrophilic aminolevulinic acid (logP –1.5). In this case full ablation (2.5 J/cm 2 fluence) resulted
in a 641.27-fold and 103.67-fold penetration enhancement when applied in aqueous buffer and 40%
PEG respectively. Again, the fractional technique resulted in lower enhancements of 41.23-fold and
0.69-fold in pH 5 buffer and 40% PEG respectively. Clearly, the removal of the SC lipophilic barrier
resulted in greater delivery for the hydrophilic than the lipophilic compound. Fractional laser abla-
tion has also been shown to allow effective delivery of 10 kDA dextran, siRNA, and plasmid DNA
using both in vitro/in vivo techniques (70) and vaccines (62, 71). While laser ablation can achieve
greater delivery rates, it is likely that the lower tissue damage profile of fractional ablation makes
this technique more feasible for further development as a skin penetration enhancement technol-
ogy. However, there would need to be significant technological developments, as current bulky and
expensive laser devices are a significant limitation for their further development in the transdermal
delivery field.
5.3.2 Biolistic Injectors

5.3.2.1 Liquid Jet Injectors
Jet injectors deliver a liquid payload at high velocity through the skin (Figure 5.5 left). Initial multiuse
devices were withdrawn from the market after an outbreak of Hepatitis B due to splashback of bodily
fluids onto the surface of the injector (72) and have been replaced by fully disposable single-use
injectors (73).
Jet injectors subject the active pharmaceutical ingredient (API) solution to high pressure so that
it is ejected through a small nozzle, at velocity greater than 100 m/s, with a maximum of approxi-
mately 200 m/s (73). The velocity and microjet size influence the delivered volume and penetration
depth of the payload, and also the amount of damage to the skin (73). Deeper penetration is achieved
FIGURE 5.5 Biolistic needle-free delivery: (left) liquid jet injector propels active compound solution through the skin
layers resulting in broad distribution of the drug; (right) particle delivery (e.g., gene gun) propels nano- or microparticles
into the skin at high velocity resulting in deposition within the upper layers.
with higher velocities, but there is also greater potential for splashback of solution from the skin
surface.
Stachowiak and colleagues developed a piezoelectric applicator integrated with a conventional
glass/stainless steel syringe, allowing an initial high-speed penetration (148 m/s) followed by low-
speed delivery (60 m/s) (74). They hypothesized that there would be a linear correlation between
the duration of the initial high velocity and penetration depth, thus permitting delivery con-
trol and eliminating the problem of splashback. Dynamic delivery of mannitol was analyzed in
ex vivo human skin using a high velocity of approximately 200 m/s with the duration increased
incrementally from 0 to 5.5 ms. The total combined injection time for the two velocities was
5.5 ms throughout. Optimal mannitol delivery occurred when the high-velocity component was
2–4 ms.
While volumes of up to 250 µL have been delivered (75), these result in more damage to surrounding
and deeper skin tissues. Volumes in the nanoliter range minimize damage and splashback (76). Jang and
colleagues used an ER:YAG laser to induce a microjet for controlled delivery of epidermal growth factor
and human growth hormone (77, 78). A 250-µs laser pulse generated vapour bubbles and downstream
shockwaves that propelled the API solution through a nozzle forming a microjet that penetrated the skin.
The device was designed with two compartments to prevent any detrimental thermal effects to the API,
and to separate the laser-ablation process from the skin. The microjet velocities between 23.0 ± 4.0 and
50.6 ± 1.6 m/s delivered a maximum of 2100 ± 28 nL and minimum of 358 ± 14 nL (an approximately
5.8-fold increase). Delivery of epidermal growth factor and human growth hormone in porcine skin was
achieved, as determined by gene expression of keratinocyte laminin and fibroblast elastin respectively.
There was no significant difference in gene expression for laser energies of 408 and 816 mJ and two
different drug concentrations of 10 and 100 ng/mL suggesting the laser energy caused minimal thermal
damage to the API. Continued development of liquid jet injector systems may continue to offer improve-
ments in delivery control with minimal tissue damage, but will need to be achieved at low cost and
complexity.
5.3.2.2 Powder/Particulate Injectors

The original biolistic particle delivery system, or gene gun, was designed for delivering exogenous DNA
(transgenes) into plant cells. The payload is typically a particle of a heavy metal coated with DNA
(typically plasmid DNA). This has been developed into biolistic injectors delivering a “shotgun” burst of
nano- or microparticles into the skin (Figure 5.5 right), injectors that have been effective for the immu-
nization of antigens including influenza and malaria, and also in anticancer applications in a range of
animals (mice, rat, ferrets, monkeys, etc.) and humans (79–82). Clinical assessment of biolistic particle
delivery reports transient localized pain and tissue damage (erythema, irritation, etc.); thus, like liquid
biolistic injection, the technique is most suitable to vaccination.
Traditionally, solid or dense particles, preferably spheroidal in the sub-micron-size range were used
for biolistic particle delivery (83, 84). However, porous particles can provide an additional option for
increased drug loading and controlled release (79).
While both biolistic approaches can deliver their payload into the skin, their sophisticated instru-
mentation and associated tissue damage is a significant limitation in successful widespread adoption
as a transdermal delivery technology. If they have a future it is most likely in the vaccine area.
5.3.2.3 Elongated Microparticles

High-aspect-ratio EMPs (85, 86), for enhanced drug delivery, are made of cylinder-shaped solid silica
with an average width of 28 ± 11 µm and an average length between 120.1 and 483.2 µm (Figure 5.6).
FIGURE 5.6 Elongated microparticle delivery showing the shallow angle of microparticle penetration. The drug can be
coated onto or mixed with the microparticles and massaged onto the skin.
EMPs can be mixed with existing formulations and massaged onto the skin; in this case, the EMPs facil-
itate permeation of the simultaneously applied active in the formulation. Alternative drugs can be coated
onto the surface of the EMPs. A 3D-printed micro-textured applicator is used to apply the formulation,
maximizing contact with the skin surface at the activation site. Thus, unlike microneedle and other
array-type enhancement technologies, EMPs can be applied to varied application site sizes and shapes.
Disruption within the epidermis is maximized because the EMPs are designed for low angular penetra-
tion within the epidermis, and penetrate to the dermal–epidermal junction (86). The normal transepider-
mal turnover and desquamation process pushes the microparticles out of healthy skin within 3 weeks.
We have demonstrated a sevenfold increase in delivery of fluorescein to the upper layers of porcine
skin using our microparticles when compared to topical application alone and enhanced delivery of
therapeutically relevant compounds (vitamins A and B3) in vitro and in vivo (87). In excised human
skin, EMPs enhanced vitamin E (3H-a-tocopherol acetate) and vitamin B3 (3H-nicotinamide) delivery
by 8.5- and 8.8-fold respectively, compared to topical alone (p = 0.0017 and 0.0001) (86). Using confocal
microscopy imaging we showed that an average of 76 ± 40 EMPs per mm2 penetrate the forearm skin of
healthy volunteers to an average depth of 48.6 ± 18.4 µm, a formulation of 5 mg of microparticles with
50 µL of 1 mg/mL sodium fluorescein (86). EMPs resulted in a significant 3.3-fold fluorescein delivery
increase compared to fluorescein alone, and provided a relatively uniform and continuous delivery pro-
file within the treatment area (86). The EMPs were eliminated from the skin within 3 weeks.
5.4 Comparison of Microneedles with Direct Enhancement Techniques

Direct comparison of the skin delivery efficiency of microneedles and other direct enhancement
techniques is difficult, as few comparative studies have been published. While the various tech-
niques have been investigated for a range of small and macromolecules, the experimental pro-
tocols vary considerably with differing donor formulations, skin membranes, receptor solutions,
etc. Consequently, it is difficult to compare data across the published literature. We conducted a
preliminary study to compare the skin penetration of sodium fluorescein applied to excised still-
born piglet skin mounted in Franz-type diffusion cells with microneedles (351 plastic micronee-
dle projections of 650 μm in length; 3M St. Paul, MN), Dermaroller (192 × 0.5 mm stainless
steel microneedles in eight rows on the rotating drum; ClinicCare, NSW) and EMP (high-aspect-
ratio silica cylinders (diameter 9.3 ± 0.9 μm, length 303.4 ± 208.7 μm). Thus the technologies
provided enhancement ratios compared to passive administration of 30, 26 and 19 respectively.
All technologies significantly enhanced sodium fluorescein skin penetration compared to pas-
sive application (P DermaRoller (20.95 ± 2.53 µg/cm 2) > EMP (15.99 ± 0.97 µg/cm 2) > passive
(0.38 ± 0.37 µg/cm 2: Mean ± SD: n = 3). Microneedles provided the greatest enhancement in skin
penetration but also exhibited greater variability than the Dermaroller and EMP. Comparison of
the amount of sodium fluorescein retained in the skin at 24 h showed a rank order of EMP (9.00 ±
2.09 µg) > DermaRoller (7.17 ± 2.45 µg) > microneedles (3.97 ± 1.71 µg) > passive (2.18 ± 0.97 µg)
representing enhancement ratios compared to passive administration of 4.1, 3.3, and 1.8 respec-
tively. In this case, the variability in sodium fluorescein delivery to the skin across the three
technologies was similar despite the significantly greater enhancement provided by the EMPs and
DermaRoller. This suggests that the choice of technologies may vary depending on the target site
for therapeutic outcome.
5.5 Conclusion
Many different strategies have been explored to overcome the SC barrier and increase the therapeutic potential
of topical and transdermal delivery. The enhancement technologies described in this chapter have played their
part in the greater utilization of the skin as a site of drug application. Microneedles, in their various fabrica-
tions, act to create pores through the SC to provide direct access to the viable epidermis and are particularly
effective for enhanced delivery of hydrophilic compounds. Other direct methods described in this chapter
apply different technologies but essentially also work on the principle of creating pores through the SC. The
direct enhancement technologies have particular promise in the delivery of macromolecules such as vaccines,
but also have potential to increase the dosages of all drugs that can be administered and may also have par-
ticular utility for targeting drugs to skin lesions (87). Some of the indirect physical methods discussed also
provide significant SC barrier reduction though they do not create pores comparable to microneedling. The
combination of microneedling with other technologies may offer more delivery but can be associated with
definite costs such as increased complexity/cost and confounding results. The goal of such a combination
is always potentiation, but the reality may just be additive. The aim of this chapter is to discuss the alterna-
tive enhancement technologies to microneedles. The potential to combine technologies with microneedles is
explored in a subsequent chapter. Microneedling and comparable technologies offer great promise for future
development. We will likely see continued technological advances to permit scale-up and manufacturing in
an efficient and cost-effective manner, and the combination of enhancement strategies to maximize delivery.
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6
Combination of Microneedles with Other Methods
Sahitya Katikaneni
Zosano Pharma
6.1 Introduction
The most common route of drug delivery to date is oral; the second most common is parenteral adminis-
tration. Drug delivery through skin provides an excellent opportunity to overcome issues with other routes
of administration such as hepatic and gastric degradation, needle phobia, and pain (1). The past decade
has seen major advancements in the field of microneedle-mediated transdermal delivery, all thanks to
the research conducted by academic groups and pharmaceutical companies worldwide. Microneedles
have proven more effective compared to other technologies as far as skin delivery is concerned (1). The
ability of microneedles to temporarily create micron-sized pores in the skin has even made it possible to
deliver hydrophilic and high-molecular-weight compounds such as proteins and vaccines through skin
(2–5). Other transdermal technologies such as iontophoresis and ultrasound have been shown to deliver
such molecules as well, but have size limitations (1, 6, 7). Microporation has also found relevance in
diagnostic testing, as it can enable sampling of biological fluids for monitoring blood glucose levels (5).
Application of advanced engineering tools in the fabrication of microneedles has opened up endless
opportunities to design the type of delivery for the desired therapeutic effect (4). Immediate release with
coated microneedles (metal/dissolvable), controlled release from microneedles containing encapsulated
drug, and infusion through hollow microneedles are a few potential ways of drug administration with
microneedles (4).
Microneedles can comprise different materials: metals such as stainless steel and titanium, polymers
such as poly(lactic-co-glycolic acid) (PLGA) and carboxy methyl cellulose, or sugars such as maltose
and dextrin (2, 3, 5, 8–12). They can be either hollow or solid and can be made in a wide variety of
geometries as per the application. They can be applied to the skin manually or with the aid of a special
device (4, 13, 14). Combining microneedles with other technologies might exhibit a synergistic response
on delivery. Several groups have published their research in this area and are continuing to gather data.
This chapter focuses on the combinatorial aspect and looks into combination of microneedle technology
with other methods.
6.2 Combination of Microneedles with Other Technologies

6.2.1 Iontophoresis
Transdermal iontophoresis refers to application of physiologically acceptable electric current
(< 0.5 mA/cm2) to enable movement of charged or ionized molecules into or across a membrane (15).
This delivery method is suitable for polar molecules with high charge density. The amount of drug
delivered via iontophoresis is proportional to the intensity of the current applied across the tissue (15).
Iontophoretic transport is governed by two major mechanisms, electromigration and electroosmosis.
Detailed information on the transport mechanisms and specific applications of iontophoresis can be
found in these review articles (6, 15–17). One of the key features of iontophoretic delivery is its ability
to be tailored to an individual’s dose requirements. Drugs can be delivered in a continuous or a pulsatile
65
fashion by programming the current (15). However, there are limitations to iontophoresis, one of the
biggest of which is that it can only deliver molecules up to approximately 15 kDa in size (18–22).
As mentioned previously, microneedles perturb the skin barrier function in a reversible manner,
enabling delivery of macromolecules. The combination of microneedles with iontophoresis will further
broaden the scope of molecules that can be delivered via skin. Programmable delivery across pores cre-
ated by microneedles will help personalize the delivery system to suit one’s needs.
In a study conducted by Lin et al., transdermal delivery of an antisense oligonucleotide was evaluated
using a combination of microneedles and iontophoresis. Microneedles were made up of stainless steel
with a length of 430 µm. The patch size was 2 cm2 and the current density applied was 100 µA/cm2.
The study was conducted in hairless guinea pig model in vivo. The skin flux was found to be 100
times higher with the combination approach than iontophoresis alone. In spite of oligonucleotides being
charged molecules, therapeutic levels were attained only upon combining iontophoretic delivery with
microneedles (23).
Wu et al. evaluated in vitro skin permeation of high-molecular-weight fluorescent tagged dextran
molecules FD-4, FD-10, FD-40, FD-70, FD-2000 corresponding to an average molecular weight of
3.8, 10.1, 39.0, 71.2, 200 kDa. Studies were performed across hairless rat skin using a combination of
microneedles and iontophoresis. Delivery was found to be higher for the combination of microneedles
with iontophoresis compared to iontophoresis alone. Permeation was approximately 14-, 26-, 12-, 7-
and 14-fold higher for FD-4, FD-10, FD-40, FD-70, and FD-2000 respectively for the combination
approach (19).
Transdermal permeation of low-molecular-weight heparin was evaluated by Lanke et al. in an in vitro
study. Skin flux with iontophoresis alone was minimal. However, iontophoresis across microneedle-
treated skin resulted in flux enhancement by 15-fold. It was mentioned in the study that low-molecular-
weight heparin interacts with stratum corneum, and hence methods like microporation in which stratum
corneum is disrupted briefly aided in the skin permeation. Combining iontophoresis with microneedles
therefore resulted in an additive effect (24).
Delivery of methotrexate (molecular weight 454 Da) was studied in vitro and in vivo by Vemulapalli
et al. (21). Delivery was enhanced by 25-fold with the combination of microneedles and iontophoresis as
compared to them individually. They also evaluated permeation of salmon calcitonin in vivo. Maltose
microneedles were used to pretreat the skin. A current density of 0.2 mA/cm2 was applied for 1 h.
Microneedles alone resulted in a 2.5-fold increase in delivery as compared to iontophoresis. However,
the combination of microneedles and iontophoresis resulted in a ninefold enhancement (20).
Katikaneni et al. studied the in vitro delivery of a 13-kDa peptide using the combination with respect
to the mechanism dominating the transport during iontophoresis (22). Tape stripping wherein the stratum
corneum is completely removed resulted in a complete impairment of electroosmosis, thus altering the
skin’s permselective properties. This study showed that partial breaching of the skin barrier as it hap-
pens during microporation did not impede electroosmosis. In vitro skin flux of the peptide was found to
be higher when microneedles and iontophoresis were used in conjunction. A total cumulative amount
of 700 ng/cm2 and 25 µg/cm2 of the peptide was delivered for the two formulations evaluated at pH 7.5
and pH 4.0 respectively. There were no detectable levels of the peptide when iontophoresis was applied
across intact skin. It was established in this case that delivery across microporated skin was higher when
electrorepulsion was the dominant force during iontophoresis as compared to electroosmosis. An in vivo
study conducted on the same peptide resulted in similar results (25). Daniplestim concentration in the
patch was 2 mg/mL. Combination of microneedles and iontophoresis resulted in a Cmax of about 9 ng/mL.
Peptide delivery with iontophoresis or microneedles alone was negligible.
6.2.2 Sonophoresis
Delivery of therapeutic molecules into or across the skin using ultrasound is referred to as sonopho-
resis or phonophoresis. High-frequency ultrasound (> 0.7 MHz) was used in early investigations and
enhancement in permeation anywhere between 1- and 10-fold were seen. However, the past two decades
have focused on using low-frequency ultrasound (20–100 kHz) for transdermal delivery along with
the development of a better mechanistic understanding of sonophoresis (26, 27). Low-frequency and
Combination of Microneedles with Other Methods 67
high-frequency ultrasound differ in the way they facilitate skin permeabilization. The primary mode
of enhancement with low-frequency ultrasound is believed to be acoustic cavitation above the skin
membrane and for high-frequency ultrasound it is believed to be cavitation within the skin. High-
frequency ultrasound has been found to be more effective in increasing the skin permeation of low-
molecular-weight compounds whereas low-frequency ultrasound has been more effective in delivering
macromolecules such as proteins, vaccines, and nanoparticles. A review article by Polat et al. provides
a detailed understanding of the history, mechanistic aspects, and applications of ultrasound for trans-
dermal delivery (7).
There are two ways of applying ultrasound to the skin: (i) a pretreatment approach wherein ultra-
sound is applied to the skin and followed by application of the drug patch and (ii) a concurrent approach
wherein ultrasound is simultaneously applied through the coupling medium containing the drug. Method
(i) is more widely followed as simultaneous application of ultrasound may result in drug degradation or
cause other undesirable effects. Some of the parameters that influence delivery during ultrasound are the
treatment time, duty cycle, distance between the ultrasound transducer and the skin, and the composi-
tion of the coupling medium. Combination of ultrasound with microneedles can provide an interesting
platform for drug delivery. However, research in this area is in the nascent stage and limited data is
available so far.
Hollow microneedles can be applied to the skin and ultrasound can be applied simultaneously so that
it can enhance delivery by convection. A study conducted by Chen et al. has used this concept to deliver
bovine serum albumin (BSA) and calcein (28). They used hollow microneedles with a length of 100 µm.
The frequency of the ultrasound applied was 20 kHz with a cycle length of 10 µs. The ultrasound trans-
ducer was attached to the back of the microneedle patch. Skin permeation was enhanced 9 times for
calcein and 12 times for BSA as compared to passive diffusion.
Solid or dissolvable microneedles can be used to create pores in the skin. Application of ultrasound
on the pretreated skin will result in permeation enhancement due to cavitational effects induced by the
ultrasound. This concept was evaluated in a study conducted by Han and Das for delivery of BSA. Solid
microneedles with two different lengths, 1.2 mm and 1.5 mm, were used to pretreat the skin. Ultrasound
with a frequency of 20 kHz was applied for 10 min.
BSA permeation was more with the combination of microneedles and ultrasound as compared
to microneedles or ultrasound alone. Maximum enhancement was achieved when combined with
1.5-mm-long microneedles (29).
Another approach that has been suggested in this area is to pretreat the skin with high-intensity ultra-
sound followed by application of short-length microneedles. This concept can be used for topical deliv-
ery of drugs or for molecules that need a rapid onset of action (30).
6.2.3 Electroporation
Skin electroporation refers to application of high-voltage electric pulses (typically 5–1000 V/cm) for a
short duration resulting in formation of aqueous pores in the skin. High electric pulses when applied
result in a temporary modification of the stratum corneum resulting in increased electrophoretic mobil-
ity and molecular diffusivity. This technique has been shown to improve skin permeability of drug
molecules with various lipophilicities and sizes. It is believed to be applicable for both ionic and non-
ionic molecules. Skin delivery of high molecular weight compounds like peptides, proteins, and oligo-
nucleotides has also been evaluated using electroporation. Detailed mechanistic understanding of skin
electroporation and applications with respect to transdermal drug delivery are presented in an excellent
review by Kevin Ita (31).
Transdermal delivery of drugs using electroporation has been widely tested in animals, but data in
humans is limited (1, 32, 33). Combining electroporation with microneedles may have a beneficial effect
on enhancing skin flux. This strategy has not been well tested and needs to be explored further.
Wilke et al. designed a novel drug delivery system called ENDOPORATOR that combined micronee-
dles with electroporation. The device consisted of hollow silicon microneedle electrode arrays with
attached sensors. Microneedles penetrate the skin while electroporation will enable injection/infusion of
drugs through the needles into the skin (34).
In a study conducted by Hooper et al., delivery of smallpox DNA vaccine was studied using a combina-
tion of electroporation and microneedles. Plasmid DNA was coated onto the microneedles and applied to
the skin. The dissolved DNA would permeate into the cells with the help of electroporation. The immune
response obtained in mice which were vaccinated with this approach was better than the response seen
in mice vaccinated with traditional live virus (35).
Delivery of FITC-Dextran with a molecular weight of 4.3 kDa was evaluated in vitro by Yan et al.
Skin was pretreated with microneedles followed by application of high-voltage pulses using electrodes.
Two types of electroporation were tested: in-skin and on-skin. Delivery was found to be higher with the
combination approach for both the electroporation methods when compared to microneedles or elec-
troporation alone. Delivery was found to be dependent on voltage and pulse width. Permeability with
on-skin electroporation was 20-fold higher and with in-skin electroporation it was 140-fold higher. No
significant skin irritation was observed (36).
6.2.4 Particulate Systems

Particulate systems (nanoparticles and microparticles) for drug delivery have been thoroughly explored
in the past decade. These systems vary in their size and physicochemical properties depending on the
material of origin such as lipids, sugars, or polymers (37). They offer several advantages over conven-
tional delivery systems such as: (i) drug release for a prolonged/defined period of time, (ii) enabling of
site-specific action by targeting the desired organ/tissue, (iii) providing protection to the drug molecule
from proteolytic or mucosal degradation by encapsulating it, thus increasing bioavailability (1, 37–41).
Transdermal delivery of nanoparticles has been mainly used to deliver drugs to the skin for local
effects. The mechanism of skin penetration for nanoparticles is not clear; however, hair follicles and
furrows are believed to be the potential sites (42). Delivery of nanoparticles into deeper layers of skin
without compromising its barrier properties has been challenging. As microporation results in formation
of micron-sized pathways in the skin, delivery of nanoparticles beyond the stratum corneum might be
possible. However, limited work has been published in this aspect.
6.2.4.1 Solid Microneedles

McAllister et al. published a first report on delivery of latex nanospheres through skin using micronee-
dles (43). Molecules of different radii such as calcein, insulin, BSA, and nanospheres were evaluated in
this in vitro study using solid microneedles. Human cadaver epidermis was pretreated with micronee-
dles. Without microporation, there were no detectable levels of any of the above-mentioned molecules.
With pretreatment, molecular diffusion on the order of 0.001–0.01 cm/h was seen depending on the
molecular radius of the molecule. Highest diffusion was seen for calcein and the lowest for nano-
spheres. Mechanism of permeation of the nanoparticles was evaluated using mathematical modeling.
It supported the theory that diffusion happens through the water-filled channels created in the skin by
microneedles.
In a study conducted by Coulman et al., diffusion of latex fluorescent nanospheres (100–150 nm diam-
eter) was evaluated (44). Skin was pretreated with silicon microneedles following application of nano-
spheres to the skin. Results suggested that the nanospheres migrated into microchannels and to the cells
of the epidermis. Similar results were obtained in a study conducted by Chabri et al. (45). Intradermal
delivery of polystyrene nanoparticles of approximately 100 nm in diameter was possible through the
microchannels. In another study, nanoparticles were found in the epidermis following application of
hydrogel/nanoparticle formulation in combination with microneedles (46).
Verbaan et al. evaluated an electrical applicator to apply microneedles with a preset speed. Various speeds
were experimented with fluorescein isothiocyanate (FITC)-tagged nanoparticles with a size of 200 nm.
Results indicated that nanoparticles were seen in the conduits irrespective of the speeds tested (14).
Delivery of PLGA nanoparticles loaded with coumarin 6 was studied by Zhang et al. Solid silicon
microneedles were used for pretreating the skin. Nanoparticles were found significantly in the epidermis
compared to dermis and the diffusion rate of nanoparticles was found to be dependent on the concentra-
tion of the nanoparticles (47).
Gomaa et al. studied permeation of PLGA nanoparticles across porcine skin pretreated with polymeric
microneedles. Permeation of nanoparticles was believed to be dependent on particle size, surface charge,
and composition (48).
6.2.4.2 Hollow Microneedles

Wang et al. conducted a study to evaluate the ability to inject particles intradermally using hollow
microneedles (49). Two different sizes of microparticles were tested 2.5 um and 2.8 um. They were
injected using a single hollow glass microneedle. Particles were successfully injected both ex vivo and in
vivo into hairless rat skin. Similarly, in another study hollow silicon microneedles were used to inject an
aqueous suspension of blue and fluorescent polystyrene microspheres (50). Observation using confocal
microscopy suggested that particles were detected at a depth of 70 um. However, the majority of the
particles were found to be 20 um from the surface of the skin.
6.2.4.3 Application in Drug and Vaccine Delivery

Several research groups have studied skin delivery of insulin using a combination of microneedles and
nano- or microparticles (51–53). In a study conducted by Ito et al., in mice, insulin was formulated into
chondroitin sulfate matrix and adsorbed onto two different types of porous microparticles (51). A control
comprising microneedles containing free insulin was included in the study. Blood samples were col-
lected from mice 8 h post-application for all treatment groups. A greater hypoglycemic effect was seen
with insulin–microparticle group compared to free insulin group. A “smart insulin patch” was developed
by Yu et al. It basically consisted of a microneedle array containing glucose-responsive vesicles loaded
with insulin in the tip (53). A chemical reaction at the local site would trigger dissociation of vesicles
leading to release of insulin. In vivo testing of this patch in a Type I diabetes mouse model indicated that
these arrays were able to control glucose levels over a period of few hours.
Skin is a very effective site for vaccination due to the presence of dendritic cells and Langerhans
cells in the epidermal region. Use of particle-based vaccine formulations could be advantageous
owing to their inherent immunogenic properties as showcased by several research groups (54). They
also have the ability to stabilize the antigen and protect it from any degradation (55–58). Also, they
can provide controlled release depending on the need. However, there might be exceptions, and sev-
eral factors such as physical, chemical properties of the antigen or particle matrix might influence the
final result. A study conducted by Bal et al. evaluated the delivery and immunogenicity of diphtheria
toxoid with N-trimethyl chitosan as the adjuvant. The vaccine nanoparticles were coated onto solid
metallic microneedles. Upon application, nanoparticles would deposit in the skin and act as a depot for
the antigen (39). Ovalbumin-conjugated nanoparticles were evaluated in another study in comparison
to a liquid ovalbumin formulation. They were applied in combination with a roller-type microneedle
device. The IgG titers obtained in mice with the nanoparticle group were higher than that with oval-
bumin solution (59).
Kumar et al. conducted a study to evaluate the combination of microneedles and nanoparticles for skin
delivery of DNA vaccine. PLGA nanoparticles were coated with plasmid DNA (60). The study was suc-
cessful in immunization of mice with a gene encoding a protective antigen against anthrax. Controlled
release using a combination of dissolving microneedles and nanoparticles was evaluated by Demuth et
al. (61). The microneedles were prepared using polyacrylic acid matrix with PLGA nanoparticles or solid
PLGA at the tip. Upon insertion, the microneedles dissolved releasing the nanoparticles. The vaccine
was found to be releasing from the nanoparticles over a few of weeks within the skin layers. Controlled
release of vaccine from particle formulations in conjunction with microneedles was also achieved in
another study conducted by Zaric et al. (62).
Combination of nanoparticles with microneedles provides a promising platform for vaccine delivery.
This approach has great potential, especially with the advantages particulate formulations have such
as antigen stability, depot release, and ability to enhance immune response. Further work is needed on
formulation optimization and microneedle fabrication to make this into a viable option for delivering
vaccines.
6.3 Conclusion
Microporation has provided an excellent platform for exploring skin as a potential route for drug admin-
istration, not limited to just small lipophilic molecules. All the published research suggests these micron-
scale devices have been shown to be very effective in administering a broad spectrum of drugs through
skin. They can be applied to elicit local or systemic action as required. Microneedles offer endless
possibilities with regard to how they can be used for drug delivery. They can be fabricated in a variety of
geometries, dimensions, and compositions.
Metallic microneedles were the first type to be introduced and tested. They used materials such as
silicon, titanium, and stainless steel. However, the past decade has seen the rise of dissolvable micronee-
dles made from biodegradable materials such as sugars and polymers. Although it would seem that
solid microneedles will be around for some time and have been proven effective, safety issues such as
immunogenicity to the metal and creating sharp waste is worrying. Dissolvable needles do not have such
issues; however, they might be subject to dosage constraints since everything needs to be incorporated
into a limited space.
Microneedles also offer a few different options on the mode of delivery, so that delivery system can
be tailored to the needs of the condition being addressed. A bolus dose can be achieved using coated
or dissolvable microneedles that release the drug right away upon insertion into the skin. Drug solution
can be injected or infused into deeper layers of the skin using hollow needles, which can also be used to
sample biologic fluid such as blood to measure glucose levels. This will be a very promising approach
especially in the case of diabetes. Insulin can be released from the patch based on blood glucose levels.
Targeting drug to a specific depth in the skin can be achieved by altering the needle length. Controlled
release is also possible. Drugs encapsulated in polymers with control-release properties can be fabricated
into microneedles to obtain a desired delivery profile.
Microneedles alone have excellent features for them to be developed into a robust delivery system.
This chapter has discussed studies conducted by several researchers to investigate and evaluate the
potential of combining them with other technologies. A clear majority of the published studies have
had a positive outcome with the combination approach. However, most of this research is in the early
stages. Combining two or more techniques seems to be practical on a lab scale at this point. Existence
of an FDA-approved microneedle product on the market will help boost further research in this area.
Gathering more information with some sort of preclinical testing will instill confidence in these combi-
natorial approaches, and more thought on device design, manufacturing and scale-up, safety, and regula-
tory aspects is needed.
Combination of microneedles with other technologies opens up a whole new arena in the field of
transdermal drug delivery. The synergistic effect seen in all the case studies discussed in this chapter
showcases its potential. More research in the coming years will add value to all the efforts in pushing
towards the development of a clinical product. Future studies should focus on development of prototypes
and gathering preclinical data.
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58. De Geest BG, Willart MA, Hammad H, Lambrecht BN, Pollard C, Bogaert P, et al. Polymeric mul-
tilayer capsule-mediated vaccination induces protective immunity against cancer and viral infection.
ACS Nano. 2012;6(3):2136–49.
59. Kumar A, Li X, Sandoval MA, Rodriguez BL, Sloat BR, Cui Z. Permeation of antigen protein-
conjugated nanoparticles and live bacteria through microneedle-treated mouse skin. Int J Nanomedicine.
2011;6:1253–64.
60. Kumar A, Wonganan P, Sandoval MA, Li X, Zhu S, Cui Z. Microneedle-mediated transcutane-
ous immunization with plasmid DNA coated on cationic PLGA nanoparticles. J Control Release.
2012;163(2):230–9.
61. Demuth PC, Garcia-Beltran WF, Ai-Ling ML, Hammond PT, Irvine DJ. Composite dissolving
microneedles for coordinated control of antigen and adjuvant delivery kinetics in transcutaneous vac-
cination. Adv Funct Mater. 2013;23(2):161–72.
62. Zaric M, Lyubomska O, Touzelet O, Poux C, Al-Zahrani S, Fay F, et al. Skin dendritic cell targeting via
microneedle arrays laden with antigen-encapsulated poly- D, l -Lactide- Co -Glycolide nanoparticles
induces efficient antitumor and antiviral immune responses. ACS Nano. 2013;7(3):2042–55.
7
Medical Applications of Microneedles
Samantha Tran
Stryker School of Medicine, Western Michigan University
Raja Sivamani
Department of Dermatology, University of California-Davis
Microneedling is a minimally invasive procedure that creates small pores called microchannels in the
stratum corneum of the epidermis layer of the skin. The microneedles can extend down farther and cre-
ate microchannels that reach the dermis layer of the skin, while keeping the skin partially intact.1 By
creating these microchannels, microneedles increase the skin’s permeability and enhance the absorption
of topically applied medications and therapies.
7.1 Types of Microneedles

Microneedles can be made from a variety of materials including silicon, metal, polymers, ceramic,
and silica glass.2,3 There are three general classes of microneedles: (1) solid, (2) dissolvable, and
(3) hollow-bore.
Solid microneedles: These create the microchannels in the epidermis to enhance delivery of topi-
cal drugs (e.g., via a drug-loaded patch, or a gel, cream, or ointment) so that the drugs can effectively
penetrate the skin. The needles might be either uncoated or coated with a drug of interest, so that, as
they penetrate, the drug is immediately delivered.3 Most clinical studies have utilized the use of solid
microneedles to create temporary holes through which topical medications are applied.
Dissolvable microneedles: These will naturally dissolve and release the drug when the needle is
embedded into the skin and the tip comes in contact with the interstitial fluid.3 The few studies that have
utilized dissolving microneedles in a clinical setting have been limited to vaccination studies (Figure 7.1).
Hollow-bore microneedles: These have openings at either the tip or the sides that allow a drug to be
delivered through the central lumen into the skin. The main limitations of hollow-bore microneedles are
the potential for clogging of the opening with tissue during insertion and flow resistance due to compres-
sion of the dermal tissue around the tips.3 The few studies that have utilized hollow-bore microneedles
have been largely limited to vaccination-based studies.
7.2 Microneedle Length

Microneedles come in a variety of lengths depending on what treatment is needed.
Microneedle
Use Length Mechanism
Topical drug application ∼0.7 mm or less Creates small pores so that drugs can effectively penetrate the skin.
Typically used for transdermal penetration enhancement.
Aging and/or wrinkles ∼0.5 to 1.0 mm Induces collagen formation and skin remodeling.
Acne scars or hypertrophic scars ∼1.5 to 2.0 mm Destroys the scar collagen bundles.
75
FIGURE 7.1 Microneedle patch (MNP) for influenza vaccination. (a) The MNP contains an array of 100 microneedles
measuring 650 μm tall mounted on an adhesive backing. (b) The MNP is manually administered to the wrist, enabling
self-administration by study subjects. (c) Microneedles encapsulate influenza vaccine (represented here by blue dye) within
a water-soluble matrix. (d) After application to the skin, the needles dissolve, depositing vaccine and leaving behind a patch
backing that can be discarded as non-sharp waste. (From ref. 7 with permission.)
In general, only a superficial penetration of the epidermis is needed for drug delivery, while a deeper
penetration into the dermis is required for cosmetic treatments for scars and acne.4
The length of the microneedle also impacts the time interval between each treatment. Longer needles
necessitate a longer gap between treatments to allow the skin to heal properly.4
7.3 Medical Therapies

Microneedles are an innovative device that can be used to deliver vaccine and enhance transdermal drug
delivery.5
7.3.1 Vaccinations
The benefit of a transdermal vaccine is that it can create a more robust antibody response compared to
an intramuscular vaccine. One of the touted benefits of microneedle-based vaccination is the possibility
of painless vaccinations.
One clinical pilot study compared intramuscular injection and microneedle-based injection with a
600-micron array of microneedles of influenza vaccines. The study was conducted in six treatment arms
among 370 volunteers.6 Microneedle-based injections generated sufficient immunogenicity and less pain
with the injection than the intramuscular injection, but caused more local edema and redness.
Another pilot phase 1 randomized study of 100 participants compared conventional administration
of influenza vaccines through intramuscular injection with self-administration of dissolving micronee-
dles (650 microns in a water-based dissolving matrix).7 The investigators found that microneedle-based
injections were just as effective at creating antigenicity while the reported pain was lower than for
Medical Applications of Microneedles 77
intramuscular injections. While pain-related side effects were lower, the two modes of injection had
similar side effects of local redness and fatigue.
7.3.2 Topical Anesthesia

Microneedles-based drug delivery has also been tested for enhancement of topical anesthesia. A study
of 15 participants that utilized 500 micron glass-based hollow microneedles found that microneedle-
based injections were just as effective as hypodermic needle–based injections for lidocaine.8 The study
found that 80% of participants did not consider the microneedle-based injection painful and 77% of
participants preferred the microneedle-based approach to anesthesia. Another study evaluated the use of
solid microneedle (200 microns) pretreatment followed by topical anesthesia in 21 participants and the
treatments were randomized to each forearm. One arm received the microneedle pretreatment while
the other received sham microneedle pretreatment prior to application of topical 4% lidocaine cream.9
The microneedle-treated arm was significantly less sensitive to needle lancet pain stimulation at 30 min,
and it showed improved pain tolerance with those with higher baseline pain by 10 min.
7.3.3 Photodynamic Therapy

Photodynamic therapy is typically used in the treatment of actinic keratoses and depends upon topical appli-
cation of 5-aminolevulinic acid that is allowed to incubate for an hour and then the skin is exposed to blue
light for the therapy. Two studies evaluated how microneedle pretreatment may alter the incubation times
needed with the 5-aminolevulinic acid. The first study utilized 690-micron solid microneedles that were
stamped onto the face as a pretreatment prior to topical application of the 5-aminolevulinic acid.10 The study
utilized a split-face design in 48 participants to compare the standard 60-min incubation on the sham-treated
side versus a 20-, 40-, or 60-min incubation (randomized) on the microneedle-treated side. The investigators
found that a 20-min incubation on the microneedle-pretreated side was as effective at clearing actinic kera-
toses as the standard 60-min incubation (Figure 7.2). A follow-up study in 33 participants evaluated the role
of using 500-micron solid microneedle pretreatments versus sham microneedle pretreatment in a split-faced
design that compared lower incubations times with the 5-aminolevulinic acid in a head-to-head fashion at 10
min and 20 min.11 While there was not statistical difference between the microneedle and sham-treated sides
with the 10-min incubation, there was a statistically significant improvement on the microneedle-treated side
at 20 min of incubation (76% on microneedle side versus 58% on the sham side, p < .01). The two studies
suggest that microneedle pretreatment can enhance the transcutaneous penetration of 5-aminolevulinic acid
and may allow for reduction of incubation times from 60 to 20 min. The results warrant further study in an
expanded group of participants to assess the role of microneedle pretreatment.
7.3.4 Glucose Sampling

Aside from delivering drugs, microneedles can be used as sensors for diagnostic purposes. For example,
microneedles can take a very small sample of blood and sample the glucose concentration in patients
with diabetes.12 Compared to the current glucometer with lancets, the microneedle will provide a pain-
less option to monitor glucose levels. By making glucose monitoring simpler, we can increase patients’
compliance and ability to control the sugars, improving health outcomes for them. A pilot clinical study
in 10 diabetic subjects showed that glucose sampling was both accurate and well tolerated over a 72-h
period. Longer use of microneedle sampling devices will need to be assessed in future studies for long-
term usability and tolerability.
7.4 Possible Side Effects and Risks

Overall, microneedles are well tolerated. Because it is minimally invasive and the epidermis is not bro-
ken, there is a lower risk of infection, post-inflammatory hyperpigmentation, and scarring.1 Furthermore,
the microchannels created by the needles close within 60–90 min, which reduces the risk of infections.
FIGURE 7.2 (a) Study flow schematic. (b) Forehead view of actinic keratoses before (I and III) and 1 month after (II and
IV) photodynamic therapy (PDT) treatment with microneedle (MN) pretreatment (left forehead in all images) and with
sham pretreatment (right forehead in all images). (c) Actinic keratosis complete response rate (CRR) results. Average CRR
(SEM) for the 20‐, 40‐, and 60‐min treatment and control arms were 71.4% (5.8) and 68.3% (3.3); 81.1% (4.6) and 79.9%
(4.5); and 72.1% (5.5) and 74.2% (6.9) respectively (n = 15, P = 0.51; n = 16, P = 0.79; n = 16, P = 0.72). (d) Pain scoring after
MN application. Pain assessment using a 100‐mm visual analogue scale was performed after MN pretreatment and after
PDT in all treatment groups (PDT 20, 20‐min aminolaevulinic acid [ALA] incubation; PDT 40, 40‐min ALA incubation;
PDT 60, 60‐min ALA incubation). Average pain scores after MN pretreatment (SEM) in the treatment and control arms
were 13.1 mm (2.6) and 2.4 mm (0.5) respectively (N = 48, P < 0.01). Average pain scores after PDT light treatment (SEM)
in the 20‐, 40‐, and 60‐min treatment and control arms were 15.7 mm (4.9) and 17.7 mm (4.9); 26.4 mm (7.5) and 24.7 mm
(7.1); and 37.2 mm (6.6) and 26.0 mm (4.9) respectively (n = 15, P = 0.35; n = 16, P = 0.23; n = 17, P = 0.046). *P < 0.05,
**P < 0.01. (From ref. 10 with permission.)
Side effects are minimal and include transient redness, mild dryness, and small hematomas.13 Erythema
may be present after treatment lasting up to three days, although this may persist longer with vaccina-
tions as the vaccine may induce redness apart from the microneedle itself.
Finally, it will be important to carefully choose what substances are delivered transcutaneously, as
there is always the potential for an allergy to topically applied products. As clinical research expands in
the area of microneedle-assisted topical delivery, we will get an increasingly better understanding of its
clinical efficacy and side effects.
REFERENCES
1. Hogan S, Velez MW, Ibrahim O. Microneedling: a new approach for treating textural abnormalities and
scars. Semin Cutan Med Surg. 2017;36(4):155–163.
2. Bhatnagar S, Dave K, Venuganti VVK. Microneedles in the clinic. J Control Release. 2017;260:164–182.
3. Garland MJ, Migalska K, Mahmood TM, Singh TR, Woolfson AD, Donnelly RF. Microneedle arrays as
medical devices for enhanced transdermal drug delivery. Expert Rev Med Devices. 2011;8(4):459–482.
4. Singh A, Yadav S. Microneedling: advances and widening horizons. Indian Dermatol Online J.
2016;7(4):244–254.
Medical Applications of Microneedles 79
5. Kwon KM, Lim SM, Choi S, et al. Microneedles: quick and easy delivery methods of vaccines. Clin Exp
Vaccine Res. 2017;6(2):156–159.
6. Levin Y, Kochba E, Shukarev G, Rusch S, Herrera-Taracena G, van Damme P. A phase 1, open-label,
randomized study to compare the immunogenicity and safety of different administration routes and
doses of virosomal influenza vaccine in elderly. Vaccine. 2016;34(44):5262–5272.
7. Rouphael NG, Paine M, Mosley R, et al. The safety, immunogenicity, and acceptability of inactivated
influenza vaccine delivered by microneedle patch (TIV-MNP 2015): a randomised, partly blinded, pla-
cebo-controlled, phase 1 trial. Lancet. 2017;390(10095):649–658.
8. Gupta J, Denson DD, Felner EI, Prausnitz MR. Rapid local anesthesia in humans using minimally inva-
sive microneedles. Clin J Pain. 2012;28(2):129–135.
9. Ornelas J, Foolad N, Shi V, Burney W, Sivamani RK. Effect of microneedle pretreatment on topical
anesthesia: a randomized clinical trial. JAMA Dermatol. 2016;152(4):476–477.
10. Lev-Tov H, Larsen L, Zackria R, Chahal H, Eisen DB, Sivamani RK. Microneedle-assisted incuba-
tion during aminolaevulinic acid photodynamic therapy of actinic keratoses: a randomized controlled
evaluator-blind trial. Br J Dermatol. 2017;176(2):543–545.
11. Petukhova TA, Hassoun LA, Foolad N, Barath M, Sivamani RK. Effect of expedited microneedle-
assisted photodynamic therapy for field treatment of actinic keratoses: a randomized clinical trial.
JAMA Dermatol. 2017;153(7):637–643.
12. Smart WH, Subramanian K. The use of silicon microfabrication technology in painless blood glucose
monitoring. Diabetes Technol Ther. 2000;2(4):549–559.
13. Al Qarqaz F, Al-Yousef A. Skin microneedling for acne scars associated with pigmentation in patients
with dark skin. J Cosmet Dermatol. 2018;17(3):390–395.
8
Therapeutic Drug and Biomolecule Monitoring
Potential for Microneedle Technologies
Sahan A. Ranamukhaarachchi1,2, Urs O. Häfeli2,3

1 Department of Electrical and Computer Engineering, University of British Columbia
2 Faculty of Pharmaceutical Sciences, University of British Columbia
3 Department of Pharmacy, University of Copenhagen
8.1 Introduction
Therapeutic drug and biomolecule monitoring (TDM) is the process of measuring the concentra-
tion of active pharmaceutical compounds and biomolecules in blood that, with proper interpreta-
tion, will influence therapy and future medical procedures [1]. TDM is of utmost importance when
drug candidates with a narrow therapeutic window are administered (Figure 8.1). Outside of this
window, a patient can be overdosed to cause potentially life-threatening side effects or under-
dosed to provide ineffective therapy [2]. Similarly, there are biomolecules that become available
or change concentration in the blood after intake of food and beverages, such as glucose, that are
not therapeutic drugs, but rather metabolites or disease-causing agents that need to be monitored.
The ability of continuously monitoring such biomolecules provides information for timely and
effective treatment to ensure the health and well-being of patients [3]. Furthermore, the detection
of elevated levels of specific markers, such as nitric oxide for inflammatory diseases or the protein
CA19-9 for pancreatic cancer, can indicate the occurrence of physiological changes in the human
body. Monitoring such biomolecules thus will help to diagnose health issues early and start treat-
ment on time [4–6].
TDM and diagnostic testing are conventionally conducted in blood samples withdrawn from patients
at regular intervals [7]. Blood sampling utilizes an invasive needle, or another sharp device such as a
lancet, to access blood and extract it from capillaries or veins. Each TDM time point requires at least
100 µL of whole blood [8]. Whole blood requires processing, such as centrifugation to extract serum,
before the analysis can be performed. Many of the TDM analytes in blood are separated and quanti-
fied using expensive and time-consuming laboratory processes that include liquid chromatography and
mass spectrometry (e.g., LCMS) [7]. Significant resources are thus allocated to TDM analyses in terms
of money and time, and there exist substantial opportunities to monitor and diagnose patients in more
efficient ways.
An exciting opportunity to improve on the painful blood sampling and expensive and slow sample
processing in TDM is the exploration of interstitial fluid (ISF) as a matrix for biosensing of drugs and
biomolecules, many of which show a predictable correlation with blood concentrations. With the devel-
opment of technologies that allow easy, minimally invasive, and pain-free access to ISF, novel concepts
have begun to emerge that will lead to a paradigm shift in TDM and point-of-care diagnostics. The
objectives of this chapter are to (1) explore the potential for TDM in ISF and compare it to blood analyses
and (2) provide a review of the significant work completed to date using microneedle (MN) technologies
for biosensing in TDM applications.
81
FIGURE 8.1 A typical therapeutic drug monitoring profile showing the narrow therapeutic window. The red line indi-
cates the blood concentration profile of the drug during multiple dosing; the ideally provided blood concentration required
for therapy is shown in blue. The total dose delivered by the blue curve, shown as the light blue area, is called the area under
the curve (AUC). (Figure obtained from Kim et al. (2008) with modifications [2].)
8.2 Therapeutically Monitored Drugs

Clinically, about a dozen drugs are regularly tested in patients to verify that the drug’s blood concen-
tration is in the optimal range, which means non-toxic but effective. The most important TDM drugs
include the immunosuppressant drugs tacrolimus and mycophenolate, the antibiotics gentamicin and
vancomycin, and some antiepileptic and anticancer drugs (Table 8.1).
TABLE 8.1
Clinically Important TDM Drugs
Drug Category Drug Frequency of Use
Immunosuppressants to prevent Cyclosporine Trough or 2 h post dose
rejection of transplanted organs, Mycophenolate*, tacrolimus, Trough
autoimmune disorders sirolimus
Antibiotics for treatment of resistant Aminoglycosides (amikacin, Both trough and 1 h post dose (daily)
bacteria gentamicin, tobramycin),
vancomycin*
Cardiac drugs for congestive heart Digoxin, digitoxin Trough or > 6 h post dose
failure, arrhythmias, angina Amiodarone Trough
Lidocaine, procainamide 2 h post dose
Antiepileptic drugs to prevent seizures Carbamazepine, levetiracetam, Trough (daily)
valproic acid At steady state (weekly or longer)
Phenobarbital*, phenytoin
Bronchodilators for asthma treatment Theophylline* Trough and 2 h (immediate release) or
4–8 h (slow release) post dose
Anticancer drugs, also used in Methotrexate* Often 24, 48, and 72 h after high-dose
psoriasis and rheumatoid arthritis therapy
Psychiatric drugs for bipolar disorder Lithium 12 h post-dose
and psychosis Valproic acid, amitriptyline, clozapine, Trough
fluoxetine
*Suitable or likely suitable for direct concentration measurements in ISF [10]
Adapted from Hallworth and Watson [9].
Therapeutic Drug and Biomolecule Monitoring 83
Testing the drug concentrations instead of blood in ISF would be directly possible in vancomycin and
other drugs listed in Table 8.1. Others, such as tacrolimus, are not appropriate for these analyses, as they
are typically highly protein-bound and cannot be found in ISF or do not establish a reliable presence
there with known correlations to blood concentrations and drug effects. Correlations between blood and
ISF concentrations of a few important TDM drugs have been established recently [11], but more work is
necessary to turn the currently exotic method into a useful and practical method.
For suitable drugs, however, the benefits of ISF sampling and especially on-device analysis can be
major. Microneedle sampling of ISF is pain-free and without bleeding, so even older people with sensi-
tive skin and children of all ages could undergo extensive analyses. One example in which ISF sampling
would have huge benefits is the measuring of the mycophenolate pharmacokinetics in pediatric intes-
tinal transplantation patients [12]. Children show enormous differences in the rate of mycophenolate
metabolism. Jia et al. (2017) showed, for example, that the AUC of three children after taking entero-
coated mycophenolate sodium was 5.3, 56.5, and 87.5 mg h L−1, which is an interindividual difference
of 16 times. Since side effects are often serious and include headache, nausea, and bloody diarrhea, it is
important to establish a patient’s reached drug concentration. Currently, this requires typically 11 blood
samplings within 12 hours, something that is difficult to do in a child, and would be easy to accomplish
with ISF sampling using microneedles.
8.3 Microneedle Technologies for Therapeutic Drug Monitoring

MN technologies have been developed, prototyped, and evaluated in vitro and in vivo for their respective
TDM, diagnostics, and physiological health monitoring, as described in this section. Work performed
to date has explored many strategies to employ MN devices for minimally invasive diagnostics and
monitoring activities creatively and uniquely. These strategies include point-of-care diagnostics devices,
using: MNs for ISF extraction followed by off-device analysis, ISF extraction followed by on-device
analysis without ISF extraction at all; and continuous monitoring systems using MNs. As the area of
MN-integrated biosensors for TDM and diagnostics improve and continue to develop, it is likely that
more unique and creative approaches will emerge to change the ways current TDM procedures are
conducted.
8.3.1 Interstitial Fluid Extraction Devices for Off-Device Analysis

ISF, which is abundant in the skin layers, is tightly trapped in its extracellular matrices [13], presenting
challenges to successful and repeatable extraction for biosensing applications. Considering that ISF is
present at ∼20 nL mm−2 in the epidermis and ∼800 nL mm−2 in the dermis [13], the necessity for extrac-
tion of large volumes of ISF for quantitative biomolecule analyses appears to be a major roadblock
in developing biosensors for ISF extraction. However, several studies have successfully demonstrated
various techniques for ISF extraction from the skin, followed by analysis of its content outside the ISF-
collecting MN device (termed off-device analysis henceforth).
In one of the first studies exploring the potential of ISF extraction using MNs, Wang et al. (2005) used
a glass MN device to penetrate 0.7–1.5 mm into the skin in hairless rats and healthy adults, and collect
ISF using a 26.6–66.6 kPa vacuum for 2–10 min [14]. They collected 1–10 µL of ISF and measured ISF
glucose concentrations, and compared to blood glucose collected from the tail vein of rats and finger
sticks in humans. ISF glucose levels correlated well with blood glucose levels in rats and human subjects,
although a 20-min time lag was observed. Several practical challenges faced during implementation of
this method included multiple steps required to conduct the analysis, requirement of transferring the
fluid out of the collection device for analysis, and evaporation of the collected fluid leading to mea-
surement variability and error. Nonetheless, Wang et al. provided the first indication of ISF extraction
through pores created through MNs on the skin.
To obviate the need for vacuum-assisted extraction of fluid and risk of ISF evaporation, Sakaguchi
et al. (2012) developed an alternative approach to poke-and-collect [15]. Sakaguchi et al. utilized solid
MN arrays to create micropores on the skin surface of human subjects through an applicator-driven
insertion. Upon removal of the MN arrays, a hydrogel patch was placed on the MN-treated area of the
skin to facilitate the collection of ISF from the skin by swelling action. Glucose and sodium ion con-
centrations were determined from the hydrogel matrix to generate the AUC for ISF (as shown in Figure
8.1), and compare to plasma glucose from the oral glucose tolerance test (OGTT). Sakaguchi et al. found
strong correlations between the ISF and plasma glucose levels, providing a simple solution for glucose
measurements without requiring blood. While they could extract and assess multiple analytes from ISF
through one process, drawbacks of the proposed process included prolonged measurement time com-
pared to the standard measurement, many steps required to obtain a measurement, and variability in the
rate of fluid collection during sampling.
Combining the approaches used by Sakaguchi et al., Donnelly et al. (2014) developed a hydrogel-
forming MN array, which increased its mass upon skin insertion, due to uptake of ISF from the skin by
the hydrogel [16]. These MNs were fabricated using blends of hydrolyzed poly(methyl vinylether-co-
maleic anhydride) and polyethylene glycol (PEG) cross-linked by esterification. Initially, it was shown
that the mass of the MN array increased by 30% after 6 h of being inserted in the skin. In a subsequent
study, Caffarrel-Salvador et al. (2015) demonstrated ISF extraction by swelling action of these hydrogel-
forming MNs during insertion for 1–2 h ex vivo into excised porcine skin, and in vivo into rats and human
subjects (Figure 8.2) [17]. Theophylline and caffeine were extracted from the hydrogel MNs and assessed
using high-performance liquid chromatography (HPLC), while glucose concentration was determined
using a glucose assay kit.
In a similar study, Romanyuk et al. (2014) developed solid MN patches with cross-linked hydro-
gels composed of poly(methyl vinylether-alt-maleic acid) and PEG, and demonstrated ISF uptakes up to
FIGURE 8.2 Hydrogel-forming microneedles for extraction of analytes from ISF. (Figure obtained from Caffarel-
Salvador et al. (2015) with permission [17].)
50 times the original array volume [18]. These patches were manually inserted by pressing into rat skin
in vivo for 1 h to extract ISF, followed by wetting the MN patch with 0.1 mL of water and ultracentri-
fugation to extract the collected ISF from the hydrogel matrix. Though the ability to extract ISF was
demonstrated through hydrogel-forming MN arrays, major limitations needed to be overcome for these
devices to be commercially viable, including but not limited to prolonged ISF collection periods, a need
to extract the ISF and its content from the hydrogel matrix, the requirement of large volumes (microliter-
range) of ISF for sample evaluation, and the requirement for large and expensive laboratory equipment
to conduct measurements.
8.3.2 Interstitial Fluid Extraction for On-Device Analysis

Due to the limited volume of ISF that could be extracted from the skin, MN-integrated biosensing
systems were developed to extract ISF and perform the biomolecule analysis on-device, without being
transferred to a separate instrument. In most on-device examples, the collected ISF is transferred out of
the MNs to a different compartment of the same biosensing system, such as a fluid reservoir or a sensing
chamber.
In the earliest demonstration of the capability of ISF extraction using MNs, Mukerjee et al. (2004)
designed an integrated biosensing system with a hollow MN array for transdermal biological fluid
extraction and sample analysis, all in one integrated device [19]. Hollow silicon MN arrays were fabri-
cated using a combination of deep reactive ion etching (DRIE), diamond-blade circular sawing, and wet
chemical etching techniques. The MN lumens were connected to a microfluidic chip located at the back
side of the array, where continuation of the MN lumens to microfluidic channels ensured the flow of fluid
by capillary action to the desired location in the chip. Mukerjee et al. demonstrated the ability of the
system to collect non-biological and biological fluids, such as water, glycerol, ISF, and whole blood using
this system. They demonstrated the ability of their hollow MN system with a “snake fang” tip design to
extract ISF in vivo from human earlobe skin over a 15–20 min period. The extracted ISF was analyzed
qualitatively for glucose by placing components of a commercial blood glucose test strip on the fluid
reservoir behind the MN array in the chip, and observing a color change in the test strip that indicated a
glucose concentration between 80–120 mg dL−1. The drawbacks of the Mukerjee sensor were the needs
for microliter-level volumes of ISF for analysis, prolonged time to collect ISF, and transfer of ISF to the
back side of the MN for analysis.
In a similar, but potentially more advanced approach for glucose sensing, Zimmerman et al. (2004)
developed a hollow silicon MN array to be integrated into an enzymatic glucose sensor with a porous
dialysis membrane [20]. Using this glucose sensor, Zimmerman et al. demonstrated a significant sensor
response after exposure to ISF suggesting the capability and potential for glucose sensing.
A decade later, Strambini et al. (2015) developed a similar glucose-sensing MN device with hollow
silicon dioxide MN arrays, containing projections at 100-µm height, 4-µm tip diameter, and 1 × 106 nee-
dles cm−2 [21]. These MN projections were an order of magnitude smaller than other MN technologies
that have been used for biosensing. A 10-µL-volume reservoir on a chip is integrated to the back side of
the MN array for ISF collection via capillary action through the MN lumens. A screen-printed enzymatic
glucose sensor was integrated to the chip located at the back of the array. The sensor was assessed for
glucose in MN-extracted simulated ISF from a reservoir in a petri dish, where the volume uptake was
estimated gravimetrically as the mass loss in the petri dish. This sensor could determine glucose at a
detection range between 0 and 35 mM at an accuracy within ±20% of the actual glucose concentration
in sample, a sensitivity of 0.46 µA mM−1 and a limit of detection of 0.6 mM. In contrast to Mukerjee
et al. and Zimmerman et al., Strambini et al. showed that their device can perform rapid and quantitative
analysis of glucose in ISF, although no in vivo evaluation was conducted. Nevertheless, drawbacks were
seen in Strambini’s system similar to those of Mukerjee et al., including the need to move the sample
outside the array for detection and micro-liter level of fluid, meaning a very small volume, making bio-
molecule analysis challenging.
Considering the drawbacks of the system designed by Mukerjee et al., Ranamukhaarachchi et al.
(2016) developed a point-of-care TDM device by integrating a gold-coated hollow microneedle with
an optofluidic sensing system to detect vancomycin (a therapeutically monitored drug) in sub-nanoliter
FIGURE 8.3 Functionalization of gold-coated hollow microneedle lumens for fluid collection, drug binding, and detec-
tion. (Figure obtained from Ranamukhaarachchi et al. (2016) with permission [22].)
volumes of fluid in vitro [22]. The coated needle’s inner lumen was surface-functionalized with a van-
comycin-specific peptide, which was then preloaded with a vancomycin-horseradish peroxidase (HRP)
conjugate (Figure 8.3).
The functionalized microneedle device was integrated into the sensing elements, where a microflu-
idic chip consisting of a simultaneous detection chamber and an optical waveguide was equipped with
micro-optical fibers for drug quantification using a simple absorbance scheme. During biological fluid
collection, the sample filled the microneedle lumen volume of 0.6 nL by capillary action, which was
significantly smaller than previously required sample volumes for sample analysis. Vancomycin pres-
ent in the sample competed for the vancomycin-specific peptide on the lumen surface, and displaced
the preloaded vancomycin-HRP conjugate. The remaining vancomycin-HRP was quantified by the 3,3′
5,5′-tetramethylbenzidine (TMB) assay, where a TMB solution was passed through the lumen to cause
a color change from clear to blue in the presence of vancomycin-HRP in a concentration-dependent
manner. The magnitude of color change was determined by absorbance measurements in the optoflu-
idic chamber requiring minute volumes (<50 nL) of TMB solution. Using this microneedle-optofluidic
biosensor, Ranamukhaarachchi et al. demonstrated the potential of the sensor to assess vancomycin
in its clinically relevant range (2.2–22.0 µM) with a high detection sensitivity (0.41 AU per 10 µM)
and extremely low limit of detection of 84 nM. The signal-to-noise ratio of this system was extremely
high, between 42.6 and 59.4 dB. The system’s main advantages were the extremely low volume of fluid
requirement, the capability to detect low-concentration TDM candidates with high signal-to-noise ratio,
the rapid operation from collection to analysis (altogether less than 5 min TDM time), and the lack of
need for sample transfer from the collection site to analysis. However, the system needs to be validated
using preclinical and clinical studies.
8.3.3 Microneedle-Biosensors without Interstitial Fluid Extraction Requirements

Considering the challenges of extracting ISF, several research groups have developed MN-integrated
biosensors for TDM and diagnostics purposes that did not require ISF extraction.
Corrie et al. (2010) developed a point-of-care diagnostic device to selectively extract biomarkers
directly from the skin using solid microprojection arrays (MPAs), made by deep reactive ion etching of
silicon, to eliminate the need for blood draws for diagnostics [5]. The device was evaluated on its capabil-
ity to capture anti-Fluvax®-IgG antibody, 21 days after administration of the Fluvax® from the epithelia.
Corrie et al. surface-functionalized the MPAs with thiolated PEG after coating the surface with a layer
of gold, and grafted anti-Fluvax®-IgG capture proteins. After applying the MPAs for a period of 10 min
in serum and in vivo in mouse ear skin, fluorescence intensity measurements on the MPA surfaces were
determined by confocal microscopy. Further, the functionalized MPAs were assessed by an enzyme-
linked immunosorbent assay (ELISA) method for anti-Fluvax®-IgG capture after insertion in mouse ear
skin for 10 min. Sensitive detection capability of the anti-Fluvax®-IgG biomarker showed promise for
the solid MN-based minimally invasive diagnostic devices. In addition, Muller et al. (2012) modified
the surface of the MPAs to immobilize anti-NS1 monoclonal capture antibody to bind the NS1 antigen,
which is a biomarker for dengue fever, in mice over a 20-min duration [23]. Using an ELISA assay in
a 96-wellplate, the captured concentration of the NS1 biomarker was quantified at a detection limit of
8 µg mL−1. Development of surface-functionalized MPAs has eliminated the need for a set volume of ISF
collection for analysis, which is a significant advantage, given the limited availability of ISF in the skin.
However, the prolonged duration for biomarker capture (10–20 min) and the need for expensive and large
laboratory equipment, such as a confocal microscope and 96-wellplate readers for measurement, present
drawbacks to using MPAs for diagnostics.
Windmiller et al. (2011) designed and developed an electrochemical biosensor using a two-component
MN system, which included solid and hollow MN devices, for monitoring glutamate and glucose. Solid
MNs were positioned inside the hollow MN, closing the lumen of the hollow MN and providing micro-
cavities, where analyte-recognition enzymes (glutamate oxidase and glucose oxidase) were entrapped in
a poly(o-phenylenediamine) film by an electropolymeric process [24]. This entrapment ensured the rejec-
tion of interfering electroactive compounds in the sample. The electrochemical sensor was assessed for
detection of glutamate and glucose in vitro in a buffer solution and in undiluted human serum. The sen-
sor measured the pathophysiological glutamate concentration range (0–140 µM) at a sensitivity of 8.1 nA
µM−1 and a limit of detection of 21 µM. Similarly, the sensor detected glucose over its pathophysiological
range from 0–14 mM at a sensitivity of 0.353 µA mM−1, a limit of detection of 0.1 mM, and a signal-
to-noise ratio of 3. Similarly to Keum et al. and Corrie et al., the major benefit of this technology is the
lack of need for extraction and sampling of biological fluids in monitoring and diagnostics applications.
Similarly, Miller et al. (2012) devised an all-in-one MN-based sensor for in vitro amperometric detec-
tion of pH, glucose, and lactate to monitor metabolic acidosis and presence of tumors [6]. Hollow MNs
in an array were aligned with a well, which was filled with a carbon paste for sensing either pH, glucose,
or lactate, and electrically isolated from one another. Change in pH, glucose concentration, and lactate
concentrations in ISF-like physiological conditions (between pH 5 and 8) was detected by the carbon
electrode in 0.1 M phosphate buffer against an external Ag/AgCl reference and Pt counter electrodes.
However, the sensitivity of detection using this sensor (2.5 nA mM−1 glucose) was significantly lower
than previously mentioned approaches. In addition, Miller et al. demonstrated the potential of a cell-
resistant coating, called Lipidure®, to prevent biofouling of the sensors by macrophage adhesion, which
is expected to increase the lifetime of the sensor in vivo when implanted as an array of sensing electrodes.
Keum et al. (2015) developed an MN sensor system (MSS) using a solid array connected to an endo-
microscope for detection of colon cancer [4]. The MSS was fabricated using polycaprolactone, with
coatings of polydopamine and poly(3,4-ethylenedioxythiophene), followed by functionalization of hemin
molecules on the surface for nitric oxide (NO) binding and detection. Keum et al. confirmed the perfor-
mance of the MSS for NO detection in vitro in simulated biological fluids and cell culture media, and
in vivo in melanoma tissue. Further, when the MSS combined with the endomicroscope was inserted
into mouse melanoma polyp regions, a sudden drop in the current detected by the electrical sensor was
observed, in contrast to lack of significant current change in normal tissue. The MSS, operating at 100
mV, demonstrated detection of NO at a high sensitivity of 1.44 µA cm−2 µM−1 with a limit of detection
of 1 µM NO to detect and distinguish cancer tissues in vivo from normal tissue in real time. Further
developments to this MSS system for clinical applications will contribute significantly to improve early
detection of cancers.
8.3.4 Continuous Monitoring Microneedle Devices

One of the most promising applications for MN-integrated biosensors is continuous monitoring of bio-
molecules from the skin’s ISF. Though some approaches described previously hinted at the possibility of
continuous monitoring, this area of research and development remains to be explored in greater detail.
The first-ever MN-based continuous monitoring device that might be partially implanted in the epi-
dermis was described by Jina et al. (2014), who developed a hollow MN-integrated continuous glucose
monitoring (CGM) biosensor [25]. They demonstrated its capability accurately and continuously mea-
sured glucose concentrations in the body using ISF. The first prototype of the CGM biosensor consisted
of a silicon MN array (∼200 hollow projections), a glucose sensor, an electronics module, and a fluid flow
system. The sensing chamber in Figure 8.4, which was located outside the cross-section of the skin, was
filled with a proprietary buffer solution containing phosphate and citrate ions, to perform mutarotation
of glucose and reduce the rate of wound healing in the skin due to the tissue damage caused by the MN
insertion, respectively. In doing so, this CGM biosensor was designed to be inserted into the epidermal
layer of skin to allow glucose present in the ISF to passively diffuse to an external glucose sensor located
behind the array. This approach was unique among MN-integrated biosensors, since ISF extraction was
not required as a primary function of the device.
The biosensor, currently being commercialized by Arkal Medical (Fremont, CA, USA), was clini-
cally evaluated in 10 patients, who have received insulin treatment for over 16 years. CGM was done
over periods of 48 h and 72 h, and measurements were compared with finger-stick blood glucose levels
[25]. A lag of 17 min was found between the ISF glucose measurements and the blood glucose mea-
surements, which was comparable to that of other commercialized subcutaneously implanted glucose
FIGURE 8.4 Continuous glucose-monitoring biosensor. (Figure obtained from Chua et al. (2013) with permission [26].)
sensors [27]. The method introduced and validated by Jina et al. for monitoring analytes in the ISF
using hollow MNs can be applicable to and useful for other TDM candidate drugs to obtain real-time
data to guide therapy.
8.4 Conclusions and Outlook

With predominant benefits of painless insertion, ability to extract ISF, presence of many biomolecules
in ISF, and already identified correlations between ISF and blood for some biomolecules, microneedle-
integrated biosensing devices have the potential to revolutionize diagnostics and TDM. Limited explo-
ration of methodologies to utilize microneedles for minimally invasive biosensing has been performed
to date, and though biosensing concepts have been presented previously with various MN technolo-
gies, the lack of preclinical and clinical validation on such systems presents gaps in knowledge on the
performance of MN biosensors. It is envisioned that, similarly to the use of strategies employed in
microneedle-based drug delivery systems, using unique microneedle strategies for biosensing will facili-
tate the development and commercialization of a plethora of novel devices for a multitude of applications.
Combined with the movement toward digital health and wellness, it is likely that some MN technolo-
gies for continuous monitoring of biomolecules will be integrated to communicate with digital health
trackers, such as mobile phones and activity watches. In contrast, other MN technologies will be used
as single-use cartridges for point-of-care diagnostics. As the field of MN biosensors continues to grow
over the next decade, more clinical and preclinical data, regulatory considerations, usability and human
factors inputs, and biosensing applications will emerge to mark an exciting era for MN technologies.
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hensive panel of drugs. Journal of Pharmaceutical Sciences, 2012. 101(12): p. 4642–4652.
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15. Sakaguchi, K., et al., A minimally invasive system for glucose area under the curve measurement using
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16. Donnelly, R.F., et al., Microneedle-mediated minimally invasive patient monitoring. Therapeutic Drug
Monitoring, 2014. 36(1): p. 10–17.
17. Caffarel-Salvador, E., et al., Hydrogel-forming microneedle arrays allow detection of drugs and glu-
cose in vivo: potential for use in diagnosis and therapeutic drug monitoring. PloS One, 2015. 10(12):
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18. Romanyuk, A.V., et al., Collection of analytes from microneedle patches. Analytical Chemistry, 2014.
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9
Commercialized Microneedles
KangJu Lee
SeungHyun Park
Ji Yong Lee
Won Hyoung Ryu
School of Mechanical Engineering, Yonsei University
9.1 Factors Driving Microneedle (MN) Technology into the Market

Microneedle (MN) technology has been rigorously investigated during the last decade for various appli-
cations such as vaccination, cosmetics, pain treatments, ophthalmology, and many more. Recently, MN
technology started rapidly moving from the research to commercial development stages. One of the
reasons for such fast development is ascribed to the maturation of MN fabrication technology. The major
portion of MN research in the beginning was focused on how to make MN structures using biocompat-
ible polymers, metals, or ceramics. Now, after a decade of research, MN fabrication can be scaled up for
mass production, and it can be even outsourced. Another factor can be found in the minimally invasive
nature of MN-based drug delivery. The MNs penetrate through the epidermal and dermal layers, and
they deliver drug into the tissue. In many cases, MNs are pulled out and they leave only drug beneath
the dermal layer of the skin. This is a huge benefit for an FDA approval process compared to other drug-
delivery methods whose devices remain in the human body. This expectation of shorter and possibly
easier FDA approval processes makes MN technology attractive to many companies for commercial
development. In addition, expandability of MN technology to a wide range of diseases is also a strong
factor that drives the commercialization of MN technology for various diseases. Interestingly, since MN
technology allows easy and relatively safe access to the inside of human body, it can also be used as a
biomedical sensor to collect various biological information without expensive equipment or the aid of
health care professionals. Thus, rapid commercialization efforts of MN technology in the biosensor field
are also expected in the near future. In this chapter, various MN-related technologies will be introduced
and their current efforts in commercialization development and clinical trials will be discussed.
9.2 Microneedle Injection System

Injection systems that use an MN to temporarily inject a drug formulation into the body are listed in
Table 9.1. The MN injection system is based on an intradermal route by which a liquid or solid drug
can be injected painlessly into the body using a hollow or solid MN with an applicator. As a one-time
delivery system, it is different from a patch drug delivery system, which is attached to the skin and
continuously releases drugs or injects drugs at regular intervals over a certain period. MN injection
systems are divided into two types. First, a disposable injection unit with an applicator typically deliv-
ers a drug using a hollow MN that can be mounted on the applicator. Second, an integrated microin-
jection system, which is a combined system of the MN, prefilled reservoir, and applicator, delivers a
drug into the body. In this chapter, the features, use, research, clinical trials, and certifications for the
commercialization of MN injection systems are discussed.
91
92
TABLE 9.1
Microneedle Devices for Commercialization
Manufacturer Product Certification Drug and Purpose Dimension Remarks
Disposable injection NanoPass Technologies MicronJet 600™ FDA 510(k) cleared, Vaccine for polio, MN height: 600 μm Commercialized
unit with applicator Ltd. CE marked zoster, and influenza;
insulin
Debiotech Debioject™ FDA phase 1 Pasteur® rabies MN height: 350–900 μm;
completed, vaccine single MN or 3-MN array
CE marked
NanoBioSciences AdminPen™ unknown Liquid formulations MN height: 500–1400 Commercially available for clinical
μm; trials
31-to-187-MN array
3M™ Hollow FDA phase 1 ongoing Cancer vaccine MN height: 1500 μm; Panacea Pharmaceuticals Inc.
Microstructured (PAN-301-1) 12-MN array started FDA phase 1 clinical trials
Transdermal System for intradermal injection of
(hMTS) PAN-301-1: HAAH Nanoparticle
Therapeutic Vaccine using 3M™
hMTS.
Bayer HealthCare BETACONNECT™ FDA approved BETASERON® Needle diameter: Commercialized
Pharmaceuticals Inc. (interferon beta-1b) 300 μm

Integrated Becton Dickinson Soluvia™ FDA approved Fluzone® (influenza MN height: 1500 μm Sanofi Pasteur obtained FDA
microinjection vaccine) approval of Fluzone® Intradermal
system Quadrivalent Vaccine using BD
Soluvia™.
Commercialized
Clearside Biomedical SCS microinjector FDA phase 3 Triamcinolone MN height: 700–800 μm
Inc. completed acetonide (TA)
(continued)
TABLE 9.1 (Continued)
Microneedle Devices for Commercialization
Manufacturer Product Certification Drug and Purpose Dimension Remarks
MN patch for Karatica Co., Ltd I’m Fill Needle Patch FDA human OTC Hyaluronic acid, 400-MN array Commercialized
cosmetics drug acetylhexapeptide-8
moisturizing,
anti-aging
Junmok International Royal skin FDA Human OTC Hyaluronic acid, MN height: 500–750 μm Commercialized
Co., Ltd. hyaluronic acid drug lactose moisturizing,
micro patch anti-aging
RAPHAS Co., Ltd Acropass FDA human OTC Hyaluronic acid, EGF MN height: 350 μm; Commercialized
drug moisturizing, needle diameter: 30 μm
anti-aging
Nissha Co., Ltd Neo Basic HA Fill - Hyaluronic acid skin 3600-MN array Commercialized
Micro Patch care
MN patch for Micron Biomedical, Inc Micron Biomedical’s FDA phase 1 ongoing Flu vaccination MN height: 650 μm;
vaccination microneedle patch base diameter: 200 μm;
100-MN array
Vaxxas Nanopatch™ ANZCTR phase 1 Vaccine, Fluvax® 20,000-MN array
ongoing
Corium International, MicroCor® FDA phase 2a PTH(1-34) MN height: 200 μm
Inc. completed
Zosano Pharma, Corp. ADAM FDA phase 3 ongoing Zolmitriptan MN height: 500 μm
Nemaura pharma, Ltd. Micropatch™ Unknown Vaccine Unknown
MN patch using Valeritas, Inc. V-Go® FDA 510(k) cleared Insulin Needle dimeter: 300 μm Commercialized
micro-sized needle Nemaura Pharma, Ltd. Memspatch Insulin Unknown Insulin Unknown
injection Microneedle Device
(IMD)
SteadyMed, Ltd. Trevyent™ Ready to resubmit for Treprostinil Unknown
NDA approval
Enable Injections, Inc. Enable Smart Unknwon Various Unknown
enFuse™
93
FIGURE 9.1 (a) MicronJet 600™ from NanoPass Technologies Ltd., (b) Debioject™ from Debiotech, (c) AdminPen™
from NanoBioSciences, (d) 3M™’s Hollow Microstructured Transdermal System (hMTS), and (e) BETACONNECT™
from Bayer HealthCare Pharmaceuticals Inc. Scale bar indicates 1 cm.
9.2.1 Disposable Injection Unit with an Applicator

A disposable injection unit with an applicator is a combination of a disposable MN and an applica-
tor. As it is not a prefilled injection unit, any liquid formulation can be delivered. The injector of
a disposable injection unit is divided into two concepts that are commercial syringes and custom-
ized applicators. In addition, a pen-type injection system has been developed, in which a commer-
cial syringe is embedded in a pen-type injector, and the insertion depth or injection speed can be
controlled.
As a painless intradermal injection system, a disposable unit connected to a syringe may be the first
developed injection system that consists of a hollow MN unit and a standard commercial syringe. MicronJet
600™ from NanoPass Technologies Ltd. (Figure 9.1a), Debioject™ from Debiotech (Figure 9.1b),
and AdminPen™ from NanoBiosciences (Figure 9.1c) are disposable MN units that can be mounted on
the syringe tips. MicronJet 600™ is a pyramid-shaped hollow MN with a height of 600 μm for intra-
dermal injections. Debioject™ is a microstructured hollow MN with a height of 350–900 μm that can
infuse drug solutions into the dermis using a poke-and-flow approach. AdminPen™ is a planar MN
with a height of 500–1400 μm and consists of a rectangular base and tapered tip. It is a solid MN and it
creates a passage where the drug is delivered through the skin layer during the injection. For the lower
cost of fabrication, these devices are manufactured by microfabrication technology. MicronJet 600™
is fabricated using a silicon etching technique to form a sharp tip [1]. Debioject™ was also developed
using photolithography and deep silicon etching [2], and AdminPen™ uses electrochemical machin-
ing, electrical discharge machining, and other techniques [3]. MicronJet 600™ and Debioject™ are the
most actively researched MNs. MicronJet 600™ has obtained FDA 510(k) clearance and CE mark, and
Debioject™ is also a CE1-marked MN device. MicronJet 600™ is currently undergoing FDA phase 2
clinical trials for allergy and cancer immunotherapy, and the varicella-zoster vaccine. MicronJet 600™
has demonstrated an improved immune response to an intramuscular full dose of Fluzone® with 4% to
40% of the intramuscular dose [4, 5]. Debioject™ completed FDA phase 1 clinical trial for intradermal
rabies immunization using the vaccine Rabique Pasteur® with 20% of the standard intramuscular dose
1 The CE mark indicates that the manufacturer of a product takes responsibility for the compliance of this product with all
applicable European health, safety, performance and environmental requirements.
Commercialized Microneedles 95
in 2015. A reduced dose of rabies vaccine administered with Debioject™ induced a humoral immune
response similar to a full dose delivered by intramuscular injection with classical needles [2].
A disposable MN unit embedded in its customized applicator has been developed. The 3M™
hollow microstructured transdermal system (hMTS) (Figure 9.1d) and a multi-injection adaptor
from Microdermics are disposable units which can be mounted in a customized applicator. 3M™’s
polymeric hollow MN array is located on a 1.27-cm 2 circular base and consists of eighteen 500–900
μm microstructures [6]. Recently demonstrated models contain a polymer MN array with 12 hol-
low MNs, each approximately 1500 μm on 1 cm 2 of a circular base. The polymeric MN fabricated
using a molding technique is mounted on a designed applicator consisting of a spring and liquid
reservoir. The hMTS system delivers approximately 0.5–2 mL of pharmaceutical formulations, such
as Cimzia®, Monoclonal AB, and protein, with an injection time of 1–5 min. Intradermal delivery
using the hMTS had a larger immune response than that of intramuscular delivery [7]. The 3M™
human tolerability study showed that approximately 2 mL of the drug formulation could be delivered
within 2 min using the hMTS [8]. In addition, Panacea Pharmaceuticals Inc. started FDA phase 1
clinical trial for intradermal injection of PAN-301-1: HAAH Nanoparticle Therapeutic Vaccine
(cancer vaccine) using 3M™ hMTS in 2017. Microdermics has recently developed metallic hollow
MNs using MEMS technology and fabricated a prototype of the disposable unit that can be con-
nected to a commercial syringe. They demonstrated unique multi-injection adaptors and customized
kits using their patented platform. In 2017, Microdermics entered a strategic agreement with con-
tract development and manufacturing organization (CDMO), Vetter, for drug product manufactur-
ing and packaging.
Finally, a pen-type injection system, in which an extremely long and slender needle is used,
has been reported that can control the depth of insertion and the injection time, for example, the
BETACONNECT™ electronic auto-injector from Bayer HealthCare (Figure 9.1e). BETACONNECT™
delivers BETASERON®, which is used to reduce relapsing-remitting multiple sclerosis (RRMS).
A user can control the injection volume 0.25–1 mL of the drug at a depth of 8–12 mm using its
FDA-approved smartphone application myBETAapp™ via Bluetooth technology. Bayer HealthCare
conducted a study on patient satisfaction using BETACONNECT™. The user satisfaction score was
higher than the conventional syringe injection for its ability to adjust the injection depth and speed [9].
In addition, as the first and only electronic auto-injector, Bayer HealthCare received FDA approval for
BETACONNECT™ in 2015.
9.2.2 Integrated Microinjection Systems

An integrated microinjection system is a combined system of MNs and reservoirs that are prefilled with
a desired drug, and syringes. Most integrated microinjection drug-delivery systems transfer liquid drug
into the body (referred to as a prefillable microinjection system); however, solid MN injection using an
applicator, referred to as separable MN injection, has also been demonstrated).
The first examples of an integrated microinjection system are the Soluvia™ from Becton
Dickenson (BD) (Figure 9.2a) and the SCS (suprachoroidal space) microinjector from Clearside
Biomedical Inc. (Figure 9.2b). The BD Soluvia™ prefillable microinjection system is a glass prefill-
able spring-based syringe system integrated with a 1.5 mm long 30 gauge stainless steel needle. The
SCS microinjector is a prefillable suprachoroidal microinjection system with a height of approxi-
mately 700–800 μm for ocular injection. The SCS microinjector was fabricated from a 33G stain-
less steel needle with laser shaping and electropolishing [10]. BD conducted clinical trials involving
more than 700 subjects and 3500 injections with BD Soluvia™ and demonstrated the safety and
ease of use [11]. In addition, the BD clinical tests showed that the MN was barely perceptible when
penetrating the skin, and effectively injected drug into the intradermal layer regardless of the sub-
ject’s gender, ethnicity, and body mass [12]. Consequently, Sanofi Pasteur obtained FDA approval
of Fluzone® Intradermal Quadrivalent (influenza vaccine) for adults using BD Soluvia™ in 2014.
In addition, an FDA phase 3 clinical trial for suprachoroidal injection of CLS-TA (triamcinolone
acetonide) in subjects with noninfectious uveitis (AZALEA) using the SCS microinjector has been
completed in 2018.
FIGURE 9.2 Soluvia™ from Becton Dickenson.
As another example, the JUVIC Microlancer device is a painless and patchless shooting microstruc-
ture that delivers solid insulin MNs directly into the body [13]. This spring-loaded system injects cone-
shaped solid MNs into the tissue by detaching individual MNs from a thin substrate by punching MNs
with pillars through the thin substrate. Injected MNs have a height of 600 μm and a bottom radius of
252 μm with an injection depth of approximately 50–100 μm in 50–100 ms. Microlancer overcomes
the difficulties of complete injection through the thick hair-covered areas of the skin. A report on the
progress of the clinical trials using Microlancer has not been published yet; however, it is an anticipated
product that can achieve sustained drug delivery using a solid MN injection system.
9.3 Microneedle Patch System

9.3.1 Cosmetics
Recently, an MN patch has gained rapid momentum in the cosmetic field for skin moisturizing or
anti-aging. Most of the commercialized MN patches are composed of HA that dissolves into the
skin after administration. MNs made of HA can moisturize skin tissue and deliver small therapeutic
molecules for skin improvement via their dissolution. Karatica Co., Ltd. developed an MN cosmetic
patch for the treatment of tissue around the eyes and mouth. The I’m Fill Needle Patch contains over
400 HA needles with acetylhexapeptide-8 (Figure 9.3a). The Royal Skin Hyaluronic Acid Micro
Patch developed by Junmok International Co., Ltd. is a HA MN patch that contains lactose and
allows the ingredients to penetrate the stratum corneum (Figure 9.3b). The I’m Fill Needle Patch
and Royal Skin Hyaluronic Acid Micro Patch obtained FDA Human OTC drug for moisturization
and removal of fine wrinkles. RAPHAS Co., Ltd. has developed a HA-based dissolving microstruc-
ture patch, referred to as Acropass (Figure 9.3c). The backbone materials of the MN patch are the
swellable polymer mixtures which contain epidermal growth factor for anti-aging. RAPHAS Co.,
Ltd. has international patents, including a droplet-born air blowing (DAB) method for fabrication
of the Acropass MN [14]. The clinical trials showed positive outcomes in terms of the overall
condition and elasticity improvement of skin after treatment by HA MN patches. The Acropass
was also registered Human OTC drug in FDA. The Neo Basic HA Fill Micro Patch is based on
the MicroCure ®, dissolving MN technology of the Nissaha Co., Ltd. (Figure 9.3d). COSMETEX
ROLAND Co., Ltd adopted the MicroCure ® technology and developed MNs with flat-end shapes
for greater safety.
9.3.2 Vaccination
An MN vaccine patch induces low pain, reduces administration times, and does not contain a
cold-chain that might be affected by temperature variation during storage and transport. Micron
FIGURE 9.3 (a) Karatica Co., Ltd., I’m Fill Needle Patch, (b) Junmok International Co., Ltd., Royal Skin Hyaluronic
Acid Micro Patch, (c) RAPHAS Co., Ltd., Acropass, (d) Nissha Co., Ltd., Neo Basic HA Fill Micro Patch.
Biomedical, Inc. and Vaxxas lead the development of vaccine-coated MN patches worldwide.
Micron Biomedical’s Microneedle Patch (Figure 9.4a), attached like a bandage, delivers dermal
immune system cells into the skin to enhance the immune response in the epidermis. A phase 1
clinical trial for FDA approval showed that the Micron Biomedical’s Microneedle Patch was safe
and demonstrated an immune response as a flu vaccine. Vaxxas developed and commercialized
Nanopatch™ for vaccine delivery that enables immune system activation below the skin surface
(Figure 9.4b). Nanopatch™ consists of a 1 cm 2 square of silicon with approximately 20,000 vaccine-
coated MNs on the surface. In a mouse model, the Nanopatch™ array increased immunogenicity
with much reduced dose of Fluvax® (100-fold reduction was achieved) and higher vaccine efficacy
was achieved. The Nanopatch™ is currently undergoing clinical trials for Australian New Zealand
Clinical Trials Registry (ANZCTR).
Different types of MN applicators have been developed. Using an applicator, drug and vaccine
could be delivered by a simple and one-step administration and the MN insertion pressure on the
skin surface could be controlled. Corium International, Inc. has developed proprietary MicroCor ®
transdermal technology that utilizes dissolving MNs for drug delivery (Figure 9.4c). MicroCor ®
is fabricated by a combination of a water-insoluble backing layer and a solid-state biodegradable
microstructure array containing an active therapeutic agent using the drug-in-tip technology. The
MicroCor PTH(1-34) product, being developed for the treatment of osteoporosis, has successfully
completed a phase 2a clinical evaluation. The Zosano Pharma Corp.’s patch system developed its
unique microprojection array, called adhesive dermally applied microarray (ADAM) (Figure 9.4d).
ADAM is mounted on the ZP-applicator and attached on the skin surface like an adhesive ban-
dage. In the phase 1 clinical trial, ADAM showed a three-times-higher drug effect than that of
the oral administration of Zolmitriptan for migraine treatment [15] and a phase 3 clinical trial has
been conducted. Nemaura Pharma, Ltd. developed an advanced drug loading system, a solid dose
delivery device called Micropatch™ (Figure 9.4e). Since the drugs are coated on the surface of the
needle with a frustoconical-shaped pellet, Micropatch™ can deliver a solid dose below the skin. The
FIGURE 9.4 (a) Micron Biomedical, Inc., Micron Biomedical’s Microneedle Patch, (b) Vaxxas, Nanopatch™, (c) Corium
International, Inc., MicroCor®, (d) Zosano Pharma Corp., ADAM (e) Nemaura Pharma, Ltd., Micropatch™.
pellet is fabricated by compressing the combination of a freeze-dried vaccine and excipients using
a micro-press to the desired size.
9.3.3 Micro-Sized Needle Injection Patch

For a patient who requires multiple and continuous drug delivery, patch-type needle injection devices
that combined a micro-sized hypodermic needle have been developed. A patch-type applicator is able to
sustain drug delivery while attached to the skin for dose control of drug delivery. Especially for a diabetic
patient, a patch-type device decreases discomfort and amplifies drug efficacy owing to the automatic,
continuous, and self-administered drug delivery. Valeritas, Inc. developed FDA 510(k) cleared V-Go®, a
simple and disposable device for the delivery of basal-bolus insulin therapy (Figure 9.5a). V-Go® deliv-
ers insulin using 30-G hypodermic floating needle by pressing a button, without the use of batteries or
complicated programming that help Type 2 diabetic patients easily control their glucose levels [16]. The
Memspatch® insulin microneedle device (IMD) of Nemaura Pharma, Ltd. is an injector that infuses
insulin by sliding the operating portion that reduces the patient’s fear of needle pain (Figure 9.5b).
Currently, the clinical trial showed that Memspatch® induced a lower pain level in Type 2 diabetic
patients than other pen injectors.
SteadyMed, Ltd. has developed pump-type drug infusion devices utilizing hypodermic needles. The
SteadyMed, Ltd.’s Trevyent™ is equipped with a self-powered expanding ECell® that pushes a piston
and collapses the primary container that is filled with a sterile liquid drug (Figure 9.5c). SteadyMed, Ltd.
was advised by the FDA to resubmit its new drug application (NDA) for Trevyent™ for the treatment of
pulmonary arterial hypertension (PAH).
Finally, other micro-sized needle injection patches include Enable Injections, Inc.’s Enable Smart
enFuse™ and Microdemics’s Prefill Patch. Enable Smart enFuse™, which can store various volumes by
selecting reservoir size, has a function that allows the user to pause the injection at any time (Figure 9.5d).
Enable Smart enFuse™ is equipped with a reconstitution filling system that allows mixing/reconstitution
and transferring of the lyophilized formulations or mixing of two liquid formulations. Microdermics also
developed prototypes of needle patch devices called Prefilled Patch (Figure 9.5e), designed to enable
pain-free injection and improvement of comfort and treatment to patients while attached on the skin.
These devices contain various volumes of drugs and induce the dose-sparing effect of intradermal vac-
cine delivery.
FIGURE 9.5 (a) Valeritas, Inc., V-Go®, (b) Nemaura Pharma, Ltd., Memspatch Insulin Microneedle Device (IMD),
(c) SteadyMed, Ltd., Trevyent™, (d) Enable Injections, Inc., Enable Smart enFuse™, (e) Microdermics, Prefilled Patch.
9.4 Other Microneedle-Related Techniques

Several techniques have been developed and used over the past few decades for transdermal drug deliv-
ery enhancement, including sonophoresis, iontophoresis, and electroporation for improving the mode of
drug delivery across the stratum corneum at the therapeutic level. However, these techniques have low
efficiency of drug delivery. Since the first MNs were developed for transdermal use in 1998, they have
been applied to the drug delivery field alone, and attempts have been made to improve transdermal drug
delivery by combining the MNs with electrically driven technologies as well. Hollow or solid MNs can
be pre-injected to provide a certain permeability increment, while a simultaneous ultrasound or electric
field can enhance the flow rate via convection. Chen et al. attempted this combination (MNs with
sonophoresis) to deliver calcein and BSA, and the enhancement showed drug permeability 9 times
higher for calcein and 12 times higher for BSA than that of passive diffusion [17]. Han et al. used
two sets of solid MNs to disrupt the skin surface and conducted sonophoresis. As a result, the per-
meability with the MN treatment was 2 times higher than that of a non-MN [18]. When an MN was
integrated with iontophoresis, large molecular compounds were delivered to the skin or into the eye
with high efficiency [19, 20]. Furthermore, in the field of electroporation, a commercialized prod-
uct for a medical esthetic application, an electroporation needle (EPN) was developed by Eunsung
Global Corporation (Figure 9.6a). An EPN has an MN array (9 MNs and a 200-µm diameter) at the
end of an electroporation applicator. The array is repeatedly injected at a rate of 4000–6000 times
per minute, and the penetration depth can be adjusted from 100 to 2000 µm, with respect to the
target tissue. Because of the fractioned microneedling treatment combined with the electroporation
treatment, the EPN improves the delivery of the active substances in the different layers of the facial
skin and scalp.
MNs have also been developed for the delivery of drugs to vascular tissues. Arteries and veins
have three layers: the adventitia (the outermost layer), the tunica media (the middle layer), and
the endothelium (the innermost layer). The main factor that induces vascular disease is the nar-
rowing of the blood vessels caused by abnormal growth of the smooth muscle cells (SMCs) that
exist within the tunica media. Therefore, treatment to prevent the proliferation of SMCs requires
the delivery of anti-proliferative drugs to the middle layer. Direct vascular drug delivery routes
are either perivascular (via the outermost layer) or endovascular (via the innermost layer). Both
methods have drawbacks owing to the micron-scale thickness of the adventitia and endothelium,
FIGURE 9.6 (a) Electroporation microneedle (EPN) system, Eunsung Global Corporation and (b) Bullfrog® micro-
infusion device, Mercator.
which act as physical barriers. A novel MN [21] cuff and MN mesh [22] have been studied to
enhance the efficiency of drug delivery compared to that of conventional perivascular-wrap-
type devices. A drug-coated MN array attached to a curved poly(lactic-co-glycolic) acid (PLGA)
film can achieve conformal contact with the vascular tissue and increase the efficiency of drug
delivery 200 times higher than that of a flat film device (non-MN). A flexible mesh device with
an MN array enhances the wrappable mountability surrounding the perivascular region with the
strength of MN drug delivery. In endovascular drug delivery, the Mercator Bullfrog® micro-
infusion device was introduced by combining a 34G micro-scale needle with a balloon catheter
(Figure 9.6b). The Bullfrog device is tipped with a balloon-sheathed MN. When the desired injec-
tion site is reached, the balloon is inflated to 2 atm, securing the system for injection and sliding
the MN through the vessel wall. The Bullfrog device has received 510(k) clearance from the FDA
and CE mark in 2016.
In addition to the drug delivery field, biosensing of target analytes in interstitial fluid (ISF) is
an emerging field for MN applications. ISF has been extensively explored for metabolites, such
as glucose and lactate [23, 24]. Continuous glucose monitoring (CGM) has been extensively stud-
ied, and there is good clinical evidence that effective CGM in Type 1 diabetic patients leads to
a reduced frequency of hypoglycemic episodes and lowered HbA1c [25]. Intensive treatment of
diabetes reduces the risk of complications [26, 27], and glucose monitoring is a core component
of successful management, especially for those who are insulin-dependent. Despite the promise
of minimally invasive continuous monitoring, the CGM use of some of the approved commercial
devices, such as those from Medtronic (Enlite), Dexcom (G5), and Abbott (FreeStyle Libre), is
< 10% [28, 29]. This can be attributed to poor accuracy and precision (numerous false alarms)
and high manufacturing costs. An MN patch platform allows the device to be in constant contact
with the skin, providing permanent access to the ISF and enabling the device to operate con-
tinuously [30]. The short length of the MNs creates optimal penetration for ISF sensing, as the
MNs do not reach the dermis layer. This minimizes damage to the blood capillaries and nerve
endings found in the dermis layer. Moreover, as the MNs penetrate the skin, sweat contamina-
tion is avoided [30]. Although this study remains in a research stage, the tests have shown that
this device can operate successfully for up to 72 h with a 17-min lag time caused by the passive
diffusion of the analytes from the blood into the ISF matrix [31]. To increase the lifetime of the
device, the skin healing process must be inhibited. This might be achieved by designing a sensing
patch with MNs of optimal length, width, tip, and pitch characteristics and by coating the MNs
with a biocompatible material exhibiting mechanical properties similar to that of biological tis-
sue. Currently, the device must be recalibrated daily using the finger-prick method [31]. Potential
clogging of the MNs and the distortion of their shape upon penetration of the skin can also affect
the dynamics of sampling. Despite these drawbacks, this novel device has great potential for a
noninvasive CGM.
9.5 Commercial and Clinical Development of Microneedles

As summarized in Table 9.1, there are a number of commercialized MN products available in
the market. MN injection systems such as MicronJet 600™, Debioject™, BETACONNECT, and
Soluvia™ are FDA-cleared and now available as products. Cosmetic MN patches are also in the mar-
ket such as the I’m Fill Patch from Karatica Co., Ltd. and Royal Skin Hyaluronic Acid Micro Patch
from Junmok International Co., Ltd. for moisturizing and anti-aging. The V-Go from Valeritas Inc.,
an insulin delivery needle system, is also on sale for diabetes treatment. On the other hand, most
of the MN techniques described thus far have completed phase 1 clinical trials and are perform-
ing the next-level clinical trials. To explore the trends of the recent MN development for clinical
applications, this section examines the MN technology at the initial development stages: phase 1
or N/A. “N/A” is used to describe trials without FDA-defined phases, including trials of devices
or behavioral interventions. From the database of the U.S. National Library of Medicine and
International Clinical Trials Registry Platform, ongoing or before-phase-1 data of clinical trials
related to the MN were investigated and analyzed. The screened MN developments can be clas-
sified into five categories according to similar technologies: the MN patch, the radio frequency
(RF) MN, microneedling, the suprachoroidal space (SCS) injection MN, and MN injection into
the gingiva (Table 9.2).
The research spectrum using an MN patch is broad, including the comparison of vaccinations with
a hypodermic needle, various drug delivery trials, the effect of the MN patch injection, and finally the
MN for continuous glucose monitoring. An inactivated influenza vaccine was injected into a healthy
adult for a comparative study with a hypodermic vaccine (NCT02438423). In another study, in situ
MN array-directed chemo-immunotherapy using doxorubicin was conducted to eliminate tumor cells
(NCT02192021). In addition, various immunotherapies (NCT02837094) and stem cells (NCT02329457)
have been delivered using an MN patch. As MN patch drug delivery has increased, further research has
been conducted. The insertion mechanism of an MN patch with respect to the ethnicity was examined
to define the rate of skin barrier recovery following an MN treatment (NCT03332628). Integrated with
a topical ointment treatment, the study of therapeutic efficacy using a hyaluronic acid MN patch was
conducted to enhance the efficacy of the patch on the psoriatic plaques (NCT02955576). In addition to
transdermal drug delivery, the MN patch has been applied in the biosensing field. A comparative study
with three glucose measurement techniques, including an intravenous catheter, lancet, and MN patch,
was registered in the NIH. This study aimed to determine if an MN patch, as against a lancet or intra-
venous catheter, would be a preferable option for monitoring glucose levels for the diabetic pediatric
population (NCT02682056).
The MN integrating electrostimulation RF is an emerging technology for the clinical market. The
main target application of this technique is cosmetic, such as the reduction of wrinkles or striae alba or
the treatment of acne. Male and female patients with neck wrinkle indications from 25 to 65 years of
age were evaluated (ChiCTR-INR-16010169). The patient or guardian voluntarily signed the informed
TABLE 9.2
102
Microneedles in Early Clinical Trials
Related Intervention/
Technology Main ID Primary Sponsor Phase Study Title Treatment Brief Summary and Primary Outcome (bold)
MN patch NCT02682056 Emory University N/A Glucose Measurement Device: Intravenous • Comparison of three glucose measurement techniques
Using Microneedle (IV) catheter • To determine whether an MN patch (made from biocompatible
Patches Device: Lancet polymers or metal) would be prefereable to a lancet or
Device: intravenous catheter
Microneedle patch Superior glucose level of MN patch
NCT02955576 The Catholic N/A Efficacy of Microneedle Device: • To evaluate the efficacy of MN patch on the psoriatic plaques
University of Patch on Topical Microneedle HA Improvement of psoriasis
Korea Ointment Treatment of patch
Psoriasis Device: Patch
NCT03332628 University of Iowa N/A Racial/Ethnic Device: • To define the rate of skin barrier recovery following MN
Differences in Microneedle HA treatment of the skin in healthy subjects of differing racial/
Microneedle Response patch ethnic backgrounds
Micropore closure kinetics
NCT02438423 Mark Prausnitz 1 Inactivated Influenza Biological: • Inactivated influenza vaccination (IIV) with MN patch and
Vaccine Delivered by Inactivated hypodermic needle) or placebo (by MN patch)
Microneedle Patch or influenza vaccine • Investigatation of safety, reactogenicity, acceptability, and
by Hypodermic Needle using MN patch immunogenicity
To evaluate the safety and reactogenicity following receipt of
inactivated influenza vaccine delivered by MN patch (either
by staff or self-administered)
NCT02192021 Falo, Louis, MD 1 Micro Needle Device: • In situ MNA-directed chemo-immunotherapy using doxorubicin

Array-Doxorubicin Microneedle for termination of tumor cells locally
(MNA-D) in Patients array— Safety of the MNA-D system
with Cutaneous T-Cell Doxorubicin Measurement of vital signs, hematology, comprehensive
Lymphoma (CTCL) (MNA-D) metabolic panel, assessment for skin toxicity, and adverse
(MNA-D) event evaluation
NCT02837094 Cardiff University 1 Enhanced Epidermal Drug: C19-A3 • C19-A3 GNP peptide administration via Nanopass MNs
Antigen Specific GNP To examine the risk of C19A3 GNP administration in terms of
Immunotherapy Trial-1 general safety and induction of hypersensitivity
(EE-ASI-1)
NCT02329457 The University of N/A VZV Vaccine for Biological: • Direct vaccination of hematopoietic stem cell transplantation
Hong Kong Hematopoietic Stem Zostavax • Assessment of the efficacy and safety of the novel
Cell Transplantation intradermal live-attenuated VZV vaccination using MN patch
(VZIDST) Immunological response in donors
(continued)
Radio ChiCTR-INR-16010169 Shanghai Ninth N/A The Treatment of Device: RF MN • To reduce neck wrinkles from the patient, 25–65 years old,
frequency People’s Hospital, Neck Wrinkles both male and female
(RF) MN Shanghai Jiaotong with Microneedle • Exclusion of those who are pregnant or have anesthetic
University School Radiofrequency allergy or skin ulceration
of Medicine Device: A Evaluation scale for aged skin of the neck
Prospective,
Randomized,
Self-Controlled
Clinical Trial
IRCT2014101519543N1 Vice Chancellor for N/A Treatment of Device: RF MN • Comparison of RF MN plus fractional CO2 laser efficacy
Research, Isfahan Stria Alba by versus RF MN device alone in treatment of stria alba
University of Micro Needle Stria alba lesions
Medical Sciences Radio-Frequency
Device
NCT03426098 Goldman, N/A Secret Micro-Needle Device: Secret • To assess the safety, efficacy, and patient satisfaction
Butterwick, Fractional RF Micro-Needle associated with the treatment of facial wrinkles using RF MN
Fitzpatrick and System® for the Fractional RF (Ilooda Co., Ltd., Suwon, South Korea)
Groff Treatment System® Improvement in Wrinkles Based on the Fitzpatrick Wrinkle
of Facial Scale
Wrinkles
NCT03380845 Massachusetts N/A Comparison of Device: Fraxel • To compare the efficacy and safety of a erbium-doped 1550 nm
General Hospital 1550-nm Laser Restore non-ablative fractional laser and a bipolar fractional RF MN
and Fractional Device: Fractora device for the treatment of atrophic facial acne scars in ethnic
Radiofrequency skin (Fitzpatrick Skin Phototypes III-VI)
Microneedle Improvement in acne scarring
for the Treatment
of Acne Scars in
Ethnic Skin
(continued)
103
104
Micro- NCT02660320 Centre Hospitalier N/A Comparison of the Device: • To compare the efficacy of laser-assisted dermabrasion +
needling Universitaire de Efficacy of Micro- Dermabrasion autologous epidermal cells suspension grafting versus
Nice Holes vs. Laser- dermabrasion using microneedling technique + autologous
Assisted epidermal cells suspension grafting
Dermabrasion, for Rate of repigmentation lesions
Repigmenting in
Vitiligo Skin
Dermabrasion
NCT03390439 Hospital de N/A Treatment of Atrofic Device: Nd:YAP • To evaluate the response of MN and fractional non-ablative
Clinicas de Striae with 1340 nm laser laser Nd:YAP 1340 nm in the treatment of abdominal striae
Porto Alegre Percutaneous Collagen Device: alba
Induction Therapy Microneedling Clinical response in abdominal alba striae after the therapies
versus Fractional
Nonablative Laser
NCT02962180 Mohammed N/A Transplantation of Basal Device: • To develop a novel method for transepidermally delivering
V Souissi Cell Layer Suspension Dermabrasion keratinocytes and melanocytes into vitiligo skin using
University Using Derma-Rolling with dermaroller derma-rolling system.
System in Vitiligo Rate of repigmentation lesions
NCT03409965 Lutronic N/A Lutronic Infini and Device: • To evaluate the safety and effectiveness of the Infini and
Corporation LaseMD Systems in Dermabrasion LaseMD Systems for combination treatment in wrinkles,
Combination with dermaroller texture, and pigmentation of the face and/or neck

Treatment Masked, qualitative assessment of improvement
SCS NCT02952001 Clearside N/A Extension Study of Disease Models • To characterize the continued clinical benefit regarding safety
injection Biomedical, Inc. Patients with and efficacy of suprachoroidally administered CLS-TA,
MN Non-infectious Uveitis triamcinolone acetonide
Who Participated in • A non-interventional extension study of up to 6 months for
CLS1001-301 subjects completing the parent study
Time to additional therapy for uveitis
MN NCT03274674 Bezmialem Vakif N/A Use of Injectable- Other: I-PRF • To investigate whether for individuals with thin gingival
injection University Platelet-Rich-Fibrin thickness who are susceptible to gingival recession, the use of
(I-PRF) to Thicken I-PRF with MN increases gingival thickness without the need
Gingival Phenotype for surgical procedures
Gingival thickness
consent and performed a self-controlled experiment with a follow-up using RF MNs. In the past few
years, fractional RF systems have been introduced to enable controlled skin resurfacing accompanied
with dermal collagen remodeling. Facial wrinkles were treated using the Secret Micro-Needle Fractional
RF System® from Cryomed (NCT03426098). Striae alba reduction was performed using MN RF plus a
fractional CO2 laser (IRCT2014101519543N1). A fractional RF MN for the treatment of acne scars on
ethnic skin was studied at Massachusetts General Hospital and was compared with conventional laser
treatment devices (NCT03380845).
Even though advanced technologies have been developed, such as dermabrasion using a laser,
microneedling has become the essential procedure of the pretreatment of the skin for various pur-
poses. Many studies have shown promising results for the treatment of acne scars with a non-
ablative fractional laser and microneedling. A comparative study has been conducted with a
fractional Nd:YAP 1340 nm laser and microneedling for the treatment of abdominal striae alba
(NCT03390439). An evaluation of the microholes from microneedling has been performed by a
comparison of laser-assisted dermabrasion for treating repigmentation of the skin (NCT02660320).
In addition to these comparative experiments with existing technologies, microneedling enhances
the efficiency of drug delivery in combination with laser technologies. For derma-rolling, tiny
micro-injuries in the epidermis could offer a minimally invasive and painless method of cell trans-
plantation (NCT02962180). A combination of laser dermabrasion and microneedling is under clini-
cal evaluation as well (NCT03409965).
The SCS MN injection was developed and clinically demonstrated by Clearside Biomedical. They
have performed several clinical trials for the commercialization of an MN injector for drug delivery
through SCS. Recently, a clinical study was conducted to characterize the continued clinical benefit
regarding the safety and efficacy of suprachoroidally administered CLS-TA, a triamcinolone aceton-
ide injectable suspension, for the treatment of macular edema associated with noninfectious uveitis
(NCT02952001). The parent study is a phase 3 multicenter study to assess the safety and efficacy of 4 mg
of CLS-TA administered via suprachoroidal injection. Drug delivery to new sites using an MN injection
platform rather than a percutaneous method has also been clinically evaluated. Injectable platelet-rich
fibrin (I-PRF) has been administrated using an MN injector in the gingiva of patients susceptible to
gingival recession (NCT03274674).
9.6 Conclusions
In this chapter, the current states of MN products and technologies for commercial development were
surveyed. There are a number of commercialized MN products including MN injection systems, cos-
metic MN patches, and MN insulin delivery systems. Combinatory products such as MN with RF-based
technology and MN-integrated balloon catheter for endovascular drug delivery were also introduced
to the market. MN systems for various therapeutic purposes other than vaccination or cosmetics are
in either preclinical or clinical trials and FDA clearance is expected soon. These include RF MN
or microneedling for cosmetics, SCS injection MN for ocular drug delivery, and MN for dental drug
delivery. Microneedle-based biosensing such as minimally invasive CGM for diabetes treatment is
another potential market.
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using individual patient data.” BMJ 343 (2011): d3805.
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or insulin compared with conventional treatment and risk of complications in patients with type 2 dia-
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29. Lodwig, Volker, et al. “Current trends in continuous glucose monitoring.” Journal of diabetes science
and technology 8.2 (2014): 390–396.
30. Coyle, Shirley, et al. “Wearable bio and chemical sensors.” Wearable sensors (2015): 65–83.
31. Jina, Arvind, et al. “Design, development, and evaluation of a novel microneedle array-based continu-
ous glucose monitor.” Journal of diabetes science and technology 8.3 (2014): 483–487.
10
Considerations for Clinical Trials
Involving Microneedle Devices
Janet Tamada
Scientia Bioengineering Consulting
10.1 Introduction
Microneedle technology has made significant progress for cosmetic enhancement of skin appearance,
painless delivery of drugs and vaccines (1, 2), and accessing the myriad of analytes in skin interstitial
fluid for physiological monitoring or diagnosis (3). Human clinical testing is an essential part of devel-
oping microneedle products. This chapter focuses on considerations for human clinical trials involving
microneedles, including system design, manufacturing, biological interface, and ethical and regulatory
requirements for clinical testing.
Prausnitz (4) proposed a useful framework of different modes of microneedle use that incorporates the
microneedle design and the transport mechanism of the active agent (drug or vaccine) or analyte. This
is adapted below:
• Solid microneedle arrays for pretreatment (“poke and place”) are applied to disrupt the skin
barrier, and a drug-containing or -sensing patch is placed over the disrupted skin.
• Coated, dissolving, or degrading microneedle arrays (“poke and remove”) are applied to the
skin, the needle coating or microneedle array dissolves to deliver the active agent, and the
depleted array is removed.
• Hollow microneedles (“poke and push”) are applied and active agent in a fluid is pushed
through the bores of the needles.
• Microneedles with conduits, such as a hydrogel that allows diffusion or a hollow microneedle,
are left in the skin for extended duration (“poke and leave”), allowing continuous analyte sens-
ing or delivery of active agents.
For drugs and vaccines, clinical development typically involves three phases (5). Phase I testing
evaluates safety and pharmacokinetics or immune response of the drug or vaccine, respectively, deliv-
ered by the microneedle route of administration in a small number of healthy volunteers. Phase II
testing is performed on a larger group of patients in the target population and determines the dose
range for efficacy of the drug or immune response to the vaccine. Phase III testing establishes the
safety and efficacy of the final formulation and product design in a larger patient population. For
medical devices, clinical development typically involves early-stage feasibility or pilot studies, which
are performed on a small subject population using prototypes of the device, and late-stage pivotal
studies with the final device design, which are performed on a larger subject pool of the target
population.
109
10.2 Design Considerations

10.2.1 Penetration of Microneedles into the Skin
Microneedles must penetrate the outer layer of skin in order to be effective, and must remain intact
so they do not leave fragments in the skin. The skin is elastic and deforms around the needles, making
reliable penetration challenging. Two main approaches have been used to apply needles to ensure
penetration (6):
• Using sufficiently long (> 600 μm), sharp microneedles so that low force is required to pen-
etrate the skin and application can be achieved manually.
• Using a high-impact application device to drive the needles through the skin at high velocity.
Techniques such as dye staining, transepidermal water loss (TEWL) measurements, skin conduc-
tance measurements, and optical coherence tomography (OCT) have been used to evaluate penetration
success (7).
10.2.2 After Microneedles Penetrate the Skin: Mode of Use

The mode of microneedle use drives many design activities. If the microneedles are removed and a
patch system is applied (“poke and place”), then a positioning mechanism, such as marker or appli-
ance, that enables the user to place the patch over the pretreated area must be developed and active
agent or analyte transport rate over time must be measured to determine how long the system main-
tains active. For coated or dissolving microneedles (“poke and remove”), the limited capacity of a
few milligrams restricts their use to potent active agents. A formulation must be developed to ensure
that the dissolution time and the amount of residual active agent on used arrays or deposited on the
skin surface are acceptable for the intended use. For hollow microneedle systems with fluid injec-
tion (“poke and push”), injection pressure and fluid volume limitations must be considered. Hollow
microneedles can readily inject fluid volumes of up to a few hundred microliters, but volumes of 1
mL encounter resistance as the skin deforms to accommodate the fluid volume (8, 9) and two mL has
required an infusion system (10). For microneedle arrays that are left in the skin (“poke and leave”),
wear duration is limited to about one week due to shedding of the outer layer of skin, perspiration, and
movement, which dislodge the needles. In vitro and animal models of adhesion to human skin have
had limited predictive capabilities, so human clinical testing is required to determine adhesive wear
properties of the system.
10.2.3 Design for Usability: Human Factors and Patient Acceptance

Microneedles have shown good patient acceptability, as they do not penetrate to a depth to activate
the pain receptors in the skin (7). This creates an opportunity to design products that require minimal
training, such as for self-administration or for regions with limited access to trained medical personnel.
Late-phase clinical and summative human factors studies are employed to validate that the intended
population can use the product with the supplied training materials (11–13). For example, testing may
evaluate ability of users to perform the application steps correctly, keep the system on the skin long
enough for the active agent to be delivered, or dispose of the used needles properly.
10.3 Manufacturing Process Considerations

10.3.1 General Manufacturing Controls
Manufacturers must use good manufacturing practices that are appropriate for the phase of development
to ensure the safety, potency, and purity of the drug or vaccine (14, 15) or safety and functionality of a device
Clinical Trials Involving Microneedle Devices 111
clinical product (16). Microneedle products delivering active agent are considered drug–device combi-
nation products and must conform to requirements of both drugs or biologics and medical devices (17).
Content uniformity of 85% to 115% of target dose (18) can be particularly challenging for processing the
minute doses involved in microneedle products (19).
10.3.2 Bioburden Control

As microneedles pose a risk of infection, a low bioburden or sterility (20) and appropriate packaging
(21, 22) will be required for regulatory approval. This affects the formulation, design, and processing
of microneedle products. Some products can undergo terminal sterilization, such as steam, dry heat,
electron beam or gamma irradiation, or ethylene oxide exposure, in which the product is sterilized
after it has been manufactured and packaged (23). However, some analyte-sensing chemistries, many
drugs, and most biologics do not retain their activity after sterilization, and require aseptic process-
ing (24). Aseptic processing involves manufacturing in highly controlled, clean environments, using
rigorous operational procedures (25), which adds significant cost and complexity to the manufactur-
ing process.
Nonetheless, the small, shallow breaches from microneedles have been shown to pose low practical
risk of infection (26). Manufacturers should assess risk to determine what level of bioburden control is
appropriate for the clinical stage of development.
10.4 Biological Considerations

10.4.1 Biocompatibility
Microneedles have been produced from a wide range of materials, including metals, such as stainless
steel or titanium, silicon, sugars, ceramics, non-degrading and degrading polymers, and hydrogels (27).
Biocompatibility testing of the materials in their final, processed form is important to ensure that clinical
products are acceptable for human exposure. Based on the guidelines for testing of surface devices on
breached or compromised skin, Table 10.1 shows typical biocompatibility tests performed according to
duration of skin contact (28).
TABLE 10.1
Guidelines for Biocompatibility Testing
Factors to Consider, Particularly
for Degrading or Dissolving
Materials, Which Increase
Contact Duration with Skin Recommended Systemic Exposure
Limited: • Cytotoxicity • Acute systemic toxicity
≤24 h • Sensitization • Material-mediated pyrogenicity
• Irritation or intracutaneous • Chemical characterization of
reactivity extracted material
Prolonged: Same as limited Same as limited, plus:
>24 h and ≤30 days • Subacute/subchronic systemic
toxicity
• Implantation
Chronic, repeated wear of the device: Same as prolonged, plus: Same as prolonged, plus:
>30 days • Genotoxicity • Chronic toxicity
• Subacute/subchronic systemic • Carcinogenicity
toxicity
10.4.2 Irritation, Sensitization, and Immune Response

In addition to irritation from the microneedle, delivery of the active agent may irritate the skin (7). Skin
irritation testing in an animal model of microneedle drug or vaccine delivery products is performed as a
special toxicity test prior to human clinical testing (29). Human studies specifically focused on irritation
and sensitization evaluation are performed during clinical development (30), and irritation and sensitiza-
tion are also evaluated as part of the safety assessment during clinical trials.
The skin is a highly immunogenic organ, as one of its major functions is to protect the body from
pathogenic organisms. Hence, the possibility of skin sensitization or even a systemic immune response
(e.g., anaphylaxis) to microneedle delivery may be higher than for other routes of administration, such
as subcutaneous injection. For drug delivery, this safety concern must be evaluated during animal test-
ing prior to human studies, as well as during human clinical testing (31). For vaccines, the high immune
responsiveness of the skin is a potential advantage of microneedle delivery, as a smaller, dose-sparing
amount of vaccine may be sufficient to elicit the desired immune response (32).
10.4.3 Skin Healing

The skin rapidly detects a breach of its integrity and forms a rapid response to heal and seal the pores (33).
For short duration systems, such as coated or dissolving microneedles (poke and remove) or intradermal
injection (poke and push), rapid skin healing is a desirable process. It reduces the potential for infection
and minimizes skin irritation. However, for applications that require longer durations of contact, such
as pretreating the skin prior to patch placement (poke and place) or continuous delivery through hollow
needles (poke and leave), skin healing closes the pathways and decreases delivery.
The needle dimensions (34), subject age (35), occlusion (36), and formulation of material that is placed
against the skin (37) influence the rate of closure of skin pathways. An example is shown in Figure 10.1
(38). Hollow silicon microneedle arrays attached to a fluid-filled sampling chamber were worn by human
subjects for periods ranging from six hours to three days. During study sessions, fluid was removed and
replaced at 15-minute intervals and analyzed for glucose to determine the rate of glucose diffusion from
the interstitial fluid in the skin through the needle lumens and compared to blood glucose obtained by
finger-stick. The fluid was either phosphate-buffered saline (PBS) as a control or a proprietary formula-
tion, compared side by side on each study subject. Photographs of the microneedles were taken over a
light box before and after a three-day wear period. In Figure 10.1, the microneedle array and sampling
chamber are shown. After use, the microneedle lumens were blocked for the PBS control (left), but
remained open for three days using the proprietary formulation (right).
Figure 10.2 shows how the diffusion rate for glucose in the PBS (left) decreases with time relative to
blood glucose over a six-hour wear period, whereas the proprietary formulation (right) maintains the
relationship between blood glucose and the glucose diffusing through the lumens, indicating the trans-
port pathway remained open. Glucose diffusion was close to zero at three days of wear in PBS, but
continued for over three days of continuous wear with the proprietary formulation (data not shown).
FIGURE 10.1 Microneedle array and sampling chamber (a). Backlit images of microneedle lumens after 72 hours of wear
with (b) PBS and (c) proprietary formulation.
50 200 80 200
Glucose Flux Glucose Flux
Glucose Diffusion (ng/mln)
Glucose Diffusion (ng/mln)

Blood Glucose (mg/dL)
Blood Glucose (mg/dL)

Blood Glucose Blood Glucose
40
150 60 150
30
100 40 100
20
50 20 50
10
0 0 0 0
0:00 1:00 2:00 3:00 4:00 5:00 6:00 7:00 0:00 1:00 2:00 3:00 4:00 5:00 6:00 7:00
Elapsed Time (hours) Elapsed Time (hours)
FIGURE 10.2 Glucose diffusion through hollow microneedles over six hours of wear in (left) phosphate-buffered saline
and (right) proprietary formulation.
10.5 Procedural Requirements for Clinical Testing

10.5.1 Clinical Ethics Requirements
Sponsors, who initiate and manage clinical trials, and Investigators, who conduct clinical trials, must
abide by ethical standards to ensure the safety and welfare of the clinical study subjects. Ethical require-
ments include performing studies according to clinical protocols, getting approval from institutional
review boards (IRBs), and obtaining informed consent from study subjects to ensure they are aware of
the risks of the study and are participating voluntarily (39–42). For drug or biologics studies beyond
Phase I or medical device studies beyond small feasibility studies, registration on a clinical trials regis-
try, such as clinicaltrials.gov, is an ethical responsibility to ensure that there is full disclosure of clinical
data (43). For clinical studies intended for regulatory submission, Investigators must provide financial
disclosure of potential conflicts of interest (44).
10.5.2 Regulatory Submissions for Microneedles for Clinical Studies

To engage in human clinical testing, manufacturers must document implementation of controls to ensure
the benefit of the study exceeds its risks, typically through a submission to regulatory authorities. In the
United States, for medical devices, the submission is an investigational device exemption (IDE) (45) and
for drugs or vaccines it is an investigational new drug (IND) (29) application.
The submission for medical devices includes an IRB-approved clinical protocol and informed consent,
reports of nonclinical safety testing (e.g., biocompatibility), manufacturing process controls (e.g., biobur-
den control), device design controls, and risk management. Studies investigating use of microneedles as
devices (no active therapeutic agent) may qualify as nonsignificant risk studies (NSR) by submission of
rationale to an IRB. If the IRB approves NSR status, submission of the IDE to FDA is not required, and
documentation of abbreviated IDE controls is maintained by the Sponsor.
Microneedle drug or vaccine delivery products require IND submission prior to human clinical trials
and include the content described above, plus animal data on drug absorption and pharmacokinetics or
immune response by the microneedle route of administration, special local toxicity data on skin irrita-
tion, and a chemistry, manufacturing, and controls (CMC) report showing control over the composition,
potency, purity, and manufacturing of the drug product (46, 47).
A significant development activity for both medical devices and combination products is design con-
trol (16, 48). Key elements to prepare for clinical studies include a design and development plan, design
inputs, design outputs, design verification testing, and design reviews. Design inputs include specifica-
tions or requirements for the functionality (e.g., drug dose, sensor sensitivity), form (e.g., microneedle
length), and safety (e.g., biocompatibility, bioburden specifications) of the product design. Design outputs
are the results of the design process (e.g., product drawings, materials specifications). Design verification
is demonstration that the design outputs meet the requirements of the design input, typically through
in vitro or animal testing. Prior to human clinical testing, a formal design review evaluates the results of
design verification testing to ensure the clinical product meets safety and functional requirements to be
used on human subjects. Additionally, risk management is implemented to ensure controls are in place to
minimize risk to the subjects (49). The clinical studies themselves, as well as human factors studies, are
key elements of design validation to demonstrate that the product meets the user needs in the intended
use environment.
10.6 Microneedle Applications with Human Clinical Experience

10.6.1 Cosmetic Applications
Cosmetic microneedle use can consist entirely of mechanical skin perturbation, with rollers or arrays of
needles, for reduction of wrinkles, acne scars, and stretch marks, purportedly by increasing collagen pro-
duction (50). Cosmetic use can also include skin pretreatment or microinjection to enable faster penetra-
tion of cosmetic agents, such as collagen creams or vitamin C (7). Some cosmetic devices are registered
with FDA as Class I devices (510(k)-exempt), the lowest risk classification for medical devices. Class I
devices cannot make therapeutic claims (e.g., “reduces wrinkles,” “promotes collagen production”) in
promotional material, and needle lengths must be less than 0.3 mm (51). The regulatory barriers for
cosmetic use have historically been minimal, but recently the FDA has issued warning letters to several
manufacturers (52, 53) and has stated, “At this time [2015], the safe ranges of needle lengths, penetration
depths, and speeds of the device are unknown; therefore, FDA has safety concerns regarding the poten-
tial for the needles to damage vessels and nerves.” (54).
10.6.2 Sensing and Diagnostics

Microneedles can be used to painlessly access skin interstitial fluid, which has strong similarities to
plasma, with comparable concentrations for many compounds (3). Collection of interstitial fluid from
human subjects with offline analysis of analytes has been demonstrated with hydrogel microneedles
for caffeine and glucose (55) and glass hollow microneedles for glucose (56). Clinical studies have
demonstrated that interstitial fluid accessed by hollow microneedles coupled to an in situ electro-
chemical sensor can quantitatively measure blood glucose in diabetic subjects continuously over
three days (57).
10.6.3 Drug Delivery

Local delivery of drugs to human subjects has been demonstrated for methyl nicotinate for vasodila-
tion (58), lidocaine (59), and dyclonine (60) for numbing of the skin, and 5-aminolevulinate coupled
with photodynamic therapy for treatment of basal cell carcinoma (61). Systemic delivery of naltrexone
was one of the earliest clinical demonstrations of microneedle delivery (36). Studies of insulin delivery
and pharmacokinetics have shown faster absorption by intradermal compared to subcutaneous injection
(62–65). Several microneedle products are in clinical development toward commercialization. Zosano
Pharma, Inc. has reported Phase III clinical trials of microneedles coated with zolmitriptan for migraine
treatment (66), Phase II trials of human parathyroid hormone (PTH 1-34) (67) for osteoporosis treatment
(68), and Phase II testing for glucagon for emergency hypoglycemia treatment (69). Corium has reported
Phase II for a dissolving microneedle PTH formulation (70). Clearside Biomedical has used a single
microneedle for delivery of corticosteroids to the eye for treatment of uveitis (71).
10.6.4 Vaccine Delivery

The Becton Dickinson Soluvia™ Micro Injection system, consisting of a single 1.5-mm stainless steel
microneedle attached to a traditional syringe, is used in the commercial product Fluzone® intradermal
influenza vaccine (7) and has been studied for rabies vaccination (72). NanoPass™ MicronJet600™ has
510(k) clearance and is CE-marked; it consists of three 600-micron-long silicon microneedles that can
attach to a standard syringe. NanoPass microneedle devices have been used in human clinical studies
to deliver vaccines for pandemic and seasonal strains of influenza (73), herpes zoster (74), and polio in
infant populations (75), and in tuberculin skin testing (76). Dissolving microneedles have entered clini-
cal testing for influenza vaccination (77, 78).
10.7 Conclusion
Microneedles are steadily progressing from laboratory research into clinical development to commer-
cialization. Development can be a complex process, requiring an interdisciplinary approach, using
chemistry, manufacturing, mechanical, and biological knowledge and capabilities. Additionally, regula-
tory and ethical requirements must be fulfilled before engaging in human clinical testing.
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11
Cosmetic applications
Aunna Pourang, MD
Kourosh Beroukhim, MD
University of California-Davis
11.1 Introduction
The demand for effective, minimally invasive esthetic procedures is on the rise. There was a 186%
increase in the number of minimally invasive cosmetic procedures performed between 2000 and 2017, as
opposed to a 6% overall decrease in cosmetic surgical procedures in the same period (1). Microneedling
is an effective, relatively safe, minimally invasive procedure that has been shown to rejuvenate the skin,
improve scars, rhytides, and striae and provide other esthetic enhancements with limited side effects and
post-procedure recovery time.
11.2 The Origins of Microneedling

While the scope of microneedling has expanded beyond cosmetic purposes to include various medi-
cal uses, the technology is rooted in the field of esthetics. Early in the development of needling
procedures, several groups reported using needles to undermine depressed scars by cutting through
the fibrous tissue and creating a space to inject various dermal filler agents (2, 3). Orentreich and
Orentreich developed the subcision technique, a subcuticular undermining technique using a hypo-
dermic needle, for depressed cutaneous scars and wrinkles (4). Camirand and Doucet incidentally
noticed an improvement in the appearance of hypochromic scars that were previously tattooed.
They eventually developed a technique using needle microdermabrasion to repigment and soften
scars (5). Based on these concepts, Fernandes developed a rolling needle device that allowed suf-
ficient dermal penetration to stimulate collagen production (6). Shortly after, Liebl patented the
Dermaroller™ device (7). Since then many different types of microneedling devices, ranging from
home care rollers to automated pens, have been developed to meet the increasing demands of anti-
aging procedures.
11.3 The Biology of Aging Skin

The cutaneous aging process involves both intrinsic and extrinsic mechanisms, with the former
involving mostly genetic factors and the latter comprising external factors such as the sun, smoking,
and poor nutrition (8). On a histological level, intrinsically aged skin shows dermal and epidermal
119
atrophy, flattening of rete ridges, reduced fibroblasts, fragmented collagen bundles, increased num-
ber of collagen fibrils, and increased ratio of collagen III to collagen I in the dermis (9–11). On a
grosser level, these changes manifest as thin, sagging skin with exaggerated expression lines and the
loss of subcutaneous volume. Similar, yet more pronounced histologic changes are noted in extrinsi-
cally aged skin, in addition to the presence of elastosis and hyperpigmented lesions caused by UV
light exposure (8). Aging skin, in general, may be dryer and rougher with increased pallor due to
decreased vasculature.
While the avoidance of exposure to extrinsic factors is key to prevention, several treatments are avail-
able for rejuvenating aging skin. Treatments are often geared to resurfacing the epidermis and replacing
dermal volume loss. The result is youthful-appearing skin that is smooth, tight, plump, hydrated, and
wrinkle- and blemish-free.
Although lasers, chemical peels, and microdermabrasion are effective treatments, their mecha-
nism of action involves destruction of the epidermis, which leads to an inflammatory response,
subsequently producing new collagen. This mechanism also has the potential to induce post-
inflammatory hyperpigmentation (12–14). Although the dermal fibrosis produced by abla-
tive therapies can lead to skin tightening, there is an increased risk of scarring in addition to
disordered collagen formation (15–17). Microneedling, on the other hand, can produce similar
cosmetic results with decreased risk of hyperpigmentation, pain, erythema, and short recovery
downtime (18).
11.4 Mechanism of Action

Microneedling induces minimal epidermal injury, mitigating the adverse effects seen with ablative
therapies. In fact, re-epithelialization occurs within 24 hours and epidermal barrier function is, for
the most part, maintained (19, 20). The main postulated mechanism by which microneedling confers
most of its benefits is through collagen induction that occurs during the body’s normal response to
trauma and wound healing. For this reason, microneedling is often referred to as percutaneous col-
lagen induction therapy.
Microneedling devices deliver several micropuncture wounds to the skin, activating the three-step
wound healing response – inflammation, proliferation, and remodeling – ultimately resulting in dermal
collagen formation. This results in thicker skin with increased collagen deposition in a normal lattice
design, increased elastin content, epidermal thickening, and normal rete ridges (21–23). Clinically sig-
nificant results may not be seen for several weeks after treatment, with maximal effects noted at 12–24
weeks and continued changes for up to 8–12 months (24, 25).
It is hypothesized that the controlled wound milieu, as a result of minimal stress and decreased expo-
sure to infection, enables regeneration of normal tissue and avoids scar tissue formation (26). Since the
basement membrane is not damaged and the inflammatory response does not affect epidermal melano-
cytes, pigmentation issues do not typically occur, as they do in deep chemical peels, dermabrasion, and
lasers (22, 25–27). Microarray analysis has identified an upregulation of genes associated with tissue
remodeling and wound healing, and a downregulation of pro-inflammatory cytokines associated with
microneedling of in vitro skin models (28).
Another proposed mechanism by which microneedling induces collagen formation is the theory of
bioelectricity. The fine wounds caused by needling causes cells to react with a demarcation current that
is increased by the needles’ electrical potential. The change in electric potential in the cell membrane
creates increased cell activity, release of potassium ions, proteins, and growth factors. The body is fooled
into believing an injury has occurred and, through an unclear mechanism, new collagen deposition
results in the upper dermis (29).
Microneedling is also used as a transdermal drug delivery system which may account for the enhanced
effectiveness of topical agents used for various cosmetic applications, such as the treatment of melasma
and alopecia (30, 31).
Microneedling in Cosmetic Clinical Practice 121
11.5 Indications
11.5.1 Anti-Aging
Microneedling is effective for skin rejuvenation by way of neocollagenesis. Many studies have demon-
strated the improvement of rhytides, skin thickness, skin irregularity, skin texture, and skin laxity on the
face, neck, abdomen, and other parts of the body with microneedling treatments (23, 25, 32–34).
In treating photodamage and actinic keratoses using microneedling followed by photodynamic ther-
apy with either aminolevulonic acid or methyl aminolevulinate, patients found an improvement in global
photoaging, roughness, sallowness, fine lines, and mottled pigmentation (35, 36).
While the face is a common site for treatments, other areas of the body such as the neck, abdomen,
arms, thighs, and the between the breasts can also be treated (6).
11.5.2 Scars
Several studies have demonstrated the beneficial effects of microneedling on acne scars (37). Rolling
and boxcar scars respond well to microneedling treatment as opposed to deep or icepick scars, with a
corresponding increase in types I, III, VII, and newly synthesized collagen as well as tropoelastin (38).
Fractional radiofrequency microneedling, on the other hand, has been shown to improve icepick acne
scars (39). Hypertrophic scars and keloids have shown improvement in combination therapy with sili-
cone gel (40). Silicone gel is thought to improve scars by increasing hydration of the stratum corneum,
with subsequent cytokine-mediated signaling from keratinocytes to dermal fibroblasts to downregulate
extracellular matrix production (41). Microneedling’s synergistic action of collagen remodeling likely
accounts for the improvement seen in this combination.
Aust et al. demonstrated an improvement in post-burn scars with microneedling treatments in addition
to pre-procedural and post-procedural topical application of vitamins A and C (27). Histological exams
showed a normalization of the collagen and elastin matrix in the reticular dermis, and an increase in col-
lagen deposition at 12 months, postoperatively. The collagen appeared to have been laid down in a nor-
mal lattice pattern, rather than the parallel bundles seen in scar tissue. An improvement in posttraumatic
scars, post-varicella scars, and post-herpetic scars has also been noted with microneedling treatments
(42–44). Striae distensae, a form of scarring, has also shown statistically significant improvement with
microneedling (22, 45, 46).
11.5.3 Pigmentary Disorders

Pigmentation disorders respond well to microneedling when combined with other therapies. Studies
have shown an improvement in melasma in conjunction with topical agents, including tranexamic acid,
as well as a depigmentation serum containing rucinol and sophora-alpha and another containing 0.05%
tretinoin, 4% hydroquinone, and 1% flucinonide acetonide (30, 47, 48). A case of severe, idiopathic
periorbital melanosis improved with lightening and anti-aging serums and a DermaFrac device (Genesis
Biosystems, Lewisville, TX), which combines microneedling using precisely calibrated needle pen-
etration with simultaneous vacuum-assisted serum infusion (49). Similar outcomes were seen using
microneedling following 10% trichloroacetic acid peels for periorbital melanosis (50). The efficacy in
the treatment of vitiligo is limited and further studies using microneedling as a transdermal drug deliv-
ery method are necessary (51, 52).
11.5.4 Alopecia
Dhurat et al. have demonstrated an improvement in androgenetic alopecia using both microneedling
with 5% minoxidil and microneedling without a topical medication in individuals who continued
to take their routine minoxidil and finasteride (53, 54). The authors postulated that in addition to
the release of growth factors seen in wound healing, microneedling also stimulates stem cells in the
hair bulge as a result of the wound healing cascade. Microneedling is also thought to stimulate the
expression of hair growth-related genes (55–57). Cases of alopecia areata have also improved with
microneedling followed by triamcinolone acetonide, likely as a result of enhanced transdermal drug
delivery (31).
11.6 Combined Therapies

Microneedling can enhance other rejuvenation modalities while minimizing complications associated
with more abrasive interventions.
11.6.1 Peels
Thirty-five percent glycolic acid peel performed 3 weeks after microneedling was shown to enhance
acne scar improvement and post-inflammatory hyperpigmentation when compared to microneedling
alone (58). Microneedling combined with 20% trichloroacetic acid peel creates results similar to a deep
phenol peel and non-ablative fractional lasers with significantly less duration of post-procedural ery-
thema (59, 60).
11.6.2 Subcision
Microneedling and subcision of acne scars demonstrated efficacy in 100% of patients as opposed to 77%
who received microneedling alone (61).
11.6.3 Fillers
Subdermal injections of 1:1 diluted calcium hydroxyapatite (Radiesse® ) filler combined with micronee-
dling and topical vitamin C improved stretch marks. This combination was also shown to increase the
quantity and quality of collagen and elastin fibers in treated areas compared to untreated skin and areas
treated with microneedling and ascorbic acid alone (62).
11.6.4 Platelet-Rich Plasma

Platelet-rich plasma (PRP) contains multiple autologous growth factors, such as epidermal growth factor,
platelet-derived growth factor, transforming growth factor-β, vascular endothelial growth factor, fibro-
blast growth factor, and more. Not only does microneedling enhance PRP absorption in the skin, but the
growth factors found in PRP act synergistically with growth factors induced by skin needling to enhance
the wound-healing response (63, 64).
PRP with microneedling has been shown to improve acne scars more than microneedling alone with
results similar to intradermal PRP and 100% topical trichloroacetic acid (TCA) (65, 66).
11.6.5 Stem Cells

Stem cell therapy has been shown to have benefits in skin rejuvenation therapy (67–69). Like PRP, endo-
thelial precursor cells (EPCs) differentiated from human embryonic stem cells (hESCs) also contain
growth factors and cytokines, which have been shown to improve blood perfusion in damaged tissues
(70–72). Conditioned medium of hESC-derived EPCs has been shown to significantly improve the pro-
liferation and migration of dermal fibroblasts and epidermal keratinocytes and increase collagen synthe-
sis in fibroblasts (70). Microneedling is used with stem cell therapy to enhance penetration through the
stratum corneum and has been found to improve pigmentation and wrinkles more than microneedling
alone (73).
11.6.6 Topical Agents

Topical serums are often used during microneedling procedures as lubricants to minimize skin
abrasion. Some authors believe that the use of vitamins A and C is important given their impor-
tance in skin health, in particular their roles in collagen regeneration and formation (6, 22, 74–79).
There have been reports of foreign-body granuloma reactions in individuals receiving micronee-
dling treatments with topical vitamin C. Subsequent patch testing in these individuals revealed
reactivity to vitamin C. It is thought that hypersensitivity reactions can occur with the application
of topical products prior to microneedling via immunogenic particle absorption in the dermis (80).
It is important that patients using a home microneedling device be educated on using only approved
topical agents. There are different topical anti-aging regimens on the market that can be used before
and after treatments (81).
11.7 Microneedling Devices

Several different types of microneedling devices exist. A standard dermaroller consists of a handle,
attached to a single-use cylinder 2 cm in diameter and 2 cm wide, with 8 rows of microneedles around
its circumference and 24 arrays of microneedles along its width. A total of 192 needles between 0.5 mm
and 1.5 mm in length and 0.1 mm in diameter can be found in such a device. Fifteen passes over an
area using a dermaroller with 192 needles 2 mm in length and 0.07 mm in diameter results in about
250 micropunctures/cm2 (82). There are home care dermarollers on the market with needles less than
0.15 mm in length which are used for the transdermal delivery of anti-aging products (82). Tram-track
scarring has been reported with the use of manual microneedling devices. It is recommended that gentle
pressure and shorter needles be used over bony prominences and areas with thin skin when using these
devices (83, 84).
Stamps are a modified version of the dermaroller with needles of 2 mm in length and 0.12 mm in
diameter used for the treatment of hard-to-reach areas such as the upper lip or localized scars such as
varicella scars (82, 85).
Automated microneedling devices typically contain a disposable tip with needles that operate at dif-
ferent speeds in a vibrating stamp-like manner, with the ability to adjust needle length as needed. The
benefits of this device include convenience in treating narrow areas such as the nose and around the
eyes, consistent depth of penetration, ergonomic benefits of automation, and the ability to use the same
device every time (85, 86). Splashback has occurred in older devices, but newer devices have addressed
this issue. DermaFrac™ (Genesis Biosystems) technology combines microneedling with simultaneous
infusion of a serum with active ingredients (49).
Fractional radiofrequency microneedle (FRM) devices contain a disposable tip with gold-
plated insulated needles which penetrate the skin and release radiofrequency currents through
the dermis. The resultant heat induces neocollagenesis and neoelastogenesis. Needle depth,
power, and duration of energy pulse can be adjusted. This technology is safe in darker skin
types, because it does not damage the epidermis and has been shown to be effective at improv-
ing acne scars, aging skin, and enlarged pores (87–90). The FRM has been shown to decrease
NF-κβ, IL-8, and sebum excretion rates, and to improve acne. Additionally, the increase of
TGF-β1, TGF-β3, and collagen associated with FRM technology is thought to be the reason for
acne scar improvement, as transforming growth factor activates dermal fibroblasts and enhances
collagen formation (39).
11.8 Technique
Microneedling is a simple and effective tool that can be provided to patients in an esthetic medical prac-
tice. Figures 11.1–11.4 depict various aspects of a microneedling treatment session.
11.8.1 Considerations
There are several absolute contraindications to consider in individuals undergoing microneedling treat-
ment. They include:
• Presence of skin cancers, herpes, or any other active skin infections

• Tendency to develop severe keloids
• Uncontrolled diabetes mellitus
• Presence of blood dyscrasias
• Genetic conditions with aberrant collagen deposition
• Patients on chemotherapy, radiation, high doses of corticosteroids, or medications that impede
wound healing
• Metal allergy depending on the metal used for the microneedle (91)
• Hypersensitivity to topical agents
While concomitant botulinum toxin injections are not an absolute contraindication to microneedling
treatments, care should be taken when microneedling recently injected sites, to avoid toxin diffusion. See
below for further recommendations relating to performing multiple esthetic procedures in one sitting.
Although there is a low risk of dyspigmentation with microneedling, treatment would benefit from being
delayed if there is recent sun exposure to avoid post-treatment dyspigmentation. There are no established
recommendations for herpes prophylaxis. However it is important to discuss the risks and have a preven-
tive plan in place for patients with a history of facial herpes. Authors have varying opinions on whether to
perform microneedling treatments in individuals who are on anti-coagulant therapies (6, 92). No studies
have been done on this population, and as with any trauma in these individuals there is increased risk of
bruising and bleeding.
11.8.2 Pretreatment
A thorough history and focused assessment of the treatment area should be undertaken, making sure to
note the esthetic qualities of the skin.
Patients do not need to discontinue home skin care treatments prior to microneedling treatments.
Recent treatments such as chemical peels, lasers, or dermal fillers do not preclude microneedling treat-
ments, although clinical judgment should be used to determine whether the patient will be able to toler-
ate a second procedure. If multiple treatments are to be done on the same day, it is recommended that
treatments be done in the order of deep-to-superficial layers of the skin. For example, dermal fillers
should be done prior to a microneedling procedure to ensure landmarks remain visible and to prevent
diffusion of injectables (92).
Standard steps for informed consent should be taken prior to beginning the procedure. As with any
cosmetic treatment, it is important to take baseline and post-treatment photographs to demonstrate out-
comes and assist with patient satisfaction.
Clean off any makeup from the skin and apply a nonoccluded compounded lidocaine 30% cream to
the treatment area for about 20–30 minutes. Remove the anesthetic cream with water-soaked gauze and
alcohol wipes.
11.8.3 Treatment
The following instructions apply to automated microneedling devices. It is important to be familiar
with the manufacturer’s recommendations regarding the speed and needle depth to be used for vari-
ous locations. Needle depth should be adjusted based on skin thickness in the area being treated.
For scars, striae, and areas with thicker skin such as the cheeks, needle depths of 1.5–3.0 mm may
be used. In more delicate areas such as forehead, nasal bridge, and lower eyelids, needle depths of
0.5–1.0 mm may be used. Studies have shown that needle penetration matched settings up to 1.0
mm but were less consistent once needle lengths were longer than 1.0 mm (93, 94). Another study
showed that the benefits of singular microneedling sessions with a 3 mm needle could be achieved
by a singular treatment using a 1 mm needle size, which could be augmented further by repeating
the treatment (95).
A topical agent is advised to maximize the glide of needles over the skin. Oftentimes, the manufac-
turer will provide a prepared agent, usually containing a mix of hyaluronic acid and antioxidants. Sterile,
inert, water-based gels, and PRP can also be used.
Begin by ensuring there is a brand-new disposable needle cartridge in place. Apply the chosen topi-
cal agent to the skin in an adequate amount to minimize epidermal injury. Lower the device so that the
needles are perpendicular to the skin while providing mild traction nearby with a free hand, taking care
not to inflict a needlestick injury. Glide the device over the skin in all directions (horizontal, vertical,
oblique) until pinpoint bleeding is visible, which usually occurs after 3–6 passes depending on the area
treated. It may be helpful to treat thicker, less sensitive areas first to allow the patient to adjust to the
pain he or she may experience. Once the procedure is complete, remove blood and the topical agent with
sterile water-soaked gauze. Apply a post-procedure serum, also often provided by the manufacturer,
to the treatment areas. Cooling masks without active ingredients may also be used to soothe any pain
and swelling.
FIGURE 11.1 Microneedling treatment with platelet rich plasma (PRP) using automated microneedling pen. Note how
the pen is held perpendicular to the skin while the other hand is used to hold traction at a safe distance from the pen. (Photo
courtesy of Naissan Wesley, MD.)
FIGURE 11.2 Closeup of microneedling treatment with PRP using automated microneedling pen. Uniform pinpoint
bleeding is used as the endpoint of the treatment. (Photo courtesy of Naissan Wesley, MD.)
11.8.4 Post-Procedure
Patients may be supplied with a chosen topical serum to apply to their face for a few hours after the
procedure. After 4 hours the patient can apply nonallergenic moisturizing cream 3 times a day for about
3 days. It is important to emphasize the importance of applying a nonchemical sunscreen with SPF 30 in
addition to the moisturizer. Makeup can be applied 2 days after treatment but active skin care products
should be resumed 1 week after treatment (92).
11.8.5 Number of Treatments

While there is no standard treatment protocol available, the literature shows time intervals between two
sessions vary from 4 to 8 weeks with a total number of 2 to 4 treatment sessions (83). An animal study
demonstrated that the best results are achieved when microneedling treatments are repeated 4 times with
an interval time of 3 weeks (95). Starting off with 1 session every 2 to 4 weeks for a total of 3 sessions
is a good place to start. It is also important to keep in mind that maximal effects may not appear for
several months.
FIGURE 11.3 After microneedling treatment with PRP of the face using an automated microneedling pen. Note the
uniform pinpoint bleeding. (Photo courtesy of Naissan Wesley, MD.)
FIGURE 11.4 Photos of patient. (a) Before microneedling. (b) Immediately after microneedling of the face and neck
with PRP. (c) After microneedling procedure with blood and PRP removed. The inflammation typically resolves within
24 hours. (Photos courtesy of Naissan Wesley, MD.)
TABLE 11.1
The Benefits and Disadvantages of Microneedling Treatments
Benefits Disadvantages
• Decreased risk of hyperpigmentation, particularly with • Pain, swelling, and erythema can occur
strict UV-light avoidance before and after the • Bleeding can pose a risk to the provider and
procedure discomfort for the patient
• Short healing phase and minimal downtime • Results may not initially be as impressive as those
• Can be performed on areas where lasers or peels achieved with laser resurfacing
cannot • Scarring can occur if performed too aggressively
• Does not ablate the epidermis • Potential increased risk of hypersensitivity reactions
• More cost-effective than laser treatments to topicals or needles
• Excellent safety profile in all skin types
• Low risk of infection when performed under sterile
conditions and with appropriate post-procedural care (24).
11.9 Conclusion
Microneedling is an innovative procedure that is helping meet the increased demand for non-surgical
esthetic enhancement. Through a controlled wound healing cascade as a result of micropunctures, new
collagen is formed, leading to improvement in rhytides and overall skin appearance. In addition to its anti-
aging benefits, microneedling is also effective in treating scars, striae, melasma, and alopecia. When it is
combined with other modalities such as PRP, dermal filler agents, and peels, esthetic results are enhanced.
As a cost-effective, easily implementable in-office procedure, microneedling can provide esthetic benefits
similar to those of peels and lasers with fewer side effects and minimal down time (Table 11.1).
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12
Dermatotoxicology of Microneedles in Man
John Havens Cary

Louisiana State University School of Medicine
Becky S. Li
Howard University College of Medicine
Howard I. Maibach
University of California, San Francisco, School of Medicine
The authors declare no conflict of interest.
12.1 Introduction
Microneedles (MNs), minimally invasive devices designed to painlessly penetrate the stratum corneum,
were developed in 1976 as a means for more efficient transdermal drug delivery (Ma and Wu 2017).
In subsequent decades, advancement in MN technology and manufacturing has led to development of
several types of MNs including hollow, solid, dissolving, coated, and hydrogel-forming (Nguyen and
Park 2018). Hollow MNs deliver drugs through a channel in a similar manner to hypodermic needles,
while solid MNs are more frequently used in pretreatment to enhance the permeability of the skin before
application of a topical product. Dissolving MNs are constructed from a biodegradable polymer or poly-
saccharide with therapeutic molecules contained within; coated MNs contain the drug formulation on
the outside surface of the needles. Lastly, hydrogel-forming MNs are made of expanding material with
an active agent attached to the baseplate (Nguyen and Park 2018). Current and potential applications of
MNs include: dermal and intrascleral drug delivery, vaccine administration, blood and interstitial fluid
extraction, and numerous uses in cosmetics (Ramaut et al. 2018; Ma and Wu 2017).
The MNs allow delivery of higher-molecular-weight and hydrophilic drugs that would otherwise be
unable to diffuse across the stratum corneum. In contrast to enteral drug delivery, dermal drug delivery
avoids stomach degradation and hepatic first-pass metabolism, while it may also produce higher drug con-
centrations in the dermis and other target tissues. Badran et al. (2009) demonstrated effective penetration
of radiolabeled mannitol, a hydrophilic drug expected to have poor penetration into the stratum corneum,
in full-thickness human skin grafts when combined with microneedling. Dhurat et al. found enhanced
effectiveness of minoxidil in men with androgenetic alopecia when used in conjunction with micronnee-
dling in comparison to conventional minoxidil treatment; they also demonstrated effectiveness of MN
and minoxidil combination therapy in patients who failed to respond to conventional minoxidil treatment
(Dhurat et al. 2013; Dhurat and Mathapati 2015). Jiang et al. (2009) demonstrated effective intrascleral
delivery of microparticles via MNs. With possible drug diffusion to surrounding tissues like the choroid,
retina, and ciliary body, intrascleral drug delivery via MNs has the potential to treat posterior eye disease
such as glaucoma and macular degeneration, although further research is needed (Jiang et al. 2009).
The MN delivery of vaccines releases antigenic material into the viable dermis, which has shown stron-
ger immunological reactions when compared to muscle, the delivery target of traditional hypodermic
needles (Engelke et al. 2015). A multi-center, randomized open-label study of 978 healthy adults showed
intradermal influenza vaccine delivered by microinjection systems to convey a non-inferior humoral
response against three influenza strains and two superior humoral responses to both A strains (H1N1,
H3N2) (Leroux-Roels et al. 2008). Similar studies on influenza vaccination have demonstrated compa-
rable or superior responses when compared to responses from conventional intramuscular vaccination
133
(Van Damme et al. 2009; Kenney et al. 2004). In addition to potentially less expensive and superior
humoral responses for some vaccines, MNs eliminate sharp, bio-hazardous waste and painful injections
present in vaccines administered via hypodermic needles.
Development of optimized hollow MNs has resulted in additional potential applications, including
blood and interstitial fluid extraction (Li et al. 2013; Kiang et al. 2017). When paired with biosensors and
other microsystems, MNs have the potential for use in glucose and drug monitoring (Kiang et al. 2017).
While experiments with MN-integrated biosensors have yielded promising results, extensive preclinical
and clinical trials are needed before their implementation as point-of-care devices for ISF collection,
drug concentration assessment, or dosing in real time (Kiang et al. 2017).
Dermal microneedling has proven an effective therapy for atrophic acne scars and skin rejuvena-
tion (Kim et al. 2011). Although the exact mechanism is unknown, MN puncture likely disrupts
older collagen strands and promotes damaged collagen removal (Fabbrocini et al. 2009). In addi-
tion, rolling with multiple MNs to promote new collagen and elastin deposition, known as collagen
induction therapy, has become popular practice in treating disfiguring scars and rhytides and reju-
venating skin (Fabbrocini et al. 2009; Aust et al. 2008). Other methods used to improve the clinical
appearance of acne scarring such as laser resurfacing carry risks associated with a disrupted skin
epidermal barrier. Cho et al. (2012) showed microneedling to lead to improved grade of acne scars
and global assessment of large pores in more than 70% of 30 tested patients. Kim et al. (2011) com-
pared the effects of microneedling to those of intense pulsed light therapy for skin rejuvenation,
finding significantly higher levels of collagen in microneedling when evaluated via caliper, micro-
scopic examination, Western blot analysis for type I collagen, and enzyme-linked immunosorbent
assay for total collagen content.
12.2 Adverse Events

Perhaps the most extensive use of MNs in any one application occurs with collagen-induction therapy.
Consequently, most discussion of adverse events and normal post-procedural expectations involve this
application.
Common contraindications to MN collagen-induction therapy include active acne; herpes labialis
or other active current infection such as impetigo or warts; patients on anticoagulant therapy such as
warfarin and heparin or with other blood dyscrasias; patients with extreme keloid scarring tendency;
and patients on chemotherapy, radiotherapy, or high doses of corticosteroids (Singh and Yadav 2016;
Fernandes 2005).
In the healthy patient without contraindication to treatment, typical post-procedural expectations in col-
lagen induction therapy with MNs include bleeding, bruising, erythema, and irritation (Fernandes 2005).
Fernandes (2005) outlines a predicted appearance timeline and general recommendations following per-
cutaneous collagen induction. Patients may note a bruised skin appearance with a swollen face following
collagen induction therapy with a minimal, temporary ooze of serum. He recommends soaking the skin
with saline swabs for 1–2 hours followed by treatment with a tea-tree-oil cleanser, while also encouraging
patients to use topical vitamin A and vitamin C cream or oil to enhance healing. However, it is important
that patients use only topical products approved for intradermal use, as inappropriate topical formula in
conjunction with MN therapy increases the potential for allergic and irritant reactions. Note that vitamin
A is known to aggravate flush and cause dry, flaky skin. Patients should thoroughly wash their face until
all serum, blood, and oil is removed to prevent any minor eschar formation, as minor eschars may result
in development of simple milia or tiny pustules. The skin should look less dramatic following day 1
with moderate flush on day 4 to 5 and very few visible signs post-procedure day 7. Patients should avoid
unapproved topical formulations for at least 24 hours and refrain from direct sun exposure for at least
10 days. Fernandes advises at least 1 month in between retreatment with MNs, although the optimal
interval is not currently known.
Despite the potential uses and existence for over 4 decades, MNs have yet to be fully integrated into the
medical system. The following discussion investigates potential side effects of MNs, including infection,
irritation and irritant contact dermatitis (ICD), allergic contact dermatitis (ACD), hyperpigmentation,
Dermatotoxicology of Microneedles in Man 135
abnormal scarring, and irritant and allergic granulomas. We also consider the potential for photoirritation/
phototoxicity, photoallergic contact dermatitis, non-immunologic contact urticaria, and immuno-
logic contact urticaria. For a summary of literature documenting adverse events with MNs, please see
Table 12.1.
12.2.1 Infection
The stratum corneum serves many purposes, including a physical defense against microorganisms.
Microchannels formed during MN therapy have the potential to facilitate access of microorganisms
and increase susceptibility to infection. Gupta et al. (2011) evaluated the kinetics of stratum corneum
TABLE 12.1
Literature Documenting Adverse Events to MNs
Adverse Reaction Type Author(s) and Year Number of Patients Additional Details
Infection Aust et al. (2008) 2 2/480 patients with herpes
simplex infection
Torezan et al. (2013) 1 1/10 patients with infection
based on symptoms
Cunha et al. (2017) 1 Microsporum canis infection
of bilateral arms and legs
ICD Cercal Fucci-da-Costa and 1 Suspected irritation to
Reich Camasmie (2018) arnica-based cream
ACD Yadav and Dogra (2016) 1 “Rail track appearance” of
adverse reaction with
positive patch test to nickel
Allergic/irritant Soltani-Arabshahi et al. 3 Two patients with
granulomas1 (2014) granulomatous reaction,
systemic symptoms, and +1
reaction to Vita C serum;
one patient with
granulomatous reaction and
no systemic symptoms
Irregular scarring Pahwa et al. (2012)2 1 “Tram tracking” appearance
over temporal area,
zygomatic arch, and
forehead
Dogra et al. (2014)2 2 2/36 patients in study with a
“tram track” adverse event;
1/2 “tram trek” patients
withdrawn from study
Post-inflammatory Dogra et al. (2014) 5 5/36 patients in study; 3/5
hyperpigmentation patients forced to withdraw
from study; 2/5 patients
improved with
photoprotection
Sharad (2011) 4 4/36 patients in study with
more transient
hyperpigmentation
Majid (2009) 1 1/37 patients in study with
transient
hyperpigmentation
1 Allergic/irritant granulomas may be considered a subset of ICD or ACD.
2 “Tram tracking” or “tram trek” lesions may be due to ICD or ACD, as the authors did not determine the underlying cause.
resealing in MN versus hypodermic needles, finding faster resealing in MN-treated skin. Donnelly
et al. (2009) evaluated the microbial penetration in hypodermic needles versus MN-induced holes in
Silescol® membranes and neonate porcine skin. They demonstrated significantly lower penetration of
Candida albicans, Pseudomonas aeruguinosa, and Staphylococcus epidermidis across viable epidermis
in MN than with hypodermic needle puncture. Vicente-Perez et al. (2017) evaluated the effect of MN
patches on mice, testing for biomarkers of inflammation and infection, weight, and several other vari-
ables. They found no detectable levels of TNF-α among mice and no statistically significant increase in
C-reactive protein, immunoglobulin G, or interleukin 1-beta in MN-tested mice in comparison to control
mice, regardless of formulation type, needle density, number of applications, or mouse sex (p > 0.05 in all
cases). In addition, mice in all study and control groups demonstrated increased weight over the course
of the study. Collectively, the authors were unable to detect any infection or any variable indicative of an
infection across all tested mice.
Aust et al. (2008) performed a retrospective analysis of 480 patients with fine wrinkles, lax skin, scar-
ring, and striae gravidarum treated with percutaneous collagen induction using the Medical Roll-CIT
with topical vitamins A and C cosmetic creams for a minimum of 4 weeks postoperatively. Two patients
developed herpes simplex infection following a full-face needling that was successfully treated with
acyclovir.
In a pilot split-face study comparing conventional methyl aminolevulinate-photodynamic therapy
(PDT) with microneedling-assisted PDT on actinically damaged skin, 1 of 10 patients developed an
infection on the MN-treated side 7 days post-treatment, determined by signs and symptoms of high local
temperature, redness, pain, and crusts (Torezan et al. 2013).
Cunha et al. (2017) document a case of tinea corporis that emerged in corresponding locations of
dermaroller use approximately 3 weeks after start of her home MN therapy for bilateral scarring of her
arms and legs. Potassium hydroxide examination of the lesions was positive for fungus with lesion cul-
ture growing Microsporum canis. While the patient confirmed skin-cleaning prior and sanitation of the
MN device before and after therapy, inadequate sterilization of the patient’s skin and MN device cannot
be excluded.
Leatham et al. (2018) document a case of facial autoinoculation of varicella via a home microneedling
roller device. A healthy woman with a distant history of primary varicella zoster virus (VZV) infection
and no prior shingles vaccination reported grouped lesions over her chest, which she presumed an acne-
iform eruption. The patient self-treated the area with an at-home microneedling roller device and used
the device over her face to reduce the appearance of rhytides. On presentation, the patient had “grouped,
eroded papules and vesicles on the right T4 dermatome” and “eroded papules on the forehead, lateral
cheeks, many located at spaced distances.” PCR yielded positive results for VZV. Patient was started on
oral valacyclovir and was free of lesions and experienced no postherpetic neuralgia at 6 weeks.
12.2.2 Irritant Contact Dermatitis

The ICD is an eczematous-like reaction occurring from contact with a chemical, biological, or physical
agent (Tan et al. 2014). Severity of the reaction is dependent upon the physiochemical property of the
agent and the degree of activation of the innate immune system (Tan et al. 2014). Keratinocytes, which
comprise 95% of epidermal cells, are responsible for production of the majority of cytokines likely respon-
sible for the ensuing erythema and edema (Tan et al. 2014). In contact with any agent, there is potential
for ICD; however, it is likely that disruption of the stratum corneum provides increased susceptibility to
a particular irritant. MNs are most frequently manufactured from non-irritating metal, polymer, silicon,
and glass, none of which are particularly common irritants (Nguyen and Park 2018). However, irritation
following a procedure may result from the MNs themselves or any substance used in conjunction.
Cercal Fucci-da-Costa and Reich Camasmie (2018) document a case of likely ICD due to skin rejuve-
nation MN therapy over the patient’s dorsal hands. Following her MN therapy, the patient inadvertently
applied arnica-based cream and developed yellowish papules compatible with MN perforation sites on
an erythematous base 48 hours post-arnica cream application. The authors attributed the lesions to ICD
from the arnica-based cream due to the sparing of MN-treated areas in which the cream was not applied
and the patient’s improvement 72 hours post–topical corticosteroid treatment.
Soltani-Arabshahi et al. (2014) document three cases of post-MN therapy granulomatous presentation
of possible irritant or allergic origin discussed in “Allergic/Irritant Granulomas.” In addition, it is likely
that MN-related ICD is significantly underreported in the literature. Assessment of post-procedural ery-
thema allows a rough estimate of the irritation incurred during the procedure. However, post-procedural
erythema is likely dependent on factors such as: MN application site, amount of MN applications, MN
length and type, combination therapy with topical products, and variability between skin types.
Bal et al. (2008) applied MN arrays (200, 300, or 400 μm solid metal MN arrays and 300 or 550 μm hol-
low metal MN arrays) using a standardized electrical applicator to the forearms of 18 human volunteers and
measured redness using skin color assessment and laser Doppler imaging. They found longer needle lengths
to result in greater irritation, evidenced by the 400 μm solid MNs resulting in significantly greater change
in redness in comparison to the 200 μm solid MNs (P < 0.001). Lastly, they concluded 15 minutes post-
application as the maximum change in redness with minimal irritation lasting less than 2 hours for all MNs.
Gill et al. (2008) investigated safety of single, longer MN lengths (480, 700, 960, and 1450 μm) on the
volar forearm of healthy human volunteers, finding decreasing erythema over 2 hours in all subjects with
no excessive erythema self-reported by research subjects when contacted at 24 hours.
Han et al. (2012) used a chromameter to measure post-treatment erythema following MN therapy using
150 and 250 μm MN rollers over one side of the face of healthy human volunteers. They found recovery
time to baseline erythema to be 24 hours in the 5-application group and 48 hours in the 10-application
group and a significant difference in the erythema index ratio between the two groups after 24 hours
(p = 0.002). In contrast, they did not find a significant difference between the erythema index ratio of
the 150 and 200 μm MN roller groups, although the mean erythema index ratios were higher in the
250 μm MN roller group.
12.2.3 Allergic Contact Dermatitis

The ACD is a type IV hypersensitivity reaction requiring prior sensitization and re-exposure to the
allergen (Mowad et al. 2016). In the sensitization phase, the unprocessed chemical allergen, known as a
hapten, penetrates the lower levels of the epidermis, where it is engulfed by a Langerhans cell and later
presented to T-cells (Marks and deLeo 2016). Upon subsequent exposure to the allergen, cell-mediated
immune response results in an eczematous-like lesion. As previously mentioned, microneedling disrupts
the stratum corneum, increasing the ability of molecules, possibly allergens, to enter the dermis.
Yadav and Dogra (2016) identified a potential case of ACD occurring as a result of a microneedling
procedure for the treatment of atrophic acne facial scars. Other than a local anesthetic applied 1 hour
before and completely cleaned with normal saline and betadine, no serum or chemical was applied
before, during, or after the procedure. The patient developed erythema and edema over the next 2 days,
which gradually subsided. Simultaneously, the patient developed vesiculopustular lesions and erythema-
tous papules arranged linearly along the lines of the microneedling device, giving a “rail track appear-
ance.” The lesions cleared in 4 weeks, and after 3 months, she was patch-tested with both nickel sulfate
(5% in petroleum) and titanium (10% in petroleum) with readings taken at 48 and 96 hours. The patient
demonstrated a negative reaction to titanium patch testing and experienced tiny vesiculopustular lesions
and intense erythema, extending beyond the margins at 48 hours in response to nickel.
Of note is that Pahwa et al. (2012) and Dogra et al. (2014) document cases of “tram tracking” and “tram
trek” scarring respectively. It is unclear whether Yadav and Dogra’s documentation of a “rail track”-
appearing reaction represents a similar or a distinct entity. However, the former authors were unable to
attribute the scarring to a particular allergen or irritant, so they are discussed here in section 12.2.5 below.
12.2.4 Allergic/Irritant Chronic Inflammatory Reactions and Granulomas

Granulomatous inflammation is most commonly characterized by a collection of histiocytes (macro-
phages) surrounding an antigenic center, which may occasionally be necrotic; however, granulomatous
inflammation encompasses presentations ranging from a well-organized granuloma to loose aggregates
of epithelioid cells mixed with other inflammatory cells (Shah et al. 2017). Granulomas may develop
with or without immunologic modulation in the case of granulomatous hypersensitivity and foreign-body
granulomas respectively (Epstein 1989). Dermal granulomatous hypersensitivity has historically been
associated with intradermal tattooing of red dyes with metallic elements and injection of dermal fillers
such as hyaluronic acid and poly-l-lactic acid (PLA).
Pratsou and Gach (2013) report two sisters who underwent a facial microneedling procedure with a
trained practitioner using a CE-marked,1 US Food and Drug Administration (FDA)-registered device cou-
pled with skin cleansing and topical anesthetic cream. Within 24 hours, both sisters developed significant
lymphadenopathy, and the older sister developed pinpoint erythema, malaise, and headache. Systemic
antibiotics were unhelpful, as the older sister’s condition worsened with a “florid erythematous papular
rash over her face” with spread to her trunk and limbs. The patient gradually improved over 2 weeks with
systemic and topical corticosteroid treatment. Biopsy of lesions showed a nonspecific, chronic inflamma-
tory infiltrate. Patch testing yielded a positive reaction to nickel sulfate (D4++), a known allergy to the
patient. The authors were unable to attribute the reaction to her allergy, as the MN device contained up
to 0.006% sulfur and 8% nickel bound to surgical-grade stainless steel (per manufacturer)—an amount
thought to pose little or no risk in short-term contact with nickel-sensitive individuals.
Soltani-Arabshahi et al. (2014) document a total of three cases of granulomatous reactions to MN therapy.
In the first case, two women presented after Dermapen MN therapy followed by high dose of lipophilic vita-
min C (Vita C Serum; Sanítas Skincare) applied to the skin at the same medical spa. Both patients developed a
progressive erythematous rash over the face in addition to systemic reactions, including arthralgias of varying
intensity. In both cases, biopsy of indurated papules showed foreign-body-type granulomatous reaction with
focal, polarizable material present in giant cell cytoplasm. Patch testing both patients showed +1 reaction to
Vita C Serum, while patch testing with Vita C Serum in five healthy volunteers yielded negative reactions.
Both patients had persistent, mildly indurated, erythematous papules and plaques at 9-month follow-up. In the
last of the three cases, patients presented following three microneedling procedures, two in which a gel prod-
uct (Boske Hydra-Boost Gel; Boske Dermaceuticals) and one in which Vital Pigment Stabilizer (Dermapen,
LLC) were applied before microneedling. In the last of the three cases, patients underwent three consecutive
microneedling procedures, two in which a gel product (Boske Hydra-Boost Gel; Boske Dermaceuticals) and
one in which Vital Pigment Stabilizer (Dermapen, LLC) were applied before microneedling. While none of
the patients experienced systemic symptoms in any of the procedures, one presented with a progressively
worsening erythematous rash that developed papular features, with biopsy showing a similar granulomatous
reaction. However, she refused patch testing and demonstrated resolution at 3 weeks.
12.2.5 Irregular Scarring

Pahwa et al. (2012) reported “tram tracking” or multiple discrete papular scars in a linear pattern in the
horizontal and vertical directions in a 25-year-old woman 1 month after treatment with a dermal rolling
device for management of post-acne scarring. The scarring was predominantly located over the temporal
area, zygomatic arch, and the forehead of the patient, who slightly improved with topical silicone gel at
6-month follow-up. They were unable to attribute the atypical scarring to an allergen or irritant.
Dogra et al. (2014) reported 2/36 patients undergoing MN therapy for atrophic acne scars to have a
similar “tram trek” adverse effect. One patient developed severe tram trek scarring over the malar prom-
inence and was forced to withdraw; however, the patient did improve with topical tretinoin. The second
patient developed less severe tram trek scarring over the forehead and was able to complete the study.
It is possible that the “tram trek” scarring may be a result of excessive force during the microneedling
procedure over bony prominences of the patient’s face.
12.2.6 Post-Inflammatory Hyperpigmentation

Post-inflammatory hyperpigmentation (PIH) is a hypermelanosis resulting from dermal inflammation
or injury most commonly in people with skin of color (Davis and Callender 2010). The inflamma-
tion may be endogenous in the case of primary dermatoses or exogenous from external insults such
1 The CE mark indicates that the manufacturer of a product takes responsibility for the compliance of this product with all
applicable European health, safety, performance and environmental requirements.
as trauma or physical injury (Epstein 1989). While the pathogenesis is not completely known, PIH is
believed to result from increased production of melanin or increased release of melanin due to mela-
nocyte-stimulating signals such as cytokines and various other inflammatory mediators (Davis and
Callender 2010).
Dogra et al. (2014) found 5/36 patients to present with PIH following 2–3 treatments of MN therapy
for post-acne scarring. Of the five patients, three had severe hyperpigmentation forcing them to withdraw
from the study, while the other two gradually improved with photoprotection.
Sharad (2011) and Majid (2009) reported more transient PIH in 4/36 patients and 1/37 patients respec-
tively in similar studies on MN therapy for atrophic scarring. Each of the previously mentioned cases
of hyperpigmentation featured phototype III or greater skin, except for one patient of unspecified type.
To date, the amount of adverse hyperpigmentation reactions remains minimal and is possibly a result of
improper UV protection following the procedure (Ramaut et al. 2018).
12.2.7 Other Adverse Effects to Consider

Lastly, other reactions of which MN users should be aware are photoirritation, photoallergy, non-
immunologic contact urticaria (NICU), and mmunologic contact urticaria (ICU).
Phototoxic, or photoirritant, reactions are evoked from the combination of an exogenous or endog-
enous compound and ultraviolet (UV) irradiation (Ibbotson 2014). Phototoxic reactions most often
appear similar to an acute sunburn; however, they occasionally present with urticarial, eczematous,
lichenoid, or, rarely, pigmentary changes (Maibach and Honari 2014). In contrast, photoallergy
requires a prior sensitization to the chemical in the presence of UV radiation and an additional expo-
sure, in which there is a cell-mediated immune response and clinical presentation of the photoallergy
(Ibbotson 2014). Photoallergic reactions most often present with eczematous-like changes (Maibach
and Honari 2014).
Contact urticaria comprises a group of inflammatory reactions ranging from itching, burning, and
tingling to systemic anaphylaxis (Gimenez-Arnau and Maibach 2014). Contact urticaria can be divided
into NICU and ICU, the two separate entities being distinguished by immunologic memory in the case
of ICU but no required prior sensitization in NICU (Gimenez-Arnau and Maibach 2014). The ICU and
NICU are distinct in mechanism and etiology, but have very subtle, if any, difference in their clinical
presentation (Gimenez-Arnau and Maibach 2014; Lahti 2000).
There is little to no current literature documenting photoirritation, photoallergy, NICU, or ICU result-
ing from MN therapy; however, we believe they are conditions of which it is important to be aware in
view of the potential growth of MN use in the future.
12.3 Conclusion
Of all MN applications, the growth of MN use in the cosmetics industry for skin rejuvenation in the
spa or the home setting raises the most concern. As previously mentioned, skin rejuvenation with
MNs or collagen-induction therapy represents the most extensive use of MNs in any one therapy of
all potential MN applications. In addition, skin rejuvenation is frequently performed outside of the
medical setting, which also increases the chance of adverse events, especially those stemming from
improper sterilization or the coupling inappropriate topical products. We advise patients to understand
contraindications for use and follow post-therapy guidelines, especially when seeking therapy outside
of the medical setting.
Ramaut et al. (2018) systematically reviewed the MN literature and its potential application in atro-
phic acne scars, skin rejuvenation, hypertrophic scars, keloids, striae distensae, androgenetic alopecia,
melasma, and acne vulgaris. They generally favored MN therapy due to minimal side effects with shorter
recovery periods and similar results when compared to other treatments.
In addition, various clinical trials involving MNs that are completed, active, or recruiting are listed
in Table 12.2. Some of the more common clinical trial applications include uveitis with five and actinic
keratosis with three clinical trials completed, ongoing, or recruiting.
TABLE 12.2
Completed, Active, and Recruiting Clinical Trials Involving MNs in the United States According to
ClinicalTrials.gov*
Enrollment
Clinical Trial Targeted Number of (Number of Age of Patients
Course Application Trials Trial Phase Patients) (Years)
Completed Type I diabetes 1 2, 3 16 8–18
Hyperhydrosis 1 1 13 12+
Actinic keratosis 3 N/A; N/A; 2 33; 51; 137 18+
Intracutaneous 1 N/A 12 18–49
drug delivery
Uveitis 4 1, 2; 3; 3; 2 11; 38; 160; 22 18+
Overactive 1 N/A 8 18+
bladder
Acute migraine 1 2, 3 365 18–65
Atopic dermatitis 2 1; N/A 40; 368 18–64
Postmenopausal 2 1; 2 24; 250 55–85; up to 85
osteoporosis
Polio immunity 1 2 231 18–90
Diabetic macular 1 1, 2 20 18+
edema
Influenza 1 N/A 24 18–49
Active Influenza 1 1 100 18–49
Type I diabetes 1 2 20 18+
Face and neck 1 N/A 21 18+
wrinkles, texture,
pigmentation
Diabetic macular 1 2 71 18+
edema
Recruiting Macular edema, 1 3 460 18+
retinal vein
occlusion
Vaccination, skin 1 N/A 50 6 weeks–24
absorption months
Diabetes 1 N/A 15 7–18
Wrinkles 1 N/A 32 22+
Cutaneous T-cell 1 1 54 18+
lymphoma
Skin laxity 1 N/A 20 18–75
Migraine 1 3 250 18–75
Uveitis 1 3 38 18+
* Note that there are two additional trials testing MN systems in healthy patients.
We believe MNs may be a relatively safe alternative and, in some circumstances, a superior option
to many conventional therapies. However, further research and experience is needed to clarify the most
appropriate and safe way to utilize this technology.
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Index
Note: Page numbers in italics indicate figures and bold Biosensor, 83, 86–87
indicate tables in the text. CGM, 88, 88–89
3,3′5,5′-tetramethylbenzidine (TMB), 86 Bovine serum albumin (BSA), 67, 75–76, 99, 107
3M™’s Hollow Microstructured Transdermal System Brazzle, J. D., 36
(hMTS), 94, 95 Bullfrog® microinfusion device, 100, 100
A C
Accuracy and reproducibility, 24 Candida albicans, 136
Active pharmaceutical ingredient (API), 55 Carboxymethylcellulose (CMC), 28
Adhesive dermally applied microarray (ADAM), 97 Cercal Fucci-da-Costa, 136
AdminPen™ (NanoBioSciences), 94, 94 Chabri, F., 68
Adventitia, 99 Chemical enhancers, 2, 2
Adverse events to MN, 134–139 Chemistry, manufacturing, and controls (CMC), 113
allergic contact dermatitis (ACD), 135, 137 Chen, B., 67, 99
granulomatous inflammation, 137–138 Chua, B., 44
infection, 135, 135, 136 Clearside Biomedical, 105
irregular scarring, 135, 137–138 Clinical trials, 119–128, 140
irritant contact dermatitis (ICD), 136–137 biological considerations, 111–112
post-inflammatory hyperpigmentation (PIH), 135, design considerations, 110
138–139 manufacturing process considerations, 110–111
Aging skin, 119–120 microneedle applications, 114–115
Allergic contact dermatitis (ACD), 135, 137 overview, 109
Allergic/irritant granulomas, see Granulomatous procedural requirements for, 113–114
Alopecia, 121–122 Coat-and-poke approach, MNA, 20
Anesthesia, 77 Coated microneedle array (MNA), 20, 20, 26
Anti-aging, 121 fabrication of, 26–27
Anti-FluVax®-IgG antibody, 87 materials for, 28
Apex shape and dimensions, 22 Coherent porous silicon (CPS), 42
Applicator, 94–95 Commercialized microneedles, 101–105
Area under the curve (AUC), 82 devices, 92–93
Arkal Medical (Fremont, CA, USA), 88 factors driving microneedle (MN) technology, 91
Aust, M. C., 121, 136 microneedle injection system, 91–96
Australian New Zealand Clinical Trials Registry microneedle patch system, 96–98
(ANZCTR), 97 microneedle-related techniques, 99–101
Complete head penetration phase, MNA, 23
B Complete response rate (CRR), 78
Computer numerical control (CNC), 38
Back-side illumination electrochemical etching Considerations, 124; see also specific considerations
(BIEE), 42 Contact and deflection phase of skin, 9
Badran, M. M., 133 Continuous glucose monitoring (CGM) biosensor,
Bal, S. M., 137 88, 88, 100
Becton Dickinson Soluvia™ Micro Injection system, Continuous monitoring microneedle devices,
114–115 88, 88–89
Benign processing, 24 Contract development and manufacturing organization
BETACONNECT™ (Bayer HealthCare Pharmaceuticals (CDMO), 95
Inc.), 94, 101 Corium International, Inc., 97, 98
Bevel angle, 22 Corrie, S. R., 87
Bioactive component, 12 COSMETEX ROLAND Co., Ltd., 96
Bioburden control, 111 Cosmetics, 96
Biocompatibility, 111, 111 applications, 114
Biolistic injectors, 55–58, 56 Coulman, S. A., 68
Biological considerations, 111–112 Crichton, M. L., 29
Biology of aging skin, 119–120 Cryomed (NCT03426098), 105
145
146 Index
D dissolvable MNA, 27
hollow microneedles, 35–42
Das, D. B., 67 hybrid techniques, 25–26
Davis, S. P., 10, 41, 43, 44 Factors driving microneedle (MN) technology, 91
D’Cunha, N. M., 136 Fernandes, D., 134
Debioject™ (Debiotech), 94, 94–95, 101 Fillers, 122
Deep reactive ion etching (DRIE), 36–38, 85 Fillet radius, 22
Demuth, P. C., 69 Final tissue relaxation phase, MNA, 23
Dermabrasion, 54; see also Microdermabrasion Fleck, N. A., 9, 10
DermaFrac™ (Genesis Biosystems) technology, 123 Fluorescein isothiocyanate (FITC), 68
Dermatotoxicology of MN, 133–139 Fluvax®, 87, 97
adverse events, 134–139, 135 Fluzone®, 94, 114–115
overview, 133–134 Fractional radiofrequency microneedle (FRM), 123
Dermis, 1, 8 Fracture, skin, 8–10
Design considerations, 110 Fu, C., 38
Detergents, 2
Dextrin, 28, 65
Dhurat, R., 121, 133 G
Diabetic pediatric population (NCT02682056), 101 Gach, J., 138
Diagnostics, 114 Galactose, 28
Direct enhancement techniques vs. microneedles, 58 Gardeniers, H. J. G. E., 44
Direct fabrication techniques, 25 Gastrointestinal (GI) tract, 19
Direct physical methods, 53–58 General manufacturing controls, 110–111
biolistic injectors, 55–58 Geometric capability, 24
microdermabrasion, 54 Gill, H. S., 137
Disposable injection unit with applicator, 94–95 Glucose diffusion through hollow microneedles, 113
Dissolvable microneedle array (MNA), 3, 20, 20, 26 Glucose sampling, 77
fabrication of, 27 Glycerol, 28
materials for, 28 Gold-coated hollow microneedle, 86
Dogra, S., 137, 138–139 Gomaa, Y. A., 69
Donnelly, R. F., 84, 136 Granulomatous, 135, 137–138
Droplet-born air blowing (DAB), 96 Griss, P., 38
Drug delivery, 114 Gupta, J., 135–136
application in, 69
Dye delivery, 12, 13
H
E Han, T., 67
Han, Tae Y., 137
ECell®, 98 Han, Tao, 99
Electromigration, 50 Henderson, H. T., 42
Electroosmosis, 50 Henry, S., 14
Electroporation, 2, 51, 67–68 High-density arrays, 12
Electroporation needle (EPN), 99, 100 High-performance liquid chromatography (HPLC), 84
Elongated microparticles (EMP), 49, 57, 57–58 Hollow-bore microneedles, 75
Enable Injections, Inc., 98, 99 Hollow microneedles, 3, 37, 39, 69
Enable Smart enFuse™, 98, 99 fabrication technology for, 35–42
Endothelial precursor cell (EPC), 122 insertion methods, 44
Endothelium, 99 integration, 43–44
Enhanced passive diffusion, 50 mechanical strength, 42–43
Enhancer arrays, 13–14 overview, 35
Enzyme linked immunosorbent assay (ELISA), 87 Hollow Microstructured Transdermal System
Epidermis, 1, 2, 7–8 (hMTS), 38
Erbium:yttrium-gallium-garnet (Er:YAG), 55 Hooper, J. W., 68
Ethics, 113 Huang, H., 38
Eunsung Global Corporation, 99, 100 Human embryonic stem cell (hESC), 122
Hyaluronic acid (HA), 28
F Hybrid fabrication techniques, 25–26
Hydrogel-forming microneedles, 84
Fabrication Hypertrophic scars, 121
coated MNA, 26–27 Hypodermic vaccine (NCT02438423), 101
direct techniques, 25 Hypodermis, 1
Index 147
I Leatham, H., 136

Lee, H., 36, 52, 54
Immune response, 111–112 Lee, K., 40, 43
Immunologic contact urticaria (ICU), 139 Lee, W. H., 36
Immunotherapies (NCT02837094), 101 Lee, W. R., 54, 55
Indications, 121–122 Li, C. G., 40, 42–43, 44
Indirect physical methods, 49–53 LidoSite™ Topical System, 51
electroporation, 51 Lin, L., 36
iontophoresis, 50, 50–51 Lipidure®, 87
laser-assisted delivery, 52–53, 53 Liposomes, 2
magnetophoresis, 51 Lippmann, J. M., 36
sonophoresis, 51–52, 52 Liquid jet injectors, 55–56, 56
Infection, 135, 135, 136 Low cost and scalability, 24
Initial piercing phase, MNA, 23 Low-frequency ultrasound, 51–52
Injectable platelet-rich fibrin (I-PRF), 105 Lutrol F-68 NF, 28
Injection system, 91–96
In-plane microneedles, 35–36
Insertion methods, hollow microneedles, 44 M
Institutional review boards (IRB), 113 Magnetophoresis, 51
Integrated circuit (IC), 35 Majid, I., 139
Integrated microinjection system, 95–96 Maltose, 28, 65
Interstitial fluid (ISF), 81, 83–85, 88–89, 100 Mansoor, I., 38, 40, 42–44
Interstitial fluid extraction for on-device analysis, Manufacturing process considerations, 110–111
85–86, 86 Manufacturing techniques, microneedles, 24–27, 26
Investigational device exemption (IDE), 113 Martanto, W., 14
Investigational new drug (IND), 113 Massachusetts General Hospital, 105
Ionsys™, 51 Materials, 27–28
Iontophoresis, 2, 50, 50–51, 65–66 applicability, 24
Iontophoretic drug delivery, 50 for coated MNA, 28
Irregular scarring, 135, 138 for dissolvable MNA, 28
Irritant contact dermatitis (ICD), 135, 136–137 McAllister, D., 41, 68
Irritation, 111–112 Mechanical micromachining, 25
Ita, Kevin, 67 Mechanical strength, hollow microneedles, 42–43
Ito, Y., 69 Medical therapies, 76–77
side effects and risks, 77–78
J Meliga, S. C., 12–13
Memspatch®, 98
Jang, H. J., 56 Memspatch Insulin Microneedle Device (IMD), 98, 99
Jia, Y., 83 Metal manufacturing, 11
Jiang, J., 133 Metal out-of-plane microneedles, 39–42, 40, 41
Jina, A., 88–89 MicroCor®, 97, 98
Junmok International Co., Ltd., 101 MicroCor PTH(1-34), 97
MicroCure®, 96
K Microdermabrasion, 54
Microdermics, 98, 99
Karatica Co., Ltd., 96, 101 Microelectromechanical systems (MEMS) technology, 35,
Katikaneni, S., 66 39, 43
Keum, D. H., 87 Micron Biomedical, Inc., 96–97
Khanna, P., 42, 44 Micron Biomedical’s Microneedle Patch, 97, 98
Kim, K., 40, 43 Microneedle array (MNA)
Kim, S. E., 134 administration methods, 29, 29
Kobayashi, K., 40, 44 coated, 20, 20, 26, 26–27, 28
Kumar, A., 69 conformable, 22
designs, 21, 21–24, 22
L dissolvable, 20, 20, 26, 27, 28
hollow, 20, 20
Langerhans cells, 52 layer-loaded, 22
Laser ablation, 55 manufacturing techniques, 24–27, 26
Laser-assisted delivery, 52–53, 53 overview, 19–21
Laser-based approaches, 25 solid, 20, 20
Laser treatment devices (NCT03380845), 105 trans/intradermal drug delivery concepts, 20, 19–21
148 Index
Microneedle injection system, 91–96 Needle integration, 43–44

Microneedle patch Needle-tissue insertion force, 24
application, 12 Nemaura Pharma, Ltd., 97, 98, 98, 99
manufacture, 11 Neo Basic HA Fill Micro Patch, 96
system, 96–98 New drug application (NDA), 98
Microneedle perforator, 13–14 Nissaha Co., Ltd., 96
challenges of, 14 Nitric oxide (NO), 87
clinical use, 14 Non-immunologic contact urticaria (NICU), 139
Microneedle-related techniques, 99–101 Nonsignificant risk studies (NSR), 113
Microneedles; see also specific microneedles Norman, J. J., 41
administration to living rats, 29 Number of treatments, 126
combination of, 65–69
commercial, see Commercialized microneedles O
defined, 3
direct enhancement techniques vs., 58 O’Mahony, C., 12
dissolving, 3 Optical coherence tomography (OCT), 3–4
in early clinical trials, 102–104 Oral glucose tolerance test (OGTT), 84
geometry, 4, 23 Out-of-plane microneedles, 37; see also Polymer out-
hollow, see Hollow microneedles of-plane microneedles; Silicon out-of-plane
length, 75–76 microneedles
manufacturing techniques, 24–27 Ovsianikov, A., 38
materials, 27–28
medical therapies, 76–77 P
other transdermal technologies vs., 49–58
penetrate, 3, 4, 110 Pahwa, M., 137, 138
puncture of skin, 8–14 Paik, S.-J., 36, 42
roller, 11 Painless intradermal injection system, 94
shapes and sizes, 3 Passport® system, 54
side effects and risks, 77–78 Patient acceptability, 110
solid, see Solid microneedles Pearton, M., 14
transdermal drug delivery, 3–4 Peels, 122
types of, 75 Penetration of microneedles, 110
Microneedling, 119–128 Penetration phase of skin, 9
biology of aging skin, 119–120 Penetration route of API, 50
combined therapies, 122–123 Pen-type injection system, 94–95; see also Disposable
devices, 123 injection unit with applicator
indications, 121–122 Phosphate-buffered saline (PBS), 112, 112, 113
mechanism of action, 120 Photoallergy, 139
origins of, 119 Photodynamic therapy (PDT) treatment, 77, 78
overview, 119 Photoirritation, 139
technique, 123–126 Physical enhancers, 2, 2
MicronJet 600™ (NanoPass Technologies Ltd.), 94, 94, Pigmentary disorders, 121
101 Pisano, A. P., 36, 44
Micropore closure rate, 4 Platelet-rich plasma (PRP), 122, 125, 126, 127
Micro-sized needle injection patch, 98 Poke-and-flow approach, 21
Microsporum canis, 136 Poke-and-patch approach, 19
Mikszta, J. A., 13 Poke-and-release approach, 20
Miller, P. R., 87 Polat, B. E., 51
MN sensor system (MSS), 87 Poloxamer 188, 28
MN treatment (NCT03332628), 101 Polydimethylsiloxane (PDMS), 38
Moon, S. J., 38 Polyethylene glycol (PEG), 36, 84
Mukerjee, E., 85 Poly-glycolic acid (PGA), 28
Muller, D. A., 87 Poly(lactic-co-glycolic) acid (PLGA), 28, 65, 100
Multiphoton microscopy-fluorescence lifetime imaging Poly-L-lactic acid (PLA), 28, 138
microscopy (MPM-FLIM), 51 Polymer(s), 38
manufacturing, 11
N Polymer out-of-plane microneedles, 38, 39
Poly(methyl vinylether-comaleic anhydride), 84
Nanoparticles, 2 Poly(vinyl) alcohol (PVA), 28
NanoPass™ MicronJet600™, 114–115 Poly(vinyl)pyrrolidone (PVP), 28
Nanopatch™, 97, 98 Post-inflammatory hyperpigmentation (PIH), 135, 138–139
Index 149
Post-procedure, 126 dermis, 1

Potassium hydroxide (KOH), 35–36 drug delivery through, 2–3
Powder/particulate injectors, 57 dye delivery into, 12, 13
Pratsou, P., 138 as engineering material, 7–8
Pravaz, Charles Gabriel, 8–9 epidermis, see Epidermis
Prefilled Patch, 98, 99 fracture, 8–10
Pre-penetration phase, MNA, 23 goals of skin delivery, 7
Pretreatment, 124 healing, 112
Procedural requirements for clinical testing, 113–114 hypodermis, 1
Progressing head penetration phase, MNA, 23 layers of, 7–8, 10
Pseudomonas aeruguinosa, 136 material composition of, 7
Psoriatic plaques (NCT02955576), 101 microneedle puncture of, 11–14
Pulmonary arterial hypertension (PAH), 98 overview, 7
Pulsed electromagnetic fields (PEMF), 51 puncture, 8–14
Puncture of skin, 8–14 resealing time, 4
aspects of, 9–10 scale dependency of, 8
contact and deflection phase, 9 stratum corneum, 1
mechanisms of, 10 transdermal extraction from, 4–5
microneedle patch application, 12 Skin substrate (fat/muscle), 12–13
microneedle perforators/enhancer arrays, 13–14 Smart insulin patch, 69
skin substrate (fat/muscle), 12–13 Smooth muscle cells (SMC), 99
Sodium alginate, 28
Q Solid microneedles, 3, 68–69, 75; see also Dissolvable
microneedle array (MNA)
Quil-A, 28 Solid microprojection array (MPA), 87
Soltani-Arabshahi, R., 137, 138
R Soluvia™ (Becton Dickenson),
95, 96, 101
Rabique Pasteur®, 94 Solvents, 2
Radio frequency (RF) MN, 101 Sonophoresis, 3, 51–52, 52, 66–67
Rajaraman, S., 42 Stachowiak, J. C., 56
Ranamukhaarachchi, S. A., 85–86 Staphylococcus epidermidis, 136
Regulatory submissions, 113–114 SteadyMed, Ltd., 98, 99
Reich Camasmie, 136 Stem cells, 101, 122
Resnik, D., 12 Stemme, G., 38
Rodriguez, A., 42, 43 Stem shape and dimensions, 22
Romanyuk, A. V., 84 Strambini, L., 42, 85
Roxhed, N., 12, 43, 44 Stratum corneum (SC), 1, 7–8, 10, 19, 49
Royal Skin Hyaluronic Acid Micro Patch (Junmok Stupar, P. A., 36, 44
International Co., Ltd.), 96, 101 Suprachoroidal space (SCS), 95, 101, 105
Suzuki, H. A., 40, 44
S
T
Sakaguchi, K., 83–84
Sampling chamber, 112, 112 Takei, K., 42, 43
Scale for skin, 8 Takeuchi, S., 36
Scars, 121 Talbot, N. H., 36, 42
Secret Micro-Needle Fractional RF System®, 105 Techniques/technologies; see also specific techniques and
Sensing, 114 technologies
Sensitization, 111–112 hybrid fabrication, 25–26
Sharad, J., 139 microneedling, 123–125
Shergold, O. A., 9, 10 thermal ablation, 54
Shikida, M., 41 Tensile testing of skin, 10
Silica and ceramic microneedles, 42 Tetramethylammonium hydroxide (TMAH), 42
Silicon dioxide (SiO2), 42 Therapeutically monitored drugs, 82, 82–83
Silicone gel, 121 Therapeutic drug and biomolecule monitoring (TDM)
Silicon manufacturing, 11 diagnostic testing and, 81
Silicon out-of-plane microneedles, 37, 37–38 microneedle technologies for, 83–89
Silk, 28 overview, 81, 82
Skin Thermal ablation technologies, 54
anatomy of, 1 Tip or layerloaded MNA, 27
150 Index
Tip radius, 22 V-Go®, 98, 99, 101

Tip sharpness, 12, 22 Viable epidermis (VE), 7–8, 10
Tip-to-tip distance controls, 22 Vicente-Perez, E. M., 136
Topical agents, 123 Vital Pigment Stabilizer, 138
Topical anesthesia, 77
Transdermal drug delivery W
methods, 1–3, 2
microneedles for, 3–4 Wang, P. M., 83
Transdermal extraction from skin, 4–5 Wang, Y., 69
Transforming growth factor (TGF), 122, 123 Wildnauer, R. H., 10
Treatment, 124–125 Wilke, N., 67
Trevyent™, 98, 99 Windmiller, J. R., 87
Trichloroacetic acid (TCA), 121, 122 Wood, A., 8–9
Tumor cells (NCT02192021), 101 Wu, X. M., 66
Tunica media, 99
Y
U
Yadav, S., 137
Ultrasound, 66–67; see also Sonophoresis Yan, K., 68
Yttrium scandium gallium garnet (YSGG), 55
V Yu, J., 69
Yung, K. L., 38
Vaccinations, 76–77, 96–98
Vaccine delivery, 14, 69, 114–115 Z
Valeritas, Inc., 99, 101
Vancomycin-HRP, 86 Zahn, J. D., 36
Van der Maaden, K., 44 Zaric, M., 69
Varicella zoster virus (VZV), 136 Zhang, W., 68
Vaxxas, 96–97, 98 Zimmermann, S., 85
Vemulapalli, V., 66 Zosano Pharma, 97, 98, 114
Verbaan, F. J., 12, 29, 44, 68

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Microneedling in Clinical Practice

Raja K Sivamani, MD, MS (Bioengineering), AP

and by CRC Press

© 2021 Taylor & Francis Group, LLC

CRC Press is an imprint of Taylor & Francis Group, LLC

Library of Congress Cataloging-in-Publication Data

Cataloging-in-Publication Data are on file in the Library of Congress

ISBN: 978-1-138-63315-5 (hbk)

ISBN: 978-1-138-03569-0 (pbk)

ISBN: 978-1-315-26561-2 (ebk)

Typeset in Times LT Std

1. Microneedles and Transdermal Transport.................................................................................... 1

2. Skin Perforation and Solid Microneedles....................................................................................... 7

3. Dissolvable and Coated Microneedle Arrays: Design, Fabrication,

5. Microneedles vs. Other Transdermal Technologies.................................................................... 49

6. Combination of Microneedles with Other Methods.................................................................... 65

7. Medical Applications of Microneedles.......................................................................................... 75

8. Therapeutic Drug and Biomolecule Monitoring Potential

10. Considerations for Clinical Trials Involving Microneedle Devices......................................... 109

11. Microneedling in Clinical Practice: Cosmetic applications.......................................................119

12. Dermatotoxicology of Microneedles in Man...............................................................................133

Heather A.E. Benson Yeakuty Jhanker

Kourosh Beroukhim Sahitya Katikaneni

Urs O. Häfeli KangJu Lee

Becky S. Li Sahan A. Ranamukhaarachchi

1.1 Anatomy of the Skin

1.1.1 Stratum Corneum and Epidermis

1.2 Modes of Transdermal Delivery

c. Sonophoresis: Like electroporation, high-frequency sonophoresis also forms small holes in

1.4 Microneedles for Transdermal Drug Delivery

1.4.1 Depth of Microneedle Penetration

1.4.2 Rate of Micropore Closure

1.5 Transdermal Extraction from the Skin

Adapted from Gupta et al.22

Michael L Crichton1,2,3, Mark Kendall2,3,4,5

Institute of Mechanical, Process and Energy Engineering (IMPEE)

and Nanotechnology (AIBN)

The University of Queensland

Royal Brisbane and Women’s Hospital

2.1 Overview/The Goals of Skin Delivery (from a

2.2 Skin as an Engineering Material

2.2.1.1 The Epidermis (Comprising the SC and VE)

2.2.1.2 The Dermis

2.2.2 The Scale Dependency of Skin

2.3 Skin Fracture and Puncture

a. Contact and deflection phase:

2.4 Microneedle Puncture of Skin

2.4.1 Microneedle Patch Manufacture

2.4.2 Microneedle Patch Application

2.4.3 Skin Substrate (Fat/Muscle)

2.4.4 Microneedle Perforator/Enhancer Arrays

2.4.5 Challenges of MEAs

2.4.6 Clinical Use

Emrullah Korkmaz1 and O. Burak Ozdoganlar1,2,3

3.2 Microneedle and Array Designs

FIGURE 3.5 A typical needle-tissue insertion force diagram [71].

3.3 Microneedle-Manufacturing Techniques

3.3.1 Direct Fabrication Techniques

3. Dissolvable and Coated Microneedle Arrays: Design, Fabrication,

8. Therapeutic Drug and Biomolecule Monitoring Potential

2.1 Overview/The Goals of Skin Delivery (from a