A thorough knowledge of microneedling contraindications is an ethical and professional obligation for any aesthetician performing this technique. An inadequate client assessment can result in serious complications such as infections, keloid scarring or activation of pre-existing skin conditions. This article systematically describes absolute and relative contraindications, and the special precautions to be taken in specific situations.
Absolute contraindications
Absolute contraindications are conditions in which microneedling is completely prohibited, regardless of treatment intensity or depth:
Active infections in the treatment area
- Active herpes: herpes simplex virus can spread across the entire treated area with the dermapen if performed during an active outbreak
- Bacterial impetigo: superficial infection that can spread during treatment
- Active folliculitis
- Viral warts: HPV can be mechanically spread
- Molluscum contagiosum
Severe active inflammatory acne
Active inflammatory acne (papules, pustules or cysts) in the area to be treated is an absolute contraindication. The dermapen can disseminate Cutibacterium acnes bacteria to unaffected follicles, worsening acne and potentially causing secondary infections. The perilesional area may be treated if the acne is highly localised, but active lesions must always be avoided.
Active keloids
Keloids are benign tumour-like scars characterised by fibrous tissue growth beyond the borders of the original lesion. Dermapen micro-injury can trigger new keloid formation in predisposed individuals. If there is a history of keloid scarring anywhere on the body, microneedling in the affected area is contraindicated.
Coagulation disorders
Haemophilia, thrombocytopenia, or any condition preventing normal coagulation are contraindicated. Pinpoint bleeding is part of the technique's mechanism, and in anticoagulated patients (warfarin, acenocoumarol, novel oral anticoagulants) the risk of uncontrolled bleeding is significant.
Active psoriasis in the treatment area
Psoriasis can be triggered by the Koebner phenomenon: the appearance of psoriatic lesions in response to mechanical trauma. Microneedling can induce new psoriatic plaques in previously unaffected areas.
Recent systemic isotretinoin (Roaccutane)
Patients undergoing oral isotretinoin treatment or who have discontinued it within the past 6 months exhibit atypical healing with increased risk of hypertrophic scarring. Wait a minimum of 6 months after the last isotretinoin dose.
Pregnancy
Contraindicated in any trimester of pregnancy due to uncertainty about the safety of cosmetic actives used and the hyperreactive state of the skin during gestation.
Metal implants or pacemakers in the area
Especially relevant when using RF-needling. Subcutaneous metal implants may interfere with radiofrequency energy. For pure microneedling without RF, the risk is lower but caution is recommended.
Relative contraindications
Topical retinoids in use
Topical retinoids (tretinoin, adapalene, tazarotene) sensitise the skin and can excessively potentiate the inflammatory response. Discontinue 5–7 days before treatment.
Active rosacea
Rosacea with active telangiectasias or papules may worsen with microneedling. If rosacea is controlled and the client wishes to proceed, start with minimal depths and progressively assess tolerance.
Highly reactive skin or active atopic dermatitis
The compromised skin barrier in atopic skin reacts excessively to micro-injury. During stable remission phases, treatment may be considered with maximum caution.
Diabetes mellitus
Diabetic patients have reduced healing capacity and more frequent infections. This is not an absolute contraindication, but the practitioner must ensure strict hygiene, reduce depth and shorten post-treatment follow-up intervals.
Recent IPL or laser treatments
Wait at least 4–6 weeks after any IPL or laser treatment in the same area before performing microneedling.
Special precautions by phototype
Phototypes IV–VI (Fitzpatrick)
Darker phototypes have a higher risk of post-inflammatory hyperpigmentation (PIH) after microneedling. To minimise this risk:
- Use more conservative depths
- Apply anti-inflammatory actives in post-treatment
- Insist on strict sun protection during and after the treatment cycle
- Avoid retinol and irritating acids in the days before treatment
Complication management
Microneedling complications are infrequent when correctly applied, but practitioners must know how to recognise and manage them:
- Bacterial infection: redness, warmth, oedema and purulent discharge post-treatment. Refer to a doctor to assess antibiotic therapy.
- Herpes activation: appearance of vesicles in the treated area. Consult a doctor for antiviral prescription.
- Post-inflammatory hyperpigmentation: if it occurs, initiate a depigmenting protocol immediately and maximise photoprotection.
- Persistent erythema (more than 5–7 days): assess whether superinfection or other causes are present.