Combined microneedling and platelet-rich plasma for atrophic acne scars: a systematic review, meta-analysis and trial sequential analysis

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Atrophic acne scars remain a challenging concern. Microneedling and platelet-rich plasma (PRP) have demonstrated promising results. However, evidence supporting their combined use is limited. This study aims to compare the effectiveness of combined microneedling and platelet-rich plasma (PRP) therapy with microneedling or PRP monotherapy for the treatment of atrophic acne scars. A systematic search of electronic databases was conducted to identify relevant studies published up to July 2025. Primary outcomes included changes in the Goodman and Baron’s quantitative score, proportions of patients achieving good or excellent response, and patient satisfaction. Meta-analysis was performed using R version 3.4.3. Trial Sequential Analysis (TSA) was applied to assess the conclusiveness of statistically significant outcomes. Seventeen studies with 1111 participants were included. Combined microneedling and PRP therapy resulted in significantly greater improvement in acne scars compared to microneedling alone (MD = − 2.91; 95% CI: − 4.16 to − 1.65; p < 0.01; I² = 43.5%). The odds of achieving excellent outcomes (> 2-grade improvement) were higher with combination therapy (RR = 3.05; 95% CI: 1.68–5.51; p < 0.01). Similarly, combination therapy was associated with greater odds of achieving > 75% improvement (MD = 2.39; 95% CI: 1.25–4.59; p < 0.01; I² = 0%); with TSA confirming that the required information size was reached. For > 50% improvement, the effect remained significant (RR = 2.01; 95% CI: 1.16–3.48; p = 0.01), although the accumulated sample size was insufficient. Adverse events including erythema, edema, pain, and hyperpigmentation were comparable between groups, with no significant differences. In conclusion, combined microneedling and PRP therapy provides clinically meaningful improvement in atrophic acne scars compared with monotherapy, without additional safety concerns. However, standardized treatment protocols and larger, well-designed randomized controlled trails with longer follow-up are required to strengthen the current evidence.

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