Comparative Efficacy and Safety of Needling‐Based Therapies Versus Ablative Fractional Lasers for Scar Management: A Systematic Review and an Exploratory Meta‐Analysis
Kholoud Almahzoum, Waleed Alfailakawi, Abdullah M. Alharran, Omar W. Alrumaih, Retaj N. Hazaa, Dalal Ali Al‐Mutairi, Abdulrahman Talal Alqallaf, Bader N. Almutawaa, Merwi S. Alhadeyah, Abdulaziz Abdullah Alenezi, Fanr F. Alraqum, Ebraheem AlbazeeABSTRACT
Background
Needling‐based therapies and ablative fractional lasers are widely used for scar management, but their efficacy and safety remain uncertain. In this systematic review, we aimed to assess the safety and efficacy of both needling‐based therapy and ablative fractional laser therapy.
Methods
This review followed PRISMA 2020 and the Cochrane Handbook. PubMed, Scopus, Web of Science, and Cochrane were searched from inception to 9 April 2026 without restrictions. Studies enrolling patients with scars of any etiology and comparing a needling‐based therapy with an ablative fractional laser were included. Randomized controlled trials (RCTs), non‐randomized trials, and cohort studies were eligible. Risk of bias was assessed using RoB 2, ROBINS‐I, and the Newcastle–Ottawa Scale. Because of heterogeneity, findings were synthesized narratively, with exploratory random‐effects meta‐analysis where data were sufficiently comparable.
Results
Twenty‐seven studies involving 1137 participants were included, comprising 17 RCTs, 2 non‐randomized comparative trials, and 8 cohort studies. Most studies evaluated atrophic or hypertrophic acne scars (18 studies; 870 patients), while fewer studies assessed striae (4 studies; 87 patients), burn or postburn scars (3 studies; 105 patients), and traumatic scars (2 studies; 75 patients). Both treatment categories improved scar appearance. In many comparisons of atrophic acne scars, ablative fractional lasers, particularly fractional CO 2 and, in some studies, Er:YAG systems, suggested greater improvement than microneedling. However, needling‐based therapies were associated with shorter downtime, better tolerability, and fewer pigmentary adverse effects. Microneedling radiofrequency appeared to provide efficacy closer to that of ablative lasers in several individual studies and demonstrated a more favorable safety profile. Recent combination regimens appeared promising.
Conclusion
Available evidence suggests that both modalities can improve scars. Ablative fractional lasers may offer greater efficacy, whereas needling‐based therapies may provide better tolerability and pigment safety. These conclusions should be interpreted cautiously because of clinical heterogeneity and the sensitivity of the exploratory pooled estimate to individual studies. Treatment selection should remain individualized according to scar type, patient priorities, and acceptable downtime.
Trial Registration
The protocol was registered in PROSPERO (CRD420261383840)