Alopecia
areata is a chronic inflammatory disease which results in non-scarring hair
loss. It occurs as an acute and complete loss of hair in a single or several
areas in the course of a few weeks. It
can affect different areas such as scalp, beard, eyebrows, eyelashes or can be
generalized being called alopecia universal 5.
Trichoscopy
is used in patients with scarring or nonscarring alopecia conditions as a
quick, noninvasive method to examine the scalp and hair. It is a helpful
monitoring tool 6 Dermoscopic features of AA
include: Yellow dots: Round or
polycyclic yellow to yellow‑pink dots that represent distended follicular
infundibula filled with sebum and keratin remnants, black dots: remnant of
broken hair shafts inside follicular ostia, exclamation mark hairs: broken
hairs that tapered toward follicles, short vellus hairs: thin, nonpigmented
hairs with length ≤10 mm may demonstrate early disease remission, broken hairs:
due to fracture of dystrophic hair shafts or rapid regrowth of hairs that
formerly manifested as black dots 7.
Trichoscopics features as indicators of activity8:
·
Black spots.
·
Exclamation mark hairs
·
Broken hair shafts
·
Pohl-Pinkus constriction
Trichoscopic findings seen in regrowth:
•
presence of thin and unpigmented
vellus hair within the patch
•
evidence of transformation of
vellus hair into terminal hair, appearing as increased proximal shaft thickness
and pigmentation, characteristic of remitting disease and indicative of a
response to treatment
•
decreased trichoscopic features
such as yellow dots, black dots, broken hair, vellus hair and tapering or
exclamation mark hair7.
The
evaluation of the hair regrowth can be done using MacDonald Hull and Norris4 grading system which is as follows:
Grade 0: no hair regrowth. Grade 1: regrowth of vellus hair. Grade 2: regrowth
of sparse pigmented terminal hair. Grade 3: regrowth of terminal hair in
clusters. Grade 4: complete regrowth of terminal hair over alopecia patch9.
Trichoscopic evaluation will be done using 2 grading scores:
- Dystrophic
follicular units that is percentage of empty follicular units/dystrophic
hair forms (yellow dots, black dots, broken hairs and exclamation mark
hairs) in the representative fields of the patch area will be calculated
as follows at baseline and 12 weeks:
•
0: no/empty follicular units
or dystrophic hair in field
•
1: 1–24%
•
2: 25–49%
•
3: 50–74%
•
4: 75–100%)
- Terminal hair
that is percentage of terminal hairs in the patch area will be calculated
as follows at baseline and 12 weeks:
•
0: no terminal hair in field
•
1: 1–24%
•
2: 25–49%
•
3: 50–74%
•
4: 75–100%
Steroids
with low solubility are preferred for their slow absorption from the injection
site, promoting maximum local action with minimal systemic effect.
Immunosuppression is the main mechanism of action. Corticosteroids suppress the
T-cell-mediated immune attack on the hair follicle.10 Intralesional
steroid are considered first line treatment in localized alopecia areata involving ‹ 50% of scalp, although painful
and associated with various side effects. Thus there is a need for alternative
methods.
Laser
treatments of different wave lengths have been used to manage alopecia areata
including ablative Fractional laser11. The fractional laser produces a
microthermal zone and creates numerous tiny columns of thermal injury12. Laser
treatment can also precisely and selectively remove the stratum corneum in a
controlled and noncontact manner, the laser also interacts with sebum to break
up the barrier function, increasing the skin delivery of drugs13. The
generation of microthermal zones by fractional lasers provides the channels for
a uniform and controlled delivery of drugs. Fractional lasers can penetrate up
to 2–3 mm into the dermis, depositing thermal energy where the dermal papilla
is, which is where the capillaries surround the hair germ cells 14.
Lasers
stimulate drug delivery by means of 3 processes; 1) tissue ablation, which
removes the stratum corneum and the most superficial layers of the epidermis;
2) photomechanical waves, resulting from the conversion of light into
mechanical energy giving the laser a therapeutic effect; and 3) non-ablative
resurfacing where thermal and physical injuries disrupt the skin barrier,
promoting the delivery of medications through these laser channels15
Fractional
CO2 laser in combination with topical corticosteroid application shows
excellent clinical response in resistant alopecia areata with negligible side
effects.14
In
a study comparing intralesional steroid versus fractional CO2 laser for
alopecia areata, latter showed better response11
Fractionated
Er: YAG laser with local corticosteroids has been proved to be efficient
treatment modality in alopecia areata.16
In
a study comparing fractional CO2 laser alone vs in combination with topical
triamcinolone, with topical platelet rich plasma and with topical vitD3, all
showed significant response.17
It is highly recommended to only deliver drugs
or molecules that are FDA-approved or studied for the dermis18. Ablative lasers are generally
considered superior to non-ablative lasers. Non-ablative lasers disrupt the dermal
epidermal junction but do not create an opening for larger molecules to gain
access to the dermis18
LACUNAE
•
A similar study where fractional CO2
laser-assisted topical steroid delivery versus I/L steroid in the treatment of
AA has been done in Egypt using topical triamcinolone acetonide involving 30
patients in 2021, where one patch was treated with fractional CO2 laser
followed by a one time application of topical triamcinolone and other patch
with I/L triamcinolone in which group 2 showed significantly higher improvement
compared to group 1. However we have modified our study and suggested daily
topical steroid application after fractional co2 laser therapy.
•
Similar studies have been done for other
dermatosis such as hypertrophic scars, vitiligo etc
•
To the best of our knowledge, no studies
have been conducted comparing the efficacy of
combination of fractional carbon dioxide laser and daily topical
steroids with intralesional steroids in alopecia areata. The present study is
an attempt to fill this gap in literature. |