Comparison of efficacy of combination of fractional CO2 laser and topical tacrolimus with combination of fractional CO2 laser and topical minoxidil in alopecia areata

Alopecia Areata AA is an autoimmune disorder characterized by well defined areas of non scarring alopecia. The diagnosis is primarily clinical with trichoscopy serving as a valuable non invasive modality for visualizing hair follicular units at a higher magnification. The use of polarized light aids in identification of different patterns and structures specific to particular hair disorders. Topical and intralesional steroids are the commonest drugs used in treatment of localized alopecia areata. Topical and intralesional steroids though effective are constrained by side effects which may be local or systemic. Local side effects like skin atrophy, telangiectasia, acneiform eruptions, secondary bacterial or fungal infection or hypo to depigmentation may be seen frequently. Efficacy of local application may be limited by tachyphylaxis on continuous usage. Systemic absorption may lead to side effects such as hypertension, metabolic changes like worsening of diabetes, deranged lipid profile or hypertrichosis. This has prompted use of alternative agents like topical calcineurin inhibitors, topical calcipotriol and minoxidil. Topical tacrolimus is a calcineurin inhibitor which has been used for alopecia areata with variable results. Most studies have shown unpredictable and sometimes inadequate response to topical tacrolimus used as monotherapy. This may at least in part be due to its large molecular size and incomplete penetration through an intact epidermal barrier. Various techniques have been used to facilitate penetration of topical tacrolimus. The concept of Assisted drug delivery ADD utilizes various physical modalities to enhance penetration through intact epidermal barrier.

Microneedling
Electroporation
Ultrasonic waves
Radiofrequency devices
Laser assisted drug delivery : Fractional CO2 laser Excimer laser Erbium laser

Laser assisted drug delivery LAD is a recent concept of using an ablative fractional laser in combination with a topically applied agent to enhance its penetration. It has two mechanisms of action. The first mechanism involves eliciting an inflammatory response by thermal injury which induces apoptosis of activated T cells. The second mechanism is the creation of multiple vertical microchannels in the skin through which the topically applied agent penetrates into the dermis. Laser assisted drug delivery has been used in literature in combination with topical agents like minoxidil, steroids, vitamin D3 analogues, topical dutasteride and even biological agents like platelet rich plasma PRP. However to the best of our knowledge there is only one small case series of 3 patients which has used Fractional CO2 laser in combination with topical tacrolimus in alopecia areata showing clinical and trichoscopic improvement in all treated areas. This combination has also been studied in vitiligo.

Fractional CO2 laser has also been used along with topical minoxidil to treat androgenetic alopecia and alopecia areata. Topical 5 minoxidil solution whether used alone or combined with FCO2 laser therapy has been shown to be a safe and well tolerated option for the treatment of alopecia areata.

There is only one study comparing tacrolimus 01 and minoxidil 2 in alopecia areata which found that 2 minoxidil had better stimulatory effects on hair growth compared to tacrolimus 01 ointment in the treatment of mild to moderate patchy alopecia areata.

The present study aims to compare the efficacy of topical tacrolimus 01 ointment applied once daily after sessions of fractional CO2 laser with combination of fractional CO2 laser and daily application of 5 minoxidil solution.

Aim: To compare the efficacy of combination of fractional CO2 laser and topical tacrolimus with the combination of fractional CO2 laser and topical minoxidil in alopecia areata

Primary objective: To compare the response to treatment between the combination of fractional CO2 laser with topical tacrolimus 01 ointment and the combination of fractional CO2 laser with topical 5 minoxidil solution in patients with alopecia areata.

Secondary objectives:
To evaluate the efficacy of fractional CO2 laser assisted topical tacrolimus in alopecia areata.
To evaluate the efficacy of fractional CO2 laser assisted topical minoxidil in alopecia areata.
To assess clinical response before and after treatment using Macdonald Hull and Norris grading and to evaluate trichoscopic response using trichoscopic grading scores.
To assess patient satisfaction levels in both treatment groups using a 5 point Likert scale.

Setting: Departments of Dermatology and STD University College of Medical Sciences and Guru Teg Bahadur Hospital
Study design: Randomised prospective therapeutic trial
Sampling method: Simple randomization of alopecia patches within each patient.
Informed consent and assent: Informed consent and assent will be taken from patients parents or guardians prior to the study. The duration and nature of the study will be explained.
Study Duration: August 2025 to November 2026
Study Participants: Patients visiting dermatology OPD with alopecia areata diagnosed clinically who fulfill inclusion criteria and are willing to participate in the trial.

Inclusion criteria: Patients with patchy pattern of alopecia areata with two or more adjacent and non contiguous patches above the age of 12 years not taken any form of treatment for at least 1 month.

Exclusion criteria: Patients with confluent scalp lesions patients with severe alopecia areata alopecia universalis alopecia totalis ophiasis patients on anticoagulant pregnancy and lactation patients with history of hypertrophic scar or keloid patients on any form of immunosuppressive therapy hypersensitivity to topical minoxidil or tacrolimus application.

Sample size: Since no previous studies are available giving mean grade score for Fractional CO2 laser assisted topical Tacrolimus versus Fractional CO2 laser assisted topical Minoxidil delivery in patients of alopecia areata the mean grade score and the standard deviations is being estimated to be the same as for Fractional CO2 laser assisted topical steroid delivery as given by Soror et al in their study and with an expected difference in mean score as 0.5 in the better of the two groups. To estimate this difference at alpha 5 and power 80 a sample of minimum 30 subjects are required. Considering attrition of 10 a minimum of 34 patients will be included in the study population.

Methods: Ethical clearance will be obtained from the Institutional Ethics Committee. Written informed consent and assent will be obtained from all recruited patients. A detailed clinical history will be taken and recorded in case record form Annexure 1. A complete general physical and cutaneous examination will be done at baseline. Clinical photographs will be taken and stored for documentation purposes.

Simple randomisation in one patient left lesion will be labelled as patch A and right as patch B in the next patient right lesion will be labelled as A and left as patch B will be done for allocation of intervention. Intervention will be done on the 2 largest lesions. In each patient one patch A will be treated with fractional CO2 laser followed by tacrolimus ointment application once daily while other patch B will be treated with fractional CO2 laser followed by the application of  minoxidil solution once daily. Treatment sessions will be repeated every 3 weeks for a maximum of four sessions. Patients will be examined at 12 weeks for final evaluation. Trichoscopy using Dinolite AM7515 series USB dermoscope at 50X of the scalp will be done at baseline 6 weeks and 12 weeks and representative images will be stored in jpeg format. Number of dystrophic follicular units and terminal hair will be calculated at baseline and at 12 weeks. Trichoscopic evaluation by 2 independent observers blinded to allocation of groups.

Any adverse effects observed such as erythema swelling peeling scarring or any skin color changes at each session will be recorded.

Patient satisfaction level will be determined using a five point Likert scale.

Outcome measures
Primary outcome measure:
Difference in response to treatment with combination of fractional CO2 laser and topical tacrolimus and combination of fractional CO2 laser and topical minoxidil in alopecia areata.

Secondary outcome measure:
To compare patient satisfaction with two treatment modalities.

Statistical analysis: The data will be entered into a computer based spreadsheet and analyzed using SPSS 20.0. The statistical analysis will comprise calculating means and proportions. The grade scores in the two comparison groups will be reported with mean and standard deviation as summary measures other categorical variables shall be reported as proportions. Appropriate statistical test of significance including paired t test for the difference in mean grade scores between the two groups after follow up will be used for testing the difference in the two groups. Qualitative parameters between the 2 groups will be compared by Chi square test or Fischers exact test. The level of significance shall be taken as 0.05 for the study.