10.5826/dpc.1204a196
Introduction: Transepidermal drug delivery,  using “laser-assisted drug delivery'', or microneedling, are new treatment modalities, that can improve drug penetration into skin in treatment of alopecia areata patients.
Objective: To evaluate the use of fractional carbon dioxide laser versus microneedling in transepidermal delivery of triamcinolone acetonide and platelet rich plasma in alopecia areata treatment.
Methods: Interventional comparative study carried out on 60 patients, randomly divided into four equal groups. Group I :Fractional Carbon dioxide laser and triamcinolone acetonide. Group II: Microneedling with Dermapen and triamcinolone acetonide. Group III: Fractional Carbon dioxide laser and Platelet-rich plasma. Group IV: Microneedling with Dermapen and Platelet-rich plasma. Patients were assessed clinically, using Severity of Alopecia Tool score and hair regrowth scale, and dermoscopically.
Results: In all treatment groups, there was improvement in the Regrowth scale, with statistical significance between the different groups at fourth (p= 0.001*) and last (p= 0.008*) visits, with highest, most significant changes in Pen-Steroid group. Comparing Regrowth scale at last visit,  results were in favor of dermapen, compared to Carbon dioxide laser for Transepidermal drug delivery (p=0.023*); and in favor of triamcinolone acetonide, compared to Platelet-rich plasma as topical medication (p=0.015*). Dermoscopic signs of improvement included decrease in black dots, and appearance of Upright regrowing hairs (p= &lt;0.001*).
Conclusion: Microneedling and fractional Carbon dioxide laser can be effectively used for transepidermal drug delivery for Alopecia areata treatment. Microneedling for delivery of Triamcinolone acetonide showed best treatment outcomes. Dermoscopy can be used in alopecia areata for evaluation of treatment response.
text/xml
2160-9381
2272
en
Eman Hassan
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
Carbon Dioxide Laser
Transepidermal Delivery of Triamcinolone Acetonide or Platelet Rich Plasma using either Fractional Carbon Dioxide Laser or Microneedling in Treatment of Alopecia Areata
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2022-10-31
2021-12-21
2022-10-31
2022-12-02
e2022196
Dermatol Pract Concept
Introduction: Transepidermal drug delivery,  using “laser-assisted drug delivery'', or microneedling, are new treatment modalities, that can improve drug penetration into skin in treatment of alopecia areata patients.
Objective: To evaluate the use of fractional carbon dioxide laser versus microneedling in transepidermal delivery of triamcinolone acetonide and platelet rich plasma in alopecia areata treatment.
Methods: Interventional comparative study carried out on 60 patients, randomly divided into four equal groups. Group I :Fractional Carbon dioxide laser and triamcinolone acetonide. Group II: Microneedling with Dermapen and triamcinolone acetonide. Group III: Fractional Carbon dioxide laser and Platelet-rich plasma. Group IV: Microneedling with Dermapen and Platelet-rich plasma. Patients were assessed clinically, using Severity of Alopecia Tool score and hair regrowth scale, and dermoscopically.
Results: In all treatment groups, there was improvement in the Regrowth scale, with statistical significance between the different groups at fourth (p= 0.001*) and last (p= 0.008*) visits, with highest, most significant changes in Pen-Steroid group. Comparing Regrowth scale at last visit,  results were in favor of dermapen, compared to Carbon dioxide laser for Transepidermal drug delivery (p=0.023*); and in favor of triamcinolone acetonide, compared to Platelet-rich plasma as topical medication (p=0.015*). Dermoscopic signs of improvement included decrease in black dots, and appearance of Upright regrowing hairs (p= &lt;0.001*).
Conclusion: Microneedling and fractional Carbon dioxide laser can be effectively used for transepidermal drug delivery for Alopecia areata treatment. Microneedling for delivery of Triamcinolone acetonide showed best treatment outcomes. Dermoscopy can be used in alopecia areata for evaluation of treatment response.
Eman Hassan
2022/10/31
10.5826/dpc.1204a196
e2022196
Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Alexandria University, Egypt
2160-9381
Carbon Dioxide Laser
en
e2022196
Srivastava S, Goyal S, Dhillon K, Singh N. Dermoscopic evaluation of therapeutic response to intralesional triamcinolone acetonide in the treatment of Alopecia areata. Int J Adv Med. 2017;4(4):1175.
Transepidermal Delivery of Triamcinolone Acetonide or Platelet Rich Plasma using either Fractional Carbon Dioxide Laser or Microneedling in Treatment of Alopecia Areata
https://dpcj.org/index.php/dpc/article/download/2272/1830
     Transepidermal Delivery of Triamcinolone
   Acetonide or Platelet Rich Plasma Using Either
 Fractional Carbon Dioxide Laser or Micro-needling
          in Treatment of Alopecia Areata
              Khaled Fawzy El Mulla1, Eman Hamed Elmorsy1, Dalia Ibrahim Halwag1,
                                    Eman Mohamed Hassan1


1 Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Alexandria University, Egypt



Key words: alopecia areata, drug delivery systems, carbon dioxide laser, platelet rich plasma, triamcinolone acetonide
Citation: El Mulla K, Elmorsy EH, Halwag DI, Hassan EM. Transepidermal Delivery of Triamcinolone Acetonide or Platelet Rich
Plasma using either Fractional Carbon Dioxide Laser or Microneedling in Treatment of Alopecia Areata. Dermatol Pract Concept.
2022;12(4):e2022196. DOI: https://doi.org/10.5826/dpc.1204a196
Accepted: March 21, 2022; Published: October 2022
Copyright: ©2022 El Mulla et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding author: Dalia Ibrahim Halwag, Dermatologist,Lecturer of Dermatology, Venereology, and Andrology, Faculty of Medicine,
Alexandria University, Alexandria, Egypt. Phone numbers: 0201224489473- 02034252781, E-mail – daliahalwag@gmail,com; dalia.
hlwag@alexmed.edu.eg




  ABSTRACT             Introduction: Trans-epidermal drug delivery, using “laser-assisted drug delivery”, or micro-needling,
                       are new treatment modalities, that can improve drug penetration into skin in treatment of alopecia
                       areata patients.
                       Objectives: To evaluate the use of fractional carbon dioxide laser versus micro-needling in
                       trans-epidermal delivery of triamcinolone acetonide and platelet rich plasma in alopecia areata
                       ­treatment.
                       Methods: Interventional comparative study carried out on 60 patients, randomly divided into four
                       equal groups. Group I: Fractional Carbon dioxide laser and triamcinolone acetonide. Group II:
                       ­micro-needling with Dermapen and triamcinolone acetonide. Group III: fractional carbon dioxide
                        laser and platelet-rich plasma. Group IV: micro-needling with Dermapen and platelet-rich plasma.
                        Patients were evaluated clinically, using Severity of Alopecia Tool score and hair regrowth scale, and
                        dermoscopically.
                       Results: In all treatment groups, there was improvement in the Regrowth scale, with statistical sig-
                       nificance between the different groups at fourth (P = 0.001) and last (P = 0.008) visits, with highest,
                       most significant changes in Pen-Steroid group. Comparing Regrowth scale at last visit, results were in




Original Article | Dermatol Pract Concept. 2022;12(4):e2022196                                                                      1
                      favor of Dermapen, compared to Carbon dioxide laser for trans-epidermal drug delivery (P = 0.023);
                      and in favor of triamcinolone acetonide, compared to platelet-rich plasma as topical medication
                      (P = 0.015). Dermoscopic signs of improvement included decrease in black dots, and appearance of
                      Upright ­regrowing hairs (P < 0.001).
                      Conclusions: Micro-needling and fractional carbon dioxide laser are effective tools for trans-epidermal
                      drug delivery for Alopecia areata treatment. Micro-needling for delivery of Triamcinolone acetonide
                      showed best treatment outcomes. Dermoscopy is highly beneficial in evaluating treatment response in
                      alopecia areata.




Introduction                                                            Closed envelope method was used to randomly distribute
                                                                     the patients over the study groups. The study included four
Trans-epidermal drug delivery (TED) depends on ­
                                               using                 groups, 15 patients each:
ablative method (CO2 laser, erbium lasers or ­
­                                            ablative                   Group I: Fractional Carbon dioxide laser (CO2 Laser)
radiofrequency), to create vertical channels through the
­                                                                    and triamcinolone acetonide (TrA; 10mg/ ml) [1,4]:
epidermis. This is followed by applying a medication                    Fractional CO2 laser was used in ablative mode, using
(eg ­triamcinolone actenoide, platelet rich plasma) that is deliv-   (ATL-250 laser): 10,600nm CO2 medical laser system built
ered through these channels into the skin. “Laser-­assisted drug     by Advanced Technology Laser Company, Ltd., Shanghai,
delivery” is the specific use of lasers for TED. ­Micro-needling     China. Scanning mode was used with the following param-
technique can be used for the same purpose [1].                      eters: power of 20 Watts, density of PPI 4 (pulses per inch,
                                                                     i.e. array density), and pulse duration/time on of three mil-
Objectives                                                           liseconds. One pass was applied to the treated area without
                                                                     gaps between pulses, overlap of about 20% was allowed.
The aim of this study is to evaluate the use of fractional           Scanning area was set to square shape, ratio 9/9, and size
­carbon dioxide laser versus micro-needling in trans-epidermal       100%. In smaller patches, dimensions were modifiable.
delivery of triamcinolone acetonide and platelet rich                Immediately after the laser pass, TrA solution was dripped
plasma in alopecia areata (AA) treatment, clinically and             on the treated area and spread evenly using the blunt end
dermoscopically.                                                     of syringe.
                                                                        Group II: Micro-needling with Dermapen and triamcino-
Methods                                                              lone acetonide (TrA; 10 mg/ml) [5]:
                                                                        Dermapen with a 36-needle disposable tip was used,
Patients Group                                                       with 2-2.5 mm long needle depth. The speed of the needles’
This interventional comparative study was carried out                movement and of the Dermapen movement was adjusted to
on 60 patients, of either sex, presenting with AA to the             the patient’s tolerance to pain. The desired end point was
Dermatology, Venereology and Andrology outpatient and
­                                                                    minute pinpoint bleeding points or mild erythema. TrA was
Hair clinics in the Main University Hospital. The local Ethics       applied before, during and after performing micro-needling.
Committee approved the study, and all procedures were in                Group III: Fractional carbon dioxide laser (CO2 Laser)
accordance with the Helsinki Declaration of 1975, as revised         and platelet-rich plasma (PRP) [6]:
in 2000. All patients signed an informed written consent.               The same laser parameters as group I were used, followed
Assent was obtained from minors, and their parents signed            by application of freshly prepared PRP. PRP was prepared
written consents.                                                    using double-centrifugation protocol, which results in higher
    The inclusion criteria were patients with AA of both sexes,      platelet concentrations, compared to single centrifugation
aged 6-60 years, not responding to treatment (topical and/           protocol [7]. For PRP, 10 cc of venous blood were collected
or systemic) for at least 3 months, and off treatment for at         from antecubital vein under aseptic conditions, into tubes
least 1 month, prior to the study. The exclusion criteria [2,3]      containing sodium citrate (10:1) as anticoagulant. The initial
included AA with spontaneous hair regrowth, active scalp             centrifugation (“soft”/ light spin) was done at 2000 rpm for
inflammation, other scalp or hair diseases, history of hyper-        5 min. The second centrifugation step (heavy / “hard” spin)
trophic scar or keloid, bleeding disorders, and long-term use        was carried out at 4000 rpm for 15 min.
of anti-coagulant therapy. Pregnant and lactating females               Group IV: Micro-needling with Dermapen and P
                                                                                                                   ­ latelet-
and immunocompromised patients were excluded.                        rich plasma (PRP) [2,5]:



2                                                                        Original Article | Dermatol Pract Concept. 2022;12(4):e2022196
    Micro-needling was performed as Group II; however, di-          Results
luted TrA was substituted by PRP.
    For all groups:                                                 Demographic Data (Table (1))
    Each patient received four treatment sessions, spaced           Table (1) represents different demographic data and p
                                                                                                                        ­ atients
three weeks apart [1,2,5] , followed by a follow up visit, four     details, with no significant difference between all groups.
weeks after the last treatment session. Prior to the procedure      There was no significant difference between the stud-
topical anesthetic cream, (pridocaine2.5% + lidocaine 2.5%)         ied groups as regards the Baseline Hair loss, using SALT
was applied under occlusion for 15-60 minutes. Patients             score [8,9].
were instructed not to wash their scalp on the treatment
day. No treatments for the alopecia were allowed. Topical           Baseline and Follow-up SALT Scores
post-procedure care, including topical antibiotics, emollient       There was no significant difference in SALT score at baseline
or sunscreen could be used.                                         between the 4 groups.
    On the first visit, thorough history was taken, followed           However, SALT score at last follow-up visit showed sta-
by clinical and trichoscopic evaluation [2-4,8]. Trichoscopic       tistically significant difference between the different groups
evaluation [9-11] was performed using a DermLite® DL4               (P = 0.005). Eighty percent of patients in Pen-Steroid group
(3 Gen), at 10× magnification in polarized mode.                    improved to SALT S0 (no hair loss), compared to only 40%
                                                                    of patients in CO2-Steroid and Pen-Steroid groups, and only
Patient Evaluation                                                  13.3% in the CO2-PRP group. Pen-Steroid group showed
The patients were assessed clinically and dermoscopically for       significantly higher improvement compared to CO2-PRP
signs of hair regrowth at each visit, and at the follow up visit.   group (P = 0.001).
Using Samsung J5 Pro 13-megapixel camera with F1.7 lens,
serial digital photographs (clinical and dermoscopic) of the        Rate of Hair Regrowth (Figures 1-5)
alopecic patches were taken prior to commencement of the            Over subsequent visits, in all treatment groups, there was a
treatment, during the treatment sessions and at the end of          shift in the RGS towards higher scores with improved hair
the treatment. Two independent investigators evaluated the          regrowth percentages. However, this improvement showed
photographs.                                                        statistical significance between the different treatment
    Severity of Alopecia Tool (SALT) score at baseline, at          groups only at fourth (P = 0.001) and fifth (P = 0.008) ­visits.
each visit, and at end of study, and hair regrowth scale,           At fourth visit, Pen-Steroid group showed maximum im-
were used to calculate treatment response [2,8]. Global             provement with 53.3% of patients scoring RGS4, followed
assessment score [8] was used to assess the overall im-             by Pen-PRP group (40% of patients), then CO2-Steroid
provement, taking into account extent and density of                group (33.3% RGS4+5), and finally CO2-PRP group with
­regrowth by SALT score: A0 = no change or further loss,            only 13.3% of patients. The difference between Pen-Steroid
A1 = 1-24% regrowth, A2 = 25-49% regrowth, A3 =                     group and CO2-PRP group was significant (P = 0.003). At the
50-74% regrowth, A4 = 75-99% regrowth, and A5 = 100%                final follow up visit, Pen-Steroid group showed maximum
regrowth. ­
          According to the ­
                           Regrowth scale (RGS), the                improvement with 80% of patients scoring RGS5, followed
­degree of clinical improvement was evaluated according to          by Pen-PRP and CO2-Steroid group (40% of patients), and
a 6-point semi-quantitative score: RGS 0 (re‐growth <10%),          finally CO2-PRP group with 13.3% of patients. The differ-
RGS1 (re‐growth 11%‐25%), RGS2 (re‐growth 26%‐50%),                 ence between Pen-Steroid group and CO2-PRP group was
RGS3 (re‐growth 51%‐75%), RGS4 (re‐growth ≥75%), and                statistically significant (P < 0.001).
RGS5 (re‐growth =100%) [12].
    Any side effects like atrophy and telangiectasia were           Hair Regrowth Score (RGS) at the End of Study
observed, clinically and dermoscopically. Patient satisfac-         Improvements in RGS at the end of study, were in favor of
tion with results of the procedure was graded as satisfied,         using Dermapen for TED (mean RGS 3.93 ± 1.66), com-
fair, and unsatisfied. Pain during procedure was graded as:         pared to CO2 laser (mean RGS 3.13 ± 1.68) , with P = 0.023.
no pain - mild -moderate -severe- pain as bad as it could           Moreover, higher RGS were obtained with TrA as topical
be [13].                                                            medication (mean RGS 4.0 ± 1.53), compared to PRP (mean
                                                                    RGS 3.07 ± 1.76), with P = 0.015.
Statistical Analysis
Data were fed to the computer and analyzed using IBM SPSS           Dermoscopic Evaluation (Table (2); Figures 6-8)
software package version 20.0. (IBM Corp). Significance of          At baseline, most common dermoscopic findings were black
obtained results was judged at 5% level.                            dots, in 65% of patients, yellow dots and white dots in 45%



Original Article | Dermatol Pract Concept. 2022;12(4):e2022196                                                                    3
           Table 1. Comparison between the four studied groups according to demographic data.
                            Steroid CO2          Steroid Pen           PRP CO2             PRP Pen
                              (N = 15)             (N = 15)            (N = 15)            (N = 15)          Test of
                          No.         %         No.         %       No.         %        No.       %      Significance        P
 Sex
 Male                       6        40.0        9         60.0       6        40.0      10        66.7                    0.333
                                                                                                            χ2=3.404
 Female                     9        60.0        6         40.0       9        60.0       5        33.3
 Age (years)
 <15                        5        33.3        2         13.3       2        13.3       3        20.0                    (MC)
 15 – 30                    8        53.3        6         40.0       7        46.7       2        13.3    χ2=10.849       0.075
 >30                        2        13.3        7         46.7       6        40.0      10        66.7
 Duration (years)
 <2 Y                       7        46.7        9         60.0       6        40.0       9        60.0                    0.614
                                                                                                            χ2=1.802
 ≥2 y                       8        53.3        6         40.0       9        60.0       6        40.0
 Present episode (months)
 <6 months                  8        53.3        6         40.0       7        46.7      12        80.0                    (MC)
 6 - 1Y                     7        46.7        9         60.0       7        46.7       3        20.0     χ2=8.192       0.135
 >1 Y                       0         0.0        0         0.0        1        6.7        0        0.0
 No of relapse
 First attack               7        46.7        6         40.0       5        33.3       6        40.0                    0.907
                                                                                                            χ2=0.556
 Recurrent                  8        53.3        9         60.0      10        66.7       9        60.0
 Type of AA
 Patchy                     11       73.3        14        93.3      11        73.3      13        86.7                    (MC)
 Ophiasis                    3       20.0         0         0.0       2        13.3       0         0.0                    0.214
                                                                                                             2
 Subtotalis                                                                                                χ =10.065
                             0        0.0         1         6.7       2        13.3       2        13.3
 Universalis                 1        6.7         0         0.0       0         0.0       0         0.0
 Family history
 Negative                   9        60.0        9         60.0       8        53.3      11        73.3                    0.720
                                                                                                            χ2=1.340
 Positive                   6        40.0        6         40.0       7        46.7       4        26.7
 Hair loss (%)
 Min. – Max.                1.0 – 100.0           1.0 – 80.0          2.0 – 80.0          2.0 – 80.0                       0.802
 Mean ± SD.               12.80 ± 24.65         11.47 ± 19.50       16.60 ± 25.99       13.53 ± 20.53
                                                                                                            H=0.996
 Median (IQR)                  4.0                   4.0                  7.0                5.0
                          (2.50 – 12.50)         (3.0 – 12.0)         (5.0 – 8.0)        (3.0 – 12.0)

H = H for Kruskal Wallis test; IQR = Inter quartile range; MC = Monte Carlo.




of patients, exclamation mark hairs in 38.3%, and the least          Yellow dots were present at baseline in all groups, and
common finding was vellus hair in 11.7% of patients.              decreased with treatment, but without statistical significance.
    Black dots were present at baseline in all groups, and           The decrease in white dots at end of treatment was sig-
their incidence decreased with treatment. This decrease in        nificantly better in Pen-steroid group compared to the other
black dot, indicating improvement, was statistically signifi-     three groups (P = 0.002). White dots disappeared in 53.3%
cant in all groups (CO2-Steroid group P = 0.008, Pen-Steroid      of affected patients in Pen-steroid group (P = 0.008), com-
group P = 0.002, Pen-PRP group P = 0.031), except in the          pared to only 13.3% in CO2-PRP and Pen-PRP groups, and
CO2-PRP group.                                                    none of the affected patients in the CO2-Steroid group.
    Exclamation mark hairs were present at baseline in all           Vellus hairs showed no statistically significant difference
groups, as third most common dermoscopic finding, and             in occurrence, along sessions.
­decreased with treatment, especially in Pen-Steroid group           Upright regrowing hairs were the most consistent fea-
(p = 0.002), where the exclamation mark hairs completely          ture to indicate hair regrowth. It started to appear after
disappeared in all patients, after the third treatment session.   the first treatment session, in most patients in all 4 groups,



4                                                                     Original Article | Dermatol Pract Concept. 2022;12(4):e2022196
                                    5
                                                 STEROID CO2
                                                 STEROID PEN
                                                 PRP CO2
 MEANOF HAIR REGROWTH SCALE (RGS)



                                    4            PRP PEN




                                    3




                                    2




                                    1




                                    0
                                             2ND                           3RD                           4TH                    AFTER 1 MONTH

Figure 1. Comparison between the four studied groups according to hair regrowth scale (RGS) over the treatment course.
PRP = platelet-rich plasma.




Figure 2. Pen-Steroid group. (A) At baseline. (B) At last follow up visit with complete hair regrowth (100%), hair regrowth scale
score 5.



with a statistically significant increase in all study groups                             hairs, which was significantly higher than only 13.3% of
(P < 0.001).                                                                              patients in CO2-PRP group (P = 0.008). Also, patients who
                           Terminal hairs, also started to appear after first treatment   showed pig tail hairs in Pen-PRP group where significantly
session, indicating hair regrowth. There was statistically                                more compared to CO2-PRP group (53.3% versus 13.3%,
significant rise from baseline to follow up, in all treatment                             P = 0.020).
groups (P < 0.001 in CO2-Steroid, Pen-Steroid and Pen-PRP                                    The study procedure caused no complications that could
groups; P = 0.002 in CO2-PRP group).                                                      be observed by dermoscopy. However, telangiectasia and ar-
                           Pig tail hairs appeared transiently in the course of treat-    eas of fibrosis, due to previous intralesional steroid injection,
ment. In Pen-Steroid group 60% of patients showed pig tail                                could be visualized dermoscopically.



Original Article | Dermatol Pract Concept. 2022;12(4):e2022196                                                                                           5
              Figure 3. Pen-PRP group. (A) At base line. (B) At 3rd visit. (C) At 4th visit. (D) At last follow-up visit with
              complete hair regrowth (100%), hair regrowth scale score 5.




Relation Between Clinical Response and                                      Responders were those with hair regrowth ≥ 75%
Dermoscopic Features at Baseline (Table 6)                             (ie ≥ RGS 4/ global assessment score A4) [14].
Amongst all 60 patients, presence of black dots at baseline,
could not indicate response to treatment. However, pres-               Onset of Dermoscopic Improvement
ence of Exclamation mark hairs at base line was signifi-               Most patients across all treatment groups showed first
cantly related to response (P = 0.024), where it was present           signs of dermoscopic improvement after first treatment
in 48.7% of responder patients, compared to only 19% of                session. Out of the 30 patients receiving TrA, 86.7%
non-responder ones. Yellow dots were significantly related             showed dermoscopic improvement after first treatment
to poor response to treatment (P = 0.003), present in 71.4%            session, compared to 80% of the 30 patients receiving
of non-responder patients at baseline, compared to only                PRP, without statistical significance. The number of pa-
30.8% of responder ones. White dots and vellus hairs were              tients in Dermapen groups, who showed dermoscopic im-
represented insignificantly among responder patients and               provement after first treatment session, was significantly
non-responder ones at baseline.                                        higher than in CO2 groups (P = 0.010). This indicates that



6                                                                            Original Article | Dermatol Pract Concept. 2022;12(4):e2022196
Figure 4. CO2-Steroid group. (A) At baseline. (B) At last follow up visit with complete hair regrowth (100%), hair regrowth scale score 5.




  Figure 5. CO2-PRP group. (A) At baseline. (B) At last follow-up visit with complete hair regrowth (100%), hair regrowth scale score 5.



Dermapen might show faster improvement, compared to                     significantly higher (P = 0.046), than CO2 groups (80.0%
fractional CO2.                                                         versus 56.7%).


Onset of Hair Growth Clinically                                         Relation Between Onset of Dermoscopic and
Seventy percent of patients in Steroid groups started to                Clinical Improvement
show hair regrowth after first treatment session versus                 Across all 60 patients included in the study, 82% who
66.7% in PRP groups, without statistical significance.                  sowed dermoscopic improvement after first session also
The number of patients in Dermapen group, who started                   showed clinical hair regrowth after first session (statistically
to show hair regrowth after first treatment session, was                significant).



Original Article | Dermatol Pract Concept. 2022;12(4):e2022196                                                                             7
        Table 2. Agreement (sensitivity, specificity and accuracy) for Exclamation mark hairs and
                                                Yellow Dots.
                             Non responders            Responders
                                (n = 21)                 (n = 39)
            1st                No.          %         No.          %        Sensitivity     Specificity     PPV        NPV       Accuracy
 Exclamation mark hairs
 No                              17       81.0         20         51.3
                                                                               48.72           80.95       82.61      45.95         60.0
 Yes                             4        19.0         19         48.7
 Yellow Dots
 No                              6        28.6         27         69.2
                                                                               30.77           28.57       44.44      18.18         30.0
 Yes                             15       71.4         12         30.8

PPV: Positive predictive value
NPV: Negative predictive value




Figure 6. Pen-Steroid group: Black dots and Exclamation mark hairs. (A) At baseline. (), (B) Disappearing at 4th follow up visit (), that fea-
tures mainly upright regrowing and terminal hairs.
† Black dot
** Exclamation mark hairs




Figure 7. Pen-PRP group: Black dots and Exclamation mark hairs. (A) At baseline. ( (B) Significant decrease at 4th follow up visit (), with
appearance of upright regrowing and terminal hairs.
† Black dot
** Exclamation mark hairs
|| Upright regrowing


8                                                                             Original Article | Dermatol Pract Concept. 2022;12(4):e2022196
Figure 8. CO2-Steroid group: Yellow dots, few vellus hairs and black dots. (A) At baseline. (B)Disappearing at last follow up visit, with
­appearance of pigtail, upright regrowing and terminal hairs.
 * Yellow dot
 † Black dot
 ‡ Vellus hair
 § Pig tail hair
 || Upright regrowing
 ¶ Terminal hair




    Nevertheless, dermoscopic improvement can herald clin-            in patients with first attack of alopecia (100 %), compared
ical hair growth. Out of the 22/30 patients in CO2 groups             to patients who had recurrent disease (65%) (P = 0.031).
who showed dermoscopic improvement after first session,               In CO2-Steroid, Pen-Steroid, and Pen-PRP groups there was
3 started to show clinical hair regrowth after second session         a negative correlation between the total duration of disease
and 2 after third session. In Dermapen groups, among the 28           and overall hair regrowth. However, this correlation was
patients who showed dermoscopic improvement after first               significant only in CO2-Steroid (rs = –0.678, P = 0.005)
session, clinical hair regrowth was delayed after second ses-         and Pen-PRP (rs = –0.593, p = 0.020) groups. The shorter
sion in 4 patients. Clinical hair regrowth was also delayed           the duration of the current episode of alopecia, the higher
to after the second treatment session in four patients in the         the hair regrowth. This negative correlation was significant
PRP group. Out of the 26 patients in the Steroid groups who           only in Pen-PRP group (rs = –0.702, P = 0.004). Patients
showed dermoscopic improvement after first session, 3 pa-             without body hair affection scored higher hair regrowth
tients showed clinical improvement after the second session           rates, in all groups. This negative correlation was statisti-
and 2 after the third session.                                        cally significant only in the Pen-PRP group (rs = –0.577,
                                                                      P = 0.024). Although not statistically significant, the less the
Relation Between Hair Regrowth and                                    hair loss at baseline, the better the improvement at end of
Different Parameters                                                  treatment. This was the case in all the groups, with the ex-
There was no significant correlation between final hair               ception of the Pen-Steroid one. Hair regrowth, at one month
regrowth and patients age, Family history and site of AA              follow up, was higher in patients with patchy hair loss. This
patches , in all study groups. Only in CO2-Steroid group,             was significant in Pen-Steroid (P = 0.021) and Pen-PRP
Hair regrowth at end of treatment, was significantly higher           (P = 0.022) groups.



Original Article | Dermatol Pract Concept. 2022;12(4):e2022196                                                                         9
Side Effects and Patient Satisfaction                             may actually correspond to the upright regrowing hairs, that
Most patients were satisfied by the results, with no statisti-    were the most consistent features of hair regrowth in our
cal significance between the four study groups (CO2-steroid       study, as the differentiation between both may be difficult
86.7%, CO2-PRP 73.3%, CO2-Steroid and Pen-Steroid 80%).           [29]. Exclamation mark hairs and black dots decreased sig-
     Unlike intralesional steroid injection, no atrophy or tel-   nificantly with treatment. Yellow dots decreased mildly, but
angiectasia were observed. Pain during the procedures, was        without statistical significance. This was in accordance with
appreciated as more tolerable compared to injection, in pa-       a study by Ganjoo and Thappa [26], indicating that excla-
tients who experienced intralesional steroid or PRP injection     mation mark hairs, and black dots are markers of disease
before. In CO2 groups, the patients expressed their discom-       activity, and are the first parameters to change in response to
fort as related to heat generated from laser procedure.           therapy, whereas yellow dots were the least responsive [26].
     No major complications, including secondary infection,       Trichoscopy is useful in identification of early atrophy and
ulceration or scaring, occurred in any patient.                   telangiectasia in patients treated with TrA injections. This al-
                                                                  lowed avoiding reinjection in these areas [26].
                                                                     As with our study, changes in the dermoscopic findings as
Conclusions                                                       well as hair RGS were observed from the first follow up [30].
                                                                     Hence, from the present study it can be concluded that,
A main challenge in AA treatment is directing therapies to
                                                                  micro-needling and fractional CO2 laser can be effectively
the hair follicle. Stratum corneum forms a barrier to topical
                                                                  used for TED for AA treatment, and that trichoscopy can be
drug penetration, especially hydrophilic and large m
                                                   ­ olecule
                                                                  used in AA for evaluation of treatment response.
drugs [15] . Fractional lasers [4] and micro-needling devices
may be used deliver drugs to deeper skin layers [16], by cre-
ating small channels through the stratum corneum to the
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Original Article | Dermatol Pract Concept. 2022;12(4):e2022196                                                                                        11
