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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 4  |  Issue : 2  |  Page : 164-166

Scalp micro-needling: A new tool in the treatment of alopecia totalis


1 Consultant Dermatologist, Anagha Skin Care Clinic, Bagalkot, Karnataka, India
2 Junior Resident, S N Medical College, Bagalkot, Karnataka, India

Date of Submission19-Aug-2019
Date of Decision16-Feb-2020
Date of Acceptance15-Apr-2020
Date of Web Publication18-Aug-2020

Correspondence Address:
Savitha L Beergouder
Consultant Dermatologist, Anagha Skin Care Clinic, Bagalkot - 587 101, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CDR.CDR_29_19

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  Abstract 


Alopecia areata is the most common form of nonscarring alopecia. It may vary from a single round patch to that involving large surface area termed as alopecia totalis (AT). Pediatric age of onset, more extensive disease, and recalcitrance to initial therapies are more challenging to treat and require the synergy of two or more established therapy. Here, we have treated a case of AT with scalp micro-needling with topical steroids.

Keywords: Alopecia totalis, scalp micro-needling, topical steroid


How to cite this article:
Beergouder SL, Reshme A. Scalp micro-needling: A new tool in the treatment of alopecia totalis. Clin Dermatol Rev 2020;4:164-6

How to cite this URL:
Beergouder SL, Reshme A. Scalp micro-needling: A new tool in the treatment of alopecia totalis. Clin Dermatol Rev [serial online] 2020 [cited 2020 Nov 27];4:164-6. Available from: https://www.cdriadvlkn.org/text.asp?2020/4/2/164/292474




  Introduction Top


Alopecia areata (AA) is a chronic inflammatory disorder characterized by patches of non-scarring alopecia on the patient's scalp, face, and other hair-bearing skin of the body. It is the most common type of non-scarring alopecia.[1] Pediatric AA is not uncommon. Up to one-third of newly diagnosed AA cases have been reported in patients aged 20 years and below, in both Singapore and India.[2] Most of the time, there is spontaneous regrowth of hair, within a year in cases of the limited disease, but in chronic recurrent cases, various treatment options to be considered depending on childs age and extent of the disease. Here, we have reported a case of alopecia totalize successfully treated scalp micro-needling.


  Case Report Top


A 11-year-old female presented to us with complete hair loss over the scalp for 2 years, initially started as a small asymptomatic patch of hair loss, which gradually progressed to complete loss of hair over scalp. There was no itching, scaling, or any oozing. There was no complaint of loss of hair over eyebrows. She has no history of asthma or allergies in the past. She has taken treatment for the same for the past 2 years, she was diagnosed as AA and has been treated with a tapering dose of steroids for few days, and oral mini pulse was given for 1 year. Later, she discontinued as new lesions continued to appear. She was then started on cyclosporine, but she could not continue the therapy because of the high cost of the therapy.

On examination, we observed a complete loss of hair over the scalp, skin over the scalp appeared smooth with no signs of scarring [Figure 1]. Systemic examination was within normal limits. Dermoscopy of the scalp revealed multiple black dots and regularly arranged white dots. Biopsy done in the previous hospital showed findings suggestive of AA. Depending on these findings, the diagnosis of AT was made.
Figure 1: Clinical picture showing complete loss of hair over the scalp

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Parents were counseled, and the patient was treated by micro-needling using dermaroller having needles 1.5 mm length. The treatment was done with aseptic precautions, and roller was moved five times each in vertical, horizontal, and diagonal directions, pinpoint bleeding was considered as endpoint. Triamcinolone acetonide was used in a concentration of 10 mg/ml; 0.1 ml of it was applied to each area before and after performing dermaroller, 1 ml of triamcinolone acetate was used per sitting. Topical anesthesia with EMLA- eutectic mixture of lignocaine and prilocaine cream applied 20 min before the procedure which made the procedure relatively pain free. Three sittings were done with an interval of 20 days. The patient was prescribed fudic cream for 3 days after the procedure and followed by minoxidil 2% at night.

Satisfactory hair growth was noticed after three sessions [Figure 2], and no side effects were noted. The patient was asked to continue topical minoxidil, follow-up after 3 months showed sustained hair growth with complete coverage of the scalp [Figure 3].
Figure 2: Clinical picture showing hair growth after three sittings of micro-needling

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Figure 3: Clinical picture showing sustained hair growth at follow-up after 3 months

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  Discussion Top


The majority of pediatric AA patients present with localized mild disease affecting <50% of the scalp. Some studies suggest pediatric AA have been associated with a guarded long-term prognosis, with patients having multiple relapses and progression to AT or alopecia universalis.[3],[4] AA is also associated with other auto-immune disorders such as vitiligo, thyroid abnormalities, and diabetes and in pediatric cases of AA usually associated with atopic dermatitis, nail changes, and positive family history.[5]

Treatment of AA is challenging as there are many therapies available which can induce hair growth but there is no proven therapy that alters the course of the disease and sustains remission. Prognosis in extensive and long-standing alopecia's is usually less favorable.[6]

Management of pediatric AA is particularly challenging, given the chronicity of the condition. It is crucial to evaluate the impact of the disease on the child's physical and emotional well-being, including issues such as self-confidence, self-image, and acceptance by peers. Hence, holistic management of the patient is important.[7]

Treatment of AA varies on the basis of disease extent, duration, and age of the patient.

Topical or intralesional steroids, topical minoxidil, and topical immunotherapy are considered as first-line of therapy. Topical dithranol, topical calcineurin inhibitors, pulsed systemic corticosteroid, systemic corticosteroids, psoralen and ultraviolet A therapy, other immunosuppressive agents and laser, and light therapies are considered second or third-line of treatment.[5],[7],[8]

Micro-needling is popularly used in the treatment of acne scars; recently it is also used in treatment androgenic alopecia and has proved effective adjunctive therapy. It is a minimally invasive dermatological office procedure. The proposed mechanism of action is the stimulation of dermal papillae and stem cells. It causes release of platelet-derived growth factor, epidermal growth factors are increased through platelet activation and skin wound regeneration mechanism. It also induces neovascularization. Micro-needling also facilitates penetration of medications, and hence, it is successfully paired with hair growth-promoting therapies such as minoxidil, platelet-rich plasma (PRP), and topical steroids.[9],[10]

Ninama et al. have compared the efficacy of betamethasone oral mini pulse therapy with intralesional steroids and PRP with dermaroller. He concluded that intralesional injection of triamcinolone acitonide is more effective than oral mini-pulse in adults with limited involvement, and PRP with derma roller shows promising results, especially in children with extensive involvement.[11]

Chandrashekar et al. have used micro-needling with triamcinolone acetonide in the treatment of AA in two patients with patchy AA and have concluded that combination treatment can induce faster re-growth of hairs due to uniform and painless administration of the drug and one more advantage could be that the collagen induction by micro-needling may counter the possible atrophy caused by triamcinolone.[12]

Our patient is an 11-year-old female with a total loss of hair over the scalp, because of which she had stopped going to school. Her parents were very anxious and frustrated. They were counseled about the condition and were explained different treatment options, they were advised pulsed methyl prednisolone therapy, but they refused for admission and further investigations due to economic constraints. Hence, we decided to try micro-needling with topical triamcinolone acetate.


  Conclusion Top


According to our knowledge, this is the first case of AT where we have successfully used dermaroller with a topical steroid, and we conclude this can be a safe and relatively painless office procedure, especially for young children with extensive disease. Further studies with more number of patients are required to establish this therapy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Safavi KH, Muller SA, Suman VJ, Moshell AN, Melton LJ 3rd. Incidence of alopecia areata in Olmsted County, Minnesota, 1975 through 1989. Mayo Clin Proc 1995;70:628-33.  Back to cited text no. 1
    
2.
Tan E, Tay YK, Giam YC. A clinical study of childhood alopecia areata in Singapore. Pediatr Dermatol 2002;19:298-301.  Back to cited text no. 2
    
3.
van der Spek FB, Oranje AP, De Raeymaecker DM, Peereboom-Wynia JD. Juvenile versus maturity-onset alopecia areata – A comparative retrospective clinical study. Clin Exp Dermatol 1989;14:429-33.  Back to cited text no. 3
    
4.
Tosti A, Bellavista S, Iorizzo M. Alopecia areata: A long term follow-up study of 191 patients. J Am Acad Dermatol 2006;55:438-41.  Back to cited text no. 4
    
5.
Sharma VK, Dawn G, Kumar B. Profile of alopecia areata in Northern India. Int J Dermatol 1996;35:22-7.  Back to cited text no. 5
    
6.
Messenger AG. Alopecia areata. In: Griffiths C, Barker J, Bleiker T, Chalmers R, Creamer D, editors. Rooks Text Book of Dermatology. 9th ed. West Sussex: Willey Blackwell; 2016. p. 28-34.  Back to cited text no. 6
    
7.
Wang E, Lee JS, Tang M. Current treatment strategies in pediatric alopecia areata. Indian J Dermatol 2012;57:459-65.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Firooz A, Tehranchi-Nia Z, Ahmed AR. Benefits and risks of intralesional corticosteroid injection in the treatment of dermatological diseases. Clin Exp Dermatol 1995;20:363-70.  Back to cited text no. 8
    
9.
Fertig RM, Gamret AC, Cervantes J, Tosti A. Microneedling for the treatment of hair loss? J Eur Acad Dermatol Venereol 2018;32:564-9.  Back to cited text no. 9
    
10.
Strazzulla LC, Avila L, Lo Sicco K, Shapiro J. An overview of the biology of platelet-rich plasma and microneedling as potential treatments for alopecia areata. J Invest Dermatol 2017:32751-3.  Back to cited text no. 10
    
11.
Ninama K, Mahajan R, Bilimoria FE, Vaghani A. A clinical study on alopecia areata. Int J Res Dermatol 2018;4:66-71.  Back to cited text no. 11
    
12.
Chandrashekar B, Yepuri V, Mysore V. Alopecia areata-successful outcome with microneedling and triamcinolone acetonide. J Cutan Aesthet Surg 2014;7:63-4.  Back to cited text no. 12
[PUBMED]  [Full text]  


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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