Clinical Dermatology Review

CASE REPORT
Year
: 2021  |  Volume : 5  |  Issue : 1  |  Page : 120--122

Alopecia totalis successfully treated with modified platelet-rich plasma therapy in a patient recalcitrant to traditional treatment modalities


Sumit Gupta, Priyanka Borde Bisht, Charisma Kannan 
 Department of Dermatology, Dr Gupta's Skin and Hair Hospital, Lalbagh, Lucknow, Uttar Pradesh, India

Correspondence Address:
Priyanka Borde Bisht
Dr. Gupta's Hair and Skin Hospital, Lalbaug, Lucknow - 226 001, Uttar Pradesh
India

Abstract

Alopecia areata (AA) is an autoimmune, nonscarring, inflammatory disorder of the scalp and/or body resulting in hair loss. Extensive AA such as alopecia totalis is increasingly unresponsive to conventional treatment modalities. We report a case of alopecia totalis showing a promising response with the application of platelet-rich plasma therapy modified with triamcinolone acetonide.



How to cite this article:
Gupta S, Bisht PB, Kannan C. Alopecia totalis successfully treated with modified platelet-rich plasma therapy in a patient recalcitrant to traditional treatment modalities.Clin Dermatol Rev 2021;5:120-122


How to cite this URL:
Gupta S, Bisht PB, Kannan C. Alopecia totalis successfully treated with modified platelet-rich plasma therapy in a patient recalcitrant to traditional treatment modalities. Clin Dermatol Rev [serial online] 2021 [cited 2021 Aug 5 ];5:120-122
Available from: https://www.cdriadvlkn.org/text.asp?2021/5/1/120/309766


Full Text



 Introduction



Alopecia areata (AA) is a nonscarring hair loss condition. It is an autoimmune disorder that has a significant impact on the patient's life by altering the function and appearance. AA is an inflammatory process characterized by patchy loss of hair, which can later progress to involve the entire scalp (alopecia totalis) or the entire body (alopecia universalis). This disease has limited treatment modalities, none of which has proven to be curative.[1] Platelet-rich plasma (PRP) has emerged as a recent treatment advance in various hair loss conditions in dermatology as well as esthetic medicine.[2] There is a paucity of studies showing the efficacy of PRP as a monotherapy in AA. We present a case of alopecia totalis treated with modified PRP in conjunction with intralesional triamcinolone acetonide (TrA).

 Case Report



A 23-year-old male patient presented to us 2 years back with a history of patchy loss of scalp hair over the crown which later progressed to involve the entire scalp in the next 2 months. There is a family history of AA in the father, while other significant autoimmune conditions associated with AA such as hypothyroidism were ruled out. After getting baseline investigations such as CBC, LFT, KFT, sugar (random), and thyroid profile, he was started on tablet prednisolone 40 mg daily along with tablet azathioprine 50 mg once daily. He was also advised topical 5% minoxidil and 0.01% tacrolimus. The patient showed hair growth by the end of the month and was maintained on the same medications for another month. When we started tapering the oral steroid, he started to have relapse; hence, we increased the dose of azathioprine to 100 mg daily and added tablet cyclosporine 100 mg daily as we did not want to continue the oral steroid for a long time. The patient was showing good improvement to tapering prednisolone, azathioprine, and cyclosporine. Over the period of 6 months, prednisolone was stopped eventually and doses of azathioprine and cyclosporine were reduced to 50 mg daily of each. Two months later, the patient had recurrence of AA gradually progressing to alopecia totalis irrespective of starting the oral steroid again and increasing the doses of azathioprine and cyclosporine [Figure 1]. By the end of 3 months, he was showing thin hair growth. To boost the hair thickness and density, we decided to use PRP injections along TrA, all over the scalp and eye brows.{Figure 1}

Topical anesthetic cream containing lidocaine and prilocaine was applied over the scalp and eye brow areas of the patient. 10 ml of the patient's whole blood was collected in acid citrate dextrose containing Vacutainers and put to centrifuge at 3500 RPM for 10 min. The plasma collected was then further centrifuged for 8 min with 2100 RPM speed. Supernatant clear plasma that is platelet-poor plasma was discarded. PRP of 3.5 ml was collected in 4 insulin syringes with 40 units markings, up to the mark of 35 units, and then the remaining 5 units were filled with TrA of 10 mg/ml concentration. The injections were given intradermally over the entire scalp and eyebrows. Four weeks after the first session itself, the patient presented with significant improvement in hair thickness and density [Figure 2]. The sessions were repeated at 4 weeks' interval for 3 times in total. The patient regained the complete hair growth at the scalp and eyebrows [Figure 3]. He was tapered off the oral steroids over the next few weeks and tablet cyclosporine over 2 months and currently is tablet azathioprine 50 mg once daily which we plan to stop over the next 2 months.{Figure 2}{Figure 3}

 Discussion



Alopecia can be categorized based on the extent of involvement as: AA with partial hair loss, alopecia totalis with complete scalp hair loss, and alopecia universalis with 100% scalp and body hair loss.[3] The first line of treatment of AA is intralesional corticosteroid such as TrA in the dosage of 5–10 mg/ml over the scalp and 2.5–5 mg/ml over the beard and eyebrow areas.[4] These intradermal injections are repeated every 4–6 weeks until a favorable hair growth is seen. PRP also has its implication in significantly increasing hair growth and decreasing the dystrophy of hair in other types of hair loss such as androgenetic alopecia, female pattern alopecia, and acute telogen effluvium. A randomized, double-blinded study has shown that both PRP and TrA significantly increased the levels of Ki-67 in AA patches compared to placebo.[5]

Various treatment modalities are available for AA. The effect of a single intralesional corticosteroid injection has been observed to persist for up to 9 months. The relapse rates were 29% in limited AA and 72% in alopecia totalis during a 3-month follow-up period.[6],[7] In a placebo-controlled, double-blind study, hair regrowth was observed in 63.6% and 35.7% of the minoxidil-treated and placebo groups, respectively.[8] However, complete relapse was observed after stopping of minoxidil. Various forms of systemic corticosteroids have been used in different regimens. A once-monthly oral pulse of 300 mg prednisone or oral prednisolone 200 mg once weekly in the treatment of extensive AA induced a complete response in 41% of patients. The relapse rate was 25%, and side effects of the therapy were noted in 55% of patients.[9],[10] Other medications include methotrexate (with relapse rate of more than 50%), cyclosporine (with a high relapse rate of almost 100%), azathioprine, and others.[11]

PRP stimulates growth factors such as platelet-derived growth factor, vascular endothelial growth factor, and transforming growth factor, which further promote the cellular proliferation and angiogenesis around the dermal papilla, thus leading to better blood circulation around hair follicles.

Giusti et al. demonstrated that the optimal platelet concentration for the induction of angiogenesis in human endothelial cells was 1500,000 platelets/μL, whereas excessively high concentrations of platelets were suggested to decrease the angiogenic potential. In this study, a mean of 1484,555.6 platelets/μL in the PRP preparation could effectively stimulate follicular and perifollicular angiogenesis, which is suggested to be one of the major factors in active hair growth.[12]

Alopecia totalis and alopecia universalis are indicators of poor prognosis. Conventional treatment modalities such as oral/topical/intralesional/intravenous pulse corticosteroid therapy or topical/oral immunomodulators such as azathioprine, cyclosporine, tacrolimus, and psoralen + UVA have failed to show remarkable improvement in severe forms of AA.[13] This case report suggests that a treatment regimen of PRP in combination with TrA may be effective in alopecia totalis, at least for the coverage of scalp and eyebrows, maintaining the cosmetic appearance of the patient and thus helping his mental and social health and professional progress. However, studies with larger study population are required to formulate a protocol for modified PRP therapy in cases of alopecia totalis to have long-lasting results and reducing the burden of immunosuppressants on the patient's other organ systems.

 Conclusion



Alopecia totalis can be successively treated with modified PRP with TrA, causing early regrowth of hair over the scalp and face, thus reducing the total response time to therapy and prolonged consumption of immunosuppressants.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Dr. Gupta's Hair and Skin Hospital, Lalbaug, Lucknow 226001, India.

Conflicts of interest

There are no conflicts of interest.

References

1Garg S, Messenger AG. Alopecia areata: Evidence-based treatments. Semin Cutan Med Surg 2009;28:15-8.
2Singh S. Role of platelet-rich plasma in chronic alopecia areata: Our centre experience. Indian J Plast Surg 2015;48:57-9.
3De Waard-van der Spek FB, Oranje AP, De Raeymaecker DM, Peereboom-Wynia JD. Juvenile versus maturity-onset alopecia areata-a comparative retrospective clinical study. Clin Experim dermatol 1989;14:429-33.
4Shapiro J. Alopecia areata. Update on therapy. Dermatol Clin 1993;11:35-46.
5Trink A, Sorbellini E, Bezzola P, Rodella L, Rezzani R, Ramot Y, Rinaldi F. A randomized, double-blind, placebo-and active-controlled, half-head study to evaluate the effects of platelet-rich plasma on alopecia areata. Br J Dermatol 2013;169:690-4.
6Abell E, Munro DD. Intralesional treatment of alopecia areata with triamcinolone acetonide by jet injector. Br J Dermatol 1973;88:55-9.
7Orentreich N, Sturm HM, Weidman AI, Pelzig A. Local injection of steroids and hair regrowth in alopecias. Arch Dermatol 1960;82:894-902.
8Price VH. Double-blind, placebo-controlled evaluation of topical minoxidil in extensive alopecia areata. J Am Acad Dermatol 1987;16:730-6.
9Ait Ourhroui M, Hassam B, Khoudri I. Treatment of alopecia areata with prednisone in a once-monthly oral pulse. Ann Dermatol Venereol 2010;137:514-8.
10Kar BR, Handa S, Dogra S, Kumar B. Placebo-controlled oral pulse prednisolone therapy in alopecia areata. J Am Acad Dermatol 2005;52:287-90.
11Gupta AK, Ellis CN, Cooper KD, Nickoloff BJ, Ho VC, Chan LS, et al. Oral cyclosporine for the treatment of alopecia areata. A clinical and immunohistochemical analysis. J Am Acad Dermatol 1990;22:242-50.
12Giusti I, D'Ascenzo S, Mancò A, Di Stefano G, Di Francesco M, Rughetti A, et al. Platelet concentration in platelet-rich plasma affects tenocyte behavior in vitro. BioMed Res Int 2014;2014.
13Assouly P, Reygagne P, Jouanique C, Matard B, Marechal E, Reynert P, et al. Intravenous pulse methylprednisolone therapy for severe alopecia areata: An open study of 66 patients. Ann Dermatol Venereol 2003;130:326-30.