Fractional carbon dioxide laser alone and as an assisted drug delivery for treatment of alopecia areata: a clinical, dermoscopic and immunohistochemical study

Abstract

Alopecia areata (AA) is a common cause of hair loss with no available universally successful treatment. Thus, new innovative treatments are urgently needed. This research aimed to evaluate the effectiveness of fractional carbon dioxide laser (FCL) alone or combined with triamcinolone acetonide (TA) solution, platelet-rich plasma (PRP), or vitamin D3 solution in treating AA. Sixty-four AA patients with 185 lesions were recruited and divided into four treatment groups. All patients received FCL either alone (group A, n = 19) or followed by topical TA (group B, n = 16) or PRP (group C, n = 15), or vitamin D3 solution (group D, n = 14). The response was assessed using Alopecia Areata Severity Index (AASI), MacDonald Hull and Norris grading, and trichoscopy. Histopathological features and immunohistochemical decorin expression were studied. All groups showed significant improvement in AASI compared to the baseline, with insignificant differences between them. Post-treatment, trichoscopic features of disease activity significantly decreased in all groups. Compared to control biopsies, both anagen follicles and decorin expression were significantly decreased in all pretreatment specimens. After treatment, all groups showed significantly increased anagen follicles and decorin expression compared to the baseline. Accordingly, FCL is an effective treatment for AA alone or combined with TA, PRP, or vitamin D3 solution. In AA, Decorin expression was downregulated, while enhanced expression following successful treatment occurred. This suggests the role of decorin in AA pathogenesis. However, further research is still recommended to clarify the exact role of decorin in AA pathogenesis and to investigate the therapeutic benefits of decorin-based therapy.

Keywords: Alopecia areata; Decorin; Fractional carbon dioxide laser; Platelet-rich plasma; Triamcinolone acetonide; Vitamin D3 solution.

Fig. 1

Flow chart for the study patients. FCL Fractional Carbon dioxide Laser, TA Triamcinolone Acetonide, PRP Platelet-Rich Plasma

Fig. 2

Excellent improvement in a female patient with patchy alopecia areata in group A, (a: before treatment, b: after treatment); Excellent improvement in a male patient with patchy alopecia areata in group B (c: before treatment, d: after treatment); Excellent improvement in a female patient with patchy alopecia areata in group C (e: before treatment, f: after treatment); Moderate improvement in a male patient with patchy alopecia areata in group D (g: before treatment, h: after treatment)

Fig. 3

Grading of patients improvement according to Alopecia areata severity index

Fig. 4

Trichoscopic images of alopecia areata patients. a and c Before treatment, showing exclamation mark hair—red circles, black dots—blue squares, broken hairs—yellow arrows, yellow dots—yellow circles. b and d After treatment, showing disappearance of all features of AA activity and appearance of terminal hair—blue arrows and short vellus hair—brown squares

Fig. 5

Histopathologic examination of the scalp biopsies of the study groups (scale bar 100 µm): a Uniformly distributed follicular units with multiple anagen follicles (inset) in the control group (× 200). b Increased number of the telogen hairs (arrows) in AA before treatment (× 200). Higher magnification (× 400) of scalp biopsies from AA group before treatment shows: c telogen hair, d telogen germinal unit, e catagen hair, f vellus hair, g Peribulbar lymphocytic inflammation and h fibrous stelae. (i–l, × 200) Increased number of anagen hair follicles in the treated groups. Immunohistochemical expression of decorin, m Strong expression of decorin in the peri-follicular extracellular matrix (ECM) of the anagen hair follicles in the control group (× 400). n Weak decorin expression in the perifollicular ECM of the anagen hair follicles in AA group before treatment (× 400). o and p loss of decorin expression in the perfollicular ECM of the telogen hair and in the areas of perifollicular inflammation (× 400) respectively. q–t Increased decorin expression in the perifollicular ECM of the anagen hair follicles in treated groups