Transepidermal Delivery of Triamcinolone Acetonide or Platelet Rich Plasma Using Either Fractional Carbon Dioxide Laser or Microneedling in Treatment of Alopecia Areata
Phase: NA
Conditions: Alopecia Areata
Sponsor: Alexandria University

 
 
 
 
TRANSEPIDERMAL DELIVERY OF TRIAMCINOLONE 
ACETONIDE OR PLATELET RICH PLASMA USING  
EITHER FRACTIONAL CARBON DIOXIDE LASER OR 
MICRONEEDLING IN TREATMENT OF  
ALOPECIA AREATA  
May 2019 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

2. 
 
 
 
INTRODUCTION 
 
Alopecia areata (AA) is one of the most common forms of non-scarring 
alopecia involving the scalp and/or body.(1) Estimated incidence of alopecia 
areata is 20.9 per 100,000 person-years with a cumulative lifetime incidence of 
2.1%.(2) 
The exact pathophysiology of alopecia areata remains unknown. The most 
widely accepted hypothesis is that alopecia areata is a T cell-mediated 
autoimmune condition that is most likely to occur in genetically predisposed 
individuals.(3) 
Alopecia areata can be classified according to its pattern, as follows: patchy, 
reticular, ophiasis, alopecia totalis and alopecia universalis.(4)  
Although, alopecia areata is a benign condition and most patients are 
asymptomatic, it can cause emotional and psychosocial distress in affected 
individuals.(5) 
First-line therapies include intralesional corticosteroids, topical 
corticosteroids, minoxidil, anthralin, topical immunotherapy, prostaglandin 
analogues, topical retinoids bexarotene, and capsaicin.(6) Second- and third-line 
treatments include topical and systemic immunomodulatory therapies such as oral 
and topical psoralen plus UVA radiation and photodynamic therapy.(7) No 
treatment is either curative or preventive.(8) Since no single treatment option is 
certain to treat alopecia areata, the need for new therapies is mounting. 
Intralesional corticosteroids, most commonly triamcinolone acetonide are 
considered a first-line treatment method for limited disease and can be used as 
adjunctive therapy in extensive disease.(9) Because triamcinolone is only 

3. 
 
emulsified temporally to the water, usually it is delivered  by the painful 
intralesional injection.(10) 
Platelet-rich plasma (PRP) has emerged as a new treatment modality in 
dermatology, and preliminary evidence has suggested that it might have a 
beneficial role in hair growth.(8) 
Drugs  applied topically have the advantage of fewer side effects , and  
bypassing  the  first-pass  effect.(11) However, transepidermal dermal drug 
delivery has limitations,  including  decreased  penetration  of  larger  and  water-
soluble  molecules.(12) Only lipophilic  and smaller than 500Da molecules are 
capable of penetrating an  intact stratum corneum. Furthermore, only 1% to 5% 
of the  product applied to the skin is absorbed and becomes bioavailable  to exert 
its therapeutic effect.(13) In addition, the stratum corneum acts as a barrier that 
limits the penetration of substances through the skin. (14) 
Several strategies have been used to improve many drug penetrations into 
the skin: microneedling, ultrasound, and more recently transepidermal drug 
delivery (TED). TED is a technique based on applying a medication following an 
ablative method (CO2 laser, erbium lasers or ablative radiofrequency), which 
create vertical channels to assist the delivery of topically applied drugs into the 
skin. The use of nonablative lasers as well as microneedling technique has been 
reported with the same purpose. (14) 
Fractional laser–assisted drug delivery of corticosteroids for resistant 
alopecia areata is a new concept in dermatological therapy.(15) Lasers stimulate 
drug delivery by the means of three processes: tissue ablation, which removes the 
stratum corneum  and the most superficial layers of the epidermis; 
photomechanical waves, resulting from the conversion of light into mechanical 
energy; and non-ablative resurfacing, where thermal  and physical injuries 
rupture the skin barrier, promoting the  delivery of medications.(16) 

4. 
 
Microneedle devices, such as Dermaroller and Dermapen, are minimally 
invasive devices that bypass the stratum corneum barrier, thus accessing the skin 
microcirculation and achieving systemic delivery by the transepidermal route.(17) 
They create transient aqueous microchannels in the stratum corneum, that vary 
from 0.5 to 2.5 mm Subsequently, a conventional, topically applied  drug 
formulation can permeate through these microchannels  via passive diffusion.(18) 
Trichoscopy, hair and scalp dermoscopy, is a fast, non-invasive method 
useful in the diagnosis and therapeutic monitoring of scalp and hair diseases. (19) 
The trichoscopic features of alopecia areata were first described in 2004.(20) The 
reported features of alopecia areata are: yellow dots (6–100% patients), short 
vellus hairs (34–100%), black dots (0–84%), broken hairs (0–71%) and 
exclamation mark hairs (12–71%). The diagnosis should be based on the 
coexistence of several trichoscopic findings, not on the presence of a single 
feature. (19) 
 
 
 
 
 
 
 
 
 
 
 
 
 

5. 
 
 
AIM OF THE WORK 
 
The aim of this study is to evaluate the use of fractional carbon dioxide laser 
versus microneedling in the transepidermal delivery of triamcinolone acetonide 
and platelet rich plasma in treatment of alopecia areata. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

6. 
 
 
PATIENTS  
 
This study will be carried out on sixty patients, of either sex, presenting with 
alopecia areata to the outpatient clinic of Dermatology, Venereology and 
Andrology, Alexandria University Hospitals, after approval of the local Ethical 
Committee and having an informed written consent from every patient included 
in the study, or his/her legal guardian in case of children. 
 
 
Inclusion criteria:  
1. Patients with alopecia areata of either gender, diagnosed both clinically 
and by trichoscopy 
2. Patients not responding to treatment (topical and/or systemic), used 
properly and regularly, for at least 3 months duration  
Exclusion criteria:(8, 21-23) 
1- Alopecia areata with evidence of spontaneous hair regrowth 
2- Patients having active scalp inflammation or other scalp or hair diseases  
3- Pregnant and lactating women 
4- Patients with any bleeding disorder or receiving anti-coagulant therapy  
5- Immunocompromised patients 
 
 
 
 
 
 
 
 

7. 
 
 
 
METHODS 
 
 
 
History will be obtained at baseline according to the guidelines of the National 
Alopecia Areata Foundation including:(8, 15, 21, 24) 
• Patient demographics (name, age, sex, address, contact number,…)  
• Hair loss: age of onset, total duration of disease, number of relapses, 
family history  
• Onset and duration of hair loss of the present episode, and number of aa 
patches 
• Associated symptoms,  
• Any history of previously received treatment for the hair loss,  
• History of bleeding tendencies, or intake of any anticoagulant drugs  
• History of any medical or autoimmune disease 
Clinical evaluation:(15, 21, 24) 
The clinical evaluation of  alopecia areata will be made in accordance with the 
guidelines of the National Alopecia Areata Foundation.(24)  Under adequate 
illumination, patient will be examined for: 
• The pattern of hair loss 
• Number of patches 
• Skin changes over the affected area 
• Baseline SALT score (24-26) 
• Any associated nail changes 
• Also the patient will be thoroughly assessed for any associated 
autoimmune and endocrine disorders with relevant history, physical 
examination, and investigations wherever indicated.  
 

8. 
 
 
Trichoscopic/Dermoscopic evaluation : (25, 27, 28)  
Trichoscopic evaluation will be performed using a DermLite® IV (3 Gen, San 
Juan Capistrano, CA, USA), which can be used without immersion gels because 
of the presence of polarizing filters. The dermoscopic/trichoscopic features of the 
alopecic patch(es) will be noted.  
Patients will be randomly allocated, by closed envelope method , into one of 
four equal groups, fifteen patients each:  
Group I :Fractional Carbon dioxide laser (CO2 Laser) and triamcinolone 
acetonide (TrA; 10 mg/ mL). 
Group II: Microneedling with Dermapen and triamcinolone acetonide (TrA; 10 
mg/ ml). 
Group III: Fractional Carbon dioxide laser (CO2 Laser) and Platelet-rich plasma 
(PRP) 
Group IV: Microneedling with Dermapen and Platelet-rich plasma (PRP) 
Each patient will receive four treatments, with an interval of three weeks between 
the treatment sessions, for a total of 12 weeks. (14, 21, 29) This will be followed by a 
follow up period of another 4 weeks. The patients will be given no topical 
treatments for the alopecia areata in between the sessions. Topical post-procedure 
care in the form of  topical antibiotics, emollient or sunscreen may be used.   
Group I:Fractional Carbon dioxide laser (CO2 Laser) and triamcinolone acetonide 
(TrA; 10 mg/ ml) (14, 15) 
The ablative fractional CO2 laser is delivered to the patients’ scalp.  
The fractional ablative method is applied immediately before the topcial 
medication. 
Laser treatment will be given to the affected area, and immediately after the 
treatment, triamcinolone solution (10 mg/ml) will be dropped on the treated area 
and spread evenly. 
Group II: Microneedling with Dermapen and triamcinolone acetonide (TrA; 10 
mg/ ml) (29-32) 

9. 
 
Microneedling is performed using Dermapen. 
This creates pin point bleeding or mild erythema which will be considered as the 
end point. 
Triamcinolone acetonide in concentration of 10 mg/ml (0.1 ml containing 1 mg 
of triamcinolone) will be applied on each lesion twice, before and after 
performing microneedling.  
Group III: Fractional Carbon dioxide laser (CO2 Laser) and Platelet-rich plasma 
(PRP)(33) 
The same laser parameters as group I will be used, followed by application of 
freshly prepared PRP. The applied PRP will be spread over the whole affected 
area. 
Group IV: Microneedling with Dermapen and Platelet-rich plasma (PRP) (21, 29-32) 
Microneedling using dermapen is performed as Group II. 
Microneedling is preceeded and followed by intermittent application of freshly 
prepared PRP. The applied PRP will be spread over the whole affected area and 
again rolled till pinpoint bleeding points are noticed.  
Assessment criteria: (21, 24) 
Each patch will be digitally macrophotographed,  and evaluated clinically and by 
dermoscopy at baseline and at the end of the study, for signs of hair regrowth. 
Other criteria that will be evaluated: 
• Patient's satisfaction  
• Any complications, side effects clinically and using a dermoscope 
• Ease of the technique 
• Cost 
 
 
 
 

10. 
 
 
ETHICS OF RESEARCH 
 
Research on human or human products:  
Prospective study: Informed consent will be taken from patients. In case of 
incompetent patients the informed consent will be taken from the guardians. 
 
Retrospective study: Confidentiality of records will be considered   
 
DNA / genomic material: Informed consent for DNA / genomic test and for 
research will be taken from patients. No further tests will be carried out except 
with further approval of committee and patients. If the samples will travel outside 
Egypt the researcher will be responsible for transportation and security approval.  
 
All drugs used in the research are approved by the Egyptian Ministry of Health  
 
Research on animal: 
The animal species are appropriate for the test.  
 
After test, if the animal will suffer, it will be euthanized and properly disposed.  
 
After operation, it will have a proper postoperative care.  
 
 
√
√ 

11. 
 
 
RESULTS 
 
The results obtained from this study will be tabulated and statistically 
analyzed using the standard statistical methods. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

12. 
 
 
DISCUSSION 
 
The results obtained from this study will be discussed in view of 
achievement of the aim and compared with any available published data in the 
same field of the research. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

13. 
 
 
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