A New Approach of Treating Scarring Alopecia by Hair Transplantation and Topical Minoxidil

ABSTRACT OBJECTIVE To investigate the effective method to treat cicatricial alopecia. METHODS 20 cases with multi-region or great-dimensional cicatricial alopecia were treated with hair autografting using FUE technique followed by topical Minoxidil 5 % application . Among them, there were 12 males and 8 females, aged from 15 to 30 years old. The treatment was divided into two stages. Stage one surgical stage in which autogenous hair are transplanted .In second stage topical application of 5% minoxidl lotion was done on transplanted area RESULTS All cases, no matter what the position and area, were repaired successfully. The biggest dimension of repaired alopecia was 240 cm2. The normal hair direction changed in two cases. CONCLUSION Combined use of hair autografting using FUE followed by topical minoxidil 5% is an effective method to treat multi-region or great dimensional cicarticial alopecia.

INTRODUCTION
Cicatricial (scarring) alopecia refers to a group of rare disorders which destroy the hair follicle and replace it with scar tissue, thereby causing permanent hair loss. Causes of cicatricial alopecia are considered either primary or secondary. In primary cicatricial alopecia, the hair follicle is the target of inflammatory destruction, with little effect of the disease process on other components of the dermis. Examples of Primary alopecia include lichen planopilaris, pseudopelade of Brocq, central centrifugal cicatricial alopecia, discoid lupus erythematosus, folliculitis decalvans, and acne keloidalis. In secondary cicatricial alopecia, the hair follicle is an "innocent bystander" and is destroyed indirectly. Examples of secondary alopecia include burns and blistering disorders such as pemphigus vulgaris 1
Treatment of the primary cicatricial alopecias such as lichen planopilaris, frontal fibrosing alopecia, chronic cutaneous lupus erythematosus, central centrifugal alopecia, pseudopelade of Brocq , alopecia mucinosa, and keratosis follicularis spinulosa decalvans etc. involves use of anti inflammatory medications. The goal of treatment is to decrease or eliminate the lymphocytic inflammatory cells that are attacking and destroying the hair follicle. Oral medications may include hydroxychloroquine, doxycycline, mycophenolate mofetil, cyclosporine, or corticosteroids. Topical medications may include corticosteroids, topical tacrolimus, topical pimecrolimus, Derma-Smoothe/FS scalp oil; Triamcinolone acetonide (a corticosteroid) may be injected into inflamed, symptomatic areas of the scalp2.
Treatment of the primary cicatricial alopecias neutrophilic group such as folliculitis decalvans, tufted folliculitis, and dissecting cellulitis etc. is directed at eliminating the predominant microbes that are invariably involved in the inflammatory process. Oral antibiotics are the mainstay of therapy, and topical antibiotics may be used to supplement the oral antibiotics. Isotretinoin is sometimes helpful in controlling the neutrophilic group, especially dissecting cellulitis2.
Treatment of the mixed group of cicatricial alopecias like folliculitis keloidalis and erosive pustular dermatosis may include antimicrobials, isotretinoin etc 2.
The course of cicatricial alopecia is usually prolonged. Treatment is continued until the symptoms and signs of scalp inflammation are controlled, and progression of the condition has been halted. In other words, itching, burning, pain and tenderness have cleared, scalp redness, scaling, and/or pustules are no longer present, and the hair loss has not extended. Treatment may then be stopped. Unfortunately, the cicatricial alopecias often re-activate after a quiet period of one or more years, and treatment must be started again. Till date there is no treatment available for cicatricial alopecia .Now a days hair transplantation is being used with variable controversial effects .In this study we have used FUE technique for autologous hair transplant followed by topical 5% Minoxidil solution for 6 months period in 20 cases
METHODS
Twenty cases ( 12 male and 8 female) ranging from 15-30 yr of age with multi-region or great-dimensional cicatricial alopecia were treated with hair autografting using follicular unit extraction technique.
The treatment was divided into two stages :
I. Stage one surgical stage in which autogenous hair are transplanted .
II. In second stage topical application of 5% minoxidil lotion was done on transplanted area .
Result was evaluated according to percentage of alopecia sites with succesfull graft uptake , percentage uptake of grafts in different types of cicatricial alopecias.Patient was called for regular follow up at interval of 15 days and graft area was photographed to assess graft uptake and growth.
RESULTS
A total of 20 patients with cicatricial alopecia were identified. The demographic details of the two study groups were as follows: the mean age of the patients in the study was 24 years [figure 1 ]. There were 12 male and 8 female in study groups.The etiology of cicatricial alopecia of patients in each study group is shown in [figure 2]. All sites accepted the graft successfully. The biggest dimension of repaired alopecia was 240 cm2 and smallest being 10 cm2 .Maximum graft uptake 70% was seen in case of lichen plano pilaris [photo1-3,figure 3]. The normal hair direction changed in one case.




DISCUSSION
The term "cicatricial alopecia" or scarring alopecia implies the potential of permanent destruction of hair follicle 3most likely as a result of irreversible damage to epithelial hair follicle stem cells in the region of bulge4,5 . It consist of diverse group of rare disorders that destroy the hair follicle, replace it with scar tissue, and cause permanent hair loss. In some cases, hair loss is gradual, without symptoms, and is unnoticed for long periods. In other cases, hair loss is associated with severe itching, burning and pain and is rapidly progressive. The inflammation that destroys the follicle is below the skin surface and there is usually no "scar" seen on the scalp. Affected areas of the scalp may show little signs of inflammation, or have redness, scaling, increased or decreased pigmentation, pustules, or draining sinuses. Cicatricial alopecia occurs in otherwise healthy men and women of all ages and is seen worldwide2. Treatment of the lymphocytic group of cicatricial alopecia's involves use of anti-inflammatory medications such as steroids, cyclosporine, hydroxychloroquine. When hair follicle get destroyed, hair will not grow back. However in some cases using minoxidil solution can help to stimulate growth of some of the remaining hair. Hair transplant could only be used in the patients who have normal healthy hair in donor area 6.Scar revisions with/without a tissue expander and flaps are the major surgical procedures for cicatricial alopecia, and there have been few reports on hair transplantation into scar tissue. There is a apprehension of a lower survival rate of donor hair for cicatricial alopecia due to a poorer blood supply. However, hair transplantation can also show good results by using appropriate techniques and guidelines 7. This study concludes that combined use of hair auto grafting followed by topical minoxidil 5% appears to be an effective method to treat irreversible alopecia however such study on large scale needs to evaluate its usefulness in clinical practice.








REFERENCES:
1. Mehergan AH. Pinkus' guide to dematohistopathology . 4th ed. Norwalk: Appleton-Century-Crofts; 1986

2. Cicatricial alopecia research foundation . Available from http://www.carfintl.org/faq.html#Anchor-Ho-4683


3. Ross EK,Tan E , Shapiro J : Update on primary cicatricial alopecias .J Am Acad Dermatology 53:1,2005

4. Hermes B, Paus R: [Scar forming alopecia. Comments on classification, differential diagnosis and pathobiology] Hautarzt 49:462, 1998


5. Sterry W, Paus R, Burgdorf W: Dermatology, Thieme Clinical Companions, Thieme, Stuttgart/New York, 2006

6. Hairdoc weblog .Posted on April 3, 2008 at 10:40 pm and is filed under FUE, FUT, Hair transplant cost, Los Angeles Hair Transplant, hair growth cycle, hair transplant, hair transplant srugeon and male pattern baldness. Available from http://hairdoc.wordpress.com/2008/04/03/treatment-of-cicatricial-alopecia/

7. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. Treating cicatricial baldness with scalp expanding and hair autografting.
2001 Mar;15(2):99-100.

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