Hair and Scalp Treatments: A Practical Guide

By Antonella Tosti

Conditions of the hair and scalp often cause significant psychological distress and sometimes physical discomfort for patients. Similarly, finding the right treatment can prove challenging for the physician. Hair and Scalp Treatments -- A Practical Guide, focuses on therapy with each chapter briefly describing the disease to the reader and then teaching the step-by-step therapeutic algorithm. Procedures commonly used in the treatment of alopecias are also reviewed and detailed in specific chapters.

This book also discusses everyday questions that patients commonly ask doctors and provides practical tips such as how to recommend the best shampoo, conditioner or hair dye for your patient, or how to prescribe the right nutritional supplements. There are additional sections on future treatments on the horizon and how regenerative medicine can be used.

Hair and Scalp Treatments -- A Practical Guide, is the only book of its kind focused on treatment and addresses topics that are not covered by current titles on hair disorders. Written and edited by leading experts in the field, this practical guide can be used not only by dermatologists but by general practice and family physicians as well.

• Language: English
• Publisher: Springer
• Release date: Sep 12, 2019
• ISBN: 9783030215552

Book preview

© Springer Nature Switzerland AG 2020

A. Tosti et al. (eds.)Hair and Scalp Treatmentshttps://doi.org/10.1007/978-3-030-21555-2_1

1. How to Best Confirm Diagnosis Before Starting Treatment

Rodrigo Pirmez¹   and Antonella Tosti²

(1)

Department of Dermatology Santa Casa da Misericordia, Rio De Janeiro, Brazil

(2)

Fredric Brandt Endowed Professor of Dermatology, Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, USA

Rodrigo Pirmez

Keywords

TrichoscopyDermoscopyAlopeciaTrichogramAnagenHairHair lossLichen planopilarisLupusAlopecia areataAndrogenetic alopeciaTelogen effluvium

In many patients presenting with hair loss, diagnosis can be made (or at least suspected) through a detailed history and clinical examination. However, in doubtful cases, some diagnostic tools such as trichoscopy and trichogram may help to confirm diagnosis and, many times, avoid invasive methods, such as a cutaneous biopsy. When a biopsy is needed, trichoscopy is also helpful in selecting the best site for the procedure. This chapter will cover the basics of trichoscopic examination, trichoscopy-guided biopsies, and the trichogram.

Trichoscopy

Dermoscopy of hair shafts and the scalp is currently regarded by many specialists as an essential part of the consultation of patients presenting with hair loss. Dermoscopy allows visualization of morphologic structures that are not readily visible by the naked eye, including perifollicular and interfollicular features, as well as, changes to hair shaft thickness and shape [1]. In 2006, the name trichoscopy was proposed for dermoscopy in the diagnosis of hair and scalp disorders, and the term is now widely adopted [2].

How to Perform Trichoscopy?

Devices

Which device to choose? Each type of dermatoscope has its pros and cons, and the clinician should opt for the one that will best fit to his/her practice profile. A few points regarding the most common types of devices are detailed below [3]:

Handheld portable dermatoscopes: These devices usually only allow lower magnifications (tenfold). However, this is quite satisfactory for the daily practice, and such devices tend to be reasonably cost-effective. In addition, lower magnifications provide a better overview of a large scalp area [4].

Digital videodermatoscopes: Higher magnifications (20- to 100-fold and higher) provided by digital dermatoscopes allow better visualization of fine details, particularly of hair shaft defects and changes in scalp vessels. Another advantage of this more expensive group of devices is that they are usually equipped with photo storage and image analysis software. Cheaper video dermatoscopes that can be connected to any computer via USB are also available. These cheap devices have low image quality but still allow diagnosis in most common hair disorders [5].

Mobile-connected dermatoscopes: These are a somewhat in between and practical option which allow photography usually at a magnification of 10–20×.

The Exam

How to start the exam? First, the type of hair loss should be determined: is it diffuse or localized?

Diffuse hair loss: In this scenario, it is important to part the hair and examine at least three different sites: the frontal and middle scalp and the vertex (Fig. 1.1a). Lower magnifications (10–20×) will enable visualization of a larger area. If available, higher magnifications facilitate evaluation of hair shaft diameter, a hallmark of androgenetic alopecia (AGA). Nonandrogen-dependent areas (occipital scalp) are usually spared in AGA and can be examined for comparison (Fig. 1.1b).

Localized hair loss: In these cases, both the affected area and the periphery of lesions should be examined. In the affected scalp, it is important to establish whether hair follicle openings are present or not. Loss of follicular openings will guide the diagnosis toward a scarring condition. Signs of disease activity may be present at the alopecic area and/or at the periphery of the lesion (Fig. 1.2), depending on the etiology. So, the periphery should always be examined, as well. In marginal alopecia, loss of vellus hairs is a typical sign of frontal fibrosing alopecia.

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Fig. 1.1

Examination sites in a patient with diffuse or patterned alopecia. (a) Frontal and mid-scalp and vertex. (b) The occipital (nonandrogen-dependent) scalp is examined for comparison

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Fig. 1.2

Signs of disease activity may be present at the center of the lesion and/or at its periphery. (a) Patient with discoid lupus presenting with marked erythema and scaling at the center of the lesion. (b) In this case of lichen planopilaris, the center of the lesions presents as a milky area without follicular openings, suggestive of scarring. Perifollicular scaling in the hair-bearing periphery indicated disease activity

Tips

Some questions are frequently asked regarding the examination. Here we will approach some of them and also common pitfalls in trichoscopy.

Polarized vs. nonpolarizedlight: Both can be used in trichoscopy, but nonpolarized devices may require the use of an immersion fluid in order to cancel out reflections from the stratum corneum.

Immersion fluid: As a general rule, we start examination with dry dermoscopy and then use an immersion fluid if we judge necessary. Some points to consider:

Contact dermoscopy will always be necessary if an immersion fluid is being used.

Immersion fluids make the visualization of scales, vellus, and white hairs difficult (as they disappear when a fluid is used).

Elimination of scaling with immersion fluid is sometimes desirable, as excessive scaling may interfere with visualization of underlying trichoscopic features (Fig. 1.3).

Contact vs. no contact: When studying hair shafts and the scalp, contact is important; otherwise shafts will appear in different levels and out of focus. An exception is the study of vascular patterns, because excessive pressure may hamper the visualization of vessels.

Pitfalls: Some artifacts may simulate hair disorders and lead to misdiagnosis, so it’s important to look out for them. The most important pitfalls are secondary to scalp deposits (such as dirty dots simulating black dots like the ones seen in alopecia areata, for example) (Fig. 1.4a), scalp staining (hair dye mimicking skin hyperpigmentation or, when deposited in the follicle, dots) (Fig. 1.4b), and hair shaft deposits (secondary to dry shampoos or hair styling products that may look like nits or hair casts).

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Fig. 1.3

Trichoscopy of tinea capitis (a) without and (b) with the use of immersion fluid. Diagnostic features such as comma and corkscrew hairs become more visible after scales disappear with the use of immersion fluid

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Fig. 1.4

Pitfalls in trichoscopy: (a) Dirty dots, exogenous particles or fibers that may simulate trichoscopic structures; and (b) hair dye. In this case, it is staining both the interfollicular and follicular region

Trichoscopy-Guided Biopsy

Several papers have demonstrated the benefits of performing trichoscopy-guided scalp biopsies. It allows the physician to select and mark the optimal biopsy site for pathological evaluation, and this has been shown to increase the accuracy of pathological diagnosis in scarring alopecias, in which 95% of trichoscopy-guided biopsies yield a specific pathological diagnosis [6–8]. In this topic, we will summarize the trichoscopic features that best correlate with pathological diagnosis (Table 1.1). For further detailing of any particular alopecia, please refer to specific chapters in this book and suggested readings.

Table 1.1

The best biopsy sites in each condition

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Fig. 1.5

In patients suspected to have lichen planopilaris, the biopsy site should contain hairs with perifollicular scaling/casts or small tufts surrounded by casts

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Fig. 1.6

Frontal fibrosing alopecia: terminal hairs with concentric scaling

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Fig. 1.7

Fibrosing alopecia in a pattern distribution: look for small tufts with concentric scales and sometimes erythema in an area with hair shaft variability

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Fig. 1.8

In discoid lupus, select an area with keratotic plugs and/or red dots, as shown

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Fig. 1.9

In central centrifugal cicatricial alopecia, the selected site should contain hair shafts surrounded by white/gray halos like the ones seen in the picture and/or broken hairs

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Fig. 1.10

Folliculitis decalvans: biopsy site selected in an area containing large hair tufts (>5 hairs) surrounded by scales

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Fig. 1.11

Dissecting cellulitis: early lesion of dissecting cellulitis showing keratotic plugs, broken hairs, and black dots over an erythematous background; features indicating an optimal biopsy site

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Fig. 1.12

An optimal biopsy site in a patient with acute alopecia areata: exclamation mark hairs, broken hairs, and black dots

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Fig. 1.13

Androgenetic alopecia: hair shaft diameter diversity in the biopsy site

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Fig. 1.14

Trichotillomania: this biopsy site contains broken hairs and black dots. This patient also has some dirty dots, commonly seen in children and in the elderly

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Fig. 1.15

Traction alopecia: hair casts indicate active traction and designate a good biopsy site. A black dot and follicular bleeding are additional signs of follicular trauma

Trichogram

The trichogram is a simple, inexpensive, and semi-invasive technique that estimates the percentage of hairs in the anagen, catagen, and telogen phases and also dystrophic hairs. It is therefore mainly useful in the evaluation of the hair cycle of patients [20]. In addition, the microscopic analysis of hair shafts reveals distinguishing features that may help in the differential diagnosis of hair loss (i.e., cicatricial, noncicatricial, hair shaft disorders). We believe trichoscopy has successfully replaced this technique in most situations. However, the trichogram may still be used as a complementary tool and is particularly helpful in cases of diffuse hair loss, confirming the diagnosis of telogen effluvium, loose anagen hair syndrome, and suggesting the diagnosis of androgenetic alopecia [21].

How to Perform the Trichogram?

Before the Exam

Different authors state that patients should not wash their hairs before examination for a certain period of time, ranging from 3 to 7 days [22–24]. Washing or frequent combing the hair before the procedure may release telogen or dystrophic anagen hairs undermining the results [25].

Performing the Trichogram

A tuft of 20–50 hairs is selected and plucked using a rubber-armed forceps. The forceps should be closed tightly over the hairs at about 0.5 cm above the scalp and rotated to ensure a firm grasp (Fig. 1.16). With a quick and forceful pull perpendicular to the scalp, along the direction of hair growth, hairs are plucked. Hesitation during this step may result in damage to the shafts and in an inadequate sample [23, 24, 26, 27].

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Fig. 1.16

A small lock of hair is grasped with a forceps

Hair Analysis

Hair bulbs are immediately positioned on a glass slide in an embedding medium which allows microscopic evaluation later on. Hair roots are evaluated under a low-power microscope or with the dermatoscope to determine the percentage of hairs in the different phases of the hair cycle (Fig. 1.17). A histochemical stain may be used to ease the differentiation between anagen and telogen hairs. The internal root sheath of anagen hair follicles develop a bright red color when stained with 4-dimethylaminocinnamaldehyde, while telogen hairs do not.

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Fig. 1.17

Microscopic analyses of hair bulbs: observe that in anagen hairs, the bulb is large and well pigmented, while telogen hair is similar to a cotton swab

Results

According to the percentage of hairs in each phase, the trichogram may be classified as normal, telogenic, or dystrophic (Fig. 1.18). Catagen hairs are uncommon and when present are counted as telogen hairs (Table 1.2) [22].

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Fig. 1.18

Hair bulbs are mounted side-to-side

Table 1.2

Trichogram results

A trichogram with an increased rate of telogen hairs is characteristic of telogen effluvium. It is also seen in androgenetic alopecia (due to reduced anagen), in which case, hair shaft diameter variability is also present. A telogenic trichogram is also characteristic of the short anagen syndrome, where length of telogen hairs is shorter than 5 cm.

An abnormally increased rate of dystrophic hairs can be seen in patients undergoing chemotherapy or scalp radiotherapy, in patients with alopecia areata or in any other condition that presents with anagen effluvium.

Loose anagen hair (LAH) syndrome is caused by a defective anchorage of the hair shaft to the follicle. LAH is an anagen hair devoid of sheaths. The bulb of LAH is often misshapen, and its proximal portion often shows a visible ruffled cuticle with a floppy sock appearance (Fig. 1.19). The trichogram of patients with LAH syndrome shows 70–100% LAH and absence of telogen hairs [28].

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Fig. 1.19

Loose anagen hair syndrome. Trichogram shows prevalence of anagen hairs devoid of sheaths. Note ruffled cuticle

Observation of the hair shafts beyond the bulb may reveal a number of features depending on the condition, such as constrictions, twists, nodosities, and others. However, such analysis can be done with the dermatoscope without the need of epilation.

References

1.

Miteva M, Tosti A. Hair and scalp dermatoscopy. J Am Acad Dermatol. 2012;67(5):1040–8.Crossref

2.

Olszewska M, Rudnicka L, Rakowska A, Kowalska-Oledzka E, Slowinska M. Trichoscopy. Arch Dermatol. 2008;144(8):1007. https://​doi.​org/​10.​1001/​archderm.​144.​8.​1007.CrossrefPubMed

3.

Pirmez R, Tosti A. Trichoscopy tips. Dermatol Clin. 2018;36(4):413–20. https://​doi.​org/​10.​1016/​j.​det.​2018.​05.​008.CrossrefPubMed

4.

Rudnicka L, Rusek M, Borkowska B. Introduction. In: Rudnicka L, Olszewska M, Rakowska A, editors. Atlas of trichoscopy: dermoscopy in hair and scalp disease. 1st ed. London: Springer-Verlag; 2012. p. 3–8.Crossref

5.

Verzì AE, Lacarrubba F, Micali G. Use of low-cost videomicroscopy versus standard videodermatoscopy in trichoscopy: a controlled, blinded noninferiority trial. Skin Appendage Disord. 2016;1(4):172–4.Crossref

6.

Tosti A. Dermoscopy guided biopsy. In: Tosti A, editor. Dermoscopy of the hair and nails. 2nd ed. Boca Raton: CRC Press; 2016. p. 136–41.

7.

Miteva M, Tosti A. Dermoscopy guided scalp biopsy in cicatricial alopecia. J Eur Acad Dermatol Venereol. 2013;27(10):1299–303. https://​doi.​org/​10.​1111/​j.​1468-3083.​2012.​04530.​x.CrossrefPubMed

8.

Mubki T, Rudnicka L, Olszewska M, Shapiro J. Evaluation and diagnosis of the hair loss patient: part II. Trichoscopic and laboratory evaluations. J Am Acad Dermatol. 2014;71(3):431.e1–431.e11. https://​doi.​org/​10.​1016/​j.​jaad.​2014.​05.​008.Crossref

9.

Martínez-Velasco MA, Vázquez-Herrera NE, Misciali C, Vincenzi C, Maddy AJ, Asz-Sigall D, et al. Frontal fibrosing alopecia severity index: a trichoscopic visual scale that correlates thickness of peripilar casts with severity of inflammatory changes at pathology. Skin Appendage Disord. 2018;4(4):277–80. https://​doi.​org/​10.​1159/​000487158.CrossrefPubMedPubMedCentral

10.

Baquerizo Nole KL, Nusbaum B, Pinto GM, Miteva M. Lichen planopilaris in the androgenetic alopecia area: a pitfall for hair transplantation. Skin Appendage Disord. 2015;1(1):49–53. https://​doi.​org/​10.​1159/​000381588.CrossrefPubMedPubMedCentral

11.

Lanuti-Lanuti E, Miteva M, Romanelli P, Tosti A. Trichoscopy and histopathology of follicular keratotic plugs in scalp discoid lupus erythematosus. Int J Trichology. 2012;4(1):36–8. https://​doi.​org/​10.​4103/​0974-7753.​96087.Crossref

12.

Tosti A, Torres F, Misciali C, Vincenzi C, Starace M, Miteva M, et al. Follicular red dots: a novel dermoscopic pattern observed in scalp discoid lupus erythematosus. Arch Dermatol. 2009;145(12):1406–9.Crossref

13.

Miteva M, Tosti A. Dermatoscopic features of central centrifugal cicatricial alopecia. J Am Acad Dermatol. 2014;71(3):443–9.Crossref

14.

Waśkiel A, Rakowska A, Sikora M, Olszewska M, Rudnicka L. Trichoscopy of alopecia areata: an update. J Dermatol. 2018;45(6):692–700. https://​doi.​org/​10.​1111/​1346-8138.​14283.CrossrefPubMed

15.

de Lacharrière O, Deloche C, Misciali C, Piraccini BM, Vincenzi C, Bastien P, et al. Hair diameter diversity: a clinical sign reflecting the follicle miniaturization. Arch Dermatol. 2001;137(5):641–6.PubMed

16.

Miteva M, Tosti A. Flame hair. Skin Appendage Disord. 2015;1(2):105–9. https://​doi.​org/​10.​1159/​000438995.CrossrefPubMedPubMedCentral

17.

Bergfeld W, Mulinari-Brenner F, McCarron K, Embi C. The combined utilization of clinical and histological findings in the diagnosis of trichotillomania. J Cutan Pathol. 2002;29(4):207–14.Crossref

18.

Miteva M, Romanelli P, Tosti A. Pigmented casts. Am J Dermatopathol. 2014;36(1):58–63. https://​doi.​org/​10.​1097/​DAD.​0b013e3182919ac7​.CrossrefPubMed

19.

Tosti A, Miteva M, Torres F, Vincenzi C, Romanelli P. Hair casts are a dermoscopic clue for the diagnosis of traction alopecia. Br J Dermatol. 2010;163(6):1353–5.Crossref

20.

Pereira JM, Pereira FCN, Pereira VCN, Pereira IJN. Abordagem do paciente com tricose. In: Pereira JM, Pereira FCN, Pereira VCN, Pereira IJN, editors. Tratado das doenças dos cabelos e couro cabeludo – tricologia. Rio de Janeiro: DiLivros; 2016. p. 21–86.

21.

Tosti A. Hair root evaluation. In: Tosti A, editor. Dermoscopy of the hair and nails. 2nd ed. Boca Raton: CRC Press; 2016. p. 133–5.

22.

Pereira JM. The trichogram – part II – results and interpretation. An Bras Dermatol. 1993;68(4):217–22.

23.

Aschieri M, Lopez E. Le trichogramme, aide au diagnostic et à la prise en charge des patients présentant une alopécie. Paris: MSD; 2003.

24.

Blume-Peytavi U, Hillmann K, Guarrera M. Hair growth assessment techniques. In: Blume-Peytavi U, Tosti A, Whiting D, Trüeb R, editors. Hair growth and disorders. Berlin Heidelberg: Springer Verlag; 2008. p. 124–57.Crossref

25.

Braun-Falco O, Fisher C. [On the effect of hair washing on the hair root pattern]. Arch Klin Expe Dermatol 1966;226:136-143 APUD Pereira JM, Pereira FCN, Pereira VCN, Pereira IJN. Abordagem do pciente com tricose. In: Pereira JM, Pereira FCN, Pereira VCN, Pereira IJN, editors. Tratado das doenças dos cabelos e couro cabeludo – tricologia. Rio de Janeiro: DiLivros; 2016. p. 21–86.

26.

Pereira JM. The trichogram – parte I – significance and method of performing. An Bras Dermatol. 1993;68(3):145–52.

27.

Serrano-Falcón C, Fernández-Pugnaire MA, Serrano-Ortega S. Hair and scalp evaluation: the trichogram. Actas Dermosifiliogr. 2013;104(10):867–76. https://​doi.​org/​10.​1016/​j.​ad.​2013.​03.​004.CrossrefPubMed

28.

Tosti A, Piraccini BM. Loose anagen hair syndrome and loose anagen hair. Arch Dermatol. 2002;138(4):521–2.Crossref

Suggested Reading

Rudnicka L, Olszewska M, Rakowska A. Atlas of trichoscopy: dermoscopy in hair and scalp disease. 1st ed. London: Springer-Verlag; 2012.Crossref

Tosti A. Dermoscopy of the hair and nails. 2nd ed. Boca Raton: CRC Press; 2016.

© Springer Nature Switzerland AG 2020

A. Tosti et al. (eds.)Hair and Scalp Treatmentshttps://doi.org/10.1007/978-3-030-21555-2_2

2. Intralesional Steroids: When and How to Inject?

Rodrigo Pirmez¹  

(1)

Department of Dermatology Santa Casa da Misericordia, Rio De Janeiro, Brazil

Rodrigo Pirmez

Keywords

AlopeciaSteroidsIntralesionalTriamcinoloneBetamethasoneAtrophyHairAlopecia areataCicatricial alopeciasAcne keloidalisDiscoid lupusLichen planopilarisDissecting cellulitisFolliculitis decalvansAdrenal suppression

Introduction

Intralesional steroid (IL-S) injections have been used to treat a variety of dermatological and nondermatological diseases. Infiltration of IL-S is a relatively simple, effective, and minimally invasive procedure. It allows transposition of the epidermal barrier, delivering the drug directly into the involved area. In addition, targeted treatment with IL-S prevents the occurrence of adverse effects related to the systemic use of the drug. In the treatment of alopecias, IL-S are an important therapeutic tool for many types of both scarring and nonscarring hair loss [1, 2]. For patchy alopecia areata in adults, for example, it is commonly considered as a first-line therapy [3]. This chapter will cover important topics for the daily practice of a physician in charge of patients with alopecia.

Which Intralesional Steroid Should I Use?

There are a few options of steroid salts available for intralesional use in dermatological conditions. The majority of studies report data from the use of triamcinolone acetonide (TA) which is widely used for the treatment of alopecias [2, 4]. However, other injectable steroids have also been studied, including triamcinolone hexacetonide (TH) [5], the associations of betamethasone dipropionate with betamethasone disodium phosphate [6], the acetate salt with betamethasone disodium phosphate [7], and dexamethasone acetate with dexamethasone disodium phosphate [8].

TH is known to be much less soluble than other steroids (including TA), increasing the risk of local side effects such as cutaneous atrophy [9]. Some authors have even considered TH to be unsuitable for intralesional injection due to its long half-life [1]. For this reason, using intralesional TH to treat cutaneous lesions should be regarded with caution.

One study from 1974 with healthy individuals investigated adverse events of intradermal injections of betamethasone acetate-phosphate 6 mg/mL suspension in comparison to triamcinolone 40 mg/mL preparations. Hypopigmentation, atrophy, and telangiectasia were much more marked and persistent at the sites of triamcinolone injection than in the areas injected with betamethasone. On the other hand, suppression of the pituitary-adrenal axis in individuals occurred with different doses of betamethasone, while injections of up to 20 mg of triamcinolone had no effect on cortisol levels [7].

Considering the more robust data on the use of TA and personal experience, this author has preference for TA in the treatment of patients with hair disorders.

Which Drug Concentration Should I Use?

Concentrations of TA used to treat patches of alopecia on the scalp commonly range from 5 to 10 mg/mL in most papers and textbooks [10, 11]. For patches involving the beard, eyebrows, or any other area outside of the scalp region, lower concentrations are generally recommended (up to 2.5 mg/mL of TA), although some authors have used the same concentrations in these sites (up to 10 mg/mL) as on the scalp [10, 12]. However, recent data has favored the use of lower concentrations of IL TA in alopecia areata patients. In a double-blind, placebo-controlled study, injection of 2.5 mg/mL of TA was as beneficial as 5 or 10 mg/mL for limited, patchy alopecia areata of the scalp. According to the authors, using the lowest effective concentration minimized the risk of local side effects of skin atrophy and telangiectasia and likely reduces the potential for systemic adrenal suppression. In addition, utilizing lower TA concentrations also allows for injection of a greater volume, increasing the maximal treatment area [13].

The use of lower concentrations is particularly important in diseases in which cutaneous atrophy is part of the clinical picture. In frontal fibrosing alopecia (FFA), the skin of the hairline becomes very thin, and concentrations above 2.5 mg/mL will carry a greater risk of local side effects; for this reason, caution is advised when using IL-S to treat this area in this specific group of patients (Fig. 2.1). Some authors avoid to use ILK in patients with FFA if not a absolutely necessary.

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Fig. 2.1

Frontal fibrosing alopecia: the skin between the old and new hairlines is atrophic

On the other hand, the atrophogenic effect of higher concentrations can be used in our favor. Some disorders such as folliculitis decalvans , acne keloidalis (Fig. 2.2), and dissecting cellulitis may be characterized by an intensive fibrotic process. In addition to the anti-inflammatory properties, concentrations of 10 mg/mL or higher of TA will soften this fibrotic tissue, helping clinical management of these patients.

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Fig. 2.2

Acne keloidalis nuchae presenting with prominent fibrotic tissue

As a general rule, this author uses concentrations of up to 5 mg/mL of TA for the scalp and 2.5 mg/mL for the eyebrows and other facial areas. When atrophy is present, other treatments should be considered. If IL-S are used, lower concentrations are advised. When the atrophogenic effect is desired, as in cases above mentioned, 10 mg/mL of TA (or higher) can be used. The vascular patterns are better seen with the use of immersion fluids.

What Is the Best Way to Dilute Steroids for Intralesional Injections?

IL-S may be administered diluted in local anesthetics or isotonic saline solution. The diluent is generally a matter of personal choice, but some points need to be considered.

The acidic pH of lidocaine can cause an unpleasant burning sensation when the medication is injected. Intralesional injections of steroids are relatively fast procedures. The time interval between each skin puncture may not be enough for the onset of the anesthetic effect on the adjacent skin, and every puncture will end up being painful for the patient.

A particular situation refers to conditions with prominent fibrosis, such as acne keloidalis or folliculitis decalvans. In these cases, medication injected exerts great pression on the adjacent tissue, and patients may complain of pain for several minutes or even hours after the procedure. Using lidocaine as the diluent here will provide greater comfort after the injections.

An important point to consider is that the hexacetonide salt of triamcinolone should not be mixed with diluents or local anesthetics containing preservatives, such as parabens or phenols, since they may cause precipitation of the steroid increasing the risk of steroid deposition in the dermis and tissue atrophy [5, 14].

This author mainly uses isotonic saline solution as the diluent for IL-S injections. The exception are cases with prominent fibrosis, in which lidocaine is preferred.

The Technique

1.

First, the steroid should be diluted to the desired concentration.

2.

Most steroid salts form suspensions and will tend to deposit at the bottom of the syringe. It’s important to shake the syringe until the suspension becomes homogeneous before starting and from time-to-time during the procedure.

3.

Insert a 30-gauge needle forming an angle of 30°–45° with the scalp (Fig. 2.3a) until reaching deep dermal/subcutaneous plane: up to 0.1 mL is injected at 0.5–1-cm intervals. When treating the eyebrows, it’s helpful to lift the skin between the fingers to form a skin tent (Fig. 2.3b).

4.

Injection can be done in bolus or in a retrograde fashion. In the latter, caution is needed not to inject too superficially.

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Fig. 2.3

(a) The needle is inserted in the skin, forming an angle of 30°–45° with the scalp. (b) In the eyebrows, it’s helpful to lift the skin between the fingers to form a skin tent

When to Inject?

In the treatment of alopecias, IL-S may act as the main agent of a therapeutic regimen; be used in association with other medications in order to speed up the reduction of inflammatory signs preventing further hair loss; and reduce prominent fibrosis. Expected endpoints will vary according to the condition. In noncicatrial alopecias, such as alopecia areata (Fig. 2.4), the objective is to promote hair regrowth, in scarring conditions IL-S are used to stop disease progression. This topic presents selected indications of intralesional therapy with steroids. Information in Table 2.1 is a didactic approach and based on experience. For such, dosages and indications may differ from other sources.

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Fig. 2.4

Patient with patchy alopecia areata treated with intralesional triamcinolone injections (a) before and (b) after two sessions presenting with almost complete hair regrowth

Table 2.1

Selected indications of intralesional TA in alopecias

Where to Inject?

Steroids should be directly injected at areas with signs of disease activity, such as erythema and scaling in inflammatory scarring alopecias and exclamation marks, black dots, and dystrophic hair in alopecia areata. Trichoscopy allows better visualization of such signs and, thus, adequate selection of areas in need of treatment. In addition, their disappearance and signs of hair regrowth will assist the decision of stopping therapy.

Adverse Effects (And How to Avoid Them)

Local Adverse Effects

Atrophy secondary to IL-S is the main side effect of this therapy. Narahari reported atrophy in 10% (4 out of 37) of alopecia areata patients treated with intralesional 10 mg/mL TA [15]. Affected areas will present as a depression, and overlying epidermis may have a cigarette paper like appearance if atrophy is superficial. Telangiectasias and skin hypopigmentation may be associated, and steroid deposits may be perceived as ivory-colored areas (Fig. 2.5) [5]. Atrophy usually is due to injections that are too great in volume per injected site, too frequent, or too superficial [10]. It is commonly said to have a transient nature [4, 16], but long-lasting cases are not uncommon.

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Fig. 2.5

Patient with the ophiasis type of alopecia areata presenting (a) cutaneous atrophy secondary to intralesional steroid injections. (b) Trichoscopy reveals ivory-colored areas representing steroid deposits and telangiectasias

Observing the points previously mentioned in this chapter and spacing sessions to a minimal of 3- to 4-week interval minimizes the risk of skin atrophy.

Systemic Effects

A single injection of 75–100 mg of TA may result in a prompt fall in the plasma cortisol level lasting for 4 days, whereas doses of less than 25 mg do not result in adrenal suppression and are reasonably safe. Suppression of the adrenal gland is even more prominent with rapidly absorbed preparations such as betamethasone derivates. Intradermal injection of 6 mg of equal parts of betamethasone sodium phosphate and betamethasone acetate (equivalent to 20 mg triamcinolone) may significantly suppress plasma cortisol level for as long as 4 days [1, 7].

As a general rule, I limit the total injected dose of TA to 20 mg per session.

References

1.

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(5):363–70.Crossref

2.

Melo DF, Dutra TBS, Baggieri VMAC, Tortelly VD. Intralesional betamethasone as a therapeutic option for alopecia areata. An Bras Dermatol. 2018;93(2):311–2. https://​doi.​org/​10.​1590/​abd1806-4841.​20187423.CrossrefPubMedPubMedCentral

3.

Strazzulla LC, Wang EHC, Avila L, Lo Sicco K, Brinster N, Christiano AM, et al. Alopecia areata: an appraisal of new treatment approaches and overview of current therapies. J Am Acad Dermatol. 2018;78(1):15–24. https://​doi.​org/​10.​1016/​j.​jaad.​2017.​04.​1142.CrossrefPubMed

4.

Richards RN. Update on intralesional steroid: focus on dermatoses. J Cutan Med Surg. 2010;14(1):19–23.Crossref

5.

Pirmez R, Abraham LS, Duque-Estrada B, Damasco P, Farias DC, Kelly Y, et al. Trichoscopy of steroid-induced atrophy. Skin Appendage Disord. 2017;3(4):171–4. https://​doi.​org/​10.​1159/​000471771.CrossrefPubMedPubMedCentral

6.

Ustuner P, Balevi A, Özdemir M. Best dilution of the best corticosteroid for intralesional injection in the treatment of localized alopecia areata in adults. J Dermatolog Treat. 2017;28(8):753–61. https://​doi.​org/​10.​1080/​09546634.​2017.​1329497.CrossrefPubMed

7.

Jarratt MT, Spark RF, Arndt KA. The effects of intradermal steroids on the pituitary-adrenal axis and the skin. J Invest Dermatol. 1974;62(4):463–6.Crossref

8.

Pirmez R, Price VH, Cuzzi T, Trope BM. Acne keloidalis nuchae in renal transplant patients receiving tacrolimus and sirolimus. Australas J Dermatol. 2016;57(2):156–7. https://​doi.​org/​10.​1111/​ajd.​12271.CrossrefPubMed

9.

Porter D, Burton JL. A comparison of intra-lesional triamcinolone hexacetonide and triamcinolone acetonide in alopecia areata. Br J Dermatol. 1971;85(3):272–3.Crossref

10.

Shapiro J, Price VH. Hair regrowth. Therapeutic agents. Dermatol Clin. 1998;16(2):341–56.Crossref

11.

Kassim JM, Shipman AR, Szczecinska W, Siah TW, Lam M, Chalmers J, et al. How effective is intralesional injection of triamcinolone acetonide compared with topical treatments in inducing and maintaining hair growth in patients with alopecia areata? A critically appraised topic. Br J Dermatol. 2014;170(4):766–71. https://​doi.​org/​10.​1111/​bjd.​12863.CrossrefPubMed

12.

Donovan JC, Samrao A, Ruben BS, Price VH. Eyebrow regrowth in patients with frontal fibrosing alopecia treated with intralesional triamcinolone acetonide. Br J Dermatol. 2010;163(5):1142–4. https://​doi.​org/​10.​1111/​j.​1365-2133.​2010.​09994.​x.CrossrefPubMed

13.

Chu TW, AlJasser M, Alharbi A, Abahussein O, McElwee K, Shapiro J. Benefit of different concentrations of intralesional triamcinolone acetonide in alopecia areata: an intrasubject pilot study. J Am Acad Dermatol. 2015;73(2):338–40. https://​doi.​org/​10.​1016/​j.​jaad.​2015.​04.​049.CrossrefPubMed

14.

Triancil™ drug information: http://​www.​anvisa.​gov.​br/​datavisa/​fila_​bula/​frmVisualizarBul​a.​asp?​pNuTransacao=​1001392014&​pIdAnexo=​1962779 (as on 25 Nov 2018).

15.

Narahari SR. Comparative efficacy of topical anthralin and intralesional triamcinolone in the treatment of alopecia areata. Indian J Dermatol Venereol Leprol. 1996;62:348–50. qtd in Kassim JM, Shipman AR, Szczecinska W, et al. How effective is intralesional injection