Comparative study between topical steroid alone versus combined fractional Erbium:YAG laser with topical steroid in treatment of alopecia areata

AA is a common autoimmune skin disease that causes hair loss on the scalp and sometimes other areas of the body. New therapy approaches for alopecia areata are emerging, with the goal of improving clinical outcomes. In this study, the effects of topical steroids against fractional Er:YAG laser followed by topical steroids in the treatment of alopecia areata will be compared. A total of 30 participants with alopecia areata were included in the study. Each patient's lesions were treated with one of two methods: topical clobetasol propionate or fractional Er:YAG laser followed by topical clobetasol propionate. SALT score, patient satisfaction, and dermoscopic imaging were used to evaluate therapeutic response. Both treatment modalities showed a significant clinical improvement in alopecia areata with a statistically significant reduction in the SALT score. The SALT score was more evident in the laser-steroid group. On comparing the dermoscopy findings in both treated areas before and after treatment, a significant reduction was found regarding all dermoscopic findings of alopecia areata in both modalities. Combining fractional Er:YAG laser with topical steroids is found to be a safe treatment modality and more effective than topical steroids in alopecia areata.


Introduction
AA is a common autoimmune skin disease which causes hair loss on the scalp, face, and sometimes other areas of the body. It may also be associated with other autoimmune diseases [1]. Alopecia Areata (AA) is considered as an organspecific autoimmune disease mediated by T lymphocytes in which the inflammation mainly targets anagen hair follicles [2]. Intralesional corticosteroid is considered the drug of choice for limited scalp alopecia areata, but side effects such as pain, skin atrophy and telangiectasia may limit its use [3].
Many forms of topical corticosteroids have been prescribed for alopecia areata including creams, gels, ointments, lotions, and foams. Sixty-one percent of patients using 0.1% betamethasone valerate foam achieved more than 75% hair regrowth in comparison with 27% in the patients using 0.05% betamethasone dipropionate lotion group [4]. A highly potent topical corticosteroid under occlusion is the preferred method when using topical corticosteroids. Topical very potent steroid as clobetasol propionate 500mcg/g (0.05% w/w) is a preferred method especially in children. Topical steroids act as anti-inflammatory agents by inhibiting mast cells, chemotaxis, and lymphocytes [5]. Folliculitis may develop as a common side effect and telangiectasia and atrophy may also develop [6].
Fractional laser treatment is a non-invasive method that uses a laser beam divided into thousands of microscopic treatment zones (micro thermal zones) that target a fraction of the skin at a time. It ablates the stratum corneum, producing thermal effects below it that can enhance transdermal 1 3 delivery and increase topical absorption of several compounds [7].
The aim of the study is to compare between the effects of topical clobetasol propionate alone versus fractional erbium:YAG laser followed by topical clobetasol propionate in the treatment of alopecia areata.

Study design and subjects
An outpatient-based interventional split side comparative prospective clinical trial was conducted between March 2016 and May 2020.The study includes 30 patients with an age range of 10-47 years (19 males and 11 females) who fulfilled all the inclusion criteria and completed all the needed sessions of therapy. The patients were selected from the outpatient clinic at the National Institute of Laser Enhanced Sciences (NILES), Cairo University, and El Houd El Marsoud Hospital.
All patients or their parents gave informed consent to participate in this study; patients were informed that they are receiving a new modality for treating their AA. The study was approved by the Ethical Committee for scientific research at NILES, Cairo University. Patients were treated in the outpatient clinics of the national institute of laser enhanced sciences.
Inclusion criteria were patients aged over 10 years, the presence of 2 or more AA patches in the same patient or a single patch > 7 cm, no concurrent systemic or topical treatment of AA for the last month, and all patients should be healthy. The study excluded patients with alopecia totalis or alopecia universalis, patients with other systemic autoimmune diseases, patients suffering from hemorrhagic disorders, those on anticoagulants or NSAIDs for fear of bleeding tendency during fractional laser sessions, and patients with photosensitive disorders, such as eczema, psoriasis, solar keratosis, and warts, as well as pregnancy and lactation.

Treatment protocol
The alopecia areata lesions were randomly assigned to receive the two different treatments. Randomization was assured using a simple randomization technique: a jar with folded papers was introduced in the room and the patient blindly picked a paper with a draw of alopecia lesions and the treatment options (steroid cream or laser followed by steroid cream). The AA patch/patches were divided into A and B (with nearly equal SALT score) in the same patient. In group A, one lesion was treated by topical steroid cream (clobetasol propionate) and the other lesion (B) was treated by fractional Er:YAG laser followed by topical steroid cream (clobetasol propionate). Group A was treated with topical potent steroid in the form of clobetasol propionate cream once daily for three weeks every month for 3 months. While group B was treated by fractional Er:Yag laser immediately followed by once application of topical clobetasol propionate cream (3-6 sessions, one session every two weeks). The laser application was extended 1-2 cm perilesionally. Sessions were done every two weeks for a maximum of six sessions, or until complete resolution. Each patient has at least two lesions of alopecia areata located on their scalp. Treatment was carried out using topical anaesthetic cream [EMLA (eutectic mixture of lidocaine and prilocaine)] for 15-30 min before the laser session.

Laser device
The laser used in this study was two passes of the Er:YAG laser (XS dynamics Fotona S1-121d, Ljubljana Slovenia) with the following specifications: 2940 nm, fluence 3 J/cm 2 , SP Mode (Short Pulse), frequency (3-5 Hz) with spot size of 7 mm. The technique of fractional mode with the RO4 hand piece, offers a unique fractional Er:YAG treatment modality.

Outcome assessment
Photos were taken pre-and post-treatment by the Galaxy S7 camera, which features a 12-megapixel (4032 × 3024) rearfacing camera with "Dual Pixel" image sensor technology for faster autofocus and an f/1.7 aperture lens. The clinical assessment of the degree of AA was determined 3 months after the start of treatment by 2 independent blinded dermatologists according to the severity of alopecia SALT score as follows: dividing the scalp into 4 quadrants and visually determining the percentage of scalp hair loss in each quadrant and adding the numbers together with a maximum score of 100% [8]. The change in SALT score from baseline depends on terminal hair growth. Based on the SALT score, the following percentages of scalp hair regrowth are possible: A0 = no change or further loss, A1 = 1-24% regrowth, A2 = 25-49% regrowth, A3 = 50-74% regrowth, A4 = 75-99% regrowth, and A5 = 100% regrowth.
Dermoscopic imaging was performed by a polarized-light handheld dermatoscope (Derm Lite DL4, 4th Gen, USA), with a tenfold magnification with contact dermoscopy. The images were obtained by threefold optical zoom and were taken at the start of treatment and every month. Digital images were backed up to a computer and analysed for the disappearance of signs of activity and the presence of new hair growth by 2 blinded dermatologists.
Patients' satisfaction was recorded from 0° to 10°, as (0) represents the patient's being unsatisfied at all, while (10) represents full satisfaction.

Statistical analysis
Data were collected, coded, revised and entered to the Statistical Package for Social Science (IBM SPSS) version 20. Data were presented as number and percentages for the qualitative data, mean, standard deviations and ranges for the quantitative data with parametric distribution and median with inter quartile range (IQR) for the quantitative data with non-parametric distribution. The comparison between more than two groups with quantitative data and nonparametric distribution was done using Kruskal-Wallis test. The confidence interval was set to 95% and the margin of error accepted was set to 5%. So, the p value was considered significant at the level of < 0.05. Clinical outcome was evaluated 3 months after the start of treatment. Patients were seen after 6 months from starting the study for follow-up and recording the recurrence. Side effects and complications were recorded.

Results
The demographic data included 30 patients; 11 females (36.7%) and 19 males (63.3%), mean age was 29, with a range from 10 to 47. Family history was positive in 6 patients (20%). History was positive in 16 patients (53%). The mean duration was 3.37 months, with a range of 2-7 months, and the mean AA history was 2.81 years, with a range of 1-10 years. In the studied group of patients, the most common sites involved were the occipital region [9 patients (30%)], followed by the temporal region [ The median SALT score before treatment was 7, with a range of 2-16 in the steroid group, and the median was 8 with a range of 2-18 in the laser-steroid group. So, there was a non-significant difference between the area treated by steroid and the area treated by laser followed by steroid.
When comparing the SALT score before and after treatment for each group separately, significant improvement was found in the form of reduction of SALT score in both groups (p value < 0.001). When comparing the SALT score after treatment for both groups, the reduction of SALT score was more evident in the laser-steroid group, and a statistically significant difference was found between both groups (p = 0.035) ( Table 1; Figs. 1, 2). A non-significant relation was found between the duration of AA and the response to treatment in both groups.
On comparing the dermoscopy, findings in the steroid group before and after treatment, a significant reduction was found regarding yellow dots (from 76.7 to 43.3%), exclamation mark hair (from 63.3 to 23.3%), black dots (from 50 to 16.7%), empty follicles (from 30 to 10%), and a significant increase in short vellus hair (from 20 to 43.3%). On comparing the dermoscopy findings in the laser-steroid group before and after treatment, there was a significant reduction in yellow dots (from 76.7 to 23.3%), exclamation mark hair (from 63.3 to 10%), black dots (from 50 to 10%), empty follicles (from 30 to 6.7%), and a significant increase in short vellus hair (from 20 to 53.3%). On comparing the dermoscopy examination findings in both groups after treatment, a non-significant difference was found between the two groups (Figs. 3, 4).
There was a statistically significant difference between both groups regarding patients' satisfaction (Fig. 5). On comparing the side effects in both groups, no statistically significant difference was found between the two groups (p value > 0.05).

Discussion
Alopecia areata (AA) is a complex genetic immune mediated inflammatory non-scarring hair loss that results in decrease in the quality of life of the affected patients [8,9]. Many treatment options including topical, systemic, injectable and laser modalities have been used for the treatment of AA [10]. One of the most unique treatments of alopecia areata is ablative fractional laser treatment with little to no side effects [11]. The aim of this study was to evaluate and compare the efficacy of topical clobetasol propionate alone versus fractional Er:YAG laser followed by topical clobetasol propionate in treatment of alopecia areata.
The current study showed a statistically significant decrease in SALT score in both groups; more significant in fractional Er:YAG laser followed by steroid group (p value was 0.035). This is in line with the study of Yoo et al. [12], who treated a 35-year-old male with fractional laser weekly for 24 months whereas complete hair regrowth was documented after 6 months of therapy.
Cho et al. [13] evaluated the clinical effects of the combination of Erbium glass laser and fractional CO 2 laser on three patients with AA. Two patients showed marked improvement (according to physician global assessment done by a blinded investigator), while the third one did not show any change. This agrees with Majid et al. [14], who conducted a case series on ten cases of resistant alopecia areata using fractional carbon dioxide laser in combination with topical corticosteroid application sessions every three weeks for a maximum of eight sessions or until complete hair regrowth was achieved. They found significant therapeutic response in almost 90% of cases.
In contrast to our results, Yalici-Armagan and Elcin [15] found no significant difference between the patches treated with either Nd:YAG laser or fractional carbon dioxide lasers and those of control. The explanation for this may be the difference in the selection criteria. They included patients with long-standing and resistant alopecia areata, and we used different laser parameters in our study according to the different mechanisms of action we intended, which was laser assisted drug delivery. The generation of MTZ by fractional lasers provides the channels for the uniform and controlled delivery of drugs. As the channels are distributed throughout the target area in a uniform manner, the drug deposition also becomes uniform. The ablative fractional Er:YAG laser has been shown to induce hair growth in a murine model. Upregulation of -catenin and Wnt 10b stimulated hair development, resulting in a shift from the telogen to anagen phase [16]. Meanwhile, laser induction has a thermal effect on the papillary dermis, stimulating hair regrowth. Furthermore, creating microthermal treatment zones with fractional lasers can provide channels for uniform and controlled transepidermal drug delivery for traditional topical medications such as corticosteroids [17].
Tanakol et al. [18] reported that 62.5% of individuals with patchy AA of the scalp had at least a 50% improvement in SALT score in research involving 25 chronic AA patients (25). More than 50% improvement in the laser group was reached in 73.3% of patients, whereas 50% improvement in the laser-topical steroid group was achieved in 86.7% of patients, according to the current study. The current study has better results since it only treats patchy AA (alopecia universalis was omitted), has a bigger sample size (30 patients), a longer treatment period, and more sessions (6 sessions), whereas the Tanakol study only had three sessions. Tanakol's study focused solely on clinical evaluation, whereas ours included both clinical and dermoscopic evaluation.
Laser, in theory, causes an inflammatory response that may aid in the stimulation of hair growth. Both treatments showed a significant difference, and combined therapy showed better results. The direct therapeutic effect of fractional laser along with TED into the target hair follicles can explain the synergistic effect of fractional laser with topical clobetasol propionate used in this study. Both mechanisms may be responsible for promoting hair regrowth in alopecia areata. Another advantage is decreasing pain and side effects associated with multiple intradermal corticosteroid injections.
Topical corticosteroids act as an anti-inflammatory agent decreasing the dense peribulbar infiltrate allowing the hair follicle to restore the normal hair growth cycle [19]. Due to its easy and painless application and wide safety margin, it is considered the first line of treatment in children.
Yellow dots, black dots, broken hairs, exclamation mark hairs, and short vellus hairs are the predominant dermoscopic symptoms of alopecia areata [20]. In this study, yellow dots and exclamation mark hairs were the predominant dermoscopic finding followed by black dots. This finding agrees with Ganjoo and Thappa [21], who found that black and yellow dots were the main dermoscopic findings. Black dots and yellow dots correlated with disease severity, whereas black dots, tapering hairs, and broken hairs correlated with disease activity. In our study, we tried to evaluate the response to treatment in alopecia areata using dermoscopic features in addition to clinical features, and we found that decline in the number of yellow dots, black dots and exclamation mark hairs is good evidence of response to treatment.
The current study found that laser treatment was well tolerated by patients, with the only side effects being pain and transient post-treatment erythema, edema, and pruritus. Secondary bacterial or viral infection, post-therapy blister formation, hypopigmentation, and scarring were not observed. In the current study, no patients experienced a recurrence of alopecia areata in the treated scalp area 3 months after treatment ended. The study's limitations included a small sample size, a non-controlled study, and a short duration of follow-up. Some treated areas in some patients were close to each other so the diffusion of drug and thermal effect of laser might affect the response.

Conclusion
Fractional Er:YAG laser as a transepidermal drug delivery for topical clobetasol propionate is found to be safe modality and more effective than topical clobetasol propionate alone in the treatment of alopecia areata.
Funding This is a contributors' own work, and the working team didn't receive any funds.