Comparative Efficacy of Topical Calcipotriol, Intralesional Autologous Platelet-Rich Plasma Injection, and Combined Topical Calcipotriol with Intralesional Autologous Platelet-Rich Plasma Injection on Patients with Alopecia Areata

Alopecia areata (AA) is classified as an autoimmune disorder characterized by transient hair loss without lasting scars (1). Approximately 2% of the global population is affected by AA. The incidence of AA is greater in children than in adults and has been noted to be increasing over time. The prevalence of AA varies markedly across different locations (2). The precise etiology of AA remains incompletely elucidated; the dominant theory posits that it involves disruption of immune tolerance within hair follicles due to immunological mechanisms. The progression of AA is influenced by genetic and environmental factors (3). The progression of AA is related to the mobilization and activation of both innate and internal regions of hair follicles, leading to impairment of hair follicle function (4).

Alopecia areata is often diagnosed through the assessment of the clinical presentation of the affected region. In doubtful instances, trichoscopy may serve as a beneficial non-invasive tool to aid in diagnosis, thus circumventing the necessity for invasive procedures such as biopsies (5). The predominant clinical sign of AA is the occurrence of one or more patches. These patches generally display a round or elliptical form and are entirely devoid of hair, resulting in a smooth and hairless appearance (6). Dermoscopy is an invaluable instrument for diagnosing and following up on AA. The predominant trichoscopic features of AA include yellow dots, broken hairs, and micro exclamation mark hairs (7).

The therapeutic approach to AA is influenced by several factors, including the patient’s age, as well as the severity and duration of scalp lesions. Possible therapies include the use of steroids, anthralin, and immunosuppressive medications. It is essential to customize the treatment approach for each case, taking into account their unique needs and circumstances (8). Calcipotriol, a vitamin D analog, regulates the proliferation and development of keratinocytes. It has the capacity to stimulate hair regeneration in AA lesions by affecting the development of B lymphocytes, T lymphocytes, and dendritic cells. Despite being limited, some studies have evaluated the effects of calcipotriol in AA (9).

Platelet-rich plasma (PRP) is an autologous plasma preparation enriched with concentrated platelets, which are abundant in growth factors and cytokines. These components may enhance and facilitate the body’s intrinsic repair and regeneration mechanisms of hair follicles (10). Autologous PRP injections have been documented as useful in treating AA (11).

The present study sought to evaluate the effectiveness of topical calcipotriol, intralesional autologous PRP injection, and the combination of both treatments in individuals with AA.

The demographic and clinical characteristics of the examined groups are summarized in Table 1. The effect of various management modalities on the SALT score is illustrated in Table 2. Prior to management, an insignificant variance was found in the mean SALT score (P-value = 0.743) among the groups. Group III had an insignificantly greater SALT score (7.8 ± 0.8) compared with group I (6.9 ± 0.5, P-value = 0.597) and group II (6.7 ± 0.9, P = 0.457). There was an insignificant variance between group I and group II (P-value = 0.829) (Figures 1 - 3).

Figure 1.

Female patient 9 years old with scalp alopecia areata (AA). A, before treatment [Severity of Alopecia Tool Score (SALT) = 6.3]; B, after 3 months of treatment of topical calcipotriol (SALT = 0.6) (group I); C, dermoscopic picture before treatment (100X): Red arrow, black dots; green arrow, yellow dots; and blue arrows, short vellus hairs; D, dermoscopic picture after treatment (100X).

Figure 2.

A 22-year-old male patient with scalp alopecia areata (AA). A, before treatment [Severity of Alopecia Tool Score (SALT) = 6.5]; B, after 3 months of treatment with platelet-rich plasma (PRP) (SALT = 0.7) (group II); C, dermoscopic picture (100X) before treatment: Red arrow, black dot; green arrow, yellow dot; blue arrow, short vellus; black arrow, micro exclamation mark hair; brown arrow, Pohl-Pinkus sign; and yellow arrow, coudability hair; D, dermoscopic picture after treatment (100X).

Figure 3.

A 17-year-old male patient with scalp alopecia areata (AA). A and B, before treatment [Severity of Alopecia Tool Score (SALT) = 6.1]; C and D, after 3 months of treatment with a combination of topical calcipotriol and platelet-rich plasma (PRP) (SALT = 0) (group III); E and F, dermoscopic picture before treatment (100X): Red arrows, black dots; green arrows, yellow dots; blue arrow, short vellus hairs; black arrows, micro exclamation mark hairs; G, dermoscopic picture after treatment (100X).

Following three months of treatment, a substantial decline in the mean SALT score was detected across all three groups (P-value = 0.001). The absolute reductions were 3.73 points for group I, 6.87 points for group II, and 18.98 points for group III. The decline was markedly more pronounced in group III (P-value = 0.001), followed by group II, and then group I (Figures 1 - 3).

This study identified side effects of calcipotriol in four participants (7.69%). The adverse effects included erythema, localized discomfort, and a burning sensation. Table 3 illustrates the disparity in trichoscopy results among the examined groups. A substantial drop (P-value = 0.001) in the incidence of yellow dots and exclamation marks was observed across all three groups (Figures 1 - 3).

Alopecia areata is an autoimmune condition that disrupts the immune privilege of hair follicles. The resulting hair loss is facilitated by the invasion of CD4+ and CD8+ T cells and the secretion of Th1 cytokines, which occur due to disruption of immune privilege in hair follicles (6). The present study revealed a notable reduction in SALT score following a 3-month treatment with topical calcipotriol. This outcome aligns with the findings of Narang et al., Molinelli et al., and Abd-ElRaheem et al., who reported that calcipotriol usage led to expedited hair regrowth and a higher percentage of patches demonstrating a complete response (9, 14, 15). In contrast, Cerman et al. observed that the effectiveness of topical calcipotriol in AA is weak, with an average of 27% total hair regrowth (16). The obtained results can be attributed to the biological actions of vitamin D3 derivatives, which include regulation of proliferation and modulation of cytokine production (17).

Similarly, Albalat and Ebrahim, Khan et al., and Balakrishnan et al. observed a swift enhancement following twelve weeks of intralesional PRP treatment (18-20). This result differs from Gupta et al., who indicated that PRP had limited effectiveness in treating chronic AA (21). The disparity in outcomes may stem from the reduced number of PRP sessions in Gupta et al.’s research, which involved only three sessions, whereas our study administered six sessions over three months (21).

The combination of topical calcipotriol and intralesional autologous PRP injections resulted in a notable reduction in SALT scores. This study demonstrated that group III (combined topical calcipotriol and PRP) saw significantly greater decreases compared to group II (PRP), followed by group I (topical calcipotriol).

This study found no significant variations in microscopic findings across the three groups of AA cases. The yellow dots indicator was prevalent in the three groups, with percentages of 69.2%, 76.2%, and 84.6%, respectively. Guttikonda et al. and Chiramel et al. revealed that the yellow dots sign was prevalent in their studies, with occurrences of 88% and 87.5%, respectively (22, 23). Kibar et al. (24) observed a low incidence of yellow dot symptoms. Inui et al. (25) reported an occurrence of yellow dots at 73%; this discrepancy may be attributed to the yellowish skin tone prevalent among Asian cases, which may complicate the visual identification of yellow dots.

This study corroborated the findings of Chiramel et al. (23) and Amer et al. (26), who reported incidences of black dots at 79.5% and 75%, respectively. Conversely, Inui et al. (25) and Bapu et al. (27) observed that black dots were found in 45% and 36%, respectively. The exclamation mark was seen as a pathognomonic indicator in AA (28). The present study revealed that the prevalence of the exclamation mark was 69.2% in group I, 61% in group II, and 84.6% in group III. These findings correspond with Rakowska et al. (29), who stated a frequency of exclamation marks at 68% in their research. In contrast to research by Mane et al. (30), which indicated a lower incidence of the exclamation mark sign at a rate of 12%. Black spots, tapering hairs, and broken hairs exhibited a positive correlation with disease activity. These findings elucidate discrepancies noted across several studies (30).

In the present study, coudability hair was observed at an incidence of 61.5% in group I, 61.5% in group II, and 53.8% in group III. Rudnicka et al. (31) corroborated our results, noting that coudability hair was detected in 42% of the patients. There are several limitations of this study, such as the lack of biomarkers and PRP quantification. Future multicenter studies should extend follow-up to at least 12 months to assess relapse and durability of remission.