The role of laser and energy-assisted drug delivery in the treatment of alopecia.

Eliza Balazic, Ahava Muskat, Yana Kost, Joel L Cohen, Kseniya Kobets

Review Lasers in medical science 2024 10 인용

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Study Design

연구 유형: RCT

중재: The role of laser and energy-assisted drug delivery in the treatment of alopecia.
대조군: Placebo
효과 방향: Neutral
비뚤림 위험: Unclear

Abstract

It has been recently established that laser treatment can be combined with topical or intralesional medications to enhance the delivery of drugs and improve overall results in a variety of different dermatological disorders. The aim of this review is to evaluate the use of laser and energy-assisted drug delivery (LEADD) for the treatment of alopecia with a specific focus on ablative fractional lasers (AFL), non-ablative fractional lasers (NAFL), and radiofrequency microneedling (RFMN). A comprehensive PubMed search was performed in December 2022 for "laser-assisted drug delivery" as well as "laser" and "alopecia." The evidence regarding LEADD for alopecia treatment is limited to two specific alopecia subtypes: alopecia areata (AA) and androgenetic alopecia (AGA)/pattern hair loss (PHL). LEADD with minoxidil and platelet-rich plasma (PRP) were evaluated for efficacy in both treatments of AA and AGA. LEADD with topical corticosteroids and intralesional methotrexate were studied for the treatment of AA, while LEADD with growth factors and stem cells were studied for the treatment of AGA. Multiple RCTs evaluated LEADD for topical corticosteroids with ablative fractional lasers for the treatment of AA. There is evidence in the literature that supports the use of topical minoxidil in combination with all devices for the treatment of AGA/PHL. All the reviewed studies show a positive treatment effect with LADD; however, some trials did not find LEADD to be superior to monotherapy or microneedling-assisted drug delivery. LEADD is a rapidly emerging treatment modality for the treatment of AGA and AA.

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Tables

Table 1

Type of alopecia	Drugs	Laser type	Settings	Study design	Selected outcomes	Adverse effects	Study type/Jadad Scale (max 5)	Reference
AA	Minoxidil 5%	NAFL (1550 nm Er:Glass; GSD, Shenzhen, China)	Energy: 10–15 mJ Intensity: 300 spots/cm²	10 treatments every 2 weeks with twice daily minoxidil until last laser treatment on 8 patients	3-point scale: Score 0 (no effect): 2 patients Score 1 (hair regrowth < 50% lesions): 1 patient Score 2 (hair regrowth > 50 lesions): 5 patients Relapse of one patient at 1 year follow-up	Mild erythema, mild broken hair shafts, and pain; number not reported	Case series/0	Wang et al. [3]
AGA	Minoxidil 5%	AFL (CO₂; DEKA Smartxide2 DOT/RF c60, Italy)	Power: 5W Pulse energy: 51.6 mJ Density: 8.7% Fluence: 4.68 J/cm² Spot size: 15 mm Dwell time: 500 μs	Three groups with 45 males total: Combined group: 6 sessions with 2-week intervals, followed immediately by topical minoxidil then twice daily Laser only: 6 sessions with 2-week intervals Minoxidil only: topical minoxidil twice daily for 3 months	Total hair count: significant baseline difference between the three groups. Significant post-treatment increase in all groups: Combined group (p = 0.001), laser (p = 0.005), and minoxidil group (p = 0.007) Thick hair thickness: no significant baseline differences between groups. Significant post-treatment increase only in combined group (p = 0.008) and laser (p = 0.042)	Erythema (33%), itching (16%) and post-inflammatory hyperpigmentation (7%)	Open-labeled non-randomized clinical study/0	Salah et al. [4]
AGA	Minoxidil 5%	NAFL (1550 nm Er:glass; Finescan, TNC Meditron, Bangkok, Thailand)	Energy: 6 mJ Density: 300 spot/cm² Probe diameter: 7 mm	Randomized 30-person split scalp study for 24 weeks One half: laser one half of scalp at 2-week intervals for 12 sessions and minoxidil 5% twice daily Other half: minoxidil 5% twice daily alone	Difference in hair density and hair diameter: increased in combination group compared to monotherapy (p = 0.004, p = 0.034)	LEADD side: tolerable pain and warmth during procedure (9 patients), erythema (6), itchiness (4), and scaling (2). Topical: itching (5) and scaling (3)	Investigator blinded split scalp RCT/3	Suchonwanit et al. [5]
Pattern hair loss	Minoxidil 5%	FRMN (fractional radiofrequency microneedling; BodyTite, Derma Optic and Electronic Ltd, Chongqing, China)	Tip: 1 cm² with 49 insulated 0.25-mm diameter microneedle electrodes Bipolar RF pulses: 1 MHz Power: 12 W Depth: 1.5 mm Pulse duration: 300 ms	Randomized 19-person split scalp study for 5 months One half: five FRMN treatments at 4-week intervals with topical minoxidil 5% twice daily Other half: topical minoxidil 5% twice daily	Mean change from baseline for mean hair count: increased in combined therapy group compared to monotherapy (p < 0.01) Difference in hair thickness after 5 months of treatment: increased in combined therapy group compared to monotherapy (p = 0.02)	LEADD: tolerable pain, pinpoint bleeding, erythema (all) Topical: dandruff(8)	Split scalp RCT/3	Yu et al. [6]
AGA	PRP (injected)	NAFL (Er:Glass)	Energy: 7 mJ Coverage: 9% Passes: 8	60 patients randomized study with treatments at 1 month intervals for 4 sessions Combination group: laser treatment then PRP injections Laser group: laser only PRP group: PRP only	No significant difference was found between groups Hair density: some improvements in 80% of combined group, 65% of laser group, and 70% of PRP group		RCT/2	Haddad et al. [7]
AGA	PRP	AFL (2940 nm Er:YAG; SP Dynamis, Fotona, Slovenia)	Fluence: 7.00 J/ cm² Spot size: 7 mm Frequency 3.3 Hz	Retrospective study of 16 patients treated with laser monotherapy or combination therapy with PRP injections. Some patients were also on topical minoxidil and oral cosmeceuticals	No differences were found between different treatment groups. Most groups improved	No adverse reactions	Retrospective cohort clinical study/0	Day et al. [8]
AGA	PRP	AFL (CO₂; Pentagon Grand, Daeju Meditech Engineering, Seoul, Korea)	Low-pulse: energy: 12 mJ Density: 800 spot/cm² High-pulse: Energy: 22 mJ Density: 400 spot/cm²	Split-scalp (half-head) pilot study of 7 participants. Treatment every 2 weeks for 10 total treatments with 12-week follow-up One-half: high pulse energy followed by topical PRP Other half: low pulse energy followed by topical PRP	Mean total hair density: increased significantly in high pulse group compared to low pulse group (p = 0.023)	Tolerable pain (7), mild pruritis (2), dandruff (4)	Pilot study/0	Hanthavichai et al. [9]
AA	PRP, TAC (10 mg/mL)	AFL (10,600 nm CO₂; Advanced Technology Laser Company, Ltd., Shanghai, China)	Power: 20 W Density: 4 pulses per inch Pulse duration/time: 3 ms	60 participants randomized with treatment every 3 weeks for four treatments with 4-week follow-up Group 1: laser and TAC Group 2: microneedling and TAC Group 3: laser and PRP Group 4: microneedling with PRP Groups 1 and 3: laser treatment was followed by application of topical drug Groups 2 and 4: drug was applied before, during, and after microneedling	Regrowth scales showed microneedling to be more effective than laser for drug delivery (p = 0.023) with TAC working better than PRP (p = 0.015). All treatment groups showed improvement	Laser: discomfort from heat in some patients Both groups: pain more tolerable than intralesional injections	RCT/3	El Mulla et al. [10]
AA	TAC (20 mg/ml)	AFL (CO₂), RFMN (both devices not specified)	RFMN: Roller: 10-mm-width wheel with 6 coags/disc with 50 pins/coag Depth: 100–150 μm Diameter 80–120 μm Laser: Depth: 150–300 μm Diameter 125–150 μm	Case series of 5 patients treated with laser or RFMN then topical TAC then acoustic pressure wave ultrasound (US)	All participants had complete resolution of their lesions. Two patients with RFMN after three and six sessions, respectively. Two patients after laser treatment with laser resolving after one session. The fifth patient had laser treatment that did not follow the treatment steps	Mild burning sensation during procedure	Case series/0	Issa et al. [11]
AA	TAC (10 mg/mL)	AFL (CO₂; Lutronics, Korea)	Tip: 120 μm Fluence: 50–60 mJ/cm² Density: 100 microthermal zones (MTZ)/cm²	Case series with 8 patients with treatment resistant AA. Treatment consisted of laser, followed by TAC spray for 4–8 treatments	7 patients had excellent response (> 75% hair growth), 1 patient had “not good” response after 4 treatments	None reported	Case series/0	Majid et al. [12]
AA	TAC (10 mg/ml)	AFL (CO₂; DEKA Smartxide, Italy)	Power: 7 W Pulse energy: 51.6 mJ Density: 8.7% Fluence: 4.687 J/cm² Spot size: 15 mm Dwell time: 500 s (authors attempted unsuccessfully to contact authors to confirm	30 participants with treatment resistant AA randomized to LADD with TAC or microneedling with TAC with sessions every 3 weeks for 12 weeks	Treatment response at first follow-up (12 weeks) 13.3% in laser group and none in microneedling group. Black dot higher in microneedling group. No significant difference in effectiveness	Laser group: no significant adverse effects Pain score significantly less in laser group (p = 0.002)	RCT/1	Omar et al. [13]
AA	TAC (10 mg/ml)	AFL (CO₂; Punto, DEKA, Italy)	Power: 10 W Dwell time: 500 ms, Stack: 2 Spacing: 700 m	30 participants randomized to monthly laser or microneedling, followed by TAC until resolution or for a maximum of 6 sessions	Both groups had a significant reduction in SALT score (p < 0.001) with reduction in SALT higher in microneedling group than laser group (p = 0.013)	No statistically significant difference in side effects between groups. Only mild pain and erythema were reported	RCT/2	Abd ElKawy et al. [14]
AA	Clobetasol propionate	AFL (ER: YAG; XS dynamics Fotona S1-121d, Ljubljana Slovenia)	Fluence: 3 J/cm² Frequency: 3–5 Hz Mode: short pulse Spot size: 7 mm	30 subjects with AA had lesions randomized to LEADD or topical clobetasol alone. The laser treatment occurred every 2 weeks for 2–3 weeks, followed by one application of topical clobetasol. The other lesions were treated with daily clobetasol alone	Both groups showed significant improvement in SALT score with the combination therapy showing a greater effect (p = 0.035)	Laser group: pain and transient post-treatment erythema, edema, and pruritus	Comparative study/0	Shokeir et al. [15]
AA	Betamethasone	AFL (CO₂; DEKA SmartXide, Italy)	Power: 16* Dwell time: 600 * Spacing: 600* Fluence: 2.13 J/cm² *units not specified	30 patients received treatment for 4 months LEADD group: eight laser treatments every 2 weeks in addition to betamethasone cream after laser session and daily Laser group: eight laser treatments every 2 weeks Topical group: betamethasone cream daily	All groups showed statistically significant decrease in SALT score after treatment (all p = 0.005). Combined group reduced SALT compared to topical group (p = 0.003). Laser group also reduced SALT compared to topical group (p = 0.002). No difference between combined group and laser group was found	LEADD and laser group: discomfort during procedure and transient post-treatment scaling and erythema	Comparative study/0	Halim et al. [16]
AA	Methotrexate (intralesional)	AFL (CO₂; CO2RE Candela, Massachusetts)	Fluence: 288 J/cm² Coverage: 5% Passes: 2	Two cases treated with laser and intralesional methotrexate. Cases were additionally treated with pulse oral steroids	Case 1: hair regrowth with villous white hairs on dermoscopy at week 16 Case 2: repopulation by week 22	Transient pain, redness, mild transitory hyperpigmentation	Case series/0	Rodríguez-Villa Lario et al. [17]
AGA	Growth factors (GFs)	AFL (CO₂; Pixel CO₂, Alma Lasers Ltd., Esthetic Mode, Israel)	Tip: 50 mm Energy: 12–18 mJ/spot 361 spots/cm² Density: 40%	27 participants were treated in this split scalp study with treatment sessions every 2 weeks for 6 total sessions with final evaluation 4 months after final treatment One half: laser followed by application of GFs using acoustic-pressure ultrasound. Then GFs were applied topically once every other day for 2 weeks Other half: during treatment session, application of GFs was done using acoustic-pressure ultrasound. Then GFs were applied topically once every other day for 2 weeks	Mean hair density increased significantly in both groups (p < 0.001). The mean change from baseline was also significantly higher in combined group (p = 0.003)	Post-treatment erythema (27), edema (7), pruritus (8), dryness (3), seborrheic dermatitis (2), and dandruff (7)	Split-scalp RCT/2	Huang et al. [18]
Pattern hair loss	GFs	NAFL (1927-nm-fractionated thulium laser; LASEMD, Lutronic Corporation, Goyang, Korea)	Power: 5 W Energy: 4 mJ or 6 mJ Pulse count: 100–140 pulses	10 participants treated in this split scalp study with 12 laser sessions at 1-week intervals with follow-up at 4 and 12 weeks after laser treatment Half scalp: laser treatment only Other half: laser treatment then topical GF solution	Hair counts and hair thickness significantly increased 1 week after final treatment compared to baseline (both p < 0.001) in both groups	No side effects reported	Split scalp RCT/2	Cho et al. [19]
AGA	Adipocyte-derived mesenchymal stem cell-conditioned media (ADSC-CM)	NAFL (Mosaic; Lutronic Corporation, Goyang, Korea)	Pulse: 5 mJ/ Spot density: 500 spots/cm²	30 participants were randomized and treated in this split-scalp study. The whole scalp was treated with ADSC-CM or placebo solution once per week with weekly at home microneedling. The scalp was treated with a single laser session at the initial visit	Hair density: ADSC-CM group significantly increased hair density compared to placebo (p < 0.05)	No adverse events reported	RCT/5	Lee et al. [20]