Laser Hair Removal in Alopecia Areata of the Scalp: A Novel Therapeutic Approach
A 26-year-old man presented with an 18-year history of AA multilocularis affecting the scalp. Ultrapotent topical steroids and intralesional steroid injections had failed to give any benefit. Contact immunotherapy was suggested but our patient declined: given the extensive nature of his hair loss, he wished to explore options to remove the remaining hair-bearing areas. He had no medical history of note and did not take any regular medication. He was of skin phototype II. He had over 50% scalp hair loss and shaved the remaining hair for a more favorable appearance (Figure 1A,B).
Laser treatment was suggested for hair removal in the residual patches of hair. The patient was made aware that spontaneous regrowth of hair was still possible but after 18 years considered this unlikely and accepted the risk. He underwent 7 sessions using an alexandrite laser (Elite Laser; Cynosure, Westford, MA) (755 nm; pulse width 20 ms; spot size 10 mm; fluence 50 J/cm2; forced cold air cooling using a Zimmer device) at 6 to 8-weekly intervals over the course of 14 months. There was a sustained reduction in hair with every treatment. The laser treatment was very well tolerated.
At completion of treatment, the patient had only a few sparse small caliber white hairs. He was happy with the cosmetic outcome (Figure 2A,B) and was discharged. At 6 months telephone follow-up, hair loss was almost fully sustained, and he was happy shaving the remaining hairs.
For many years, lasers have been used to remove unwanted hair. The term “unwanted hair” has traditionally been used to describe facial or body hair, but not scalp hair. There are few reports that demonstrate the efficacy of laser in treating scalp hair. Acne keloidalis nuchae has responded well to treatment with the long-pulsed Nd:YAG laser, with excellent lasting results at 6 months follow-up.1 Hair removal with the Nd:YAG laser in recalcitrant folliculitis decalvans in an African-American patient resulted in significant improvement, which was sustained at 1-year follow-up.2 Both dissecting cellulitis and keratosis pilaris spinulosa decalvans have improved with the long-pulse non-Q-switched ruby laser.3
Laser treatment has also been used to correct unnatural-looking hairlines after hair transplantation. Adverse outcomes in hair restoration surgery in women, such as incorrect hair direction or angle, unnaturally large caliber hairs placed in the anterior hairline, and unsuitably curly or kinked hair can be treated with laser hair removal. The long-pulse Nd:YAG laser was used to reduce hair diameter in a cohort of 24 female patients after frontal hairline restoration, thereby achieving a more natural appearance.4
Surgical correction of ear deformities such as microtia, cryptotia, and lop ear can involve the use of postauricular and temporoparietal flaps. If the flap is moved from a hair-bearing donor site, the reconstructed ear will have undesirable hair growth. The diode and long-pulsed alexandrite laser have been used to remove unwanted hair after auricular reconstruction surgery.5
The use of laser hair removal has never been reported in AA or in a case where the desired outcome was a bald scalp. Although we cannot be certain that we have achieved permanent hair removal, the outcome has been excellent so far. Because of the permanent nature of laser hair removal, we suggest this as a last resort in AA.