Original Article |
Corresponding author: Tsvetana I. Abadjieva ( ts_abadjieva@yahoo.com ) © 2024 Tsvetana I. Abadjieva, Lidiya N. Todorova, Petya A. Gardjeva, Mariana A. Murdjeva.
This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Citation:
Abadjieva TI, Todorova LN, Gardjeva PA, Murdjeva MA (2024) Platelet-rich plasma efficacy in alopecia areata patients with normal and elevated levels of antibodies against thyroglobulin and thyroid peroxidase. Folia Medica 66(1): 66-72. https://doi.org/10.3897/folmed.66.e115484
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Aim: To evaluate and compare the efficacy of platelet-rich plasma (PRP) therapy in alopecia areata (AA) patients with normal and with elevated levels of anti-thyroglobulin antibodies and/or anti-thyroid peroxidase antibodies.
Materials and methods: The study included 30 AA patients divided into two groups: AA patients with normal (Group 1) and with elevated antithyroid antibodies (Group 2). PRP was applied in three consecutive monthly sessions. Treatment results were evaluated by clinical photography, assessment of scalp hair, trichoscopy, and assessment of patients’ quality of life.
Results: The mean age of patients was 42.10 years, 23 (76.6%) patients were with normal and seven (23.3%) were with elevated antithyroid antibodies. Eleven (50%) patients from Group 1 had significant hair growth, of which ten with AA partialis (45.5%), one with AA reticularis (4.6%). Two patients with alopecia reticularis and two with alopecia totalis had insignificant hair growth. Worsening was found in four patients with alopecia reticularis and alopecia totalis. In Group 2 one patient with alopecia partialis (14.3%) had a significant hair growth, five patients with alopecia reticularis and one with alopecia totalis had insignificant hair growth, and none of the patients worsened.
Conclusions: PRP therapy was effective in patients with mild to moderate form of AA and most had normal antithyroid antibodies. Patients with severe AA, AA ophiasis and alopecia totalis, with normal and elevated antibodies, did not benefit from PRP therapy.
alopecia areata, anti-thyroglobulin antibodies, anti-thyroid peroxidase antibodies, platelet-rich plasma
Alopecia areata (AA) is an autoimmune disorder characterized by non-scarring hair loss of the scalp or body. It has an incidence rate of 0.1%–0.2% in the general population.[
Data differ regarding the incidence of thyroid diseases in patients with AA.[
Diagnosis and activity of AA are based on clinical manifestation and trichoscopy.[
Application of platelet-rich plasma (PRP) is a therapeutic option in AA. Platelet-rich plasma includes concentrated platelets, 4-7 times above baseline values, that secrete growth factors (GF) including: platelet derived (PDGF), vascular endothelial (VEGF), transforming (TGF), fibroblast (FGF), connective tissue (CTGF), epidermal (EGF), and insulin-like growth factor-1 (IGF-1). They stimulate hair follicle proliferation and differentiation, anagen phase, neoangiogenesis and development of adnexal structures.[
The aim of this study was to evaluate and compare the efficacy of the PRP therapy in AA patients with normal and with elevated levels of anti-TG-Ab and/or anti-TPO-Ab.
The study was conducted from September 2020 to September 2022.
This study enrolled 30 patients with AA. The inclusion criterion was patients of both sexes with AA above 18 years of age. Exclusion criteria were: presence of acute or chronic infection of the scalp, anticoagulants and antiaggregants intake, coagulation disorders (decreased number of platelets, platelet dysfunction, hypofibrinogenemia), haemodynamic instability (collapse), chronic liver diseases, keloid formation, pregnancy or lactation. At first visit, a detailed medical history was taken, and physical examination was done. The following data were collected: patient demographics, age at onset, number of relapses, total duration of disease, duration of last relapse. Dermatological examination determined the pattern of hair loss, size, and localization of bald patches. Trichoscopy was performed, and quality of life was measured.
Patients were divided into two groups: Group 1, AA patients with normal levels of anti-TG Ab and anti-TPO Ab, and Group 2 were AA patients with elevated levels of anti-TG-Ab and/or anti-TPO-Ab. The effect of the therapy was evaluated and compared between both groups.
Serum for the evaluation of anti-TG-Ab of IgG class and anti-TPO-Ab of IgG class was taken before the treatment. The tests were performed with anti-thyroglobulin ELISA (IgG) test kit and anti-TPO ELISA (IgG) test kit, Euroimmun, respectively, according to the manufacturer’s instructions. Sera from AA patients were collected and stored at −80°C until assayed. Patients’ sera were diluted 1:201 in sample buffer. The upper limit of the normal range (cut off) for anti-TG-Ab was a value <100 UI/ml, and a value equal or above 100 UI/ml was deemed to be elevated; for anti-TPO-Ab the normal range was <50 UI/ml and a value equal or exceeding 50 UI/ml was elevated (EUROIMMUN Medizinische Labordiagnostika AG, Lübeck, Germany).
Therapy included application of autologous PRP in three consecutive monthly sessions. For the preparation of PRP, at each visit, 8-10 ml of the patient’s venous blood was drawn by venipuncture and collected in a Pure PRP (RE-GEN Ltd). After centrifugation for 10 minutes at 3500 rpm, 5–6 ml of PRP were obtained and aspirated into two 3-ml syringes. The skin of the scalp was cleaned with alcohol pads prior injections. About 0.1 ml of PRP was injected in the scalp in the subfollicular plane through multiple intradermal injections, 1 cm apart with a 30 G needle.
Treatment evaluation was done by hair loss assessment, global photography, trichoscopy and quality of life at baseline (BL), before initiation of therapy, and at follow-up (FU) one month after completion of therapy. Severity of Alopecia Tool (SALT) Score was used to assess hair loss severity. Results at BL were denoted as SALT BL, those at FU (one month after last procedure) as SALT FU. Final results were denoted as SALT, representing hair regrowth as the percentage of change from BL. The percentage change from baseline is calculated as follows:
Percentage change from baseline = (SALTbaseline − SALTfollow-up)/SALT baseline × 100%
Patients’ improvement after PRP therapy was considered a significant improvement for SALT ≥50%, insignificant for SALT <50, no change for SALT=0, and worsening for SALT<0.[
Trichoscopy was performed using a Dino-Lite Edge Digital Microscope AM7915MZT(R7), magnification ×70. Quality of life was assessed with the Dermatology Life Quality Index (DLQI) questionnaire.[
Each patient provided written informed consent before participation. The study was performed according to the Declaration of Helsinki. The Ethics Committee at the Medical University of Plovdiv approved the study.
Data were collected, computerized, and statistically analyzed using SPSS v. 23.0., (SPSS, Inc., Chicago, IL, USA). Continuous variables are given as means and standard deviations (±SD), and category variables in percentages. The Kolmogorov-Smirnov test was applied to establish the distribution of data about SALT change and disease duration. Bivariate Pearson correlation was used to test the relationship between the variables disease duration and SALT change. Statistical significance was considered significant at p<0.05.
AA patients ranged in age from 20 to 67, with a mean age of 42.10 (±11.684) years. Of these, 25 (83.3%) were women and five (16.7%) were men. The mean disease duration was 14.1657 (±13.57472) years, ranging from 0.08 to 41, and the mean duration of the last relapse was 2.5067 (±4.98603) years, ranging from 0.08 to 19. First episode of AA was reported by nine patients (30.0%), while 21 (70.0%) had recurrent episodes. Eleven patients (36.7%) had AA reticularis (AAR), 11 (36.7%) had AA partialis (AAP), six patients (20.0%) alopecia totalis (AT), one (3.3%) AA ophiasis (AAO), and one (3.3%) AA barbae (AAB). Sixteen patients (53.3%) reported involvement of other bodily parts. Normal levels of antithyroid antibodies were found in 23 (76.7%) and elevated levels in seven (23.3%) AA patients. In 12 (41.4%) of all patients, SALT was more than 50% and 91.7% were with normal antithyroid antibody levels. In eight (27.6%) patients, hair growth was less than 50%. No improvement was observed in five (17.2%) patients and worsening of AA in four (13.8%). In five patients (16.7%) SALT was 100% (Table
SALT | AA patients n=29 (%) | Group 1 n=22 (%) | Group 2 n=7(%) |
SALT BL | |||
S0 = no hair loss | 0 (0) | 0 (0) | 0 (0) |
S1 <25% hair loss | 13 (44.8) | 12 (54.6) | 1 (14.3) |
S2 = 25%–49% hair loss | 6 (20.7) | 4 (18.2) | 2 (28.6) |
S3 = 50%–74% hair loss | 2 (6.9) | 0 (0) | 2 (28.6) |
S4 = 75%–99% hair loss | 5 (17.2) | 4 (18.2) | 1 (14.3) |
S5 = 100% hair loss | 3 (10.3) | 2 (9.1) | 1 (14.3) |
SALT FU | |||
S0 = no hair loss | 5 (17.2) | 4 (18.2) | 1 (14.3) |
S1 <25% hair loss | 10 (34.5) | 9 (40.2) | 1 (14.3) |
S2 = 25%–49% hair loss | 3 (10.3) | 1 (4.6) | 2 (28.6) |
S3 = 50%–74% hair loss | 5 (17.2) | 3 (13.7) | 2 (28.6) |
S4 = 75%–99% hair loss | 1 (3.5) | 1 (4.6) | 0 |
S5 = 100% hair loss | 5 (17.2) | 4 (18.2) | 1 (14.3) |
SALT change | |||
SALT ≥50% | 12 (41.4) | 11 (50.0) | 1 (14.3) |
0< SALT <50 | 8 (27.6) | 3 (13.6) | 5 (71.4) |
SALT = 0 (no change) | 5 (17.2) | 4 (18.2) | 1 (14.3) |
SALT <0 (worsening) | 4 (13.8) | 4 (18.2) | 0 (0) |
Type of AA | n=29(%) | Group 1 n=22 (%) | Group 2 n=7(%) |
AA partialis | 11 (37.9) | 10 (45.5) | 1 (14.3) |
SALT ≥50 | 11 (37.9) | 10 (45.5) | 1 (14.3) |
0 <SALT <50 | 0 (0) | 0 (0) | 0 (0) |
SALT = 0 (no change) | 0 (0) | 0 (0) | 0 (0) |
SALT <0 (worsening) | 0 (0) | 0 (0) | 0 (0) |
АA reticularis | 11 (37.9) | 6 (27.3) | 5 (71.4) |
SALT ≥50 | 1 (3.5) | 1 (4.6) | 0 (0) |
0 <SALT <50 | 8 (27.6) | 3 (13.6) | 5 (71.4) |
SALT = 0 (no change) | 0 (0) | 0 (0) | 0 (0) |
SALT <0 (worsening) | 2 (6.9) | 2 (9.1) | 0 (0) |
AA totalis | 6 (20.7) | 5 (22.7) | 1 (14.3) |
SALT ≥50 | 0 (0) | 0 (0) | 0 (0) |
0<SALT <50 | 0 (0) | 0 (0) | 0 (0) |
SALT = 0 (no change) | 4 (13.8) | 3 (13.6) | 1 (14.3) |
SALT < 0 (worsening) | 2 (6.9) | 2 (9.1) | 0 (0) |
AA ophiasis | 1 (3.5) | 1 (4.5) | 0 (0) |
SALT = 0 (no change) | 1(3.5) | 1 (4.5) | 0 (0) |
DLQI Score | DLQI BL n=30 (%) | Group 1 DLQI BL n=23 (%) | Group 2 DLQI BL n=7 (%) | DLQI FU n=30 (%) | Group 1 DLQI FU n=23 (%) | Group 2 DLQI FU n=7 (%) |
0–1 | 4 (13.33) | 4 (17.39%) | 0 (0%) | 13 (43.33) | 11 (47.83%) | 2 (28.57%) |
2–5 | 10 (33.33) | 9 (39,13%) | 1 (14.29%) | 11 (36.67) | 7 (30.43%) | 4 (57.14%) |
6–10 | 8 (26.67) | 3 (13.04%) | 5 (71.43%) | 4 (13.33) | 3 (13.04%) | 1 (14.29%) |
11–20 | 8 (26.67) | 7 (30.43%) | 1 (14.29%) | 2 (6.67) | 2 (8.70%) | 0 (0%) |
21-30 | 0 (0) | 0 (0%) | 0 (0%) | 0 (0) | 0 (0%) | 0 (0%) |
Twelve patients showed significant hair growth, 11 with AAP, one with AAR, and most had normal antithyroid antibody levels. Insignificant treatment outcomes were found in eight patients (27.6%) with AAR, three with normal and five with elevated antibodies. Five patients remained unchanged, four of whom had AT and one had AAO, four with normal and one with elevated antibody levels. Worsening was established in four patients, two with AAT and two with AAR, and all had normal antithyroid antibody levels.
The present study showed that PRP application resulted in significant improvement in hair restoration in patients with mild to moderate forms of AA. Trichoscopy results at FU showed a decrease in dystrophic hairs and an increase in growing hairs in comparison to BL. These findings are consistent with the results of other PRP studies. A nonrandomized, placebo-controlled study has established that PRP therapy is effective in mild cases of AA.[
To the best of our knowledge, this is the first study to estimate the efficacy of PRP therapy in AA patients with normal or elevated levels of thyroid antibodies. The mechanism of relationship between AA and thyroid autoimmunity is not well established. Genetic and racial factors probably play a role in this relationship. A potential risk of autoimmune thyroid disease particularly in severe and refractory AA was suspected.[
The study also established improved quality of life due to hair growth stimulation.
Limitations of the study are the insufficient number of cases, lack of a control group, and a short follow-up period. A long-term follow-up may not be very informative because of the high rate of spontaneous remissions and relapses in AA.
Autologous PRP is a safe, relatively effective, minimally invasive treatment method. PRP therapy was effective in patients with mild to moderate form of AA and most had normal antithyroid antibodies. Patients with severe AA, AA ophiasis and alopecia totalis, with normal and elevated antibodies, did not benefit from the PRP therapy. Controlled trials with more subjects are needed to validate the reported results.
The study was financed by the Department of Science and Research at the Medical University of Plovdiv (Project No. DPDP-05/2020).
The author has declared that no competing interests exist.
The author has no support to report.