PracticalDermatology

Intralesional Kenalog Injections as Effective Treatment Therapy for Chemotherapy-Induced Alopecia

A case report of chemotherapy-induced alopecia that is being treated successfully with monthly intralesional triamcinolone 5% injections and concurrent daily application of minoxidil 5%.

By Lauren Sundick, PA-C, Mohiba Tareen, MD, Gretchen Mueller, BS, and Farnaaz Kia, BS

A 47-year-old female A.A with a history of breast cancer presented to Tareen Dermatology in March 2014 with generalized hair loss and sparing re-growth following chemotherapy treatment ending in November 2010. At presentation, A.A. reported no active shedding of hair. This was confirmed by a negative hair pull test. Upon examination, the scalp was unremarkable, with no visible perifollicular erythema or distinct alopecic patches.

A 4mm punch biopsy was taken from the patient’s left medial frontal scalp and was submitted for processing in 10% neutral buffered formalin solution to a dermatopathologist with the differential diagnosis of androgenetic alopecia versus chemotherapy induced alopecia. The final diagnosis favored chemotherapy-induced alopecia. The pathologist reported mild acanthosis of the epidermis and six follicles upon vertical sectioning, stating that one follicle demonstrated periinfundibular fibroplasias. Sparse, non-focal inflammation of the skin was found. Three follicles and follicular dropout were observed upon horizontal sectioning of the tissue. In addition, significant increase in the number of miniaturized hairs and perivascular inflammation were noted. The dermatopathologist concluded that these features showed changes in the tissue that favored the diagnosis of chemotherapy-induced alopecia.

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Treatment was started in March 2014. At each clinic visit, a series of intralesional triamcinolone injections with a concentration of 5mg/kg were administered to affected areas of hair loss on the frontal and parietal scalp. A 30 gauge needle was used to inject 0.1mL of solution into the mid-dermis of multiple sites, approximately 1cm away from each other. The frequency in which intralesional triamcinolone injections were administered ranged from every 28-60 days (Table 1). A.A. concurrently began daily application of topical minoxidil 5% once daily. About three months of treatment, A.A. switched to minoxidil 2.5% twice daily due to a minimal increase in facial hair growth. She then switched back to minoxidil 5% two months later after experiencing headaches with use of lower strength medication (Table 1). Headaches resolved after returning to minoxidil 5% daily application and increased facial hair growth did not continue.

There were 42 days between treatments one and two, 49 days between treatments two and three, 60 days between treatments three and four, 29 days between treatments four and five, 28 days between treatments five and six, and 35 days between treatments seven and eight. The frequency of treatment increased to monthly based upon patient request and visible improvement. Monthly administration of intralesional triamcinolone will be continued until desired results are obtained. After nine months of regrowth and stability, A.A. prefers to continue treatment, as she reports improvement after each treatment. A.A. has experienced approximately 80-90 percent regrowth of hair since beginning intralesional triamcinolone injections and minoxidil treatments, based on both our estimates after clinical exam and her approximation.

Figure: CIA before treatment (top) and after five months of treatment (bottom).

Discussion

Each hair follicle goes through three phases of growth: anagen (growth), catagen (regression), and telogen (rest).¹ Different disorders of alopecia can be divided based on if the hair follicle is normal but the growth cycle is abnormal, or if the hair follicle is damaged.² Cicatricial alopecia, also known as scarring alopecia, results from a condition that causes damage to the scalp or hair follicle.³

Examples of conditions that result in cicatricial alopecia include infections, autoimmune disorders, sarcoidosis, scalp trauma, cosmetic practices such has blow drying, brushing, and hair styling, and radiation therapy.3 In addition to a thorough physical examination, a 4-mm punch biopsy is recommended to confirm the diagnosis and condition.³

Chemotherapy-induced alopecia (CIA) is a recently identified histological diagnosis. CIA is a type of scarring alopecia that occurs in an estimated incidence of 65 percent of those who undergo chemotherapy.² Forty-seven percent of women who have undergone chemotherapy have reported hair loss to be the most traumatic aspect of treatments.² Chemotherapeutic agents interrupt proliferation of keratinocytes in the anagen bulb that makes up the hair shaft. These anagen follicles then enter a catagen stage, the hair shaft is compromised, and the hair breaks and falls out. Once the follicle is no longer viable, it is lost and replaced with scar tissue, resulting in hair loss.⁴ At any given time, 90 percent of all follicles are in the anagen phase, so hair is lost very quickly following chemotherapy.⁵ Permanent CIA can be described as little or no regrowth for longer than six months following chemotherapy treatments. Chemotherapy-induced alopecia can be treated by stimulating viable follicles surrounding the affected areas.⁴ Based on current recommendations for treating alopecia areata, intralesional triamcinolone injections were initially performed in the clinic every four to six weeks.⁷ The frequency of administration was increased in response to the patient’s preference. Further experimentation is necessary to determine the strength of correlation between frequency of treatment and efficacy of treatment.

Minoxidil was used as an adjunct treatment method because it affects the hair follicle itself by increasing the amount of time hair follicles spend in the anagen phase, stimulates follicles that are in the catagen phase, and makes hair follicles larger.⁷ In a study performed by Chon et. al (2012), the daily use of minoxidil 2% solution by 22 woman decreased the time for hair regrowth and prolonged the time for hair loss.⁸ The most common side effect of minoxidil use is excessive facial hair growth. This occurs in three to five percent of women who use the 2% solution, and more than five percent of woman who use the 5% solution.⁹ A.A. noticed a slight increase in facial hair growth when using the 5% solution, but she also experienced headaches that she believes were correlated to usage of the 2% solution. She has chosen to continue with applying minoxidil 5% once daily and since restarting, has experienced no adverse events.

Other treatment methods for CIA include purchasing wigs, head scarves, or applying topical minoxidil daily.² Intralesional triamcinolone injections help reduce perifollicular inflammation, in order to promote recurrence of hair growth. There are minimal adverse effects associated with intralesional triamcinolone, the most common being pain with injections, transient atrophy and telangiectasia.¹⁰ If areas of atrophy are apparent, that patch should not be re-injected in order to avoid significant atrophy.¹¹ These injections have been proven successful with our patients experiencing alopecia area. After discussion of possible treatment options, A.A. decided to pursue a more aggressive approach by using minoxidil in conjunction with intralesional triamcinolone treatments. A lower dosage of triamcinolone (5mg/kg) was used to reduce adverse effects.¹¹ A.A. has not experienced any adverse events and is pleased with the amount of hair regrowth she is experiencing, so we plan to continue treating A.A. with intralesional triamcinolone injections until she reports satisfactory results. At this time, treatments will be spaced out to once every three to six months for maintenance. A.A. will continue to use minoxidil 5% daily.

Our report represents a unique case where chemotherapy agents, used to treat breast cancer, induced permanent chemotherapy-induced alopecia. Although the chemotherapy drugs were discontinued four years prior to presentation in our practice, the patient presented with little to no hair regrowth. Intralesional triamcinolone injections are not an approved treatment method for CIA, but proved to be successful to our patient. A.A. saw 80-90 percent improvement when intralesional triamcinolone injections were administered every four to six weeks, in conjunction with daily minoxidil application. We recommend considering intralesional triamcinolone injections as an adjunctive modality when indicated for alopecia treatment. n

Lauren Sundick is a board certified Physician Assistant, specializing in medical and cosmetic dermatology.  She practices at Tareen Dermatology in Roseville, Minnesota.

Gretchen Mueller earned her Bachelor of Art in Chemistry from Saint Olaf College in 2014. She currently works as a clinical assistant at Tareen Dermatology and plans to begin Physician Assistant school in 2016.

Farnaaz Kia earned her Bachelor of Science at the University of Minnesota. She is currently a second year medical student at the University of Minnesota-Twin Cities.

Dr Mohiba Tareen is a board certified dermatologist and founder of Tareen Dermatology in Roseville, Minnesota. Tareen Dermatology specializes in medical, cosmetic and surgical dermatology with an emphasis on superior patient care.

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