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Does microneedling with 5% minoxidil offer added advantage for treatment of androgenetic alopecia in comparison to use of topical 5% minoxidil alone?

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Background: Androgenetic alopecia is the most common cause of chronic hair loss. The FDA approved treatment for male androgenetic alopecia are Finasteride and Minoxidil. But many patients do not respond to these medications. Microneedling is a recent modality that releases several growth factors and enhances penetration of minoxidil, thereby promoting hair growth.Methods: 60 patients, aged 21-40 years, with androgenetic alopecia were divided into 2 groups. In group A, patients were subjected to microneedling twice monthly, immediately followed by application of topical 5% minoxidil solution over the scalp and then 1 ml twice daily. In group B, patients were treated with application of 1ml of topical 5% minoxidil solution over the scalp twice daily. The results were evaluated based on patient’s and physician’s assessment based on the standardized 7-point evaluation scale.Results: Patients in group A showed statistically significant improvement (p value<0.05) compared to group B. Headache and erythema were the most common side effects encountered in both the groups.Conclusions: Microneedling with 5% minoxidil is a safe, simple and cost-effective modality and is a promising treatment option for patients with androgenetic alopecia. It showed much better results when compared to use of topical 5% minoxidil solution alone.
International Journal of Research in Medical Sciences | April 2020 | Vol 8 | Issue 4 Page 1282
International Journal of Research in Medical Sciences
Malhotra K et al. Int J Res Med Sci. 2020 Apr;8(4):1282-1286
www.msjonline.org
pISSN 2320-6071 | eISSN 2320-6012
Original Research Article
Does microneedling with 5% minoxidil offer added advantage for
treatment of androgenetic alopecia in comparison to use of topical 5%
minoxidil alone?
Karan Malhotra*, Kallappa C. Herakal
INTRODUCTION
Androgenetic Alopecia (AGA) is a common cause of
chronic hair loss. It affects both sexes. It affects up to
80% Caucasian men and 40% women. Its frequency
increases with age, but it may start at puberty.1
Miniaturization of the hair follicle is the hallmark of
androgenetic alopecia. It occurs between the late catagen
or early anagen phase, affecting the dermal papilla and
the dermal sheath, resulting in a smaller follicle and a
reduced anagen phase.2
Topical minoxidil and oral finasteride are the only two
currently approved drugs by the United States Food and
Drug Administration for the treatment of AGA in men.
Topical minoxidil 5% solution (1 mL) applied twice daily
is effective in preventing progression and improving
AGA in men.3
But majority of the patients show poor response to these
drugs, hence the need arose to search for newer modalities
of treatment. Microneedling is a new minimally invasive
procedure where superficial and controlled puncturing of the
skin is done by rolling with miniature fine needles. Micro
Department of Dermatology, Venereology and Leprosy, Navodaya Medical College, Hospital and Research Centre,
Raichur, Karnataka, India
Received: 10 January 2020
Revised: 17 February 2020
Accepted: 28 February 2020
*Correspondence:
Dr. Karan Malhotra,
E-mail: dr.karan2015@gmail.com
Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Background: Androgenetic alopecia is the most common cause of chronic hair loss. The FDA approved treatment for
male androgenetic alopecia are Finasteride and Minoxidil. But many patients do not respond to these medications.
Microneedling is a recent modality that releases several growth factors and enhances penetration of minoxidil, thereby
promoting hair growth.
Methods: 60 patients, aged 21-40 years, with androgenetic alopecia were divided into 2 groups. In group A, patients
were subjected to microneedling twice monthly, immediately followed by application of topical 5% minoxidil
solution over the scalp and then 1 ml twice daily. In group B, patients were treated with application of 1ml of topical
5% minoxidil solution over the scalp twice daily. The results were evaluated based on patient’s and physician’s
assessment based on the standardized 7-point evaluation scale.
Results: Patients in group A showed statistically significant improvement (p value<0.05) compared to group B.
Headache and erythema were the most common side effects encountered in both the groups.
Conclusions: Microneedling with 5% minoxidil is a safe, simple and cost-effective modality and is a promising
treatment option for patients with androgenetic alopecia. It showed much better results when compared to use of
topical 5% minoxidil solution alone.
Keywords: Androgenetic alopecia, Male pattern baldness, Microneedling, Minoxidil
DOI: http://dx.doi.org/10.18203/2320-6012.ijrms20201310
Malhotra K et al. Int J Res Med Sci. 2020 Apr;8(4):1282-1286
International Journal of Research in Medical Sciences | April 2020 | Vol 8 | Issue 4 Page 1283
punctures are created using microneedles and they produce a
controlled skin injury without damaging the epidermis.
These microinjuries lead to minimal superficial bleeding and
set up a wound healing cascade with release of various
growth factors such as platelet derived growth factor (PGF),
transforming growth factor alpha and beta (TGF-α and TGF-
β), connective tissue growth factor, connective tissue
activating protein and fibroblast growth factor (FGF).4
Microneedling also facilitates penetration of firstline
medications (like minoxidil), and this is one mechanism
by which it promotes hair growth.
METHODS
This prospective study was aimed at comparing the
clinical efficacy of microneedling with 5% minoxidil
versus topical minoxidil 5% alone for the treatment of
AGA patients
Inclusion criteria
The study included patients who agreed to participate
in the study. Age matched patients between the age
of 21 to 40 years with Stage IIIIV Androgenetic
alopecia according to Norwood-Hamilton grading
scale, and those who did not taken any treatment in
the past 1 year were enrolled in the study.
Exclusion criteria
Patients with abnormal coagulation profile, with any
dermatological disease over the scalp and those
uncooperative and unwilling for the procedure were
excluded.
60 age-matched male patients with AGA were randomly
divided into two groups of 30 patients each. In the first
group (A), patients were subjected micro needling twice
monthly, immediately followed by application of topical
5% minoxidil solution over the scalp and then 1ml twice
daily. Whereas in the second group (B), patients applied
1ml of topical 5% minoxidil solution over the scalp twice
daily.
Patients who could come for regular followup were
selected and included in the study. After taking the
written and informed consent, patients were included in
the study and procedure was started.
All participants were subjected to:
Fitness assessment: Complete history taking and
general examination.
Local scalp examination for establishment of the
diagnosis
Grading of AGA was done using the Hamilton
Norwood classification of male pattern baldness in
males.
Photographic documentation and patient’s data were
recorded prior to onset of treatment.
Scalp was cleansed with topical antiseptic. Then topical
anesthesia was applied. Microneedling was done with
derma roller with needle length 1.5 mm over affected
areas in longitudinal, vertical, and diagonal directions
until mild erythema was noted which was considered as
the end point. This activation of scalp with microneedling
was followed by application of 1 ml of 5% minoxidil on
the affected site.
Duration of study
The procedure was repeated every 15 days for duration of
6 months.
The patients were followed up for 6 months to assess the
sustainability.
Patients were assessed before starting the treatment and at
the end of 6 months on the basis of:
Patient’s self-assessment based on standardized seven-
point scale compared with baseline which is shown in
Table 1. Physician’s assessment based on standardized
seven-point scale of hair growth compared with baseline
which is shown in Table 2.
Table 1: Patient's assessment of improvement on 7-
point scale.
3
2
1
0
+1
+2
+3
Table 2: Physician's assessment of improvement on 7-
point scale.
3
2
1
0
+1
+2
+3
Statistical analysis
Calculated Mean, Standard Deviation, percentage, p
value and Chi square value were analysed by using SPSS
V 16.0 software.
Malhotra K et al. Int J Res Med Sci. 2020 Apr;8(4):1282-1286
International Journal of Research in Medical Sciences | April 2020 | Vol 8 | Issue 4 Page 1284
RESULTS
In the current study, the two groups of patients were
statistically matched regarding age (p=0.793), duration of
hair fall (p=0.711), and disease severity (p=0.855).
56.7% (n=17) patients in Group A and 60% (n=18)
patients in Group B were in age group 21-30 years
whereas 43.3% (n=13) patients in Group A and 40%
(n=12) patients in Group B were in age group 31-40
years. Average age in Group A and B were 28.6 and 29.2
years respectively, which were comparable, and
difference was not statistically significant (p=0.793).
62% (n=31) patients had hair loss duration of 1-5 years.
Maximum duration of hair loss was of 15 years, for three
patients seeking advice. There was not much difference
in duration of hair loss of the patients in both the groups.
In the study of total sixty male patients, 37 (61.7%)
patients had Grade III alopecia, and 17 (28.3%) patients
had Grade IV alopecia. Maximum patients were of Grade
III alopecia (Table 3).
Table 3: Comparison of clinico-demographic data of patients in both groups.
Parameter
Microneedling with
5% minoxidil (n=30)
5% minoxidil
only (n=30)
Test of significance
Age (years)
21-30 years
17
18
2 =0.0686, p=0.793
Difference is statistically
not significant
31-40 years
13
12
Mean±sd
28.6±6.32
29.2±7.04
Duration of hair
fall (months)
< 12
7
5
2 =0.6825, p=0.711
Difference is statistically
not significant
12-60
14
17
>60
9
8
Mean±sd
28.36±16.85
33.7±19.18
Severity of
alopecia
Mild (grade ii)
3 (10%)
4 (13.3%)
2 =0.3128, p=0.855
Difference is statistically
not significant
Moderate (grade iii)
19 (63.3%)
17 (56.7%)
Severe (grade iv)
8 (26.7%)
9 (30%)
Table 4: Comparison of patients’ assessment at the end of 6 months between two Groups A and B using
Chi-square test.
Patients’ assessment at 6
months
Group A
(n=30), n (%)
Group B
(n=30), n (%)
p value
Chi-square value
(2)
No change
4(13.3%)
11(36.7%)
0.037
8.455
Mild improvement
6(20%)
10 (33.3%)
Difference is statistically significant
Moderate improvement
16 (53.3%)
7(23.3%)
Excellent improvement
4 (13.3%)
2 (6.7%)
Table 5: Comparison of investigator assessment at the end of 6 months between two Groups A and B using Chi-
square test.
Physician’s assessment at 6
months
Group A
(n=30), n (%)
Group B
(n=30), n (%)
p value
Chi-square value (2)
No change
3 (10%)
9 (30%)
0.036
8.5105
Mild improvement
7 (23.3%)
12 (40%)
Difference is statistically significant
Moderate improvement
15 (50%)
7 (23.3%)
Excellent improvement
5 (16.7%)
2 (6.7%)
As shown in Table 4, there is a statistically significant
improvement (p<0.05) in patients’ assessment in Group
A as compared to Group B at the end of 6 months. As
shown in Table 5, there is a statistically significant
improvement (p<0.05) in physician’s assessment in
Group A as compared to Group B at the end of 6 months.
The results of group A are shown in Figures 1A-1B and
the results of group B are shown in Figures 2A-2B which
shows that there is significant improvement in group A
patients when compared to group B patients. The side
effects encountered in Group A and Group B are shown
in Table 6.
Malhotra K et al. Int J Res Med Sci. 2020 Apr;8(4):1282-1286
International Journal of Research in Medical Sciences | April 2020 | Vol 8 | Issue 4 Page 1285
Table 6: Comparison of side effects encountered
between group A and group B.
Side effects
Microneedling with
5% minoxidil
5% minoxidil
alone
Headache
4
3
Erythema
6
2
Discomfort
over scalp
3
1
Contact
dermatitis
1
1
Hypertrichosis
1
1
Figure 1: A) Pre-treatment (group A), B) Post-
treatment (group A).
Figure 2: A) Pre-treatment (group B), B) Post-
treatment (group B).
DISCUSSION
Hair loss causes a significant psychological distress and
is often associated with low self-esteem and depression.
Male-Pattern Hair Loss (MPHL) is a very common
problem among majority of males. It may occur as early
as puberty and increases with age.5
Hair cycle alteration, miniaturization of follicles, and
inflammation are the key characteristic features of AGA.
The duration of anagen phase decreases with each cycle,
and the length of telogen remains constant or is
prolonged in patients with AGA. The duration of anagen
becomes so short that the growing hair does not achieve
sufficient length to reach the surface of the skin, leaving
an empty follicular pore.6
Minoxidil is a pyrimidine derivative which has a
chemical structure 2,4-diamino-6-piperidinipyrimidine-3-
oxyde. The history on how it was introduced as a
treatment for AGA is very interesting. Initially minoxidil
was introduced in the early 1970’s as an anti-
hypertensive agent to treat hypertension. It is a direct-
acting arteriolar vasodilator, which acts specifically to
open the potassium-channels. Minoxidil exerts its effect
after transforming into its active metabolite, minoxidil
sulphate. The enzyme called sulfotransferase, which is
found in the scalp, causes this conversion. Minoxidil
converts to its sulphate form most likely at the lower
outer root sheath.7
The exact mechanism of minoxidil stimulating the
anagen phase and promoting hair growth is not fully
known. In the late telogen phase of the hair follicle
growth cycle, stem cells located in the bulge region
differentiate and re-enter anagen phase, a period of
growth lasting 2-6 years. Studies demonstrate that
minoxidil increases the amount of intracellular Ca2+,
which in turn up-regulates the enzyme adenosine
triphosphate (ATP) synthase. A recent study
demonstrated that ATP synthase promotes stem cell
differentiation. Thus, minoxidil induced Ca2+ influx
increases stem cell differentiation and therefore plays a
key role in the facilitation of hair growth.8
Microneedling is a minimally invasive dermatological
procedure. Fine needles are rolled over the skin to
puncture the stratum corneum. This therapy induces
collagen formation, neovascularization and growth factor
production of treated areas. It has been used in a wide
range of dermatologic conditions, including Androgenetic
Alopecia (AGA) and alopecia areata, among others.9
Mechanisms of hair re-growth induced by Microneedling
include:10
Increased release of platelet derived growth factor,
epidermal growth factors by platelet activation and
skin wound regeneration.
The stem cells in the hair bulge area are activated
under wound healing conditions.
Overexpression of hair growth related genes,
vascular endothelial growth factor, B catenin, Wnt3a,
and Wnt10 b.
In this study, the side effects were slightly more among
patients on microneedling with 5% minoxidil than on
topical 5% minoxidil alone. Headache and erythema were
the most common side effects encountered. NSAIDs were
given for headache and erythema subsided gradually
within 2-3 days.
CONCLUSION
Microneedling with 5% minoxidil is a safe, simple and
cost-effective modality and is a promising treatment
option for patients with androgenetic alopecia. In this
A
A
B
B
Malhotra K et al. Int J Res Med Sci. 2020 Apr;8(4):1282-1286
International Journal of Research in Medical Sciences | April 2020 | Vol 8 | Issue 4 Page 1286
study, patients who underwent microneedling with 5%
minoxidil showed better results than those treated with
topical 5% minoxidil alone and the difference was found
to be statistically significant. Patient satisfaction rate was
high. Authors opine that Microneedling procedure should
be offered to patients with AGA along with the existing
therapeutic modalities like minoxidil for faster hair re-
growth and better patient compliance.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: The study was approved by the
Institutional Ethics Committee
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1. Gkini MA, Kouskoukis AE, Tripsianis G,
Rigopoulos D, Kouskoukis K. Study of platelet-rich
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2. Martinez-Jacobo L, Villarreal-Villarreal CD, Ortiz-
López R, Ocampo-Candiani J, Rojas-Martínez A.
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May 1;84(3):263-8.
3. Kumar MK, Inamadar AC, Palit A. A randomized
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4. Singh A, Yadav S. Microneedling: advances and
widening horizons. Ind Dermatol Onli J. 2016
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5. Wirya CT, Wu W, Wu K. Classification of male-
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Clin Aesth Dermatol. 2018 Jul;11(7):32-5.
7. Palanisamy T. Minoxidil to treat androgenetic
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it work. Am J Med Med Sci. 2014;4(6):262-5.
8. Goren A, Naccarato T, Situm M, Kovacevic M,
Lotti T, McCoy J. Mechanism of action of minoxidil
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mediated by mitochondrial adenosine triphosphate
synthase-induced stem cell differentiation. J Biolog
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9. Fertig RM, Gamret AC, Cervantes J, Tosti A.
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10. Dhurat R, Sukesh MS, Avhad G, Dandale A, Pal A,
Pund P. A randomized evaluator blinded study of
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pilot study. Intern J Trichol. 2013 Jan;5(1):6.
Cite this article as: Malhotra K, Herakal KC. Does
microneedling with 5% minoxidil offer added
advantage for treatment of androgenetic alopecia in
comparison to use of topical 5% minoxidil alone?.
Int J Res Med Sci 2020;8:1282-6.
... The percentage of satisfied patients was high also it shows improved patient's compliance and quicker hair growth. (Malhotra &Herakal, 2020) ...
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Microneedling is a minimally invasive dermatological procedure in which fine needles are rolled over the skin to puncture the stratum corneum. This therapy is used to induce collagen formation, neovascularization, and growth factor production of treated areas. It has been used in a wide range of dermatologic conditions, including androgenetic alopecia and alopecia areata, among others. While there are a limited number of studies examining this therapy in the use of hair loss, microneedling has been successfully paired with other hair growth promoting therapies, such as minoxidil, platelet rich plasma, and topical steroids, and shown to stimulate hair follicle growth. It is thought that microneedling facilitates penetration of such first line medications and this is one mechanism by which it promotes hair growth. To date, the area most studied and with the most success has been microneedling treatment of androgenetic alopecia. While the current evidence does not allow one to conclude superiority of microneedling over existing standard therapies for hair loss, microneedling shows some promise in improving hair growth, especially in combination with existing techniques. This review summarizes the current literature regarding microneedling in the treatment of alopecia and calls for further studies to refine a standard treatment protocol.
Article
Male-pattern hair loss (MPHL) is a condition that affects the majority of men during adulthood. This condition is not life threatening but needs constant treatment and monitoring, especially in recent years where male appearance is gaining significant importance in society. An ideal classification with high amount of detail, practicality, and reproducibility is required to accurately diagnose and monitor this condition regularly and to assess the outcome of treatment. Numerous classifications have been invented, but many variants with different levels of detail, practicality, and reproducibility may cause confusion among clinicians. One clinician may not accurately able to convey accurate clinical description if different classifications are used. To avoid confusion, a new classification that can balance detail, practicality, and reproducibility is required. We hope that this will translate to better treatment and monitoring for patients. This review article aims to review different existing MPHL classifications and how it compares to each other in terms of detail, practicality, and reproducibility. © 2017 International Journal of Trichology Published by Wolters Kluwer-Medknow.
Minoxidil to treat androgenetic alopecia in men and women: what is it & how does it work
  • T Palanisamy
Palanisamy T. Minoxidil to treat androgenetic alopecia in men and women: what is it & how does it work. Am J Med Med Sci. 2014;4(6):262-5.