International Journal of Physiotherapy and Research,

Int J Physiother Res 2014, Vol 2(2):460-65. ISSN 2321-1822

Original Article
EFFICACY OF LOW LEVEL LASER THERAPY IN THE TREATMENT OF
ALOPECIA AREATA
*#
Nermeen Mohamed Abdelhalim. PhD PT
*
Physical Therapy Department, New Kasr El-Aini Teaching Hospital, Faculty of Medicine, Cairo University,
Egypt.
#
Physical Therapy and Health Rehabilitation Department, College of Applied Medical Sciences,
Salman bin Abdulaziz University, Saudi Arabia.
ABSTRACT
Background: Alopecia areata is a chronic inflammatory disease which affects the hair follicles and sometimes
the nails.
Purpose: The purpose of this study was to evaluate the efficacy of low level laser therapy in the treatment of
alopecia areata of the scalp.
Method: Twenty three patients (14 male and 9 female) had 2 or more patches of the scalp, one patch was left
for comparison as a control patches. The age ranged from 22 to 39 years with 30 ± 6.09 years mean. The study
patches received12 sessions of low level laser therapy for 2 minutes/cm² of the affected patch with the dose of
1.5 J/cm². Each subject received 3 sessions per week for one month. Hair count, the hairs number within the
one square centimeter space and Visual analog scale of hair loss were assessed pre-treatment, post-treatment
and follow-up time (2 months).
Results: showed significant improvement in the two outcomes of study patches (p < 0.05) with non-significant
improvement of control patches ( p > 0.05).
Conclusion: Using low level laser therapy was effective in the treatment of alopecia areata of the scalp.
KEYWORDS: Low Level Laser Therapy, Alopecia Areata.
Address for correspondence: Dr. Nermeen Mohamed Abdelhalim, PhD PT, Physical Therapy Department, New Kasr
El-Aini Teaching Hospital, Faculty of Medicine, Cairo University, Egypt. And also Physical Therapy and Health
Rehabilitation Department, College of Applied Medical Sciences, Salman bin Abdulaziz University, Saudi Arabia.
E-Mail: [email protected]

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ISSN 2321- 1822
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Received: 03-03-2014 Accepted: 18-03-2014
Peer Review: 03-03-2014 Published: 11-04-2014
INTRODUCTION cell-mediated immune reaction in AA. There is
Alopecia areata (AA) is a common disease of non- an increased suppressor T-cell function in
scarring alopecia including the scalp and/or body, patients experiencing hair regrowth. 3
characterized by hair loss without any clinical Alopecia areata usually presents as patches of
inflammatory signs. It is one of the most hair loss on the scalp but any hair-bearing skin
common form of hair loss seen by can be affected. The involved skin may be slightly
dermatologists and accounts for 25% of all the reddened but otherwise appears normal. Short
alopecia cases.1 Both males and females are broken hairs (exclamation mark hairs) are
equally affected and it can occur at any age, the frequently seen around the edges of expanding
highest prevalence age was between 30-59 patches of alopecia areata. The nails are affected
years. 2 in about 10% of patients referred for specialist
The etiology of AA is attributed to an advice.4 It may present as single or multiple
autoimmune process, which may be modified by patches. Small distinct patches may merge and
genetic factors and aggravated by emotional form larger patches. Scalp is the most common
stress. Many studies have reported an abnormal site (90%). Alopecia areata can be classified
Int J Physiother Res 2014;2(2):460-65. ISSN 2321-1822 460
 Nermeen Mohamed Abdelhalim. PhD PT, EFFICACY OF LOW LEVEL LASER THERAPY IN THE TREATMENT OF ALOPECIA AREATA.

depending on extent and pattern of hair loss.5 of low level laser therapy (LLLT) in the treatment
Alopecic patches or plaques of varying size and of alopecia areata (AA) of the scalp.
number on the scalp (whether as a single patch MATERIALS AND METHODS
or multiple ones) is the most common, other Sample of this self-study clinical research was
clinical presentations such as alopecia totalis based on 22-39 year’s male and female subjects
(hair loss from the entire scalp), alopecia (14 male and 9 female) had 2 or more alopecia
universalis (loss of body hair as well), ophiasic areata of the scalp (2-4 affected area). This study
AA (pattern of hair loss affecting the was performed over the period from May to
frontoparietal, temporal, and occipital regions), September 2013 at the physiotherapy
sisaipho AA (hair loss affecting the entire scalp department of New Kasr El-Aini Teaching
except the peripheral ring), reticular AA Hospital, Cairo University, Egypt.
(numerous patches of hair loss on the scalp with
areas of hair remaining in between), alopecia Subjects were met the following inclusive
diffusa (acute and generalized hair loss, which criteria, which are years between 20 and 40
may be hard to diagnose).6 years old and clinically diagnosed as alopecia
areata (AA) which was manifested as the hair loss
The diagnosis of AA may include: fungal culture, in well-circumscribed patches of normal-
skin biopsy, serology for lupus erythematosus, appearing skin, most commonly on the scalp (2
and serology for syphilis. The high frequency of or more patches of the scalp). Exclusion criteria
autoimmune disease in patients with alopecia consisted of any patient suffering from AA in eye
areata is probably insufficient to justify routine brow, beard, and moustache, patients who had
screening.4 used topical, intralesional, or systemic therapies
There are two principal treatment options: the for AA, had no visual evidence of new hair
use of an immunosuppressive regimen growth within the last 6 months or who had hair
(preferable for patients with acute and rapidly disorders other than AA or systemic diseases
progressing alopecia areata) or an immune- that might affect the results, patients with
deviation strategy that manipulates the history hair loss less than 6 months. In addition,
intracutaneous inflammatory milieu (favored for patients were not permitted to enter the study
patients with the chronic, relapsing form).7 if they were pregnant or lactating; had a history
Potent topical glucocorticoids are also widely of uncontrolled bacterial, viral, fungal, atypical
used, especially in children and in adults with less mycobacterial, or opportunistic infection (eg,
than 50% loss of scalp hair. High-potency topical systemic fungal infections or parasites); had
glucocorticoids with occlusive dressings are most significant pulmonary or cardiovascular disease,
effective and lead to improvement in more than a history of active tuberculosis (TB) or currently
25% of involved patients; however, undergoing treatment for TB, liver disease or
glucocorticoid-induced folliculitis is a common abnormal hepatic function. Patient with history
adverse effect. 8 of LLLT in their previous treatment and inability
Low-level laser therapy (LLLT) has been studied to comply with treatment requirements were
and used for the treatment of a variety of clinical also excluded.
indications including pain management, wound The dependant and outcome variable were hair
healing, and recently to enhance hair regrowth. count and visual analogue scale (VAS) of hair loss
Each of these applications is based on the (0 representing no hair loss and 100 indicating
principles of photobiomodulation which have total hair loss). The independent variable was
demonstrated biological effects in living low level laser therapy (LLLT) on the scalp.
organisms.9 LLLT has been used to treat patches Procedure
of AA with variable success rates10, most studies
The subjects were assessed and informed
agree that LLLT is safe for the treatment of hair
consent with ethical approval was taken.
loss, but more studies are needed to confirm its
therapeutic effects. 11 Patients had multiple patches; one patch was left
for comparison as control patches. Outcomes
The present study is designed to find the efficacy
measures were performed pre-treatment, post-
Int J Physiother Res 2014;2(2):460-65. ISSN 2321-1822 461
 Nermeen Mohamed Abdelhalim. PhD PT, EFFICACY OF LOW LEVEL LASER THERAPY IN THE TREATMENT OF ALOPECIA AREATA.

treatment (one month) and follow-up time (2 in contact with the skin of the treated area.
months after last session). Baseline demographic Subjects were advised not to use any other
variables include age, gender and number of treatment modality during laser therapy, and 2
patches carried out. Two criteria were used to months after the last session (follow-up time).
evaluate the outcome of the study. First, hair All Subjects were assessed every session for any
count, the hairs number within the one square adverse effects such as itching, erythema and
centimeter space (marked with a medical tattoo scaling.
using green ink using aseptic technique) were Data analysis
pulled and counted using a surgical skin hook and All statistics were calculated by using the statis-
a lens with five times magnification (hair counts tical package of social sciences (SPSS) version 16.
were carried out two times to confirm the Descriptive statistics (mean and standard devia-
accuracy of the data). 12 Second, Visual analog tion) were computed for all data. A repeated
scale (VAS) of hair loss. A VAS is quantifiable and measure ANOVA with a Green-Geisser correc-
easy for the patient to understand and use. In tion was applied within the group for hair count
the present study using a 100 mm VAS, with 0 and VAS of hair loss. Post hoc tests using the
representing no hair loss and 100 indicating total Bonferroni correction was applied within group
hair loss. Negative values indicate hair loss and for hair count and VAS to determine the signifi-
positive values indicate hair regrowth compared cance difference between repeated measures.
to baseline.13 Unpaired t- test was applied for hair count and
This study included 52 resistant patches (patches VAS of hair loss between study and control
had not responded to different modalities of patches.
treatment) from 23 patients suffering from AA RESULTS AND TABLES
in the scalp. All patients had multiple patches
(2-4 patches), one patch was left for comparison The mean age of the subjects was 30 ± 6.09
as a control patches (23 patches). Twenty nine years. The mean of number of patches of the
patches of AA of the scalp as a study areas were subjects was 2.26 ± 0.54.
subjected to be treated by LLLT application, 14 The mean changes in hair count of study patches
(ENDOLASER 422 – Enraf-Norius®, Netherland), and control patches are summarized in table 1.
subjects were comfort­ably seated in an There was a statistically significant difference
adjustable chair with back support and feet on between time points (F= 128.05, P<0.004) in
the floor and wore protective goggles (Endolaser study patches. Post hoc tests using the
422-Extra quality) to protect their eyes from the Bonferroni correction revealed that a high
hazards of laser therapy. The areas of skin to be improvement in hair count from pre-treatment,
treated of the scalp were cleaned with soap and post-treatment, and follow-up time (18.79±8.84,
water. The procedure consisted of 12 sessions 37.93±16.48, 41.48±17.3, respectively) where
of LLLT for 2 minutes/cm² of the affected patch P<0.001 existed between three time points. The
with the dose of 1.5 J/cm². Each subject received mean changes of hair count in control patches
3 sessions per week (day after day) for one weren’t statistically significant difference
month. The total time of session was changed between time points (F= 0.468, P>0.004).
from one subject to another according to the size Comparison revealed that there were no
of each patch. The laser used to treat the patches significant differences in mean changes for hair
was a low-level invisible pulsed infrared diode count pre-treatment between study patches
laser (905 nm) wavelength and (5000 Hz) and control patches (P>0.05) on the other hand,
frequency with a peak power of 100 W. The there were a significant differences in mean
treatment technique was carried out by multiple changes post-treatment and follow-up time
application of the LLLT in a series of circles in between study patches and control patches
close contact with each other toward the center (P<0.05).
until the total area of the patch was treated. The The mean changes in VAS of hair loss of study
laser probe is 100 mW, pulsed laser diode (LP patches and control patches are summarized in
100) with peak power of 100 W. The probe was Table 2. There was a statistically significant
Int J Physiother Res 2014;2(2):460-65. ISSN 2321-1822 462
 Nermeen Mohamed Abdelhalim. PhD PT, EFFICACY OF LOW LEVEL LASER THERAPY IN THE TREATMENT OF ALOPECIA AREATA.

difference between time points (F= 148.69, study and control patches.
P<0.004) in study patches. Post hoc tests using Fig.1: Hair count pre-treatment, post-treatment and
the Bonferroni correction revealed that a high follow-up time between study and control patches.
reduction in VAS of hair loss in target patches
when comparing pre-treatment and post-treat-
ment (87.79±7.64, 40.94±26.92, respectively)
where P < 0.005. There was a significant reduc-
tion in VAS of hair loss when comparing
pre-treatment and follow-up time (87.79±7.64,
26.1±31.33, respectively) where P < 0.003. Also,
between post-treatment and follow-up time
there was also a significant difference revealed
reduction in VAS of hair loss (40.94±26.92, Fig.2: VAS of hair loss pre-treatment, post-treatment and
26.1±31.33, respectively) where P <0.003. The follow-up time between study and control patches.
mean changes in VAS of hair loss of control
patches weren’t statistically significant differ-
ence between time points (F= 1.167, P>0.004).
Comparison revealed that there were no signifi-
cant differences in mean changes for VAS of hair
loss pre-treatment between study patches and
control patches(P>0.05) on the other hand,
there were a significant differences in mean
changes post-treatment and follow-up time
between study patches and control patches DISCUSSION
(P<0.05). This study was carried out to examine the
Table 1: Hair count pre-treatment, post-treatment and efficacy of low level laser therapy (LLLT) in the
follow-up time between study and control patches.
treatment of alopecia areata (AA) of the scalp.
Study patches Control patches Loss of hair from the head and body is known as
Time of evaluation alopecia, sometimes resulting in baldness. When
Mean ± SD Mean ± SD P- value
hair loss occurs in only one section, it is known
Pre-treatment 18.79 ± 8.84 19.08 ± 7.62 0.871 as alopecia areata. This is the most common
Post-treatment 37.93 ± 16.48 19.39 ± 8.03 0.001 form of the disease and is associated with a
Follow-up 41.48 ± 17.3 19.69 ± 9.01 0.001 sudden loss of hair, causing patches to appear
P- value 0.001 0.051 on either the scalp or other bodily areas such as
Table 2: VAS of hair loss pre-treatment, post-treatment eyebrow, beard and moustache.15
and follow-up time between study and control patches. Hair count is an appropriate and objective tool
Study patches Control patches in the evaluation of hair growth. In study by
Time of evaluation Satino and Markou, hair count approach was
Mean ± SD Mean ± SD P- value
used for evaluation of hair growth after LLLT
Pre-treatment 87.79 ± 7.64 89.78 ± 7.14 0.761 using a Hair-Max LaserComb. Number of hair
Post-treatment 40.94 ± 26.92 88.82 ± 8.07 0.001 was estimated within one cm² using a surgical
Follow-up 26.1 ± 31.33 88.52 ± 9.75 0.001 skin hook and lens with 5 times magnification.12
VAS is the simplest method of subjective
P- value 0.001 0.303 evaluation of alopecia. There are two different
Fig.1 demonstrates the mean values difference methods to use VAS in alopecia. First method in
of hair count pre-treatment, post-treatment and the trial of subcutaneous efalizumab is not
follow-up time between study and control effective in treatment of alopecia areata by Price
patches and Fig. 2 demonstrates the mean val- et al who applied a 100 mm VAS, with 0
ues difference of VAS of hair loss pre-treatment, representing no hair loss and 100 indicating total
post-treatment and follow-up time between hair loss.13 The second method in study of oral
Int J Physiother Res 2014;2(2):460-65. ISSN 2321-1822 463
 Nermeen Mohamed Abdelhalim. PhD PT, EFFICACY OF LOW LEVEL LASER THERAPY IN THE TREATMENT OF ALOPECIA AREATA.

finasteride improved the quality of life of wavelength and (5000 Hz) frequency with a peak
androgenetic alopecia patients by Yamazaki et power of 100 W, was used to treat AA of the
al who applied VAS by patients to rate their level scalp. The data analysis revealed that study
of satisfaction with the condition of their hair patches (n=29) which received LLLT showed
on a scale 0% (totally dissatisfied) to 100% highly significant improvement in hair count, VAS
(totally satisfied).16 In the present study the first of hair loss pre-treatment ,post-treatment, and
methods was applied by patients to determine follow-up time. On the other hand the data
their improvement in hair growth. analysis of the control patches (n=23) which left
The application of LLLT is a well known tool in without treatment for comparison showed non-
physical therapy and other fields as its biological significant improvement in the same two
effects are widely reported, including anti- parameters. Moreover the analysis revealed that
inflammation, pain reduction, wound healing, LLLT elicited a high improvement in hair count
anti-edema, antibiosis, immunity and local blood and highly reducing in VAS of hair loss in follow-
circulation improvement.17 The theory of LLLT at up time (after 2 months), therefore, LLLT had a
wavelengths in the red range affects the long lasting effect on hair growth.
functioning of the stem cells that cause hair In this study, wavelength of laser used was
growth. LLLT activates cytochrome c oxidase and (905nm) which was of prime importance for
enhances mitochondrial electron transport 18, producing an effect on a specific molecule.
which leads to an increase in ATP (adenosine Researchers suggested that even though they
triphosphatase) and subsequent reversal of hair did not know the actual effect of LLLT in
follicles from the dormant telogen stage of increasing hair follicles and tensile strength, it
growth, to the active growth or anagen stage.19,20 was agreed that one or more factors among
There were many previous studies using a improved micro-vascular circulation, reduced
variety of light sources, wavelengths, and inflammation and increased cell energy in the
treatment parameters for the treatment of AA form of ATP worked together.23 The patients of
with LLLT. In study by Gundogan et al reported the present study reported that laser was an
that 2 cases of AA showing homogenous and effective therapy without any side effects and
thick regrowth of hair after 11–12 treatment the hair remained to grow after completion of
sessions with the 308 xenon chloride excimer treatment which gave a long lasting effect of LLLT
laser and explained this as a result of the in hair regrowth. The control patches which left
immunosuppressive action of the excimer laser for comparison were applied to LLLT as in study
which may induce T-cell apoptosis.21 Yamazaki patches after the end of the study to get the
et al used linear polarized infrared irradiation in benefit from the procedure.
treatment of AA, a study was conducted with AA of the scalp is a common disease of hair
15 patients (6 men, 9 women) using Super follicle that leads to a potentially revisable type
LizerTM, a medical instrument emitting polarized of hair loss. In the present study, more than one
pulsed linear light with a high output (1.8W) of method of evaluation was used to confirm
infrared radiation (600–1,600nm) , they findings definite efficacy of LLLT in treatment of
concluded that LLLT accelerates the process of AA and regrowth of hair. Left control patches
hair regrowth in AA patients.22 Waiz et al used without treatment for comparison was non-
pulsed infrared diode laser (904 nm) in the significant improvement, but use of LLLT in study
treatment of alopecia areata, which gives high patches gave a significant improvement with
local energy with less heat. That means LLLT can long lasting effect.
give sufficient energy and during a pulse does CONCLUSION
not raise the temperature because heat The present study shows the efficacy of low level
dissipates between the pulses so there is no heat laser therapy in treatment of alopecia areata of
build-up but it can influence the molecules which the scalp. There were greater improvement in
play an important role in treatment of AA.14 hair count and reducing visual analogue scale of
In the present study patients received low-level hair loss in study patches underwent LLLT com-
invisible pulsed infrared diode laser (905 nm) pared to control patches.
Int J Physiother Res 2014;2(2):460-65. ISSN 2321-1822 464
 Nermeen Mohamed Abdelhalim. PhD PT, EFFICACY OF LOW LEVEL LASER THERAPY IN THE TREATMENT OF ALOPECIA AREATA.

List of abbreviations : 11. Ghanaat M: Types of Hair Loss and Treatment

AA Alopecia areata Options, Including the Novel Low-Level Light
ANOVA Analysis of Variance Therapy and Its Proposed Mechanism. Southern
ATP Adenosine triphosphatase Medical Journal 2010; 103(9):917-921.
Hz Hertz 12. Satino JL and Markou M: Hair Regrowth and
J/cm² Joule per square centimeter Increased Hair Tensile Strength Using the HairMax
LLLT Low-level laser therapy
LaserComb for Low-Level Laser Therapy.
LP pulsed laser diode
International Journal of Cosmetic Surgery and
Aesthetic Dermatology 2003; 5(2): 113-117.
mW milliWatt
13. Price VH, Hordinsky MK, Olsen EA et al:
n Number
Subcutaneous efalizumab is not effective in the
nm Nanometer
treatment of alopecia areata. J Am Acad Dermatol
P-value Probability
2008; 58: 395-402.
SD Standard Deviation 14. Waiz M, Saleh AZ, Hayani R, Jubory SO: Use of the
Statistical Package of Social pulsed infrared diode laser (904 nm) in the
SPSS
Sciences
treatment of alopecia areata. Journal of Cosmetic
TB Tuberculosis
and Laser Therapy 2006; 8: 27-30.
T-cells Transmission cells
15. Wei Q, Hwang DG, Ud Din ZM, Cho JH: Development
VAS Visual Analogue Scale
of a Portable Drug Delivery System using
W Watt
Iontophoresis for Alopecia Treatment. Applied
Conflicts of interest: None Mechanics and Materials Vols. 2011; 110-116:
2010-2014.
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How to cite this article:

Nermeen Mohamed Abdelhalim. PhD PT, EFFICACY OF LOW LEVEL LASER THERAPY
IN THE TREATMENT OF ALOPECIA AREATA. Int J Physiother Res 2014;2(2):460-65.

Int J Physiother Res 2014;2(2):460-65. ISSN 2321-1822 465