Do steroid injections help or hinder donor scar healing?

[Carlos Wesley, MD]

An article, recently accepted for publication by The Journal of Dermatological Treatment may help bring our field closer to answering the question "Do steroid injections help or hurt the wound healing process?" Carlos K. Wesley, M.D. served as the primary author of this investigation.

The single-center, prospective, randomized, controlled, single-blind study involved 57 patients that were undergoing hair restoration surgery in our clinic. The objective was to determine if injecting a corticosteroid called triamcinolone acetonide (TMC) would affect the early stages of wound healing in the patients' donor area. He used a Folliscope (magnified focused camera we use for detailed follicle analysis) to precisely measure the distance between the donor wound edges both at the time of surgery (once the donor had been closed) and again at the time of suture removal (8-10 days later).

While no statistically-significant effect on the donor wound edge apposition was revealed we did observe a trend: the administration of injected steroids appeared to help this early-phase healing in patients with minimal closing tension (e.g. much scalp laxity) and hinder this early-phase healing in patients with tight closures (e.g. no scalp laxity).

[DepressedByHairLoss]

I always wondered if steroid injections could stimulate hair regrowth WITHOUT a hair transplant. I know that they can work in patients with alopecia areata by suppressing the immune system from attacking the hair follicle, but I always wondered if they could be used as a stand-alone treatment to stimulate the dormant hair follicles in people suffering from androgenetic alopecia.

[gillenator]

We need more research on this subject. Anything that can improve healing and/or improve scar appearances would potentially help many patients seeking resolve.

[Carlos Wesley, MD]

It's an interesting idea, DepressedByHairLoss. And, wouldn't THAT make life wonderfully simple!

It's generally believed, as you mentioned, that corticosteriod injections are effective when they are blunting a body's overactive immune response. That's not believed to be the mechanism behind andogenetic alopecia (AGA) in men. Now, in women with hair loss it can be a bit more nebulous. Some physicians believe the local immune response on the hair follicle plays a much greater role in female pattern hair loss (AGA). Other women present with very subtle findings on their scalp examination that suggest an inflammatory component is involved in their rather diffuse hair loss. Those patients, rather than injections, may benefit from a topical application of corticosteroids (clobetasol cream) on a nightly basis for a stretch.

For gillenator and anyone else who's interested in reading the findings from our study on corticosteriods' impact on early-phase donor wound healing, here's a link to the manuscript:

http://informahealthcare.com/doi/abs/10.3109/09546634.2012.755253

[35YrsAfter]

While no statistically-significant effect on the donor wound edge apposition was revealed we did observe a trend: the administration of injected steroids appeared to help this early-phase healing in patients with minimal closing tension (e.g. much scalp laxity) and hinder this early-phase healing in patients with tight closures (e.g. no scalp laxity).

Is that because steroid injection reduces swelling and therefore tension, decreasing the likelihood of a stretched scar down the road? If memory serves me, Dr. Cole mentioned to me that he does not observe strip scar changes until about 3 months post-op.

CITNews works at Dr. Cole's office

[northeastguy]

This is quite interesting.... I'm going to venture and say there is an enormous amount of folks including myself who would like to see a study done on the impact steroid injections make on a mature scar.

[John P. Cole, MD]

You are not going to find any benefit from using steroids in the appearance of a strip scar. Steroids have been used systemically in hair restoration surgery for well over 20 years with no benefit what so ever on the strip scar. Strip scars do not widen until the 3rd month so an 8 day study is completely worthless. Of course, if you follow your patients out to 3 months and then 6 months, then you can come to a conclusion. That conclusion will be that they provide no benefit what so ever. I think many strip physicians would like to think that there is a way to avoid unsightly strip scars, but the bottom line always remains the same. Strip scars are a function of individual patient healing and/or poor physician technique. Steroids are not going to have an impact on either cause.

Of note is that we use steroids locally in our tumescent solution to help minimize post operative edema. This edema works its way out of the area quickly due to gravity. While the steroids can help minimize edema in the anterior scalp, edema is never an issue in the posterior scalp. Yes, we also use the same tumescent fluid in our donor area.

ONe does need to be highly careful with injecting steroids in the donor area because they can cause fat atrophy and depressions in the donor area. In order to avoid this, you must minimize the concentration of the steroid.

Pro-inflamatory agents actually stimulate hair growth. This is probably why you can occasionally see enlarged follicles adjacent to strip scars.

i don't think you are going to find anyone treating female pattern hair loss with steroids either. Maybe forms of scarring alopecia, but not female pattern loss.

[Dan26]

i read something about a method/device that closes wounds with no scarring...cant remember what it was, and it obviously is not out/widely-used....does anyone know what im talking about? will try to find out what it was lol

[John P. Cole, MD]

Dan, I wish. If you find it, let me know.

[Carlos Wesley, MD]

Thanks, 35YrsAfter, for your question. That's the fundamental question that this study set out to investigate: steroids' benefit of swelling reduction versus their potential inhibition of wound healing.

Rather than simply dismissing a valid question as worthless. Our office has taken the time to investigate the true effect of local corticosteroid injections on donor wound edge apposition. As Dr. Cole mentioned, there are certainly potential risks to corticosteroid injections in the donor area (wound dehiscence, etc.). These were not observed in our study that focused on early-phase wound edge apposition. It's also true that a more long-term investigation will yield more information regarding this question. I, along with its co-authors Drs. Walter and Robin Unger, plan to perform this subsequent study to shed light on this topic.

[Dan26]

Thanks, 35YrsAfter, for your question. That's the fundamental question that this study set out to investigate: steroids' benefit of swelling reduction versus their potential inhibition of wound healing.

Rather than simply dismissing a valid question as worthless. Our office has taken the time to investigate the true effect of local corticosteroid injections on donor wound edge apposition. As Dr. Cole mentioned, there are certainly potential risks to corticosteroid injections in the donor area (wound dehiscence, etc.). These were not observed in our study that focused on early-phase wound edge apposition. It's also true that a more long-term investigation will yield more information regarding this question. I, along with its co-authors Drs. Walter and Robin Unger, plan to perform this subsequent study to shed light on this topic.

What about a combination of a corticosteroid with something such as calcipitriol? Which reduces some of the skin atrophy/thinning effects of the steroid. And it is great for reduction of inflammation and perhaps even elevated dermal factors ie. pdg2

[Dan26]

I always wondered if steroid injections could stimulate hair regrowth WITHOUT a hair transplant. I know that they can work in patients with alopecia areata by suppressing the immune system from attacking the hair follicle, but I always wondered if they could be used as a stand-alone treatment to stimulate the dormant hair follicles in people suffering from androgenetic alopecia.

I believe there on some regrowth properties of certain steroid-based compounds in conjunction with other ant-inflammatory compounds. Either way, fighting inflammation is a key component of hair loss. I read a study that compared betamethasone, tacrolimus, and calcipitriol, as well as all those three compounds paired with one another. There were certainly some positive benefits.

[J_B_Davis]

It's good to see some real studies being conducted on this stuff Dr. Wesley. Thank you for sharing this. I have to question why doctor Cole and his staff work so hard on the forums to discredit other techniques? It's a little low brow if you ask me.

[John P. Cole, MD]

If you are looking at the 8 day mark, then your efforts really are worthless because strips look about the same right up to the about the 3rd month. If you were looking at the 8 day mark only to show that the strip wound did not go all to hell, then I guess you showed it. If you take it to 3 months, i doubt you will see any difference, but you really should do this especially given that you've already taken the time to do this much work. Hey, you are doing a study. That's more than most people do. I'd love to eat crow on this one and have you find that the procedure produces a benefit, but I'm certain that I will not.

i think my concern is that studies suggesting benefits from strip surgery might induce an individual into a strip with steroid injections due to a false sense of hope that his scar will be less visible. i think it is much better to do the study and then report the results because it seems like a you are anticipating a benefit before you get one.

Follow up your patients and report your results. It will be interesting even if you report scar width by month. Other than Beehner, Perez, and my studies, i'm not aware of any other studies looking at strip width by month. That alone will be of interest.

Actually, inflammation is probably a good thing especially in the recipient area. We should probably be looking to eliminate steroids rather than use more of them. PRP induces inflammation especially when the granulocyte count is high. I don't think you necessarily need a high granulocyte count to induce hair growth from PRP, but this would be a far more interesting study and one that you should consider. Look at a variable platelet concentration and a variable graunulocyte concentration with and without steroids for evidence of improved hair diameter, pigmentation, and rate of growth in the recipient area. That' s a steroid study that has legs.

[John P. Cole, MD]

By the way, I like physicians who do studies and evaluate patient results. These are the guys who are paying attention to their results. It is those who pay attention to their results that recognize their mistakes. The first step in correcting one's mistakes is recognizing them. I've made plenty of mistakes over the years and always done my best to correct them. Of course, one of my greatest mistakes was listening to my peers and mentors about what was in the best interest of my patient. I soon learned to stop listening to them and start listening to my eyes. That's why i don't mind going toe to toe with anyone who promotes strip procedures as a predominate practice.