What are steroid injections?
Steroid injections, when used in the context of hair loss treatment, refer to injections in the scalp using a group of medications known as 'corticosteroids.' Although confusion frequently exists when the term steroid is used, corticosteroids are very different than other steroids such as 'anabolic steroids' used by some for increasing muscle mass. There are several corticosteroids that can be used for injecting the scalp, but the most common is triamcinolone acetonide. Triamcinolone hexacetonide is another example. Corticosteroids are used to reduce inflammation.
Can corticosteroids be used for treating androgenetic alopecia?
Corticosteroids are not commonly used in treating androgenetic alopecia. That's not to say I never use them, but first I'll address why they are not commonly used, followed by situations that I might used them. Finally, I'll address the risks that must be taken into account before cortisteroids are used in the injectable form.
Why aren't steroid injections a main treatment for androgenetic alopecia ?
Androgenetic alopecia has a complex pathogenesis. In part, we don't fully understand what causes androgenetic alopecia. In men, it's clear that hormones such as dihydrotestosterone (DHT) are important but even this doesn't explain everything. In women, DHT and male type hormones are less important than in men, but clearly they have a role too.
Inflammation in the scalp does occur in some patients with androgenetic alopecia. For years, it has been thought this was simply due to yeast in the scalp or some other unrelated cause. Now, it's clear that inflammation is a part of they way some people's androgenetic alopecia develops. In fact, those individuals showing inflammation in the scalp respond less well to minoxidil therapy - meaning that this inflammation is somehow relevant. I've reviewed this in previous blog articles.
Is there any use for steroid injections for androgenetic alopecia?
I rarely use steroid injections for treating androgenetic alopecia. I use steroid injections frequently when treating alopecia areata, and scarring alopecias. But not so commonly in androgenetic alopecia. But that's not to say there is no role for corticosteroids.
In fact, increasingly, I'm using corticosteroid lotions and shampoos when treating androgenetic alopecia. I'm adding triamcinolone into many of my prescriptions for minoxidil. Increasingly I'm adding corticosteroid based shampoos (i.e. Clobetasol shampoo) to the treating plans for my patients. Less frequently I'll use steroid injections. When I do use these treatments, I sometimes even use a corticosteroid periodically with other anti-inflammatory treatments such as oral doxycycline.
The rationale behind the use of corticosteroids (and oral doxycycline) in treating androgenetic alopecia is to shut down the inflammation beneath the scalp that may have some relevance to how the androgenetic alopecia progresses or how the hair loss responds to treatment.
Frequently I will use a corticosteroid if:
1. the patient has scalp erythema (redness) that does not respond to anti-dandruff shampoos
2. the patient has increased daily shedding that persists despite effective treatment for the androgenetic alopecia
3. the patient has trichodynia or scalp symptoms that persist despite effective treatment for the androgenetic alopecia
What are the risks of steroid injections? Can they worsen hair loss?
Any treatment for hair loss comes with its own inherent set of risks and benefits. Risks must always be discussed in terms of the chances of risks versus the chance of benefit. Here are a few important considerations when steroids are used for androgenetic alopecia (AGA). Because the topic is actually quite involved, patients need to discuss these issues with their physicians in depth to gain a complete and full understanding of the risks and benefits.
1. Steroid injections can cause atrophy (thinning) of the skin.
Anyone receiving steroid injections for any condition needs to be aware that such injections can cause thinning of the skin. Short term, even a single injection can cause a dimple or indentation in the skin to form. Fortunately, these indentations are usually short term and over time the skin returns to normal (provided no further injections are given). The chance of an indentation is very much dependent on the dose of steroid the physician uses. Triamcinolone acetonide 10 mg per mL is quite likely to cause an indentation whereas 2.5 is much less likely to cause an indentation.
2. Steroid injections can cause shedding, both short term and long term, in some patients.
Corticosteroids can cause hairs to shed. We call this telogen effluvium. This phenomenon is not common but is seen with both oral corticosteroids, injectable and even topical steroids. For most the shedding is temporary and hair cycling returns to normal over 6 months. However, anytime shedding develops, one needs to be aware of the possibility of chronic shedding - even when no further injections are given.
3. Steroid injections can cause circular patches of hair loss in some patients
As surprising as it sounds, steroid injections can cause shedding to occur in the areas where the steroids are injected or the hair loss can occur diffusely over the scalp. When the shedding occurs locally (in the area where it is injected), the scalp can take on a look very much like the autoimmune condition called alopecia areata. In fact, it's not uncommon for a patient who is injected with steroids "just to see what happens" end up in my office out of concern that the patient has developed alopecia areata.
4. Steroid injections can damage tiny miniaturizing hairs and worsen hair loss
An additional risk to injections in the scalp, be that steroid injections or injections of platelet rich plasma - is that sometimes the tiny thin miniaturizing hairs that are so typical of androgenetic alopecia get damaged by the steroid injections. If hairs are small enough, these can be damaged and not regrow again. Hairs that are thin can regrow again if damaged. However, the next time they grow, they may come in every skinnier (thinner) than previous. This leads to a perception of further hair loss. In fact, anybody with androgenetic alopecia must limit all triggers of hair shedding.
If you had of asked me 5 years ago if I ever use steroid injections in treating androgenetic alopecia, I would have probably said never. If you ask me now I would modify that answer slightly to say 'rarely.' I do however, use corticosteroid shampoos and lotions from time to time. There are situations where the inflammation beneath the scalp is of concern to me and situations where I feel getting rid of this inflammation is probably a good idea. I target this inflammation first with anti-dandruff shampoos (ketoconazole, zinc pyrithione and selenium sulphide) and sometimes move on to consider topical steroids. If a steroid is used, my preference is topical steroids over steroid injections as the side effects above are even less common. Only rarely will I used steroid injections.