Journal of Drugs in Dermatology (JDD)

Examining the Potential for Koebnerization and

Disease Precipitation in Cicatricial Alopecias
January 2023 | Volume 22 | Issue 1 | 29 | Copyright © January 2023

Published online December 31, 2022

Lauren Fried MD , Melissa R. Laughter MD PhD , Katerina Svigos MD , Avani

a* b* a

M. Kolla MD , Daniel Gutierrez MD , Jerry Shapiro MD , Prince Adotama MD ,

a a a* a**

Kristen Lo Sicco MD a**

The Ronald O. Perelman Department of Dermatology, New York University

a

Grossman School of Medicine, New York, NY

University of Colorado Denver School of Medicine, Aurora, CO
b

ABSTRACT
The treatment of primary scarring alopecias is challenging and patients may be susceptible
to koebnerization. This predisposes cicatricial alopecia patients to worsening of their
disease following procedural treatments or interventions. Research and recommendations
surrounding the risk for koebnerization within scarring alopecias is extremely limited. Using
a comprehensive literature review, we summarized the risks of procedures in potentially
koebnerizing alopecias. We evaluated the risk not only with procedural treatments, but also
with common elective cosmetic procedures and potentially trauma-inducing hairstyling
techniques. Although additional studies are needed to better elucidate the risks of
procedural treatments within primary scarring alopecia, we believe this review of the current
evidence and expert insight will benefit healthcare providers and patients alike to help
guide treatments in this challenging patient population.

J Drugs Dermatol. 2023;22(1):29-34. doi:10.36849/JDD.6849

Citation: Fried L, Laughter M, Svigos K, et al. Examining the potential for

koebnerization and disease precipitation in cicatricial alopecias. J Drugs
Dermatol. 2023;22(1):29-34. doi: 10.36849/JDD.6849.

INTRODUCTION
Alopecias can be broadly categorized as scarring (cicatricial) or non-scarring. Some
primary scarring alopecias may be susceptible to the appearance of new lesions in
previously uninvolved areas following trauma, known as koebnerization, the Koebner
phenomenon, or an isomorphic reaction. Treatments for scarring alopecias vary by
1

diagnosis and include topical, intralesional, systemic, and surgical therapies. Given the
procedural nature of many of these interventions and an underlying predisposition towards
koebnerization, there may be concern for disease exacerbation. Furthermore, risk of
koebnerization may be observed following face or scalp interventions, including elective
cosmetic procedures or trauma-inducing hairstyling techniques.
Herein, we summarize the literature regarding risks of procedures in potentially
koebnerizing alopecias, and provide additional expert insight to aid hair restoration and
cosmetic practice in this challenging patient population. We will focus on primary scarring
alopecias and divide our discussion by procedure. The information provided is summarized
in Table 1.

MATERIALS AND METHODS

A comprehensive literature review was performed, using keywords for complications in
cicatricial alopecias combined with those for common face or scalp procedures to identify
articles describing procedure-induced koebnerization or disease reactivation in scarring
alopecias. Publications from 1970 to 2020 were searched using PubMed (US National
Library of Medicine) and Google Scholar (https://scholar.google.com/).

Procedures With Reported Risk of Disease Precipitation or Keobnerization

Hair Transplant
Hair transplantation (HT) can be used for an array of alopecias. HT involves harvesting hair
from an unaffected donor site through follicular unit strip surgery (FUSS) or follicular unit
extraction (FUE), and transplanting the hair follicles to the recipient site. Factors that
influence the technique used are patient dependent and include degree and type of hair
loss, laxity of the occipital scalp donor site, vascular supply, patient hair density and desired
hair length post-procedure. When appropriate, FUE is typically the gold standard for HT
due to the ability of assessing individual hair follicles and no required suturing. In scarring
2

alopecias with smaller areas of hair loss, FUE is superior to FUSS because it yields fewer
follicular units and theoretically causes less trauma. While, to our knowledge, no studies
have been performed determining the optimal time period between scarring alopecia
disease quiescence and hair transplantation
regarding koebnerization risk, most hair transplant surgeons require at least 1-2 years of
disease quiescence prior to hair transplantation.

Complications
In scarring alopecias, the underlying disease process can influence HT outcomes and
complications. Along with the aforementioned complications, tissue ischemia, necrosis, and
infection are more frequently reported in patients with scarring alopecia, likely due to
decreased vascular supply in scarred areas. Furthermore, necrosis and koebnerization of
3

scarring processes at the donor site have been reported following FUE. Not only may
4,5
disease reactivate following transplant, but there are also reports of previously healthy
patients developing new onset of LPP following HT. One review described 17 patients
6

diagnosed with LPP, at an average of 4 to 36 months following HT in the majority of

patients, suggesting that surgically-induced skin injury may be implicated in disease
pathogenesis. 7

Two possible mechanisms may help explain the development of LPP after HT. The first
suggests collapse of follicular immune privilege as a result of surgical trauma, and the
second is a belief that an underlying LPP existed prior to surgery but was unrecognized
and not diagnosed. One case report also described the development of folliculitis
8

decalvans exclusively at the areas of the punch grafts 20 years after hair restoration
surgery, while another described onset of FFA 5 years following the last of multiple hair
transplants received over a span of 40 years. To minimize the risk of complications when
9,40

using HT for the treatment of primary scarring alopecias, it is recommended that patients
have had a period of quiescence with no clinical activity or disease progression. Expert
recommendations on review of the literature suggest an interval of at least 1-2
years. Importantly, to our knowledge, no study exists which has examined the optimal time
2

frame to minimize risk of koebnerization when using HT for primary scarring alopecias.

Traction-Inducing Hairstyling Methods

Traction alopecia (TA) results from repetitive or sustained tension on the hair shaft, and
affects one-third of women of African descent. Traction-inducing hairstyles include tight
braids or buns, cornrows, high ponytails, hair weaves, and wig attachments. 10

Complications
Although TA itself may become scarring over time, the resultant inflammation may also
catalyze initiation or propagation of primary cicatricial alopecias. This was demonstrated in
a case report of a 25-year-old female patient who developed symmetric irregular patches of
scarring alopecia in areas where hairstyling placed substantial upward tension on scalp
hair. A scalp biopsy demonstrated LPP, suggesting traction as the likely inciting factor. A
11

retrospective study of 51 Black women with hair loss also reported a statistically significant
association between sewn-in hair weaving or braided hairstyles using artificial extensions
with development of central centrifugal cicatricial alopecia CCCA (P<0.03 and P<0.04,
respectively). Attachment points for wigs or hair weaves may also cause traction through
12

the use of tight braids, with 2 reports in the literature of patients who developed biopsy-
proven LPP at the sites of wig attachment. 13

Rhytidectomy
Rhytidectomy ("face-lift") is a cosmetic surgical procedure which tightens face and neck
skin to reduce the appearance of rhytides and skin redundancies. Surgical incisions
typically run from the temporal hairline to the preauricular skin near the hairline. The
14

superficial muscular aponeurotic (SMAS) layer is identified, plicated, and then reinforced.
Excess SMAS is excised and meticulous closure is undertaken.

Complications
Few reports exist of rhytidectomies performed in patients with preexisting cicatricial
alopecias. Conversely, there are multiple reports of new-onset FFA following face-lift. One
case series described 3 female patients aged 54 to 57 who developed new-onset, biopsy-
proven FFA within 3 to 18 months of rhytidectomy. A retrospective review of 53 patients
15

with FFA compared with age-matched androgenetic alopecia (AGA) controls found that
49.1% of FFA patients reported a history of facial surgical procedures compared with 7.8%
of AGA patients (P=0.002). The average time between procedure and alopecia onset was
8.7+/-9.8 years.16

Several potential mechanisms may explain the relationship between facial surgical
procedures and onset of FFA or LPP including surgical trauma-induced Koebner
phenomenon, autoimmune response to exposed follicular antigens, and loss of hair follicle
immune privilege in the setting of post-surgical inflammation, although more investigation is
needed. 15

Mesotherapy
Mesotherapy is a minimally-invasive method of drug delivery that involves multiple
intradermal and subcutaneous microinjections for targeted delivery of various agents to
regions of concern. These agents include not only medications such as minoxidil, but also
homeopathic agents, plant extracts, vitamins, and vasodilators. There are limited studies
17

investigating mesotherapy for alopecia, with the majority of encountered literature

describing AGA, and no studies describing use in cicatricial alopecias. In a small
randomized control trial of 54 patients with female pattern hair loss, the group that received
mesotherapy injections of 0.5% minoxidil had significant improvement in hair loss
compared with the placebo group. In another study, mesotherapy delivery of a
18

dutasteride-containing preparation led to improvement in female pattern hair loss. 19

Complications
Although mesotherapy is a minimally-invasive procedure, side effects including bruising,
edema, and infections have been reported. Notably, a small area of secondary cicatricial
20

alopecia was reported to be a complication in one case following mesotherapy involving the
injections of heparinoid vasodilator mesoglycan for AGA. In another case, mesotherapy
delivery of homeopathic agents (Lilium compositum, Solanum compositum, Thuja and
Tanacetum) for treatment of AGA was complicated by acute, patchy, non-scarring
alopecia. Furthermore, there was a case of mesotherapy used for postpartum hair loss
17

(with delivery of flavonoside, procaine, saline, and vitamins B1, B3, B5, B6, B8, and C) with
reported complications of ulcers, subcutaneous fat necrosis and scarring in the setting of
suspected herpes zoster eruption and subsequent superinfection. 21

Procedures With Theoretical Risk of Disease Precipitation or Koebnerization

Platelet-Rich Plasma
Although there is substantial literature supporting plateletrich plasma (PRP) for non-
scarring alopecias such as AGA and alopecia areata (AA), less is reported regarding its
22

use in cicatricial alopecias. However, PRP may have particular applications in scarring
alopecias due to its demonstrated antiinflammatory effects, promotion of perifollicular
vascularization, and beneficial effects on collagen remodeling. Multiple case reports of
23

patients with LPP and FFA have noted improvement after PRP, with resolution of
inflammation, improved hair growth, and/or hair thickening following treatment. 23

Complications
Adverse events of PRP include temporary injection site pain, bleeding, edema, headache,
scalp pruritus, desquamation, and temporary hair shedding. A recent case series followed
24

10 patients with cicatricial alopecias after PRP injection to examine risk of

koebnerization. The authors postulated that postinjection release of inflammatory
25

mediators might paradoxically cause disease exacerbation. After an average of four

months of follow-up, four patients demonstrated improvement and one patient experienced
worsened disease with increased inflammation and shedding. In subsequent investigations,
three patients with LPP/FFA were treated with PRP, with no reports of resultant disease
exacerbation. Although generalizability of these reports is limited by small sample sizes,
26

both sets of authors concluded that overall PRP appears to be safe with low risk of
koebnerization when used in patients with cicatricial alopecias. 23

Intralesional Corticosteroid Injection

Although substantial literature supports intralesional corticosteroid (ILC) injection use for
the treatment of AA, limited retrospective studies analyze its efficacy in cicatricial
alopecias. In a retrospective study, 130 patients with FFA were treated with ILCs every 3
27

to 6 months for 8 total treatments. Hairline regrowth was seen in 34% of patients, with
arrest of hairline recession in 49%.28

Complications
Donovan et al demonstrated that for FFA with eyebrow involvement, ILCs 10 mg/mL with
0.125 mL delivered to each eyebrow was beneficial with minimal chance of atrophy. A 29

more recent 2014 retrospective review examining use of intralesional TAC 2.5 mg/mL (0.5-
3 mL per injection spaced 6-8 weeks apart) for 57 patients with FFA demonstrated
immediate cessation of frontal hairline recession in 84%. Ten patients (16%) initially had
further disease progression, but all 10 had hairline stabilization within 4-5 treatment
sessions. Despite the lack of reported atrophy in the former study, we recommend
reserving higher potency TAC (5-10 mg/mL) for the scalp and using TAC 2.5 mg/mL for the
frontal scalp and eyebrows as atrophy or dyschromia are more visible in these locations.
Common adverse effects of ILCs include pain during injection and minimal transient
atrophy of the skin and hair follicles. Importantly, these effects have been primarily
30

reported in patients with AA, and it is unclear if incidence varies with use in primary
cicatricial alopecias however they are typically treated for consecutive months and
therefore using a lower potency is judicious. No reports of koebnerization following ILCs for
cicatricial alopecia were encountered on review of the literature.

Acupuncture
Acupuncture is a form of traditional Chinese medicine wherein disposable, sterile needles
are used to stimulate different points on the skin. Needles may be inserted deep into
muscles and manually or electrically stimulated, or placed superficially in subcutaneous
tissues with or without stimulation. Acupuncture has been used for thousands of years to
treat numerous medical disorders, including disorders of the skin. No reports of alopecia
31

following acupuncture were encountered on review of the literature. Of note, in a 1985 case
series of 15 patients with discoid lupus erythematosus (DLE) treated with facial and
auricular acupuncture, no adverse events were reported. 32

Thread-lift
Thread-lift involves non-surgical lifting and tightening of loose facial tissue using barbed
threads. Anchored barbs uplift tissue and stimulate fibroblast activation and collagen
production. Alopecia is rarely described as a potential adverse event of thread-lift, likely
33

due to lack of proximity of entry sites to the hairline and minimally-invasive nature of the
procedure. Only one case of hair loss following a thread-lift was encountered, wherein a
61-year-old female developed severe bitemporal pressure alopecia at the sites of temporal
thread insertion. Biopsy confirmed non-scarring pressure alopecia, and greater than 50% of
hair density was recovered within 4 months with topical minoxidil application. 34

Scalp Cooling
Scalp cooling is a preventative modality that utilizes cryotherapy. However, rather than the
liquid nitrogen spray used with traditional dermatologic cryotherapy, scalp cooling involves
either manual application of gel-filled cold caps, or use of machine scalp cooling
systems. Cold caps are placed on patients' scalps before, during, and after chemotherapy
35

infusions with the aim of minimizing chemotherapy-induced alopecia (CIA). Cold caps are
generally considered safe with few adverse effects, though superficial cold thermal injury
has been reported. Although these injuries primarily comprised mild erythema, edema, or
blisters, some patients experienced persistent alopecia in the distribution of thermal injury
at 4-6 month follow-up. No reports of new-onset alopecia following cryotherapy were
35

encountered on review of the literature.

Laser
Lasers have become a popular way to treat a myriad of dermatologic conditions and are
first-line for removal of vascular lesions, pigmented lesions, as well as unwanted hair.
Although not currently first line treatments for alopecia, laser technologies including low-
level laser therapy and excimer (narrow band UVB) laser, are utilized as adjunctive agents
for the treatment of hair loss. We were unable to identify any reports of koebnerization
36,37

following the use of lasers in patients with scarring alopecias, though importantly there are
very limited studies investigating lasers in this subset.

Microneedling
Microneedling (percutaneous collagen induction or collagen induction therapy) involves
repeated skin puncturing with devices containing rows of needles to cause controlled skin
injury and induce a wound-healing response. Microneedling has been used by itself for
treatment of a variety of dermatologic conditions, but can also be used in combination with
therapeutics to aid transcutaneous drug delivery. On review of the literature, we did not
38

encounter reports of microneedling use for treatment of cicatricial alopecias. It is unclear if

there may be an elevated risk of adverse events in this subset, though some authors do
recommend a maximum needle length of 1.5 mm to minimize the potential for follicular
damage. More studies are needed to adequately assess potential risks of microneedling in
39

patients with cicatricial alopecias. Scalp Micropigmentation Scalp micropigmentation is a

technique used for hair loss concealment. It uses tattooing in a stippling pattern to mimic
the appearance of hair follicles masking the appearance of alopecia. No reports describing
40
reactivation of a primary scarring alopecia following scalp micropigmentation were found on
literature review.

CONCLUSION
Many hair loss treatments and cosmetic interventions for scarring alopecias are procedural
in nature, and these may have a unique adverse event profile in patients with cicatricial
alopecias. The current body of literature on the natural course of primary cicatricial
alopecias and the potential for induction of the Koebner phenomenon is extremely limited.
Further studies are needed to properly guide counseling regarding surgicalbased therapies
for the cosmetic management of primary scarring hair loss disorders.

DISCLOSURES
Drs. Shapiro and Lo Sicco have been investigators for Regen Lab and are current
investigators for Pfizer. Dr. Lo Sicco is a consultant for Pfizer and Aquis. Dr. Shapiro is a
consultant for Eli Lilly.

ACKNOWLEDGMENT
LF and ML conducted the literature search. LF, ML, DG, JS, PA, and KL helped analyze
and interpret the literature search results. LF, ML, KS, and AK drafted the manuscript. DG,
JS, PA, and KL supervised the research and study conceptualization. All authors reviewed
and edited the manuscript.

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AUTHOR CORRESPONDENCE
Kristen Lo Sicco MD FAAD [email protected]