Efficacy, safety, and patient-reported outcomes of scalp micropigmentation in scarring alopecia

INTRODUCTION

Scalp micropigmentation (SMP) has emerged as a minimally invasive intervention that provides immediate visual enhancement for individuals experiencing hair loss. Initially used for androgenetic alopecia, SMP has gained recognition in conditions such as alopecia areata, female pattern hair loss (FPHL), post-surgical scarring, and traumatic scars. However, its application in primary scarring alopecia, which involves irreversible destruction of hair follicles and scalp atrophy due to autoimmune or inflammatory processes, has not been extensively studied. This presents a unique challenge in determining whether SMP can offer similar benefits for these patients, who often face additional complexities due to altered scalp texture and fibrosis.

Scarring alopecia, characterized by permanent loss of hair follicles, remains challenging to manage with traditional pharmacological treatments and surgical hair restoration. As a result, many patients resort to camouflage options.¹ These methods often fail to address the esthetic and psychosocial burdens of the condition, prompting patients to seek alternative solutions for improving scalp appearance. SMP, which replicates the appearance of hair follicles through specialized pigment implantation, has shown promise in other forms of hair loss; however, its role in primary scarring alopecias remains poorly understood. Therefore, its use in primary scarring alopecias offers a novel opportunity to improve scalp appearance, despite unique considerations such as scalp atrophy, fibrosis, and altered vascularity. These factors warrant closer evaluation to understand better how SMP can be adapted and optimized for this patient population.

This study aims to fill the gap in the literature by prospectively evaluating the efficacy, safety, and patient-reported outcomes of SMP in patients with scarring alopecia. Through serial follow-up assessments conducted over 6 months, including Visual Analog Scale (VAS) comparisons for patient satisfaction at baseline and at the end of the study, we document adverse events and the sustainability of the results.

MATERIAL AND METHODS

Aims and objectives

1. To determine the efficacy and safety of SMP in treating patches of scarring alopecia

2. To assess patient satisfaction with SMP using the VAS

3. To identify any risks or side effects associated with SMP in scarring alopecia.

This prospective interventional study was conducted at a tertiary care institution from August 2023 to February 2025. A total of 18 volunteers with scarring alopecia were enrolled after obtaining informed consent. Inclusion criteria included patients aged 18–60 years with hair loss patches ≥2 cm × 2 cm, a history of no change in patch size for at least 6 months, and a willingness to attend regular follow-ups. Exclusion criteria included clinically active inflammation, local infections, pregnancy, immunocompromised status, and keloidal tendency. A scalp biopsy was performed for histopathological examination to confirm the diagnosis. Ongoing anti-inflammatory medications (if any) were continued in maintenance doses. Overall, their study included both stable and burnt-out disease patients.

Patients were asked to stop taking drugs like aspirin at least 3 days before the procedure. A 1% lignocaine with adrenaline for ring block anesthesia was administered around the targeted treatment site. A specialized micropigmentation device (M5 by Innovation Surgicals) was used with single-needle cartridges for hairline design and multipronged 3RL cartridges for follicular unit replication beyond the hairline. An organic gel-based neutral black pigment was taken in a sterile container, in which the moving tips of the cartridge were dipped to suck up the ink. The target scalp area was stretched between the thumb and index fingers of the non-dominant hand, and ink was carefully implanted targeting the upper dermis, while holding the handle like a pen in the dominant hand. The depth and needle speed were adjusted as needed. The handle was adjusted wherever scalp topography was altered due to underlying soft tissue or bony abnormalities to obtain “pointillism” (inserting needles at a 90° angle to the scalp). The penetration depth was maintained at approximately 1.2 mm to 1.7 mm, although variable depending on the scalp condition. A random pattern of dots was chosen to mimic hair follicles. A dry gauze piece was used to blot any excessive splattered ink/bleed points that were visible on the scalp. After the procedure, a thin layer of topical antibiotic was applied, and patients were instructed to avoid vigorous cleaning and shampooing the treated area for 3–4 days.

Follow-up visits were scheduled at 1 week, 2 weeks, 1 month, 3 months, and 6 months. Touch-up sessions were conducted at 2 weeks and/or 1 month if required. Safety was assessed by documenting events such as pain, edema, ecchymosis, crusting, infection, pigment allergy, and scarring. Photographs were taken at baseline and follow-up visits to track color changes, fading, and margin definition, and to assess outcomes objectively [Figure 1]. Patient satisfaction was assessed using the VAS at baseline and at the 6-month visit. Patients with pigment retention in more than 50% of the patch area at the end of the study were considered to have had a favorable outcome.

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Figure 1:

Outcomes at the 6 months grouped by (a) diagnosis and (b) overall.

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Data were analyzed using IBM Statistical Package for the Social Sciences Statistics (Version 23.0). Continuous data were expressed as mean ± standard deviation and categorical data as percentages. The Wilcoxon signed-rank test was used to analyze VAS scores, with a P < 0.05 considered statistically significant.

RESULTS

The study included a total of 18 patients, comprising 17 females and 1 male. The most common diagnoses were traction alopecia (TA) (27.8%) and morphea (27.8%), followed by lichen planopilaris (LPP) and pseudopelade of Brocq (PBQ) (16.6% each). Frontal fibrosing alopecia (FFA) accounted for 11.1% of cases. All patients completed the follow-ups in the study period. The frontal scalp was the most commonly affected site, followed by the mid-scalp. The average size of treated patches was 13.5 cm².

At the end of the study, 50% of participants demonstrated a favorable response [Figure 1, Tables 1 and 2]. Diagnosis-specific trends showed the best outcomes in FFA (100%) and traction alopecia (80%) [Figures 2 and 3], followed by PBQ and LPP [Figure 4]. Whereas, morphea [Figure 5] had the lowest favorable response (20%). The difference between diagnostic groups was not statistically significant (P = 0.11), likely due to small sample size. In conditions with dense dermal fibrosis, such as morphea and LPP, pigment retention was notably lower, with <50% visible retention in 7 of 9 cases by 6 months.

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Figure 2:

(a) Baseline picture of a frontal patch of alopecia in frontal fibrosing alopecia (FFA) patient. (b) 6-month post-procedure picture of a frontal patch of alopecia in the FFA patient.

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Figure 3:

(a) Baseline picture of a frontal patch of alopecia in tractional alopecia (TA) patient. (b) 6-month post-procedure picture of a frontal patch of alopecia in the TA patient.

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Figure 4:

Serial changes in a pseudopelade of Brocq patient showing spread of pigment, color fading, and blue-gray color change over time (baseline >1 month >3 months >6 months).

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Figure 5:

Serial changes in a linear morphea patient showing tendency to bleed during procedure and pigment loss over time (baseline > during procedure >1 month >3 months).

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Additionally, 11 out of 18 patients reported an improvement in their VAS score, while seven patients experienced no change in their VAS score over the 6-month period. Patient perception of baldness improved significantly with the mean VAS score decreasing from 35.28 at baseline to 25.5 at 6 months (P ≈ 0.002), reflecting improved satisfaction with SMP over time as shown in [Figure 6 and Table 3].

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Figure 6:

Box plot showing Visual Analog Scale score changes between baseline and at 6 months.

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Pigment changes followed a progressive trend. No color change was noted within the first 2 weeks; however, by 1 month, 61.1% of participants reported a noticeable alteration, which increased to 72.2% at 3 and 6 months. Similarly, fading occurred universally, with all participants experiencing pigment loss by 1 month, which persisted over time. Pigment spreading was first noted in 16.7% of participants at 2 weeks, rising to 38.9% at 1 month and 55.6% at 3 and 6 months, indicating gradual diffusion. These are summarized in Figure 7. Adverse events, including pain, edema, ecchymosis, crusting, secondary infections, allergies, and scarring, were transient. These were reported by 100% of patients (18/18) at 1 week, dropping sharply to 5.6% (1/18) by 2 weeks. Ecchymosis was reported in 33.3% at 1 week but resolved thereafter. Edema was present in 66.7% of cases at 1 week and recurred in 16.7% after touch-up sessions, but was absent beyond 1 month.

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Figure 7:

Follow-up parameters in line graphs. Pain, edema, and ecchymosis were observed transiently and resolved within 2 weeks in all cases with some spikes showing recurrence at touch-up sessions, indicating good immediate tolerability. In contrast, color fading and pigment spreading demonstrated a progressive and persistent trend over time, with all patients experiencing pigment fading by 1 month and over half showing pigment diffusion by 3 months. Color change was a delayed finding, becoming evident from the 1-month mark onward.

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Pain followed a similar trend, with 33.3% initially reporting it, and some recurrence during touch-ups. While 100% of patients across all diagnoses experienced adverse events (mainly at 1 week), PBQ followed by LPP had the highest incidence of adverse events throughout the study. These are also summarized in Table 4 and Figure 7.

DISCUSSION

SMP is a cosmetic procedure that simulates the appearance of hair follicles using specialized pigment implantation, increasingly used for various forms of alopecia. Our study specifically explored the utility of SMP in patients with primary scarring alopecias to assess how fibrosis and atrophy affect pigment retention, overall efficacy, and safety. Traquina et al. (2001) first described SMP as a medical tattoo for camouflaging hair loss and scars, focusing on androgenetic alopecia and surgical scars. While their work established foundational principles, it excluded inflammatory or fibrotic scarring alopecias.¹ Our study builds on this by demonstrating moderate efficacy (50% favorable outcomes) in scarring alopecia, with significant variability tied to fibrosis severity. For example, morphea (20% favorable outcomes) and lichen planopilaris (33.3%) underperformed compared to traction alopecia (80%) and FFA (100%), highlighting how fibrosis disrupts pigment retention—a factor that Traquina’s cohort did not address. The poor results in morphea likely reflect extensive dermal fibrosis, which impairs pigment uptake and retention. Similar to sclerotic scars, morphea exhibits increased type I collagen and a disorganized fibril arrangement, resulting in reduced skin elasticity.^2,3 These findings are consistent with previous reports that pigment settlement is more difficult in atrophic and sclerotic skin.^4-6 Park et al. (2014) later evaluated SMP in 43 Korean patients, including 23 female patients with FPHL, 14 male patients with male pattern baldness, and 6 with surgical or traumatic scalp scars and reported 97.7% overall satisfaction. However, minor retouches were required in 26% of patients for focal pigment loss after crust shedding, with retouches indicated for pigment loss exceeding 10–20%.⁷ While their scar subgroup achieved satisfactory outcomes, their cohort lacked primary scarring. This distinction is critical: Surgical scars often have intact peri-scar tissue and limited fibrosis, enabling predictable pigment retention. In contrast, our cohort’s primary scarring alopecias – characterized by diffuse fibrosis, atrophy, and chronic inflammation – required touch-ups in all patients and showed poorer outcomes (50% favorable outcomes). This divergence highlights that SMP efficacy in scars is context-dependent, with fibrosis and inherent inflammatory activity presenting unique barriers that are absent in Park’s surgical scar cohort.

Rassman et al. (2015) emphasized the safety and technical artistry of SMP in their review, noting transient adverse events such as edema and pain. While our findings corroborate the transient nature of these events – 66.7% of patients experienced edema at 1 week, resolving to 16.7% after touch-ups and absent beyond 1 month – we identified higher rates of pigment spreading (55.6% at 6 months), universal fading (100% by 1 month), and progressive color changes (72.2% at 6 months) as novel complications. These outcomes starkly contrast with Rassman’s focus on operator skill as a key determinant of success, instead implicating primary pathology as a barrier in scarring alopecia. For instance, pigment spreading in morphea (60% of cases) and lichen planopilaris (50%) occurred despite meticulous technique, suggesting that fibrosis alters tissue dynamics, which technical precision could not fully overcome.⁸

Dhurat et al. (2017) also revealed challenges specific to scarring alopecia: in an LPP patient, they found that deeper needle penetration caused pigment diffusion, resulting in patchy discoloration over time. This aligns with our observation of progressive pigment spreading (55.6% at 6 months) and universal fading (100% by 1 month) in scarring alopecia. However, their protocol proved less effective in our cohort, where likely fibrosis facilitated the diffusion of pigment. Dhurat’s cohort included only three scarring alopecia cases (10% of the total), limiting their ability to explore subtype-specific outcomes.⁵ While they attributed pigment spreading to technical factors (e.g., depth of needle and rotor speeds), our data suggest that fibrosis and inflammation independently drive pigment migratio n. This highlights a limitation of “one-size-fits-all” SMP protocols – while effective in normal scalps, they neglect the altered biomechanics of scarring alopecia.

Finally, Seyhan and Kapi (2021)¹¹ conducted a prospective evaluation of SMP, which included six patients with surgical scalp scars, reporting 100% satisfaction and minimal fading at a mean duration of 20 months. While their long-term data support SMP’s durability in localized scars and non-scarring alopecia, their exclusion of inflammatory/fibrotic scarring alopecias (e.g., LPP and morphea) limits generalizability. Our cohort’s primary scarring alopecias exhibited progressive pigment changes (72.2% color shifts at 6 months), contrasting sharply with Seyhan’s stable outcomes.

Our results demonstrate that SMP is effective in conditions with mild atrophic patches but struggles with pigment retention in severely atrophic and sclerotic areas, as in some patients who experienced significantly lower satisfaction, possibly due to increased pain and edema – although transient – poor pigment uptake, and increased susceptibility to pigment diffusion. This correlates with the adverse events profile observed across our cohort – while all patients reported transient adverse events, the highest burden of adverse events was seen in PBQ and LPP cases.

Despite these challenges, VAS scores for baldness perception dropped significantly from 35.28 at baseline to 25.5 at 6 months (P < 0.001), underscoring SMP’s capacity to improve scalp esthetics and psychological well-being. In contrast, Dhurat et al. used a subjective scale (+1 to +3) to assess patient satisfaction, with all three patients with scarring alopecia rating their improvement as +2. Our use of the VAS scale, in a first such attempt, offers a more precise measurement of how SMP impacts scarring alopecia patient perception.⁵

Given the considerable psychosocial burden and limited therapeutic options in scarring alopecia, our findings position SMP as a meaningful non-surgical intervention that bridges an important therapeutic gap.⁹ In addition, the use of smaller cartridge systems (e.g., 1RL) could provide for more precise pigment deposition and potentially reduce the pigment spreading when compared to larger needle cartridges (e.g., 3RL and 5RL). Emerging microneedle-based technologies offer promise. Innovations, such as micropigment-encapsulated biodegradable microneedles, enable precise and controlled pigment implantation at optimal depths, thereby reducing diffusion risks.¹⁰ These advancements, combined with fibrosis-adjusted protocols (e.g., shallower depths in sclerotic zones) and adjunct therapies (e.g., anti-fibrotic agents), could address our observed limitations.

Based on our extended observation beyond the study period, pigment visibility typically declined in 9–12 months, especially in fibrotic scalps. Therefore, it can be advised, especially in fibrotic variants, that patient counseling should include discussion of accelerated pigment fading and the need for early and frequent repeat sessions with or without additional treatment options.

Our investigation contributes new insights into the potential of SMP for treating scarring alopecia, a complex and understudied area. By addressing this research gap, this study provides valuable evidence that can inform best practices and enhance patient outcomes in managing this challenging condition.

CONCLUSION

SMP is a viable esthetic intervention in scarring alopecia, offering diagnosis-dependent results with transient side effects and good patient-reported outcomes. It is also important to recognize that such complex cases are more frequently encountered by dermatologists than by practitioners in esthetic or transplant clinics. Unlike androgenetic alopecia or FPHL, which usually progress gradually and may not cause immediate concern, conditions such as morphea, pseudopelade of Brocq, and other scarring alopecias often present atypically and evolve rapidly – prompting early consultation. Moreover, patient selection must account for co-existing or evolving hair disorders, such as androgenetic alopecia, where progressive miniaturization may expose previously camouflaged pigment, resulting in unnatural esthetics. As such, dermatologists serve as the primary point of contact, and SMP should be considered as part of the broader therapeutic approach, complementing medical and procedural interventions to optimize both cosmetic and psychological outcomes.