The Role of Platelet Plasma Growth Factors in Male Pattern Baldness Surgery

Stromal vascular fraction-enriched platelet-rich plasma therapy reverses the effects of androgenetic alopecia

BACKGROUND

Since antiquity, humans have been trying to devise remedies to cure androgenetic alopecia (AGA). These efforts include use of oral and topical concoctions and hair transplant strategies. As AGA affects people of all colors and creed, there has been a continuous effort to find a magic bullet against AGA. Unfortunately, to date, all the strategies to negate AGA effects have limitations and thus require new treatment options.

AIM

To evaluate the efficacy of use of stromal vascular fraction (SVF) in androgenetic alopecia patients.

METHODS

Stromal vascular fraction was obtained by enzymatic digestion of autologous adipose tissue. The patients were divided into two groups, that is, platelet-rich plasma (PRP) group and SVF-PRP group. In PRP group, only PRP was injected, while in SVF-PRP group a mixture of PRP and SVF was injected in affected scalp areas. After two sessions (4 weeks apart), the patients in both groups were assessed and analyzed using various parameters.

RESULTS

Mean hair density in PRP group was increased from 52.44 hair/cm² to 63.72 hair/cm² (21.51% increase); while in SVF-PRP group, it was 37.66 hair/cm² before treatment and 57.11 hair/cm² after SVF-PRP therapy (51.64% increase). Percentage reduction in pull test was more significant in SVF-PRP group (80.78 ± 5.84) as compared to PRP group (34.01 ± 22.44). The physician and patient assessment scores also indicated a significant improvement in SVF-PRP group.

CONCLUSION

A combined SVF-PRP therapy reversed effects of AGA more efficiently as compared to PRP therapy alone.

Platelet-Rich Plasma and Stem Cells for Hair Growth: A Review of the Literature

The prevalence of hair loss, its psychological consequences, and historically subpar treatments present a unique challenge to the physician. The current Food and Drug Administration-approved treatments for hair loss are plagued by ineffectiveness, noncompliance, and adverse effects. Recent advances in our understanding of hair physiology have fueled the development of more efficacious, minimally invasive, and safer treatment options for hair restoration including plasma-rich protein and stem cell therapy. Platelet-rich plasma, the autologous preparation of concentrated platelets in plasma, when injected into the scalp of patients with both androgenetic alopecia (AGA) and alopecia areata (AA), has been shown to increase hair count and density. The clinical findings have been supported by histologic evaluation of the scalp skin. These findings have been recapitulated in numerous randomized controlled trials. Stem cell therapy, although newer in its application in hair restoration, has also been effective for treating both AGA and AA. The isolation techniques for stem cells are varied, but regardless have shown promising results in early prospective and retrospective studies.

Platelet-Rich Plasma for Hair Restoration

Platelet-rich plasma (PRP) is a promising treatment for hair restoration in patients with androgenic alopecia. Created from a platelet concentrate from an autologous blood draw, PRP is a safe therapeutic option for patients with hair loss. It is used alone or in conjunction with topical and oral therapies. Most studies of hair restoration with PRP report positive outcomes. Further research to optimize PRP preparation/administration procedures and identify patient populations that benefit most from this treatment are needed, as is long-term follow-up of objective hair loss outcomes. PRP appears to be a safe technology with excellent potential for promoting hair restoration.

Impact of Preservation Solutions on the Trichogenicity of Hair Micrografts Ascertained by Dermal Papilla Gene Expression

BACKGROUND

Appropriate storage of human hair follicle (HF) grafts during follicular unit excision (FUE) is crucial toward successful hair shaft implantation. Several commercial storage solutions are currently used to ensure ex vivo maintenance of follicular grafts viability and trichogenicity. However, quantitative experimental evidence demonstrating molecular changes in HF cells associated with the usage of different storage solutions is largely missing.

OBJECTIVE

To identify gene expression changes in HF cells caused by ex vivo storage of hair grafts in different preservation conditions.

METHODS

The authors performed gene expression analysis in dermal papilla (DP) isolated from HF stored under different temperatures and solutions. The expression signature of key genes controlling hair growth and cycling, apoptosis, inflammation, and senescence was assessed for (1) chilled versus room temperature (RT) and (2) DP cell medium, saline, Hypothermosol, platelet-rich plasma, and ATPv-supplemented saline.

RESULTS

The authors found chilled versus RT to prevent inflammatory cytokine signaling. Under chilled conditions, ATPv-supplemented saline was the best condition to preserve the expression of the trichogenic genes HEY1 and LEF1.

CONCLUSION

Data disclose DP gene expression analysis as a useful methodology to ascertain the efficacy of preserving solutions and elucidate about the best currently available option for FUE clinical practice.

Contemporary Management of Alopecia: A Systematic Review and Meta-analysis for Surgeons

BACKGROUND

The decision of surgical approach for hair restoration often involves evaluation of the type of alopecia; however, the impact of surgical hair restoration from existing techniques in specific population subsets has not been comprehensively investigated.

OBJECTIVES

The authors sought to systematically review the literature on micrografts, minigrafts, mini-micrografts, tissue grafts, tissue flaps and expanders, as well as evaluate graft survival and satisfaction within specific populations in a meta-analysis.

METHODS

PubMed and Scopus literature searches between 1980 and 2018 yielded 57 articles for systematic review and 34 articles for meta-analysis. Study design, mean patient age and gender, patient alopecia type, surgical hair restoration technique, number of treatment areas, mean follow-up, graft survival rate and satisfaction rate were extracted from each study, and a meta-analysis was performed.

RESULTS

The pooled rates of graft survival were 84.98% (95% CI 78.90-91.06) using micrografts and 93.11% (95% CI 91.93-94.29) using micrografts and minigrafts in nonscarring alopecia patients, as well as 88.66% (95% CI 80.12-97.20) using micrografts and 86.25% (95% CI 74.00-98.50) using micrografts and minigrafts in scarring alopecia patients. The pooled rates of satisfaction were 89.70% (95% CI 82.64-96.76) using micrografts and 97.00% (95% CI 92.48-100.0) using micrografts and minigrafts in nonscarring alopecia patients, as well as 97.80% (95% CI 94.59-100.0) using micrografts and 88.70% (95% CI 66.49-100.0) using micrografts and minigrafts in scarring alopecia patients. Dot plots depict rates of graft survival rate from micrografts and satisfaction from micrografts and minigrafts.

CONCLUSION

Surgical hair restoration for nonscarring and scarring alopecia yields high graft survival and satisfaction rates.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Efficacy of Platelet-rich Plasma for Treating Androgenic Alopecia of Varying Grades

BACKGROUND AND OBJECTIVES

Platelet-rich plasma (PRP) has received growing attention as a valuable therapeutic tool in androgenetic alopecia (AGA). However, knowledge regarding specific effectiveness and satisfaction of PRP for different grades of AGA in male pattern hair loss (MPHL) and female pattern hair loss (FPHL) is missing. This study aims to ascertain and compare the efficacy and safety of PRP treatment for different grades of AGA in males and females over 6 months.

METHODS

In this study, 51 MPHL patients with Norwood-Hamilton stage II-V and 42 FPHL patients with Ludwig stage I to III were enrolled for 6 monthly sessions of PRP injections. A longitudinal analysis was used to compare the hair density, thickness, and hair pull test over 6 months for MPHL and FPHL through generalized estimating equation (GEE) models. Phototrichograms of scalp inflammation and oil secretion, global photographs and overall patient satisfaction were also assessed.

RESULTS

Consequently, improvement of hair density, hair thickness, hair pull test, the level of scalp inflammation and oil secretion were observed with statistical significance in all stages for both MPHL and FPHL at 6 months. Noteworthy, lower level of alopecia (Grade II, III in MPHL and Grade I in FPHL) had better response to PRP, and also had a better tendency of increment of hair growth than that of high-grade patients with prolonged treatment.

CONCLUSIONS

PRP injections, as an efficacious and reliable therapy, can be recommended for Grade II and Grade III in MPHL and Grade I in FPHL.

A Histological and Clinical Evaluation of Plasma as a Graft-holding Solution and Its Efficacy in Terms of Hair Growth and Graft Survival

Background

There is a time lag between hair follicle harvesting and implantation; during this time, hair follicles have ischemic injury. We need a holding media or a solution to minimize or neutralize ischemic injury.

Aim and Objectives

The aim of this study was to evaluate plasma as a graft-holding solution in terms of its efficacy in hair growth and hair graft survival.

Materials and Methods

A split-scalp study was carried out. The left side was designated as the control area (Group A), where graft implanted was kept in Ringer's lactate (RL), and the right side behaved as the test area (Group B), which received grafts preserved in autologous plasma. The P value was calculated.

Observations

MTT [3-(4,5-Dimethylthiazol-2-Yl)-2,5-Diphenyltetrazolium Bromide] staining for graft stored in RL at 12-72h showed poor hair follicles cells survival, whereas graft kept in plasma showed viable cells even after 72h. The hair count and density in plasma group were significantly higher than the RL group. There was an improvement in hair thickness in both groups from 6 to 12 months.

Conclusion

Autologous plasma is an easily available graft-holding solution. Platelets along with the plasma provide multiple growth factors promoting epithelialization, neovascularization, and action on hair follicle stem cells to improve growth. The fibrin coating around graft makes it sticky and prevents dehydration. The split-scalp controlled study certainly shows the advantages of using plasma over other extracellular graft-holding solutions.

The Clinical Efficacy and Safety of Autologous Activated Platelet-Rich Plasma Injection in Androgenetic Alopecia

INTRODUCTION

Androgenetic alopecia (AGA) is a common, chronic hair loss disorder. Platelet-rich plasma (PRP) is a novel therapeutic tool for AGA. The objective of this study was to assess the clinical efficacy and safety of autologous activated PRP injections in AGA.

METHODS

Twenty-four AGA patients were enrolled in the study. All the patients received 4 PRP treatments at baseline (T1), 3 weeks (T2), 6 weeks (T3), and at 14 weeks (T5). We evaluated hair density (hairs/cm2) at 6 time points (T1-T3, T4 [9 weeks], T5, and T6 [7 months]) and patient satisfaction was assessed at T6 with a patient satisfaction questionnaire. Hair count (hairs/0.48 cm2) was assessed using dermoscopic photographs and hair density (hairs/cm2) was calculated accordingly.

RESULTS

Twenty-three men and one woman were included with baseline hair density of 102.25 ± 18.463. Hair density significantly increased at all time points with p < 0.001 compared to the baseline. Patients were satisfied with a mean result rating of 72.92 on a linear analogue scale of 0-100. Other than mild pain felt during injections, no remarkable adverse effects were noted.

CONCLUSIONS

PRP injections may have a positive therapeutic effect on AGA without major side effects.

Stimulating hair growth via hormesis: Experimental foundations and clinical implications

Numerous agents (approximately 90) are shown to stimulate hair growth in cellular and animal models in a hormetic-like biphasic dose response manner. These hormetic dose responses occur within the framework of direct stimulatory responses as well as in preconditioning experimental protocols. These findings have important implications for experimental and clinical investigations with respect to study design strategies, dose selection and dose spacing along with sample size and statistical power issues. These findings further reflect the general occurrence of hormetic dose responses within the biological and biomedical literature that consistently appear to be independent of biological model, level of biological organization (i.e., cell, organ, and organism), endpoint, inducing agent, potency of the inducing agent, and mechanism.

A Systematic Review of Outcomes and Patient Satisfaction Following Surgical and Non-surgical Treatments for Hair Loss

INTRODUCTION

This systematic review aims to examine surgical and non-surgical treatments and identify those procedures that are most effective in terms of patient satisfaction.

MATERIALS AND METHODS

A systematic review protocol was developed a priori in accordance with the Preferred Reporting for Items for Systematic Reviews and Meta-Analyses-Protocols (PRISMA-P) guidelines. The search was conducted in accordance with the PRISMA guidelines, the Cochrane handbook. A multistep search of the PubMed, MEDLINE, Embase, PreMEDLINE, Ebase, CINAHL, PsycINFO, and Cochrane databases was performed to identify studies on hair loss causes and hair loss treatment with different surgical and non-surgical techniques RESULTS: Our search generated a total of 781 articles; 646 studies were excluded based on the content of the abstracts, and an additional 105 studies were excluded based on the content of the complete article. We performed a review of the 30 remaining studies, which had sufficient data for inclusion, and met all the aforementioned inclusion criteria. Of the 30 studies, four were about minoxidil, four about finasteride, two about dutasteride, three about phototherapy, six about platelet-rich plasma injection, four about follicular unit transplantation technique, six about follicular unit extraction technique, and one about patient satisfaction following surgical treatment without a specified surgical technique. Only three studies used a patient-reported outcome measurement.

CONCLUSIONS

Our study is the first comprehensive systematic review of hair loss, looking at the problem from different points of view, and focusing on finding the best solution for the patient. In the literature, there is currently no algorithm for the management of patients who go to a plastic surgeon for a solution to the problem of hair loss.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Successful Management of Treatment-Resistant Alopecia Areata with Platelet Rich Plasma: A Case Series

Introduction. Alopecia areata (AA) is an autoimmune disease-causing non-scarring alopecia. It is usually treated with immunosuppressive agents, to which some patients fail to respond adequately.

Material and Methods. Three patients with AA refractory to standard therapy were treated with intra-dermal injection of autologous platelet rich plasma (PRP) every four weeks.

Results. All three patients showed remarkable improvement after multiple sessions of PRP treatment.

Conclusion. Autologous PRP is safe and effective in treatment-resistant forms of AA demonstrated in many case reports; therefore it deserves further study with randomized, placebo-controlled trials.

A Histological and Clinical Evaluation of Plasma as a Graft Holding Solution and Its Efficacy in Terms of Hair Growth and Graft Survival

Background  There is a time lag between hair follicle harvesting and implantation, during this time hair follicles suffer ischemic injury. We need a holding medium or a solution to minimize or neutralize ischemic injury.

Aims and Objective  To evaluate plasma as a graft holding solution in terms of its efficacy in hair growth and hair graft survival.

Method and Material  A split scalp study was performed. The left side was designated as the control area (Group A) where grafts implanted were kept in Ringer’s lactate, and the right side behaved as the test area (Group B) and received grafts preserved in autologous plasma. The p -value was calculated.

Observations  MTT staining for grafts stored in Ringer’s lactate at 12 and 72 hours showed poor hair follicle cells’ survival while grafts kept in plasma showed viable cells even after 72 hours.

The hair count and density in plasma group were significantly higher than those in the Ringer’s lactate group. There was an improvement in hair thickness in both groups from 6 months to 12 months.

Conclusion  Autologous plasma is an easily available graft holding solution. Platelets along with the plasma provide multiple growth factors promoting epithelialization, neovascularization, and action on hair follicle stem cells to improve growth. The fibrin coating around the graft makes it sticky and prevents dehydration. The split scalp controlled study certainly shows the advantages of using plasma over other extra cellular graft holding solutions.

Dermoscopic pre- and posttreatment evaluation in patients with androgenetic alopecia on platelet-rich plasma-A prospective study

BACKGROUND

Platelet-rich plasma is rich in growth factors that promote differentiation and growth of dermal papilla cells by various signaling pathways. Dermoscopy is handy, bedside tool that helps to improve diagnostic accuracy in various hair disorders.

OBJECTIVES

To evaluate and study the role of dermoscopy in patients with androgenetic alopecia (AGA) pre- and posttreatment with platelet-rich plasma (PRP).

METHODS

It is a prospective comparative study. Twenty male patients with AGA, aged 18-45 years with modified Norwood-Hamilton classification grade II-VI were included in this study. Patients were given platelet-rich plasma injections every 3 week for a period of 3 months. Dermoscopy was performed with 10 x magnifications in polarized mode at baseline and at 3 months from the baseline and photographs were taken. Patients were evaluated based on following dermoscopic findings (a) hair count, (b) hair density, (c) hair diameter diversity, perifollicular pigmentation, yellow dots, multi-hair follicular units, honeycomb pigment pattern and white dots, (d) patient's hair growth assessment score.

RESULTS

Posttherapy, patients showed significant improvement in hair count (27.4%), hair diversity (84.2%), increase in number of thick, terminals hairs, reduction in yellow dots (60%), perifollicular pigmentation (92.3%) was appreciated. Hair pull test negative after treatment in 10 patients (50%). Patient's hair growth assessment score showed 50%-75% improvement in 7 (35%) patients.

CONCLUSION

Dermoscopy helps to easily evaluate and compare the therapeutic response pre- and posttreatment which can be easily documented and visualized at every visit.

Platelet-Rich Plasma: Principles and Applications in Plastic Surgery

Platelet-rich plasma (PRP) is an autogenously harvested liquid platelet concentrate extracted from a patient's peripheral blood that contains higher than baseline concentrations of growth factors and cytokines. This innovative new technology has demonstrated great promise in the field of plastic surgery, and its use has been evaluated in several clinical settings including wound healing, hair restoration, and skin rejuvenation. The goal of this article is to explain the biology behind PRP and to review the basic principles involved in its preparation. This will be followed by a discussion of some clinical applications of PRP in both aesthetic and reconstructive plastic surgery.

Efficacy of platelet-rich plasma in androgenetic alopecia patients

BACKGROUND

Androgenetic alopecia (AGA), a patterned hair loss in both males and females, is a commonly occurring disease worldwide. Conventionally, no curative or satisfactory treatment is available for this condition. Therefore, in the current study, we aim to use platelet-rich plasma (PRP) as an alternative treatment option for the AGA patients.

MATERIALS AND METHODS

A total of 30 patients (20 men and 10 women) with AGA were included in the study between February 2017 and November 2017. Blood (9 cc) from each AGA patient was collected in 10 cc syringe, and PRP was isolated using commercially available kit under sterilized conditions. Isolated PRP was injected in the bald areas of scalp of AGA patients. The whole procedure was repeated after one month (two treatment sessions), and patients were followed for six months. The efficacy of PRP for restoration of hair was assessed using parameters such as hair density, terminal to vellus hair ratio, photographs, pull test, physician global assessment score, and patient global assessment score.

RESULTS

Mean hair density on first visit (before treatment) was 34.18 ± 14.36/cm² which was increased to 50.20 ± 15.91/cm² after 6 months of first treatment (P value <0.05). On a scale of three, mean scores of physician and patient global assessments were 1.45 ± 0.57 and 1.60 ± 0.62, respectively. Mean percentage reduction of hair pulled was 29.2% (P value <0.05) after PRP treatment. Terminal to vellus hair ratio was increased in 60% of patients after PRP therapy. No remarkable adverse effects were noted in patients.

CONCLUSION

Results showed that PRP is an effective treatment option in androgenetic alopecia as indicated by higher hair density, satisfactory physician and patient global assessment scores, and increase in terminal to vellus hair ratio.

Advances in Regenerative Stem Cell Therapy in Androgenic Alopecia and Hair Loss: Wnt pathway, Growth-Factor, and Mesenchymal Stem Cell Signaling Impact Analysis on Cell Growth and Hair Follicle Development

The use of stem cells has been reported to improve hair regrowth in several therapeutic strategies, including reversing the pathological mechanisms, that contribute to hair loss, regeneration of hair follicles, or creating hair using the tissue-engineering approach. Although various promising stem cell approaches are progressing via pre-clinical models to clinical trials, intraoperative stem cell treatments with a one-step procedure offer a quicker result by incorporating an autologous cell source without manipulation, which may be injected by surgeons through a well-established clinical practice. Many authors have concentrated on adipose-derived stromal vascular cells due to their ability to separate into numerous cell genealogies, platelet-rich plasma for its ability to enhance cell multiplication and neo-angiogenesis, as well as human follicle mesenchymal stem cells. In this paper, the significant improvements in intraoperative stem cell approaches, from in vivo models to clinical investigations, are reviewed. The potential regenerative instruments and functions of various cell populaces in the hair regrowth process are discussed. The addition of Wnt signaling in dermal papilla cells is considered a key factor in stimulating hair growth. Mesenchymal stem cell-derived signaling and growth factors obtained by platelets influence hair growth through cellular proliferation to prolong the anagen phase (FGF-7), induce cell growth (ERK activation), stimulate hair follicle development (β-catenin), and suppress apoptotic cues (Bcl-2 release and Akt activation).

A prospective study comparing topic platelet-rich plasma vs. placebo on reducing superficial perioral wrinkles and restore dermal matrix

Introduction: The goal of our prospective study was to assess the efficacy of the topical Platelet-rich plasma on reducing superficial perioral wrinkles and restoring the dermal matrix. Materials and methods: 50 women with moderate to severe perioral wrinkles were treated on the perioral area by a single session of fractional CO2 laser skin resurfacing plus intradermal injection of prp. 25 patients (group 1) applied topically prp twice a day for 12 weeks as post laser treatment. 25 (group 2) applied gentamicin and betamethasone twice a day for the first 7 days and then hyaluronic acid gel for the following 12 weeks. Results: In group 1, moisture (p < 0.001), amount of collagen fiber (p < 0.001) skin elasticity (p < 0.001), PSAl (p < 0.001) and SSAl (p < 0.001) improved significantly. In group 2 all the parameters investigated improved but did not reach significant difference. Discussion: Our medical device with a plasma-like formulation is able to maintain prp active for a period of 7 days so patients are able to apply topically growth factors at home. Conclusions: Our prospective study proves that the use of topical prp reduces superficial perioral wrinkles and restore dermal matrix when used at home for 12 weeks.

Platelet-Rich Plasma and Micrografts Enriched with Autologous Human Follicle Mesenchymal Stem Cells Improve Hair Re-Growth in Androgenetic Alopecia. Biomolecular Pathway Analysis and Clinical Evaluation

Platelet rich plasma (PRP) and Micrografts containing human follicle mesenchymal stem cells (HF-MSCs) were tried as a potential treatment for androgenetic alopecia (AGA). However, little to no work has yet to be seen wherein the bio-molecular pathway of HF-MSCs or PRP treatments were analyzed. The aims of this work are to report the clinical effectiveness of HF-MSCs and platelet-rich plasma evaluating and reviewing the most updated information related to the bio-molecular pathway. Twenty-one patients were treated with HF-MSCs injections and 57 patients were treated with A-PRP. The Wnt pathway and Platelet derived-growth factors effects were analyzed. 23 weeks after the last treatment with mean hair thickness increments (29 ± 5.0%) over baseline values for the targeted area. 12 weeks after the last injection with A-PRP mean hair count and hair density (31 ± 2%) increases significantly over baseline values. The increment of Wnt signaling in Dermal Papilla Cells evidently is one of the principal factors that enhances hair growth. Signaling from mesenchymal stem cells and platelet derived growth factors positively influences hair growth through cellular proliferation to prolong the anagen phase (FGF-7), inducing cell growth (ERK activation), stimulating hair follicle development (β-catenin), and suppressing apoptotic cues (Bcl-2 release and Akt activation).

Controversies in Hair Transplantation

Hair transplantation being a relatively new field, several aspects raise issues and controversies. The issues refer to both ethics and evidence and how practitioners and the community need to deal with them. This article deals with few of such diverse issues as follicular unit transplantation versus follicular unit excision, safe donor area, platelet-rich plasma, and minimum qualification for performing hair transplantation.

Alopecia and techniques in hair restoration: an overview for the cosmetic surgeon

PURPOSE

Alopecia is a debilitating disorder affecting millions of individuals worldwide. Although challenging to treat, advances in hair restoration technologies have led to multiple viable options with excellent clinical results. This paper seeks to provide an overview of hair loss and the currently utilized techniques in hair transplantation in order to serve as a reference source for the facial plastic surgeon.

METHODS

A comprehensive review of recent literature regarding the evaluation of, and management modalities for, alopecia was performed.

RESULTS

The follicular unit extraction technique and the strip harvest technique are both widely used for patients desiring transplantation. While both techniques can lead to successful outcomes, each has pros and cons that are important to understand prior to engaging in the procedure.

CONCLUSION

Advancements in hair restoration technologies implementing robotics, manual, or motorized follicular unit extraction have facilitated optimization of outcomes. Adjuvant treatment modalities including robotics and platelet-rich plasma injections have shown utility in augmenting transplantation.

Review of Human Hair Follicle Biology: Dynamics of Niches and Stem Cell Regulation for Possible Therapeutic Hair Stimulation for Plastic Surgeons

Plastic surgeons are frequently asked to manage male- and female-pattern hair loss in their practice. This article discusses the epidemiology, pathophysiology, and current management of androgenetic alopecia and emphasizes more recent knowledge of stem cell niches in hair follicles that drive hair cycling, alopecia, and its treatment. The many treatment programs available for hair loss include newer strategies that involve the usage of growth factors, platelet-rich plasma, and fat to stimulate follicle growth. Future research may clarify novel biomolecular mechanisms that target specific cells that promote hair regeneration.Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Efficacy of Platelet-Rich Plasma in the Field of Hair Restoration and Facial Aesthetics—A Systematic Review and Meta-analysis

As a promising alternative to traditional treatment, platelet-rich plasma (PRP) is being used to encourage hair growth through the release of growth factors and cytokines. In addition to hair restoration, PRP’s multifactorial capabilities can also be used to treat aging skin, facial scarring, and acne. The purpose of this review is to critically examine the success of PRP in the field of dermatology, with specific attention to the role of PRP in hair restoration. Where possible, meta-analyses were used to evaluate the efficacy of PRP. In androgenetic alopecia (AGA) patients, 3 monthly PRP injections (1 session administered every month for 3 months) exhibited greater efficacy over placebo as measured by change in total hair density (hair/cm2) over the treatment period (mean difference: 25.61, 95% CI: 4.45 to 46.77; P = .02). The studies included in the meta-analysis used a half-head design, which may have influenced the results because of the effects PRP can induce. Controlled studies suggest that 2 to 4 sessions of PRP combined with traditional therapies and procedures can help minimize acne scarring and facial burns, improve aesthetic results, and decrease recovery time. However, data for these indications are lacking and are less robust in design. In conclusion, to achieve an improvement in hair restoration in patients with mild AGA, 3 initial monthly PRP injections should be given. Only upon completion of rigorous, randomized, controlled studies can standardized and effective PRP protocols for treating dermatology conditions such as acne scarring, facial burns, and aging skin be determined.

Injectable-Platelet-Rich Fibrin-Smart Blood with Stem Cells for the Treatment of Alopecia: A Report of Three Patients

Hair loss or alopecia in males is very common, and so is its treatment. Until now, platelet-rich plasma has been in use for hair regeneration, which has shown results but lacks regenerative potential as compared to platelet-rich fibrin (PRF). Injectable-PRF (i-PRF) is advanced version of PRF in liquid form which can be injected and contains stem cells with high regenerative potential. Hair regeneration in Type VI and Type VII was observed which are difficult to treat. Hair growth with i-PRF has better regenerative potential. All cases reported showed improvement in hair growth.

A Study to Compare the Efficacy of Platelet-rich Plasma and Minoxidil Therapy for the Treatment of Androgenetic Alopecia

Background

Androgenetic alopecia (AGA) is the most common cause of hair loss in men with limited treatment options. Platelet-rich plasma (PRP) therapy is one of the newer treatment options in the management of AGA which has shown promising results.

Aims and Objectives

This study was aimed at comparing the clinical efficacy of PRP therapy with minoxidil therapy.

Materials and Methods

In the study, patients were randomized into two groups - Group A (given PRP therapy) and Group B (given minoxidil therapy). Both groups were followed up over a period of 6 months, and final analysis was done with the help of global photography, hair pull test, standardized hair growth questionnaire, patient satisfaction score; in addition, a comparison of platelet counts in PRP was done, to know that if a clinical correlation exists between platelet concentration and clinical improvement. A total of 40 patients clinically diagnosed with AGA were enrolled in the study with 20 patients in each group. Four patients from Group A (PRP) and six patients from Group B (minoxidil) could not complete the treatment for 6 months and were eventually excluded.

Results

At the end of 6 months, 30 patients were evaluated to compare the efficacy of intradermal PRP and topical minoxidil therapy. On global photography, Group A (PRP) was found to have a comparatively better outcome than Group B (minoxidil). In hair pull test, hair growth questionnaire, and patient satisfaction score, Group A was found to be better than Group B. Mean platelet count at baseline was 3.07 ± 0.5 lac/mm, 3 while platelet count in final PRP prepared was 12.4 ± 1.7 lac/mm, and patients with a higher platelet count in PRP had a much better clinical improvement compared to patients with a low platelet count in PRP. Side effects with PRP therapy were minimal with better results which may improve the compliance of the patient.

Conclusion

PRP therapy can be a valuable alternative to topical minoxidil therapy in the treatment of AGA.

Review of Hair Follicle Dermal Papilla cells as in vitro screening model for hair growth

Hair disorders such as hair loss (alopecia) and androgen dependent, excessive hair growth (hirsutism, hypertrichosis) may impact the social and psychological well-being of an individual. Recent advances in understanding the biology of hair have accelerated the research and development of novel therapeutic and cosmetic hair growth agents. Preclinical models aid in dermocosmetic efficacy testing and claim substantiation of hair growth modulators. The in vitro models to investigate hair growth utilize the hair follicle Dermal Papilla cells (DPCs), specialized mesenchymal cells located at the base of hair follicle that play essential roles in hair follicular morphogenesis and postnatal hair growth cycles. In this review, we have compiled and discussed the extensively reported literature citing DPCs as in vitro model to study hair growth promoting and inhibitory effects. A variety of agents such as herbal and natural extracts, growth factors and cytokines, platelet-rich plasma, placental extract, stem cells and conditioned medium, peptides, hormones, lipid-nanocarrier, light, electrical and electromagnetic field stimulation, androgens and their analogs, stress-serum and chemotherapeutic agents etc. have been examined for their hair growth modulating effects in DPCs. Effects on DPCs' activity were determined from untreated (basal) or stress induced levels. Cell proliferation, apoptosis and secretion of growth factors were included as primary end-point markers. Effects on a wide range of biomolecules and mechanistic pathways that play key role in the biology of hair growth were also investigated. This consolidated and comprehensive review summarizes the up-to-date information and understanding regarding DPCs based screening models for hair growth and may be helpful for researchers to select the appropriate assay system and biomarkers. This review highlights the pivotal role of DPCs in the forefront of hair research as screening platforms by providing insights into mechanistic action at cellular level, which may further direct the development of novel hair growth modulators.

Platelet-rich plasma for androgenetic alopecia: A review of the literature and proposed treatment protocol

Androgenetic alopecia (AGA) is a common hair loss disorder caused by genetic and hormonal factors that are characterized by androgen-related progressive thinning of scalp hair in a defined pattern. By the age of 60 years, 45% of men and 35% of women develop AGA. Currently, U.S. Food and Drug Administration-approved treatments for AGA include oral finasteride and topical minoxidil. Due to the limited number of effective therapies for AGA, platelet-rich plasma (PRP) has become an effective alternative treatment. PRP is an autologous concentration of platelets in plasma with numerous growth factors that contribute to hair regeneration. The growth factors contained within the alpha granules of platelets act on stem cells in the bulge area of the hair follicles and stimulate the development of new follicles along with neovascularization. PRP has become a promising treatment modality for AGA. Although there have been several studies previously reported, a standard practice for PRP preparation and administration as well as a method to evaluate results have not been established. This literature review was conducted to evaluate the effectiveness of PRP for AGA and discuss the various treatment protocols that have been proposed.

Introducing Platelet-Rich Stroma: Platelet-Rich Plasma (PRP) and Stromal Vascular Fraction (SVF) Combined for the Treatment of Androgenetic Alopecia

BACKGROUND

Androgenetic alopecia (AGA) is characterized by miniaturization of the hair follicles gradually causing conversion of terminal hairs into vellus hairs, leading to progressive reduction of the density of hair on the scalp. Approved therapeutic options are limited and show side effects.

OBJECTIVES

To evaluate injections of stromal vascular fraction (SVF), which is rich in adipose-derived stromal cells (ASCs) in combination with platelet-rich plasma (PRP) in the upper scalp as a new autologous treatment option for AGA.

METHODS

Ten male patients (age range, 25-72 years), suffering from AGA at stage II to III according to the Norwood-Hamilton scale, have been treated with a single injection of autologous PRS (ACPSVF: combination of PRP and SVF) in the upper scalp. Preinjection and 6 and 12 weeks postinjection changes in hair density were assessed using ultra high-resolution photography (Fotofinder).

RESULTS

Hair density was significantly increased after 6 weeks and 12 weeks postinjection (P = 0.013 and P < 0.001). In hair-to-hair matching analyses, new hair grew from active follicles. Furhtermore nonfunctioning hair follicles filled with hyperkeartotic plugs, up to today assumed incapable of forming new hair, proved to grow new hair. No side effects were noted after treatment.

CONCLUSIONS

A single treatment of platelet-rich stroma injected in the scalp of patients with AGA significantly increased hair density within 6 to 12 weeks. Further research is required to determine the optimal treatment regimen. Preferred options to our opinion include the repetition of PRS or additional treatments with PRP.

LEVEL OF EVIDENCE 4

Platelet rich plasma for the management of hair loss: Better alone or in combination?

Platelet-rich plasma (PRP) and autologous protein-based treatments have recently emerged as a potential therapeutic approach for hair loss-related disorders including androgenetic alopecia and alopecia areata. The safety and efficacy of repeated intradermal injections of PRP has proved to promote hair growth in a number of randomized clinical trials. Biologically active proteins and cytokines released upon platelet activation have shown to induce folliculogenesis and activate the anagen growing phase of dormant bulbs. Interestingly, further studies have revealed that combining PRP with other hair loss-related products may enhance the final performance of the treatment. These synergistic approaches include Food and Drug Administration (FDA) approved drugs such as finasteride or minoxidil, bioactive macromolecules and cell-based therapies. Here, recent research involving alone or combined therapy with platelet-rich plasma for the management of hair loss-related disorders are outlined and future prospects are discussed.

A Novel and Convenient Method for the Preparation and Activation of PRP without Any Additives: Temperature Controlled PRP

Platelet rich plasma (PRP) is a concentrate of autologous platelets which contain enrichment growth factors (GFs). However, the addition of exogenous anticoagulant and procoagulant may result in clinical side effects and raise the price of PRP. Herein, we report a novel method named temperature controlled PRP (t-PRP), in which exogenous additives are dispensable in the preparation and activation process. Human blood samples were processed by a two-step centrifugation process under hypothermic conditions (4°C) to obtain t-PRP and rewarming up to 37°C to activate t-PRP. Contemporary PRP (c-PRP) was processed as the control. t-PRP showed a physiological pH value between 7.46 and 7.48 and up to 6.58 ± 0.45-fold significantly higher platelet concentration than that of whole blood compared with c-PRP (4.06-fold) in the preparation process. Meanwhile, t-PRP also maintained a stable GF level between plasma and PRP. After activation, t-PRP demonstrated natural fiber scaffolding, which trapped more platelet and GFs, and exhibited a slow release and degradation rate of GFs. In addition, t-PRP exhibited the function of promoting wound healing. t-PRP is a novel and convenient method for the preparation and activation of PRP without any additives. Compared to c-PRP, t-PRP reflects more physiologic characteristics while maintaining high quality.

Comparison of the Efficacy of Homologous and Autologous Platelet-Rich Plasma (PRP) for Treating Androgenic Alopecia

BACKGROUND

Androgenetic alopecia (AGA), the most common cause of hair loss in both sexes, accounts for 95% of all cases of hair loss. Although the literature has suggested that both nonactivated (n-PRP) and activated autologous (a-PRP) PRP can be used to treat AGA, we did not find any study investigating the use of homologous PRP (h-PRP) for this purpose. Also, to the best of our knowledge, there are no studies comparing the efficacy of h-PRP, a-PRP, or n-PRP on AGA therapy.

OBJECTIVES

The aim of this study was to compare the increase in hair density, average number of platelets, complications, preparation, and duration of application in the treatment of AGA using a-PRP, n-PRP, and h-PRP.

METHODS

Between 2014 and 2015, we studied male patients who had experienced increased hair loss in the last year. Patients were divided into three groups: Group 1 received n-PRP, Group 2 received active PRP, and Group 3 received h-PRP. For Group 1, PRP was prepared by a single centrifugation prepared from the patient's own blood. For Group 2, the PRP was prepared from the patient's own blood, but a second centrifugation was applied for platelet activation with calcium chloride. For Group 3, the PRP was prepared from pooled platelets with the same blood group as the patient from the blood center. PRP was injected at 1, 2, and 6 months. The hair density (n/cm²) of each patient before and after injection was calculated. Each patient was assigned a fixed evaluation point at the time of application to calculate hair density.

RESULTS

At 2, 6, and 12 months after the first treatment, the increase in hair density was calculated as 11.2, 26.1, and 32.4%, respectively, in Group 1; 8.1, 12.5, and 20.8%, respectively, in Group 2; and 16.09, 36.41, and 41.76%, respectively, in Group 3. The increase in hair density was statistically significantly greater in Group 1 than in Group 2 and more so in Group 3 than in both groups among all controls (p < 0.05).

CONCLUSION

The efficacy of both PRPs was determined in AGA treatment in our study. However, it was determined statistically that the increase in hair density with h-PRP was greater than with autologous PRP groups. We believe that h-PRP therapy can be used in patients with AGA presenting with hair loss.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Mechanical and Controlled PRP Injections in Patients Affected by Androgenetic Alopecia

23 patients (18 male and 5 female) aged 21-70 years who displayed male pattern hair loss (MPHL) in Stage 1 to Stage 5 as determined by the Norwood-Hamilton classification scale, and female pattern hair loss (FPHL) in Stage 1 to Stage 2 as determined by the Ludwig classification scale, were treated with non-activated autologous platelet-rich plasma (A-PRP). Autologous blood (55 mL) was harvested using sodium citrate as an anticoagulant. A-PRP (23 mL) was produced for all cases using a closed system according to the transfusion service protocol. Following centrifugation (260 x g for 10 min) the A-PRP was inserted in a laser light selector device, and after the centrifugation, 9 mL of A-PRP was collected. The scalp of the patients affected by androgenetic alopecia (AGA) was divided into four areas (frontal, parietal, vertex, and occipital); local anesthesia was not performed. Interfollicular A-PRP injections (0.2 mL x cm²) were performed by controlled and mechanical injections scheduled at a depth of 5 mm using a medical injector gun. Treatment sessions were performed with a 30-day interval. For each patient, three treatment sessions were performed. PRP was injected in the androgen-related areas of scalp affected by hair loss. Placebo (normal saline solution) was loaded in another syringe (10 mL) and injected on the adjacent side in a similar fashion.

An Overview of the Biology of Platelet-Rich Plasma and Microneedling as Potential Treatments for Alopecia Areata

Platelet-rich plasma and microneedling have been investigated recently as potential therapeutic options for the treatment of hair disorders. Evidence from laboratory studies indicates that these treatments enhance growth factor production that in turn facilitates hair follicle development and cycling. Several small studies and case reports have presented encouraging findings regarding the use of these treatments for alopecia areata. Future investigations will be needed to validate these therapeutic techniques for patients with alopecia areata and further refine which subtypes of the disease these methods are best indicated for.

A Meta-analysis On Evidence Of Platelet-rich Plasma for Androgenetic Alopecia

Background:

Platelet-rich plasma (PRP) treatment has gained popularity among different surgical specialities for improving various conditions. Androgenetic alopecia (AGA) is a common disorder, with possible psychosocial implications. Plastic surgeons have increased the practice of PRP injections for hair restoration. A meta-analysis on this topic was performed comparing local injection of PRP versus control to investigate the efficacy of local PRP injections in AGA.

Methods:

We performed a systematic literature search. The increase in number of hairs was the primary outcome. Secondary outcomes were the increase of hair thickness and the percentage increase in hair number and thickness.

Results:

Seven studies involving 194 patients were retrieved and included in the present analysis. A significantly locally increased hair number per cm² was observed after PRP injections versus control (mean difference [MD] 14.38, 95% confidence interval [CI] 6.38–22.38, P < 0.001). Similarly, a significantly increased hair thickness cross-section per 10⁻⁴ mm² (MD 0.22, 95% CI 0.07–0.38, P = 0.005) favoring PRP group. The pooled results did not show a significant percentage increase in hair number (MD 18.79%, 95% CI − 8.50–46.08, P = 0.18), neither hair thickness (MD 32.63%, 95% CI − 16.23–81.48, P = 0.19) among patients treated with PRP.

Conclusion:

Local injection of PRP for androgenic alopecia might be associated with an increased number of hairs in the treated areas with minimal morbidity, but there is clearly a lack of scientific evidence on this treatment modality. Further studies are needed to evaluate the efficacy of PRP for AGA.

Evidence-based (S3) guideline for the treatment of androgenetic alopecia in women and in men - short version

Androgenetic alopecia is the most common hair loss disorder, affecting both men and women. Initial signs of androgenetic alopecia usually develop during teenage years leading to progressive hair loss with a pattern distribution. Moreover, its frequency increases with age and affects up to 80% Caucasian men and 42% of women. Patients afflicted with androgenetic alopecia may undergo significant impairment of quality of life. The European Dermatology Forum (EDF) initiated a project to develop evidence-based guidelines for the treatment of androgenetic alopecia. Based on a systematic literature research the efficacy of the currently available therapeutic options was assessed and therapeutic recommendations were passed in a consensus conference. The purpose of the guideline is to provide dermatologists with an evidence-based tool for choosing an efficacious and safe therapy for patients with androgenetic alopecia.

Alopecia and platelet-derived therapies

Background

Platelet rich plasma (PRP) injections have emerged as a promising regenerative therapy for androgenetic alopecia (AGA). To date, injections of both autologous native and activated PRP have been administered to hair loss patients, and positive results have been observed. However, little to no work has yet to be seen wherein PRP treatments are combined with hair restoration surgeries. Furthermore, the PRP activation protocol in the hair restoration setting employs compounds with potentially deleterious side effects, namely thrombin or calcium gluconate. Therefore, the objectives of this work are to evaluate the effectiveness of platelet and platelet-derived products as augmented graft therapies in hair restoration surgeries and to compare the follicular regeneration rate of follicles transplanted in the presence of platelet lysate (PL) versus activated PRP (AA-PRP).

Methods

PL was administered to the frontal scalp of three male AGA patients. Three treatment zones measuring 4 cm^-2 were mapped in the midline scalp region of each patient and equal number of follicular grafts were placed in each box along with PL, AA-PRP, or normal saline. The transplanted follicular grafts of a fourth patient were placed solely with PL. Hair checks in which the surface area of hair coverage was quantified were performed at follow-up appointments ranging from 3.5 to 7 months post-surgery. In these appointments, the number of follicular units with hairs measuring 50 mm or more were counted to determine the percentage of graft hair regeneration. Growth factor (GF) concentrations [vascular endothelial growth factor (VEGF), transforming growth factor beta 1 (TGF-β1), PDGF-BB, IGF-1] in PL and AA-PRP were also measured for an independent subject set.

Results

Follicular regeneration in transplanted grafts was found to be superior for those placed with PL rather than AA-PRP or saline at all follow-up dates. Specifically, at 3.5 months post-op, 89%±9%, 74%±7%, and 57%±10% of follicular units had regenerated hair in the PL, AA-PRP, and saline treatment zones, respectively. At 4 months post-op, 99%, 75%, and 71% of follicle regeneration had occurred in the PL, AA-PRP, and saline treatment areas, respectively. Impressively, when PL was injected alone, the patient experienced a 50% increase in follicular unit density and a 122% increase in hair density 7 months post-injection. When GF concentrations were measured, PL generated from a 30-min sonication of PRP was found to have significantly higher levels of VEGF, PDGF-BB, and TGF-β1 than AA-PRP.

Conclusions

PRP remains a promising hair loss therapy and should be evaluated further for use not only as an independent therapeutic tool, but also as a treatment to augment surgical procedures. PL in particular affords an effective and efficacious therapeutic product given that the lysate may be obtained by mechanical rather than chemical means. Ultrasonic waves provide sufficient energy to rupture platelet cell walls, and centrifugation may be used to separate the lysate from cell fragments prior to delivery.

Efficacy of subcutaneous injection of platelet-rich plasma in alopecia: A clinical and histological pilot study on a rat model with a six-month long-term follow-up experience

PURPOSE

To assess the potential of platelet-rich plasma (PRP) subcutaneous injection of to treat alopecia and to evaluate local toxicity.

MATERIALS-METHODS

Twelve Hairless rats were used. At D0, we performed systematic clinical examination and divided the rat back into four quadrants (Q). We initiated subcutaneous injection using either PRP in PRPQ+, platelet-poor plasma (PPP) in PPPQ+, physiological serum (PS) in PSQ+, or no treatment (Q4). At D7, D14, D21, and D28 but also second month (M2), M3, M4, M5, rats had exactly the same injection procedure. Follow-up with PRP efficacy and toxicity at D28 and M6 using clinical and histological evaluation was performed.

RESULTS

Hair density was significantly improved at D28 and at M6 for PRPQ+ vs PSQ+ (respectively, P = .0156 and P = .0313), PPPQ+ (respectively, P = .042 and P = .046). Significant histological improvement was observed between D28 and M6, for PRPQ+ vs PPPQ+ and PSQ+ for vessels (respectively, P = .0160 and P = .021), collagen (respectively, P = .0036 and P = .032), and epithelium (respectively, P = .0138 and P = .022) with no local toxicity.

CONCLUSION

Our study suggests that subcutaneous PRP injections using controlled concentration of platelets and leukocytes improve hair growth.

Combination Therapy for Male Cosmetic Patients

This article reviews the most common male cosmetic procedures that are performed in combination with more than one procedure. Evidence-based medicine for many of these combination therapies is not rampant in the medical literature, but the author uses his current experience to share how combining therapies can be useful for our male population seeking cosmetic improvements in our offices.