The potential role of minoxidil in the hair transplantation setting

Combination therapy in female pattern hair loss

Patterned hair loss is a common type of non-scarring alopecia, characterized by miniaturization of hair follicles. The etiology of female pattern hair loss (FPHL) is not clearly linked to androgens or other hormones thereby making it a challenging condition to treat. Various treatment modalities, like minoxidil (topical or oral), spironolactone, finasteride, have been tried alone or in combination with variable results. Combination therapy is superior to the monotherapy, since these multiple treatment modalities act by targeting different pathogenetic pathways, making the treatment aggressive and more effective.

Pharmacological Management of Pattern Hair Loss

Pattern hair loss (PHL) is a condition that worsens with time and the only way it can be slowed down is with pharmacological intervention. Pharmacological treatments for PHL, from an evidenced-based perspective with respect to safety and efficacy, are limited to only two drugs, minoxidil and finasteride. However, there are a host of drugs being used, off-label with limited evidence. This article attempts to review the literature on this topic, and the authors add to this, with their experience of over two decades on incorporating pharmacologic treatments along with hair transplantation in their management of PHL.

Head and Neck Restoration in Scar Alopecia: Hair Transplantation in Scalp, Eyebrows, Beard and Mustache

BACKGROUND

Surgical management of hair loss has become an increasingly challenging procedure, when dealing with scar alopecia. We investigated the efficacy of hair transplantation in patients with head and neck scar alopecia.

METHODS

From 2016 to 2018 in Shiraz, Iran, all patients with scar alopecia in head and neck were evaluated for efficacy of follicular unit extraction (FUE), follicular unit transplantation (FUT) or a combination of two methods from donor sites in scalp and beard various hair-grafts were compared.

RESULTS

Fifty-six patients were enrolled. Most of them were between 31 and 40 yr old (48.3%) and male (71.4%). Trauma, burn, surgical excision of adjacent skin, radiotherapy and leishmaniasis were the registered causes. Scars were visible in scalp (39.3%), beard (28.6%), eyebrow (21.4%), and moustache (10.7%) regions. FUE (87.5%), FUT (10.7%) and a combination (1.8%) were the used methods. One-hair-grafts were used in eyebrows (100%), moustache (100%), beard (88%) and scalp (7.9%), while 2-hair-grafts in beard (6%) and scalp (47.4%) and 3-haired grafts in beard (6%) and scalp (44.7%) transplantations.

CONCLUSION

In head and neck scar alopecia, hair transplantation was selected based on type and depth of scar. FUE was targeted when huge grafts were not needed, including beard, moustache, and eyebrow, while FIT was used when extensive scars were present in scalp. One-hair-grafts were mostly applied for eyebrow, moustache and beard, 2-hair- and 3-hair- grafts for beard and scalp transplantation. These findings can be added to the literature when FUE, FIT, or their combination are targeted in hair restoration of scar alopecia in head and neck.

In vivo evaluation of insect wax for hair growth potential

Insect wax is secreted by Ericerus pela Chavanness. It has been traditionally used to treat hair loss in China, but few reports have been published on the hair growth-promoting effect of insect wax. In this work, we examined the hair growth-promoting effects of insect wax on model animals. Different concentrations of insect wax were topically applied to the denuded backs of mice, and 5% minoxidil was applied topically as a positive control. We found that insect wax significantly promoted hair growth in a dose-dependent manner, 45% and 30% insect wax both induced hair to regrow, while less visible hair growth was observed in blank controls on the 16^th day. The experimental areas treated with 45% and 30% insect wax exhibited significant differences in hair scores compared to blank controls, and hair lengths in the 45% and 30% insect wax group was significantly longer than in blank controls on the 16^th and 20^th days. There were no new hair follicles forming in the treated areas, and the hair follicles were prematurely converted to the anagen phase from the telogen phase in experimental areas treated with 45% and 30% insect wax. Both 45% and 30% insect wax upregulated vascular endothelial growth factor expression. The results indicated that 45% and 30% insect wax showed hair growth-promoting potential approximately as potent as 5% minoxidil by inducing the premature conversion of telogen-to-anagen and by prolonging the mature anagen phase rather than increasing the number of hair follicles, which was likely related to the upregulation of VEGF expression. The dissociative policosanol in insect wax was considered the key ingredient most likely responsible for the hair growth promoting potential.

Perception of Hair Transplant for Androgenetic Alopecia

Importance

Hair transplant is among the most common cosmetic services sought by men, with more than 11 000 procedures performed in 2014. Despite its growing popularity, the effect of hair transplant on societal perceptions of youth, attractiveness, or facets of workplace and social success is unknown.

Objectives

To determine whether hair transplant improves observer ratings of age, attractiveness, successfulness, and approachability in men treated for androgenetic alopecia and to quantify the effect of hair transplant on each of these domains.

Design, Setting, and Participants

A randomized controlled experiment was conducted from November 10 to December 6, 2015, using web-based surveys featuring photographs of men before and after hair transplant. One hundred twenty-two participants recruited through various social media platforms successfully completed the survey. Observers were shown 2 side-by-side images of each man and asked to compare the image on the left with the one on the right. Of 13 pairs of images displayed, 7 men had undergone a hair transplant procedure and 6 had served as controls. Observers evaluated each photograph using various metrics, including age, attractiveness, successfulness, and approachability. A multivariate analysis of variance was performed to understand the effect of hair transplant on observer perceptions. Planned posthypothesis testing was used to identify which variables changed significantly as a result of the transplant.

Main Outcomes and Measures

Observer ratings of age (in number of years younger) and attractiveness, successfulness, and approachability (on a scale of 0 to 100; scores higher than 50 indicate a positive change).

Results

Of the 122 participants in the survey, 58 were men (47.5%); mean (range) age was 27.1 (18-52) years. The initial multivariate analysis of variance revealed a statistically significant multivariate effect for transplant (Wilks λ = 0.9646; P < .001). Planned posthypothesis analyses were performed to examine individual differences across the 4 domains. Findings determined with t tests showed a significant positive effect of hair transplant on observers' perceptions of age (mean [SD] number of years younger, 3.6 [2.9] years; P < .001), attractiveness (mean [SD] score, 58.5 [17.5]; P < .001), successfulness (mean [SD] score, 57.1 [17.1]; P = .008), and approachability (mean [SD] score, 59.2 [18.1]; P = .02).

Conclusions and Relevance

Men were perceived as being younger and more attractive by casual observers after undergoing hair transplant. Participants also rated posttransplant faces as appearing more successful and approachable relative to their pretransplant counterparts. These aspects have been shown to play a substantial role in both workplace and social success, and these data demonstrate that hair transplant can improve ratings universally across all 4 domains.

Level of Evidence

NA.

Androgenetic Alopecia: An Update of Treatment Options

Androgenetic alopecia (AGA) is characterized by a non-scarring progressive miniaturization of the hair follicle in predisposed men and women with a pattern distribution. Although AGA is a very prevalent condition, approved therapeutic options are limited. This article discusses the current treatment alternatives including their efficacy, safety profile, and quality of evidence. Finasteride and minoxidil for male androgenetic alopecia and minoxidil for female androgenetic alopecia still are the therapeutic options with the highest level evidence. The role of antiandrogens for female patients, the importance of adjuvant therapies, as well as new drugs and procedures are also addressed.

Female pattern alopecia: current perspectives

Hair loss is a commonly encountered problem in clinical practice, with men presenting with a distinctive pattern involving hairline recession and vertex balding (Norwood-Hamilton classification) and women exhibiting diffuse hair thinning over the crown (increased part width) and sparing of the frontal hairline (Ludwig classification). Female pattern hair loss has a strikingly overwhelming psychological effect; thus, successful treatments are necessary. Difficulty lies in successful treatment interventions, as only two medications - minoxidil and finasteride - are approved for the treatment of androgenetic alopecia, and these medications offer mediocre results, lack of a permanent cure, and potential complications. Hair transplantation is the only current successful permanent option, and it requires surgical procedures. Several other medical options, such as antiandrogens (eg, spironolactone, oral contraceptives, cyproterone, flutamide, dutasteride), prostaglandin analogs (eg, bimatoprost, latanoprost), and ketoconazole are reported to be beneficial. Laser and light therapies have also become popular despite the lack of a profound benefit. Management of expectations is crucial, and the aim of therapy, given the current therapeutic options, is to slow or stop disease progression with contentment despite patient expectations of permanent hair regrowth. This article reviews current perspectives on therapeutic options for female pattern hair loss.

Medical treatments for male and female pattern hair loss

Male and female pattern hair loss affects a large percentage of the population, and patients frequently present for treatment of this to their dermatologist. Here we review the many treatments available for hair loss. We review the evidence for each, and outline the most effective treatment strategies for both men and women.

LEARNING OBJECTIVE

At the conclusion of this article, the reader should be able to describe the most effective treatments for hair loss, understand their mechanism(s) of action, and explain which treatments are the best in different settings.

Androgenetic alopecia

Androgenetic alopecia (AGA), or male pattern hair loss, affects approximately 50% of the male population. AGA is an androgen-related condition in genetically predisposed individuals. There is no treatment to completely reverse AGA in advanced stages, but with medical treatment (eg, finasteride, minoxidil, or a combination of both), the progression can be arrested and partly reversed in the majority of patients who have mild to moderate AGA. Combination with hair restoration surgery leads to best results in suitable candidates. Physicians who specialize in male health issues should be familiar with this common condition and all the available approved treatment options.

Hair transplantation for men and women

The goal of hair transplantation is to restore a natural, undetectable frame of hair to the face. From the 1960s into the late 1990s, using 10 to 25 hair, 3-4 mm grafts was the mainstay of hair transplantation, despite the fact hair naturally grows in the scalp in bundles of 1 to 4 hair follicles. The 10 to 25 hair grafts looked unnatural because they were unnatural on the scalp. Today, surgeons meticulously harvest the natural 1 to 4 hair follicular groupings from donor hair and implant them in the recipient region in men and women. This technique consistently creates natural-appearing hair. Women can benefit from transplantation as much as men.

Management of hair loss

The management of patients with hair loss requires a customized plan. Diagnosis, prognosis, psychosocial impact, treatment options, and patient preference are key determinants. This article discusses current agents for the treatment of three commonly encountered nonscarring alopecias: male- and female-pattern hair loss, telogen effluvium, and alopecia areata. Algorithmic approaches to management are provided.

A Short Peptide GPIGS Promotes Proliferation of Hair Bulb Keratinocytes and Accelerates Hair Regrowth in Mice

The aim of this study was to discover a novel agent that promotes hair growth. We carried out a screening test in 298 types of conditioned medium (CM) from cultures of bacteria by using a hair bulb keratinocyte (HBK) growth assay. As a result, we found a HBK growth factor in the CM of Bacillus sp. M18. This HBK growth factor was purified by collecting biologically active fractions in three steps, including HP-20 batch processing, LH-20 chromatography and C18 reverse-phase high-pressure liquid chromatography, and identified as a short peptide GPIGS. GPIGS increased Akt phosphorylation in HBKs. Moreover, the GPIGS-stimulated HBK growth was inhibited by the treatment with LY294002, an inhibitor of phosphatidylinositol 3-kinase (PI-3K). These results suggest that GPIGS promotes HBK growth via the PI-3K/Akt pathway. In addition to in vitro tests, GPIGS was found to accelerate hair regrowth in telogen mice. Our results indicate that GPIGS is a potential agent to promote hair growth.

Pharmacologic management of pattern hair loss

Pharmacologic management of pattern hair loss is an active area of research, and clinicians should be aware of new data and treatment modalities. Under-standing the proper role of pharmacology as it relates to surgical hair restoration and nonmedical options is crucial to provide patients with the best clinical,aesthetic, and psychological benefits.

Hair transplanting: an important but often forgotten treatment for female pattern hair loss

The techniques used in the early days of hair transplanting were not suitable for the treatment of a majority of women with pattern hair loss. For at least the last 10 years, changes in those techniques have resulted in a reversal of that situation. Today, many women with female pattern hair loss are suitable candidates for transplanting, however, this is not widely appreciated. This article provides potential explanations for this and demonstrates examples of the current methods. Hair transplanting should be considered as a potential treatment option for most women with pattern hair loss.