Hair Loss Management with PRP at AGA and Hair

Transplants

Introduction:

Androgenetic alopecia (AGA) is the most common form of hair loss. It can affect not only

men but also women (1). Prevalence increases with age, affecting up to 80% of men and 40%

of women (2). AGA can lead to a considerable impairment of the quality of life up to

depression (3). Therefore, early intervention and management of AGA with evidence-based

medicine (EBM) is of great importance (4.5). Autologous Platelet-Rich plasma (PRP) has

recently been used for AGA. However, the market has grown faster than the research for this

promising technology and there are still many open questions.

Objective: Development of a recommendation for an evidence-based management of AGA

with PRP and as an addition to hair transplants.

Recommendation on how to proceed with consultation and diagnosis

Before a possible treatment of hair loss with PRP, its cause must be clarified exactly. Because

PRP is not a meaningful therapy for everyone or any kind of hair loss. The temporal and

schematic course of the hair loss, possible stress-inducing events in the last 3 to 6 months as

well as current blood values must be examined.

No therapy should be carried out without sufficient diagnostics!!!!

Often it is only a case of diffuse hair loss (teleogenic effluvium) in which more hair falls out

over the whole head than usual. Hair loss can be an indication of an existing disease or the

result of a traumatic event that occurred shortly before. If the cause of the hair loss disappears,

in this case the hair also starts to grow again, i.e. the hair grows even without the use of PRP

(6).

Procedure in case of diffuse hair loss: clarify cause, remove trigger and wait and see

If you have recently changed a medication that may affect your hair metabolism, you will also

need to wait and see.

A dermatoscopic examination of the scalp is mandatory and a trichsoscan (Fig. 1,2) would be

desirable.

Over 90% of patients are diagnosed with AGA (1). This form of hair loss is hereditary and is

mostly of hormonal origin and follows a pattern which is classified according to Norwood (7)

in men as NW I - VII and in women as Ludwig (8) LW I - III (Fig.3).

Currently, topical minoxidil and oral finasteride are the only drugs approved by the Food and

Drug Administration (FDA) for the treatment of AGA (Fig. 4).

Currently available therapies are sometimes considered to have limited efficacy, which is why

it is very important to find new therapies such as PRP for this pathology (9).

Therapy management by AGA

AGA therapy management should be evidence-based to ensure the best possible consultation

and treatment. In practice, this means integrating individual clinical expertise with the best

available external evidence (10), taking into account the patient's values and wishes (Fig. 5).

The EBM is based on 3 pillars

- individual clinical experience

- current status of clinical research (Table 3-S3 Guideline)

- Values and wishes of the patient

In order to be able to make a recommendation for the various therapeutic approaches of AGA

treatment according to the best EBM principles, an evidence level was assigned to each

therapy per se. A low level corresponds to a high evidence level, a high level to a low

evidence level (Table 1).

The level of evidence is determined by the fact that each study is assigned a quality level (A1

= randomized double-blind studies with high quality to D = expert opinion with low quality).

The quality grades of all studies belonging to a therapy scheme are then combined into an

evidence level (Table 2) (4.5).

The resulting evidence levels of the various therapy approaches for AGA are listed in Table 3

and serve as guideline S3 (11) for orientation in the recommendation for the management of

AGA therapy. This primarily takes into account their level of evidence, the therapy results to

be expected, the practicability for physician and patient as well as the compliance of the

patient. Together, the 3 pillars of EBM should decide which individualized therapy is best

suited for the patient (Table 3).

New recommendation of the S3 Guideline and current therapy approaches today and in

the future for the AGA.

While minoxidil and finasteride have been the only evidence-based therapies for AGA in

recent decades, further developments with new approaches have progressed in recent years.

Figure 6 shows the main components of AGA pathogenesis and current and future therapeutic

approaches (12). Very much correspondingly, the topical

25% finasteride solution (13), which, like the topical androgen receptor blocker Clascoterone

(14), is still in the preclinical study phase. For the efficacy of prostaglandin (PGE2 and PGF2)

analogues and PDG2 antagonists (15) the result of an ongoing study (16) has yet to be

determined. For other approaches such as JAK inhibitors (17), stem cell therapy (18),

mesotherapy (19) and carboxytherapy (20), there is currently no sufficient scientific evidence

of efficacy. Currently, only low-level laser therapy (LLLT) (evidence level 2) and PRP

(evidence level 3) meet the criteria of the S3 guideline in order to be recommended for AGA

management alongside minoxidil and finasteride. Evidence level 3 in PRP was achieved

through two studies evaluating the efficacy of PRP in male and female patients with AGA,

both with evidence level C and meeting inclusion criteria for the guideline (21,22,23).

However, there is currently no standard procedure for PRP, no standardized techniques or kits

for isolation and activation, and no standardized protocols for dosage and frequency of

injections. There is also uncertainty about the combination with other substances and cells. It

is therefore difficult to objectively assess the impact of PRP on AGA in order to achieve a

higher level of evidence in the long term.

Postulated effect of PRP

The platelets enriched in PRP produce growth factors that positively influence proliferation,

survival and differentiation of many different cells. This also seems to be true for hair follicle

cells. The higher the number of platelets, the higher the concentration of growth factors. The

most important growth factors involved in hair follicle formation are probably vascular

endothelial growth factor (VEGF), epidermal growth factor (EGF), insulin-related growth

factor (IGF)-1 and fibroblast growth factors (FGFs) (24,25).

AGA results from the shortening of the anagen phase and extension of the telogen phase

which results in follicle miniaturization. The injection of activated PRP into mice was shown

to reverse this process with an increased anagen telogen rate and a larger number of hair

follicles in the anagen phase (26) (Fig.7).

A similar conclusion was reached by Li and colleagues (2012) who found that activated PRP

stimulates the proliferation of human DP cells, promotes the survival of hair follicle cells

through its anti-apoptotic effects (Akt) on dermal papilla (DP) cells and can stimulate hair

growth by prolonging the anagen phase of the hair cycle (27) (Fig.8). The most likely

mechanisms of action are the triggering of various signalling cascades including the β-

Catenin (BC) pathway, the extracellular signal-regulated kinase (ERK) cascade and the

protein kinase B (Akt) cascade, which positively affect cell survival, proliferation and

differentiation (28).

Activate or not activate?

Growth factors are usually physiologically present in an inactive form. It should not be

debated whether these factors have to be activated in order to achieve an effect.

The important question is "how and when to activate".

Options include calcium chloride, bovine thrombin, mechanical (e.g. ultrasound, etc.) or

autologous thrombin serum. In a recently published study by Inslaco, a significantly improved

Hair mass index for activation with 20Hz ultrasound of 48% was found compared to 25% in

the calcium chloride control group. There was also an increased hair density (57% compared

to 33%) and a larger hair diameter (10% compared to the initial level of 0%) (29) But also

other activation methods such as extracellular matrix (Acell), autologous lipocytes or fat stem

cells can achieve good results.

PRP Protocol - Techniques to be considered

Different PRP protocols differ significantly in preparation and execution. It is recommended

to use platelet concentrations 1.5 to 4 times higher than the physiological level. Giusti et al.

showed that the optimal platelet concentration to promote angiogenesis in human endothelial

cells is 1.5 million / µl and that higher concentrations may be worse (30). The literature

recommends one PRP session per month for 3 to 4 months and a subsequent maintenance

interval of 3 to 6 months. Injection of PRP into a subdermal layer at a depth of approximately

3 to 4 mm may allow diffusion into connective tissue and subdermal space, allowing PRP to

reach the base of the hair follicle and DP cells without damaging the vessels and nerves below

and parallel to the skin surface (31) (Fig.9).

Effect of PRP on hair transplants

Hair transplants (Fig.10), 11) not only obviously improve the current hair condition, but as a

recently published study could show, also the quality of life and even health (32) (Fig.12).

PRP as adjuvant therapy shows an improved result in wound healing as well as in the growth

rate of transplanted follicles. In 2006, Übel and his colleagues published their first paper on

the use of PRP as an additional therapy for hair transplantation. They were able to show a

significant difference in the transplant density of the scalp previously treated with PRP

compared to the untreated control area: on average the transplant density in the scalp treated

with PRP was 18.7 follicular units (FUT) per cm 2 compared to 16.4 FUTs per cm2 in the

untreated scalp (33) Garg et al. This study also showed a significant influence on the quantity

and quality of hair growth when PRP was injected into the prefabricated slits during hair

transplantation (34). Some advocate PRP as the optimal holding solution for transplants

compared to NaCl solution (35), but there is still no evidence for this.

Since PRP promotes wound healing (36), it should also be recommended for use in the

extraction area, as healthy hair can also be injured here, which can be reduced by PRP. PRP

stimulates the formation of new blood vessels, scarring is reduced and the regeneration of

grafts traumatised by transplantation is improved, which can ultimately lead to an improved

growth rate of implanted grafts.

Conclusion (Fig.13)

Although hair loss is very common in both men and women, FDA approved drug treatments

are currently limited to Minoxidil and Finasteride. PRP is a promising new option to bridge

the gap between medical and surgical options for AGA. Animal models suggest that PRP

promotes hair growth, and several clinical studies have shown that PRP is effective in

androgenetic alopecia in a variety of settings, including maintaining hair density. Also, its

supportive effect as an adjuvant during and after hair transplantation is significant. Further

controlled studies with quantifiable measures of treatment success are now needed to confirm

these results.

Table 1: Evidence level (1-4)

1 Studies with evidence level 1 or studies with predominantly consistent results with

evidence level A2

2 studies Level of evidence A2 or studies with predominantly consistent results with

Level of evidence B

3 studies with evidence level B or studies with predominantly consistent results

evidence level C

4 Little or no standardized evidence

Source: Kant et al. 2018

The evidence level takes into account the methodological quality of the studies (evidence

levels) and the interim consistency of the results. <15>

Table 2: Evidence evaluation (grades A1..D)

A1 A1 Meta-analysis comprising at least one randomised clinical trial with evidence

of grade A2 with consistent results from different studies.

A2 Randomized, double-blind, high quality, comparative clinical trials (e.g., sampling,

patient involvement flowchart, ITT analysis, sufficient size).

B Randomised, lower quality clinical trials or other comparable studies (non-

randomised, cohort or case-control studies)

C Non-comparable studies

D expert opinion

Source: Kant et al. 2018

The methodological quality of each study included in the evidence-based analysis was defined

in degrees by the quality of the evidence according to the following scheme ( A1..D).

Table 3: Current recommendation for the management of AGA according to S3 Guideline

1/2018

Therapy Eviden

ce level

Evidence

prevent

progressi

on

evidence

condition

improvem

ent

Safet

y

practicabil

ity

patient

practicabil

ity

doctor

Men

Finasteride 1mg 1 +++ ++ +++ ++++ ++

Dutasteride

0,5mg

1 +++ +++ ++ ++++ ++

Minoxidil 5% 1 +++ ++ +++

+

+/++ +++

Hair

transplantation

with/without adj.

therapy

2 - +++ ++ + interv.

+++longter

m

+

LLLT (Low-level

Laser Therapie)

2 +/- +/- + +/- +

PRP 3 +/- +/- + +/- +

Women

Minoxidil 2%

Lsg.

Minoxidil 5%

Schaum

1 +++ ++ +++

+

+ +++

Hormones oral

Hyperandrogenis

mus

3 + + + +++ ++

Hormones oral

normal

Hormones

3 +/- +/- + +++ ++

Hair

transplantation

with/without adj.

therapy

4 - ++ ++ +

Eingriff

+++

Langzeit

+

LLLT (Low-level

Laser Therapie)

2 +/- +/- ++ +++ +++

PRP ( Platelet-

Rich Plasma)

3 +/- +/- 1 +/- +

Overall rating -

niedrig

+/- + ++ +++ ++++

hoch

Quelle: Kanti et al. 2018

Figure 1: Trichoscan before PRP treatment

Bestimmt die Haaranzahl, deren Dichte und die Rate der Haare in der Ruhephase

(Telogenrate)

Figure 2: Trichoscan 6 months after 4 x PRP treatments

Total number of hairs, hair density and number of growing hairs are significantly improved.

Figure 3: Classification of the AGA according to Norwood and Ludwig.

Quelle: Norwood, 1975, Ludwig, 1977

Figure 4: Previous FDA approved medication

©Bruce Reith

Quelle: Autor

While in the last 3 decades only 2 substances, Minoxidil and Finasteride, were the only

substances of choice at AGA, new and improved therapies have developed rapidly in the last

6 years.

Multiple drug treatments as well as cell therapeutics or medical devices are still in preclinical

development or clinical trials. However, these could soon come onto the market.

Figure 5: Triad of Eivdenzbased Medicine (EbM)

Quelle: Autor

Figure 6: Pathogenesis and therapeutic approaches in AGA.

Quelle: Gua H. et al. 2017

The main components of AGA pathogenesis are genetically susceptible hair follicles, the

conversion of dihydrotestosterone (DHT) in the skin from circulating androgens, accumulated

DHT-inducible suppressors of hair follicle growth, micro-inflammations and cell aging, some

of which are caused by androgen-mediated DNA damage.

Current and future treatment strategies include reducing local DHT production, targeting

androgen-regulated factors in follicular epithelial cells and dermal papilla cells, improving

perifollicular vascular supply, controlling microscopic follicular inflammation, and possibly

controlling connective tissue remodelling by balancing protease/antiprotease systems.

Figure 7: Effect of PRP on hair growth cycle

©Bruce Reith

Dermal papilla cells: Regulate the development and growth of hair follicles and is considered

a reservoir of multipotent stem cells.

Figure 8: Mechanical model of the PRP effect on the dermal papilla cells

Quelle: Autor

Activated PRP stimulates hair growth by promoting vascularization and angiogenesis, and

encourages hair follicles to enter and extend the anagen phase of the growth cycle. The

process is achieved by increased activation of β-Catenin (BC), extracellular signaling

regulated kinase (ERK) and protein kinase B (Akt) signaling pathways mediated by growth

factors, leading to the necessary cell proliferation and differentiation. Akt also

simultaneously prevents apoptosis A

Figure 9: Main protocol PRP in 4 steps

Quelle: Autor

Figure 10: Hair transplantation Strip method- FUT

Quelle: Autor

Figure 11: Single removal - FUE

A hair transplant is a surgical procedure that transplants hair follicles from the scalp, which is

resistant to hair loss, to bald or sparse areas.

The hair follicles are removed either with strips (FUT) (Fig.10) or individually (FUE)

(Fig.11), preserved in a holding solution and then implanted into the slits prefabricated by the

doctor.

Figure 12: Influence of hair transplantation on quality of life and health

RESULTS1) Kein signifikanter Unterschied in der Alters- und Ge-

schlechtsverteilung zw. Prä- und postoperativer Gruppe:

Durchschnittsalter 37.0 ± 12.1 Jahre und 88.7% männlichim Vergleich zu 36.9 ± 11.8 Jahre und 88.5% männlich.

2) 96.6% sagten, dass die Transplantation ihr Leben positiv ver-

änderte und 97.7%würden sich wieder operieren lassen (n=213).

3) Auswirkung von schönen Haaren auf……

4) Auswirkung des Haarausfalls auf......

Verbessern Haartransplantationen die geistige und körperliche Gesundheit?Reith Bruce, MD, PhD., Mojto Viliam, MD, PhD, Kottman Tanja, MD.Medizinischer Direktor bei medical hair & esthetic (Munich,Germany) / Medizinischer Direktor Haarzenrum Bodenseeklink (Lindau, Deutschland )

Kontakt: brucereith@me.com

Ausschluß: COI; Keine; Off-Label Usage; Keine.

EinleitungDas Haar ist ein wesenlicher Bestandteil unserer Erscheinung.

Zahlreiche Studien zeigten die negative Auswirkungen des Haar-

ausfalls auf das Wohlbefinden und die Lebensqualität. Darüber hinaus wurde ein Zusammenhang mit psychischen Problemen

(z.B. geringes Selbstvertrauen) und Depressionen beobachtet.

Studienziel

Diese Studie untersuchte die Auswirkungen einer Haartrans-plantation auf die psychische Gesundheit im infolge des Haar-

ausfalls und auf die allgemeine Lebensqualität.

Material und Methoden

Ø Studiendesign: retrospektive 2 Zenter KohortenstudieØ 130 Pateinten mit erblichem bedingten Haarausfall welche

eine Transplantation 9 -36 Monate vor Einschluss erhielten Ø 194 Geschlechts- und Altersgleiche Patienten die sich noch

keiner Haartransplantation unterzogen haben

Ø Alle Patienten füllten 3 Umfragen aus: (1) Autorenfragebogen mit demographischen Daten und Haar Wahrnehmungen (2)

AQoL-8D zur Beurteilung der Lebensqualität in8 Dimensionen (3) BDI-II zur Beurteilung der Schwere der Depressionen

Ø 83 weitere Pilotstudienpatienten haben den vom Auto erstel-

lten Fragebogen ausgefüllt (in Analyse mit einbezogen).

Prozentsatz der Patienten, die auf die Frage nach der Wirkung von schönen Haar eine hohe Wichtigkeit (4,5 or 6 on 6-point Likert scale) angegeben haben (n=401)

Patientenanteil, die bei der Befragung zu den Auswirkungen des Haarusfall eine hohe

Bedueutung (4,5 or 6 on 6-point Likert scale) angegeben haben (n=401)

0

20

40

60

80

100

Patien

ten

mit h

oh

er

Pu

nktz

ah

l (%

)

“mit den Haaren verliert man auch

sein Selbstvertrauen”

“Mein volles Haar hat mir zum Erfolg

alsSchauspieler geholfen”

(George Clooney)

5) AQoL-8D Resultat

6) BDI-II Resultat

AQoL 8D Werte pro Dimension prä- (n=188) versus postoperativer Gruppe (n=129)

Die AQoL 8D Werte waren in allen 8 Dimensionen der prä-opertiven Gruppe signifikant höher (p< 0,001) imVergleich

zur postoperativen Gruppe

BDI-II-Gesamtpunktzahl in der prä- und postoperativen

Behandlungsgruppe

Die Differenz zwischen dem Mittelwert von 9,58 ± 9,45 der präoperativen und 3,31

± 5,33 der postoperativen Patienten ist statistisch

signifikant (p<0,001).

Ergebnis KategorieBDI-II

PunkteSumme

Prä n=187

Postn=127

Keine Depression 0 - 8 60,4% 86,6%

Minimale Depression 9 - 13 16,6% 6,3%

Milde Depression 14 - 19 4,8% 4,7%

Mittelschwere Depr 20 - 28 11,2% 1,6%

Schwere Depression 29 - 63 7,0% 0,8%

0

20

40

60

80

100

Patien

ten

mit h

oh

er

Pu

nktz

ah

l (%

)

Pic

: w

ww

.wo

rth

10

00

.de

Pic

: w

ww

.wo

rth

10

00

.de

Selbstvertrauen

Attraktivität

Männlichkeit/

Weiblichkeit

Gesundheit

Selbstwert

Anerkennung im Freundes-

und Bekanntenkreis

Partnerwahl

Beruf

Quelle : Richardson, J.

BDI-II Resulat und Kategorie

Klinisch relevante Depres-sionen (BDI-II-Score > 20)

wurden bei 18,2% der prä-operativen Patienten fest-gestellt, verglichen mit 2,4% der postoperativen Patienten.

FazitØ Erfolgreiche Haartransplantationen haben einen signifikant

positiven Einfluß auf die geistige Gesundheit und verbessern

das Wohlbefinden und die allg.Lebensqualität des Pateinten.Ø Haartransplantationen sind nicht nur rein kosmetische Ein-

griffe sondern auch medizinische notwendige Behandlungenwelche ebenso bedeutend für die Gesundheit sind.

Figure 13: Current recommendation for AGA

Quelle:Autor

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Kontakt

Dr.Bruce Reith, (MD, PhD)

Chefarzt Medical Hair& Esthetic

Brunnstrasse 11

80331 München

Chefarzt Haarklinik Bodenseeklinik

Graf-Lennart-Bernadotte-Str. 1

DE 88131 Lindau / Bodensee

Email: Brucereith@me.com