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Hair Loss: No Reason for Therapeutic Nihilism

Presented by
Dr Glynis Ablon, Dr Melissa Piliang, Prof. Antonella Tosti, Dr Jeff Donovan
AAD 2019
Today, many therapeutic options are available for hair loss. With regard to therapy, combinations seem to work best. Platelet-rich plasma (PRP) has shown to be efficacious in a number of patients with almost no downtime.

“My first approach to the hair loss patient is to determine the type or the aetiology of hair loss,” recommended Dr Glynis Ablon (Ablon Skin Institute, USA) [1]. A medical history is of key importance as the intake of several medications can cause or enhance hair loss. In particular, antidepressants, blood pressure medications, anticoagulants, and gout medications often lead to hair loss, which is typically seen after a lag time of 2-3 months. Before treatment is started, causes of hair loss have to be identified.

Androgenetic alopecia (AGA) is the most common type of hair loss, affecting 50% of males over the age of 40 and 75% of females over 65 [2]. It is often accompanied by diffuse telogen effluvium [1]. “Especially for women, hair loss is psychologically distressing. They feel it is unnatural for their hair to thin,” said Dr Melissa Piliang (Cleveland Clinic, USA) [3]. Despite the high prevalence of hair loss in elderly women, they feel they “are the only one”. Trials have shown that women with hair loss had a pattern of less adaptive function and a negative body image [4,5]. As much as 55% of patients even displayed symptoms of depression (i.e. anxiety in women, aggressiveness or hostility in men) [5]. Treatment of hair loss produced an improvement in 89% of women and 76% of men [5]. Therefore, every hair loss patient is in need of an empathetic approach. This has also been shown in a twin study: factors associated with increased frontal hair loss and thinning of hair included higher severity of stress [6]. In addition, illness, weight loss, and nutritional deficiencies (i.e. iron, vitamin D, and zinc) are common triggers.
Trichoscopy: an important diagnostic tool

Trichoscopy should be utilised to diagnose early AGA in men and women. Typical results in AGA show hair shaft diameter diversity. In AGA, hair follicles get progressively smaller with each anagen, and are finally replaced by fibrous tracts. In the trichoscopy, there is a >20% variability together with a dermoscopic sign of miniaturisation (see Figure). “If you use a normal dermatoscope, just take a picture with your phone through the dermatoscope and then enlarge the image on the screen to recognise the hair diameter diversity,” recommended Prof. Antonella Tosti (University of Miami, USA) [7]. With this picture, the disease can be easily explained to patients. Regrowing hair has a reduced thickness in AGA but a normal thickness in telogen effluvium, which can be easily recognised in the trichoscopy. In addition, an absence of variability is typical in telogen effluvium. As trichoscopy results are so obvious, scalp biopsy is rarely required to diagnose AGA. Diffuse, rapid onset of hair loss is uncommon in AGA and should always raise suspicion for a systemic illness including a nutritional deficiency, thyroid disease or malignancy, or an autoimmune aetiology, e.g. a diffuse type of alopecia areata. Nail changes are often seen in alopecia areata. In this case, a biopsy is key to the right diagnosis. Trichoscopy is also useful for follow-up during therapy.

Figure: A typical sign of AGA is the miniaturisation of the hair follicles [7]

Figure kindly provided by and adapted from Prof. Tosti.
Lab work mandatory

Lab work should be done in every hair loss patient: most important is the free/total testosterone, DHEA-S, prolactin, thyroid function test, and ferritin. However, one has to bear in mind that many patients take high-dose biotin that can interfere with laboratory results. Therefore, clinicians should be prepared to critically evaluate laboratory results and correlate their findings with the clinical picture. With regard to therapy, all treatment options should be discussed with the patient. As Dr Jeff Donovan (Donovan hair clinic, Canada) pointed out in his lecture, the main treatment for male and female pattern hair loss are minoxidil, anti-androgens, low level laser therapy, and PRP [8]. In the current guideline, finasteride, dutasteride, and minoxidil are recommended for male and minoxidil for female patients [9].

In total, 30% of all patients get cosmetically significant improvements with minoxidil solution or foam. Patients with shorter duration of hair loss and smaller area of thinning, and larger numbers of non-vellus miniaturised hairs respond better to this treatment. The efficacy of topical minoxidil can be enhanced by several methods, all of them are off-label uses. Minoxidil can be applied by dermarolling or by combining it with tretinoin. The latter is known to increase the percutaneous absorption of minoxidil and therefore to enhance the response of AGA to minoxidil. This combination enables a once-daily application of minoxidil, instead of the twice-daily recommended application. In a trial, the once-daily application of 5% minoxidil together with 0.01% tretinoin proved to be equally effective as the twice-daily application [10]. “Basically, all methods of getting more minoxidil to the follicle are useful,” Dr Donovan explained.
Combinations work best

“I would always start with concomitant supplements, as there are interesting products out there, e.g. those that contain anti-inflammatory agents like biocurcumin or anti-oxidants like tocotrienols,” recommended Dr Ablon [1]. Other treatment possibilities are low level light lasers or topical finasteride application with or without microneedling. “I think, combinations work best in hair loss,” said Dr Ablon.

The energy used in Low Level Laser Light Therapy (LLLT) is from the red or near-infrared spectrum (<500 mW, no heat). The exact mechanism of action of LLLT in hair growth is not known; however, several mechanisms have been proposed. It has a biostimulatory effect and influences mitochondrial oxidative metabolism by stimulation of transcription factors (nerve growth factor, neurotropin receptor, and nuclear factor kappa B) [11]. In addition, it decreases inflammation. Another hypothesis is that it acts on epidermal stem cells, and shifts follicles back into the growth cycle. LLLT prolongs duration of anagen phase, increases rates of proliferation in active anagen hair follicles, and prevents premature catagen development [11]. Research data shows that it is effective in both men and women [2].
Platelet-rich plasma therapy: always worth a try

A general body of evidence has recently emerged demonstrating a positive response from treatments with PRP injections [12-16]. When platelets are activated, 7 or more growth factors are released. Platelets contain additional proteins, cytokines, and bioactive factors. PRP leads to enhanced healing, proliferation, differentiation, and angiogenesis of dermal papillae and stem cells. “PRP acts like a fertiliser on hair growth,” said Dr Ablon, although not all patients respond to the procedure. The plasma is directly injected into the patient’s hair follicles in a process that takes no more than 10 minutes. The procedure is not painful, so no anaesthetic cream is required. After the initial treatment, injections are repeated once a month for the next 3 months, and then once every 3 months for androgenetic alopecia or once every 3 to 6 months for other forms of alopecia seem to have high success and satisfaction rates. Unfortunately, not everyone is a candidate for PRP therapy. Certain hair loss patients, including those with hereditary hair thinning or baldness, show a good response. PRP may be used in conjunction with other treatments to give patients best possible results.

1. Ablon G. Session S003, AAD Annual Meeting, 1-5 March 2019, Washington DC, USA.
2. Avci P et al. Lasers Surg Med 2014:46:144-51.
3. Piliang M. Session S032, AAD Annual Meeting, 1-5 March 2019, Washington DC, USA.
4. Cash TF et al. J Am Acad Dermatol 1993;29:568-75.
5. Camacho FM et al. J Eur Acad Dermatol Venereol 2002;16:476-80.
6. Gatherwright J et al. Plast Reconstr Surg 2012;130:1219-26.
7. Tosti A. Session S023, AAD Annual Meeting, 1-5 March 2019, Washington DC, USA.
8. Donovan J. Session S032, AAD Annual Meeting, 1-5 March 2019, Washington DC, USA.
9. Kanti V et al. J Eur Acad Dermatol Venereol 2018:32:11-22.
10. Shin HS et al. Am J Clin Dermatol 2007;8:285-90.
11. Chung H et al. Ann Biomed Eng 2012; 40:516-33.
12. Hausauer A et al. Dermatol Surg 2018;44:1191–1200.
13. Stevens J et al. Int J Womens Dermatol 2018;5:46-51.
14. Crutchfield CE, Shah N. Practical Dermatology 2018;10: 55-60.
15. Ho A et al. J Am Acad Dermatology. Published online 26 March 2018.doi: 10.1016/j.jaad.2018.03.022

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