According to the International Society of Hair Restoration Surgery’s (ISHRS) 2020 practice survey, on a global scale, more than 2 million patients received surgical or nonsurgical hair restoration treatments in 2019, reflecting a 13% increase from 2016.1 Not only are approaches to common hair loss procedures evolving and multiplying, but so are the patient populations who want those treatments. Hair loss has become a significant concern among men and women aged 25 to 30, with recent studies suggesting hair loss treatment for younger patients is happening worldwide.
Anna Marie Olsen, MD, PhD, is a London, U.K. based dermatologist with practices in London, Switzerland and Greece that specialize in nonsurgical hair loss treatments. She remembers when men were the only patients concerned
about hair loss, few perimenopausal women and occasionally a woman who used too much bleach on her hair.
Today’s patients are much younger. “In fact, Generation Z patients are very much in the mix of hair loss patients,” Dr. Olsen reported. “I have patients as young as 18-years-old.”
According to Dr. Olsen, researchers have identified common triggers that lead to hair loss. Triggers include nutrition, stress, pollution – even hair extensions. As a result of these and other factors, young people are more likely to lose hair or notice decreased hair density and quality at an earlier age.
For example, younger individuals partaking in a vegan diet may be lacking iron, which can impact hair quality. Thus, one of the first questions Dr. Olsen asks young patients complaining of hair loss is if they are vegan.
Stress is very much related to the pandemicfueled reduction in social interaction. And stress manifests as increased hair loss, Dr. Olsen added.
“Another suspected trigger is pollution. We observe more hair loss and decreased hair quality in younger people living in bigger cities. While we have not been able to scientifically prove the relationship, evidence shows there is a link,” she said.
When it comes to hair extensions, Dr. Olsen stresses the importance of not wearing them for long periods of time as they can lead to traction alopecia. “Hairstylists will hate me for saying this, but it is true,” she said. “I recommend that
patients with hair extensions wear them for three months and take them off for three months between treatments, but patients that are used to wearing hair extensions usually do not listen to my advice. Therefore, the treatment I can provide
is a matter of compromise while they continue making their own choices.”
Hair Prejuvenation & Personalized Care
With this higher prevalence of younger patients seeking to avoid hair loss, Dr. Olsen coined the term and treatment approach: hair prejuvenation. This hair, scalp and follicle optimizing protocol incorporates a customized combination of peptides, vitamins, enzymes, plant extracts and regenerative medicine. Prejuvenation is also part of her maintenance regimen for all patients aged 30 years and older, male and female.
Dr. Olsen’s approach to treatment is individualized according to each patient’s needs. It starts with the patient filling out a lifestyle questionnaire, in addition to a medical history.
The questionnaire helps identify aggregate factors that could be contributing to or causing hair loss. For example, if a patient indicates on the questionnaire that they are vegan, Dr. Olsen might recommend a supplement such as saw palmetto oil, which accommodates their dietary restrictions.
In addition to questionnaires, Dr. Olsen also asks patients to have their blood drawn to analyze their hormone levels. “Often with younger women, polycystic ovaries could be a cause for the decrease in hair quality,” she said.
“Hair loss is a symptom; it is not the cause. When a patient presents with hair loss, I have to find out what the cause is behind it, and then treat that,” she said.
Jeffrey Epstein, MD, a facial plastic surgeon in Miami, Fla., has nearly 30 years of experience treating patients’ hair loss concerns. His treatment protocol for hair loss patients starts with an evaluation to rule out medical causes for
hair loss. Almost every male patient is subject to a bloodwork panel looking at iron, ferritin, thyroid, testosterone, zinc and more.
He takes the hair loss patient evaluation a step further with the use of the TrichoTest from Fagron Genomics (Austin, Texas), a DNA test that looks at 13 genes and 48 genetic variations. "The specimen is obtained by a cheek
swab, and we can evaluate the different genes and aberrations associated with hair loss,” Dr. Epstein explained. “With this information, we are able to recommend the most appropriate medical therapies.”
Treatment Protocols & Strategies
Dr. Epstein has treated close to 100 patients so far with the TrichoTest. He finds it to be a valuable tool for making therapy recommendations with custom compounded minoxidilbased agents. “There are a variety of supplements
that we can either put into the custom compound of minoxidil and/or give orally.
“The DNA test has really helped provide us with a significantly greater degree of confidence that our therapies will be indicated and helps reduce the risk of adverse side effects,” Dr. Epstein added.
“In the clinic, I do a personalized cocktail based on platelet-rich plasma (PRP), stem cells, cytokines and growth factors for my hair rejuvenation patients,” Dr. Olsen began. “Then I may add amino acids, peptides such as oligopeptide 54 and the octapeptide-11, administered through injections. I use manual mesotherapy to stimulate the scalp and encourage the absorption of the solution. I have also incorporated thulium laser, which I find has extraordinary results in stimulation of the hair follicles and maintaining hair health.”
Dr. Olsen uses only compounded topical solutions for at-home protocols, which means she can use as much minoxidil or topical finasteride that she thinks the patient needs. “I veryrarely prescribe oral finasteride because of the
side effects. However, in a topical solution, I have observed nearly no side effects,” Dr. Olsen said. “In addition, I encourage my patients to use low-level red-light caps at home. There is evidence that scalp devices can
encourage healthy hair follicles.”
She also encourages patients to use at-home microneedling stamps because there is evidence that microneedling the scalp can stimulate hair growth.
These protocols work to an extent; however, not all patients achieve dramatic enough results from nonsurgical treatments and therapies. Patients with androgenetic alopecia need hair transplant surgery, according to Dr. Olsen.
“But even then, we use these protocols before and after hair transplantation to prep the scalp and optimize results.”
Ratchathorn Panchaprateep, MD, PhD, head of the Hair and Scalp Center in Bangkok, Thailand, conducted research entitled “Proteomic Analysis in Derma Papilla from Male Androgenetic Alopecia after Treatment with Low-Level Laser
Therapy.”2 Her research findings concluded that the use of low-level laser therapy can stimulate scalp and hair growth in 24 weeks.
Each subject that partook in Dr. Panchaprateep’s study self-treated with a low-level laser therapy (LLLT) helmet device (655 nm, 5 mW) at home for 25 minutes each application, every other day for 24 weeks.
The authors identified and analyzed the proteome set of dermal papilla proteins in male patients with androgenetic alopecia treated with LLLT, thus implicating the role of LLLT in promoting hair growth and reversing the miniaturization
process of androgenetic alopecia by enhancing dermal papilla cell function.”
Low-level laser therapy is suitable for patients with early-stage hair loss and mild to moderate symptoms. However, it is not suitable for those in an advanced stage, or who already have baldness, Dr. Panchaprateep pointed out.
In a press release Dr. Panchaprateep stated, “Patients should undergo LLLT continuously at least five to ten times, every two weeks. They will start to see results after the fifth treatment. Clearer results can be seen after three months.
Patients will have new growth of stronger hair.”
Follicular unit extraction (FUE) and medical therapy maintenance remain the go-to surgical protocol for hair loss that will not respond adequately to nonsurgical treatment options, according to John Kahen, MD, chief surgeon and hair transplant specialist at Beverly Hills Hair Restoration (Beverly Hills, Calif.).
FUE is for men and women that are bald or balding who would like to have increased hair density. It is a surgical procedure, though minimally invasive, Dr. Kahen indicated.
“Everything is done under local anesthesia. We use an extraction tool to extract the follicles from the back of the scalp because those follicles are genetically programmed to stay forever,” Dr. Kahen explained. “We extract those follicles one at a time, without leaving any linear scars, and transplant those to the balding or bald areas.”
Patients see results within four to six months after the procedure. This is a lasting solution to hair loss, meaning the transplanting of follicles is permanent and they keep growing, Dr. Kahen noted.
Patients who want dramatic results need surgery. “Nonsurgical options, including PRP and exosomes are ideal for preventing further hair loss and getting some thickness back, but completely bald patients will not see results from these therapies.
They need surgery,” Dr. Kahan stated.
“Transplants that are done properly are extremely effective as long as the patient has realistic expectations in terms of the amount of coverage that he/she can achieve. Realistic expectations from FUE include age-appropriate, natural-looking outcomes. A 45-yearold man should not strive to have the hairline of a typical 20-year-old,” Dr. Epstein added.
Furthermore, “for patients who have had their donor hair at least partially depleted, and or have a significant mismatch between their total donor supply versus their advanced degree of hair loss, we use beard hairs for their scalp,” Dr. Epstein shared. “Using beard hair for treatment is very popular in our practice; about three times a week, patients are donating anywhere from 800 to as many as 2,500 hairs from their beard area.
“Transplanting hair from the beard to scalp and from scalp to beard are in demand and filling a much-needed gap in patient care,” Dr. Epstein continued. Ideal candidates for beard hair extraction include the 50-year-old male who has had two or three prior transplants, including at least one that was a FUE procedure in the last ten years. This patient may
have also had some strip procedures and has continued to lose hair. His hair is too thin even in the frontal and mid-scalp area to make him feel comfortable.”
“This patient only has an available donor supply of about 1,500 grafts, due to the prior work performed, but will need double that, Dr. Epstein advised. “The beard is an acceptable option in many cases because, he doesn’t need his beard, or at least he is able to give up the hairs from below his jawline.”
Another ideal candidate for beard hair extraction is the patient receiving gender reaffirmation from male to female, who is going to receive treatments to have her beard hair removed anyway. She may have an advanced degree of scalp hair loss and want to extract as many beard hairs as possible for transplantation.
For example, Dr. Epstein detailed an experience with a previous patient who had transitioned from male to female; “The patient was in her 40s and we were able to harvest as many as 5,000 to 6,000 beard hairs because she no longer needed or wanted them. As such, we were able to use those hairs on the top of her scalp.”
Conversely, hair from the head can also be used to grow hair anywhere, even if the hair has never grown there before. One can create a fuller-looking beard, goatee, mustache, sideburns or cheek beards, according to
In fact, many of today’s male patients prefer to have a beard over a full head of hair, especially if they are destined to lose more of their hair, Dr. Epstein pointed out. “Guys like to have that shaved head look with a nice strong beard. In the last ten years, beards have been huge!” he said.
Today’s FUE technology allows for safe beard hair extraction. Beard extractions are more challenging than other techniques. The ability to harvest beard hairs is predicated on having advanced the FUE hair harvesting techniques developed for the scalp. Thus, you need to be an experienced FUE extractor in order to perform beard extractions properly.
“Beard hairs tend to be a little thicker and more prone to damage, you need to have wellinstituted protocols for how to manage the hairs, which includes not just the processes for harvesting them but also storing and implanting,” Dr. Epstein emphasized.
Specific to Women
For women, hairline lowering surgery is extremely popular these days. “It is a singlestage procedure primarily done in women who have a sufficiently mobile scalp, where we can lower their hairline in most cases by an inch or more. The goal is to reduce the height of the forehead and the results are essentially instantaneous,” Dr. Epstein noted.
“Usually, it is one-and-done. You lower the hairline, and the patient is presentable two days later,” he said. “The stitches are removed on the eighth day. It is life-changing for some women.”
For women with female pattern thinning, which usually occurs on the top of the head, Dr. Epstein might instead use a combination of medical therapies followed by hair transplant surgery. “Particularly if the patient has a very light scalp and dark, fine hair, we can do something like scalp micropigmentation, which is a semipermanent tattoo and lasts for about five
years. It gives the look of a fuller appearance after transplant and medical therapies,” he said.
In the Pipeline
According to Dr. Epstein, among the treatments being studied for hair loss is ongoing research related to the use of an individual’s fat to help stimulate hair regrowth. “Not just stem cells, but the actual fat,” he expressed. “There is also something called hair farming, which I think is seven to ten years away. It is essentially cloning. You harvest 100 hairs and send them to a lab where a 3D printer is used to create tiny trays. This process has the ability to provide what might be an unlimited supply of hair that we can then transplant.”
1. International Society of Hair Restoration Surgery: 2020 Practice Census Results. International Society of Hair Restoration Surgery. Retrieved from https://ishrs.org/media/ statistics-research/.
2. Panchaprateep R, Pisitkun T, Kalpongnukul N. Quantitative proteomic analysis of dermal papilla from male androgenetic alopecia comparing before and after treatment with low-level laser therapy. Lasers Surg Med. 2019 Sep;51(7):600-608. doi: 10.1002/lsm.23074. E.pub 2019 Mar 7. PMID: 30843235.
3. Jeffrey Epstein. (2021, November 5). Beard Transplant Miami, FL: Facial hair implants: New York, NY. Foundation For Hair Restoration. Retrieved November 12, 2021, from https://www. foundhair.com/plastic-surgery/facial-hair-transplant.