Hair loss has historically been considered a natural consequence of aging, especially among men, but it has never been fully accepted – the toupee and comb-over are proof of that. However, the last couple decades have seen significant progress toward much more effective solutions for men – and women – wishing to stave off hair loss or restore hair to some degree.
Although some women experience thinning, “a good 90% of patients are men,” said Roger Bassin, MD, a plastic surgeon based in Orlando, Fla., who has been performing hair restoration for years. “Hair loss also tends to be more dramatic in men, with balding rather than thinning.”
According to Jeffrey A. Rapaport, MD, a cosmetic dermatologist in Englewood Cliffs, N.J., the causes of hair loss differ. “For women it is multi-factorial; for men, it is almost always conversion of testosterone to dihydrotestosterone (DHT), leading to a genetic excess of DHT in the scalp.”
A big difference between men and women is how they approach the problem, said John Kahen, MD, a hair transplant surgeon in Beverly Hills, Calif. “Men typically come into the office after they have lost a lot of hair. Women come in when they begin to shed and thin out. It is more dramatic and noticeable for them, so they seek early intervention more often.”
The advent of follicular unit transplantation, follicle plugs extracted by manual punch, or automatic extraction devices, has replaced the strip graft method, which had limitations; you could only take so much, and there was significant scarring. Improvements in the process of follicular unit extraction (FUE) have advanced the overall procedure, said Dr. Bassin. “Instead of that linear scar on the scalp prevalent with strip grafting, we thin out the harvest region by percentages virtually undetectable to the naked eye and transplant them elsewhere.”
Among the available options for early intervention, “are drugs like minoxidil or finasteride, but they have limited efficacy and there are sexual side effects to finasteride that keep men away,” Dr. Kahen explained. “Patients come in now and want to go directly to platelet-rich plasma (PRP).”
With the rapidly proliferating PRP market there are too many products to single out any one in particular. More important is how PRP is used, and could be used in the future. “PRP is a great tool for women,” Dr. Bassin began, “because it is better for thinning hair. It won’t cause regrowth of lost hair, but it can revitalize ‘minimized’ (withering, but not dead) follicles to give you thicker, fuller hair and help prevent further hair loss.”
According to Dr. Bassin, PRP is becoming almost standard with any transplant. “Application of PRP promotes healing, helps grafts grow and staves off further hair loss.”
Dr. Kahen’s technique completely depends on PRP; he injects PRP during the implant process, before inserting follicular units. “This helps encourage the blood supply and rapid healing for maximum growth and thickness of hair at the implant site,” he said.
Most exciting is PRP-based prevention, regardless of gender. “By promoting prevention with PRP we have patients coming in as early as 18 years of age – those seeing early pattern baldness,” said Dr. Kahen. “It has opened the door to a new preventative approach in both genders because any age group can use it, it is safe and very good for either preventative care or adjunctive to other therapies. Remember that for women, treatment is basically Minoxidil, hair vita- mins and PRP. For men, in my practice, it is PRP or FUE with PRP, depending on the level of hair loss. If you obtain treatment early enough, PRP should stop hair loss with maintenance every eight months or so.”
“Patients like PRP because it comes from their own body and has no side effects,” said Dr. Rapaport.
Device-based hair restoration
NeoGraft® from Venus Concept (North York, Ontario, Canada) claims the title of the first automated FUE and implantation technology. It leaves no linear scar and is minimally invasive with fast patient recovery, consistently delivering superior clinical efficacy and high patient satisfaction, as evidenced by its high “Worth It” rating on RealSelf.com. With NeoGraft, Venus Concept provides a comprehensive turnkey business solution, such as in-depth preceptorship programs, one-year business development mentorship, on-demand and highly-trained hair restoration technicians (NeoGraftersTM), ongoing account management, marketing support and patient lead generation through the advertising agency 2two5TM, and more.
SmartGraft by Vision Medical, Inc. (Glen Mills, Penn.), performs automatic FUE, incorporating additional technology to protect follicular units before transplant. It isolates and extracts micrografts of three to four follicles each for transplant to regions targeted to produce the best, most natural-looking result.
FUE with SmartGraft is quick and easy, said Dr. Bassin. “We’re done in several hours, and within a few days patients can wash their hair carefully. After the procedure and a natural cycle of shedding and regrowth, we get a great, natural-looking result 9 to 12 months after treatment. It is the next generation in FUE-based transplantation.”
ARTAS iX from Restoration Robotics (San Jose, Calif.), performs precise automatic harvesting with simultaneous destination site-making and implantation. This system uses robotic technology featuring an advanced three-camera, high-resolution stereoscopic vision system and a seven axis robotic arm to eliminate as much of the human element as possible, making the procedure more consistent and less physically taxing. The harvest site is analyzed for the best follicular units, which can be quickly collected. Computer-assisted planning precedes robotic or manual implantation, and results can be seen at about six months with continued growth.
Atera FUE-100 from INFUEZ LLC (Woodinville, Wash.) uses manual FUE with a comfortable, ergonomic hand- piece and sterile irrigation, which maximizes graft viability, variable depth and diameter control. The system also features a collection system that moistens and cools grafts, as well as counts them.
The Harris S.A.F.E. System from Harris FUE Instruments (Greenwood Village, Colo.) offers traditional manual FUE. It is FDA-cleared and designed to keep grafts healthy and whole during manual excision, with follicle damage rates as low as 2.8%, according to the manufacturer. Reusable punches are 0.8 mm,0.9 mm, 1.0 mm and 1.2 mm in diameter for 800 to 1200 extractions per hour, which cuts harvest time in half.
Energy-based follicle stimulation and at-home treatments
Low-level laser therapy (LLLT), light therapy and approximates are becoming more and more popular as there is research suggesting efficacy. “There is evidence of effectiveness, but patients must realize that this does not regrow hair, but rather helps slow the progression of hair loss,” Dr. Kahen noted. “At-home devices use these methods.”
Physicians around the globe have been using laser- and light-based devices – normally used for skin rejuvenation, tightening, or other applications – for in-office follicle stimulation. However, while they may advertise laser hair restoration, these applications are off-label.
FDA-cleared to treat androgenic alopecia for males (with Norwood-Hamilton Classifications of IIa to V) and females (with Ludwig-Savin Classifications of I to II), and for men or women who have Fitzpatrick skin types of I to IV, iRestore from Freedom Laser Therapy (Los Angeles, Calif.) is basically a helmet combining light-emitting diode (LED) LLLT tuned specifically to stimulate cell metabolism in hair follicles. Within about three to six months of 25-minute sessions every other day, the manufacturer states that users will see a slowdown in hair loss and reduction in hair follicle miniaturization, followed by some return to thicker, fuller hair with continued maintenance. The Essential version features 51 medical grade laser and LED emitters, while the Professional version features 282 emitters.
The LH80 PRO and LH40 EVO laser helmets from Theradome, Inc. (Pleasanton, Calif.) feature 40 focused VL680 (680 nm) lasers that penetrate up to 5 mm into the scalp and stimulate mitochondrial activity to slow and then stop hair loss, according to the manufacturer. Four weekly sessions of 20 minutes per day will yield visible improvement after a few months of regular use, with stronger outcomes over time.
The HairMax laser comb from Lexington INT, LLC (Boca Raton, Fla.), uses LLLT to increase hair density/fullness, revitalize follicles and improve thinning hair. It is currently the only FDA-approved device of its kind and includes patented hair-parting teeth and densely packed laser diodes for maximum, uniform delivery of collimated laser light. Products include combs, bands and a maximum coverage baseball style cap.
Professional and at-home topical and nutriceutical therapies
As the only FDA-cleared drugs for male pattern baldness on the market, finasteride and minoxidil are fairly well- known. Topical minoxidil has been demonstrated successfully in both men and women, with approximately 40% of men seeing regrowth within a three- to six-month period1,2 as long as the drug is used. “In my experience many patients are not entirely satisfied with Minoxidil and may not stay with it,” said Dr. Rapoport.
Finasteride has been shown [Varothai 2014] to slow and even improve hair loss in men after about six months with persistent, continued use. However, the caveat of sexual side effects has reduced its popularity.
Nevertheless, there are at-home therapies that may provide some help alone or in conjunction with office-based therapies. Nutraceuticals and vitamins are among those that have been in use for a long time.
LockRx Growth Factor 3X Professional Serum from Vision Medical, is a topical solution containing three specific human cell-derived growth factors (EGF, FGF and KGF) that are known to be of primary importance in hair follicle stages and scalp health.
This serum can be used in conjunction with all modalities for encouraging hair follicle stimulation, including surgical SmartGraft FUE Hair Restoration, PRP, microneedling, LED and LLLT, to increase the specific growth factors most needed for the best outcomes of the procedures.
With products for men and women, Viviscal Advanced Hair Health supplements from Viviscal Ltd. (Ewing, N.J.) have been under continuous development for 25 years and are 100% drug free. The products (including oral supplements and a topical shampoo, with an additional conditioner for women), are designed to nourish and strengthen existing hair at various stages of growth, promote revitalization of hair follicles to minimize shedding and encourage healthier hair. Clinical studies showed 18.3% reduction in shedding vs. placebo, and 125% increase in terminal hairs vs. placebo, with significant self-reported improved overall hair volume, thickness and scalp coverage after six months of continuous use.
AQ Advanced Hair Complex+ from AQ Skin Solutions (Irvine, Calif.) is designed to mitigate hair loss, rejuvenate damaged hair follicles, improve hair quality and increase circulation for overall improved scalp conditions. With growth factor technology, as well as other active ingredients, the solution is applied to treatment areas and massaged, then left on for a minimum of five minutes, every other day. The topical is for at-home use or as an adjunct to professional treatments.
Nutrafol® multi-targeting nutraceutical hair restoration treatments are designed for women entering, during and post menopause, experiencing hair-related changes. Nutrafol Core for Women contains standardized ingredients that address the key triggers of poor hair health including stress, DHT, free radicals, micro-inflammation and compromised nutrition. Core for Women was shown to improve strength, shine, texture, density, manageability and softness of hair. In a clinical study, 81% of women saw an improvement in hair growth.
Nutrafol Women’s Balance additionally addresses hormone changes associated with menopause. Ingredients are clinically shown to increase hair growth, provide fuller hair, maintain existing hair growth and improve strength, shine, texture, appearance, density and nourish hair from within.
Meant to be bundled as an adjunct to in-office treatments, the Votesse complete hair health system from Eclipse MedCorp. (The Colony, Texas), is a combination oral ‘folliceutical’ pill plus topical foam to promote health and wellness for maximum hair health. Easy- to-use Topical Hair Mousse with Amino DL-30 absorbs directly into the scalp to hydrate and promote moisture retention.
Oral formulations are customized for men and women. The women’s oral formulation includes ashwagandha root extract, flaxseed hulls, L-tyrosine and velvet bean extract, designed to manage cortisol levels and prevent hair breakage. The men’s version includes saw palmetto berry, pine-derived phytosterols, green tea leaf extract, nettle leaf extract and pumpkin seed concentrate to manage DHT, boost collagen production and improve overall hair health. “This is the first combination oral pill with topical botanical foam at our disposal, working internally and externally,” explained Dr. Rapaport.
“A lot of people want something like this, but won’t go for drugs like minoxidil or finasteride. They like the adjunctive non- drug topical and the gender-specific formulations. The pill replaces the vita- mins they probably already take, which many find appealing,” he continued. “With competing products I’ve seen GI disturbances, which we don’t see with Votesse because it includes probiotics.”
Surveying the evolving armamentarium for treating balding and thinning hair, Dr. Kahen summed it up best. “As with anything, prevention is usually the better option over reactive treatments. With the alternatives we have today, as we raise awareness we should see a significant reduction in the amount of people suffering from hair loss.”
1. Goren, A, Shapiro, J, Roberts, J, McCoy, J, et al. Clinical utility and validity of minoxidil response testing in androgenetic alopecia. Dermatologic Therapy. 2015;28(1): 13–6.
2. Varothai S, Bergfeld WF. Androgenetic alopecia: an evidence-based treatment update. American Journal of Clinical Dermatology. July 2014;15(3): 217–30.