Pearls and Pitfalls in the treatment of hair loss in women
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1 The Ronald O. Perelman Department of Dermatology Pearls and Pitfalls in the treatment of hair loss in women JERRY SHAPIRO, MD, FAAD PROFESSOR Chicago Summer AAD
2 Disclosures Consultant/Investigator for: Aclaris Samumed Incyte Applied Biology Biologics MD Replicel Life Sciences Inc. RegenLab Bioniz 2
3 Non-scarring alopecia 3
4 Androgenetic Alopecia (AGA): Most common form of alopecia in men and women Anagen phase Proportion of telogens Thinner and finer hair Time between shedding and regrowth More scalp visible + Vellus like hair
5 Androgenetic Alopecia (AGA): Female pattern hair loss: 38% of women are affect by this condition; leading diagnose in hair clinics. The severity is not age related.
6 Androgenetic Alopecia (AGA): Female pattern hair loss: It is classically divided into 3 stages, although can be presented with frontotemporal recession and as male pattern; Christmas tree pattern is the most common presentation.
7 Androgenetic Alopecia (AGA): Trichoscopy: diagnose, hair density and caliber Folliscope Fotofinder
8 Androgenetic Alopecia (AGA): Diagnosis Laboratory tests: TSH, ferritin, vitamin D and zinc Workup for androgens: women with irregular periods and/or other signs of androgen excess free and total testosterone, DHEA-S, 17- OH-progesterone
9 Androgenetic Alopecia (AGA): Treatment Minoxidil 5%: 25 drops = 1mL 1-2x/day for at least 6h First option for all patients! Side effects: contact dermatitis, itching, erythema, facial hypertrichosis in 7%; tachycardia (less than 1 in a 1000) 1/3 experience increased shedding in the first 6 weeks
10 Androgenetic Alopecia (AGA): Treatment Finasteride: 2,5 mg/day Dutasteride: 0,5mg/day Off-label use* * Women who are or potentially may be pregnant should avoid
11 Androgenetic Alopecia (AGA): Treatment Spironolactone: 100mg twice daily; May reduce shedding but has low effect on hair regrowth; Requires laboratory exams every 3 months; Main side effect is menstrual irregularities (may be corrected with decreasing the dose and adding oral contraceptive) *Contraindications: renal insufficiency, hyperkalemia, pregnancy, genetic predisposition for breast cancer and abnormal uterine bleeding.
12 Oral Contraceptives Excellent Very Good Good Bad Physicians and patients choosing OCPs should be aware of hormonal sequelae related to hair loss. Negative or low androgen indexes may protect against developing AGA. OCPs containing high doses of norethindrone and norgestrel, respectively, are least likely to inhibit pattern hair loss and may promote AGA.
13 Excellent Drospirenone Cyproterone acetate
14 Very Good: Norgestimate, Desogesterol, Norethindrone acetate
15 Good Levonorgesterol
16 BAD Norgesterol and Norethindrone
17 AGA treatments Biotin: The only conditions scientifically proven to be benefited with biotin May Vol ume 16 Issue 5 Copyright 2017 ORIGINAL ARTICLES Jour nal of Drugs in Der mat ol ogy SPECI AL TO PI C The Infatuation W ith Biotin Supplementation: Is There Truth Behind Its Rising Popularity? A Comparative Analysis of Clinical Ef cacy versus Social Popularity Teo Soleymani MD, Kristen Lo Sicco MD, Jerry Shapiro MD FAAD FRCPC a The R onald O. Perelman Department of Der matology, N ew York U niversity School of Medicine, New York, NY supplementation are trichorrhexis nodosa and alopecia induced by the use of valproic acid or excessive ingestion of raw egg whites
18 AGA treatments Oral Minoxidil: Once daily low-dose oral minoxidil (0,25mg) in combination with spironolactone 25mg in the treatment of 100 women with Sinclair stage 2-5 FPHL Most women noticed a reduction in hair shedding at 3 months and an increase in hair density at 6 months. HOW DO I USE? Minoxidil 0,625mg once daily for patients that can t use topical solution/foam
19 Platelet Rich Plasma (PRP) Cell-based therapy Concentrated suspension of autologous platelets 1980 s: Orthopedic use for bone 2000 s: Skin rejuvenation Vampire Facial : PRP with microneedling 2010 s: Hair restoration 19
20 PRP: growth factors PDGF a-b FGF EGF IGF-1 PRP VEGF CTGF TGF alfabeta 20
21 PRP clinical trial NYU Clinicaltrials.gov Double blinded placebo controlled study 50 men and women Split scalp PRP vs Saline Externally funded by Regenlab from Lausanne, Switzerland Co Investigator: Kristen Lo Sicco, Kumar Sukhdeo and Anthony Ho
22 Platelet-Rich Plasma (PRP) Treatment Protocol / / / / / / > 3/4/5/6 Month Repeat assessment PRP Treatment Month 0 Assessment PRP Treatment 22 Month 1 Assessment PRP Treatment PRP responses in androgenetic alopecia Month 2 Assessment No further PRP Continue other treatments >
23 Combination Therapy Achieves Quantitative Increases in Hair Density All patients (N=24) Responders (N=17) Responders: Start count: 163 hair/cm 2 End count: 198 hairs/cm 2 Mean : +35 hairs/cm 2 (P<0.0001) Average Age: 44 Month 0 Month 6 Start count: 155 hair/cm 2 End count: 179 hairs/cm 2 Mean : +24 hairs/cm 2 (P=0.022) Non- Responders (N=7) Non-Responders Start count: 135 hair/cm 2 End count: 133 hairs/cm 2 Mean : -2 hairs/cm 2 (Not significant Average Age: 37 No significant change in hair diameter 23 PRP responses in androgenetic alopecia
24 Trichologic Responses are Time-Dependent Segregation of responders vs non-responders after 2 months Most benefit achieved within 2 to 4 months No shock loss 24 PRP responses in androgenetic alopecia Change in Hair Density (hairs/cm 2 ) Month 0 Month 1 Month 2 Month 3 Month 4 Time Responders (N=17) +10 hairs/cm2 Threshold Non-Responders (N=7)
25 Take Home Points Can I use PRP with other treatments? No apparent downside to use PRP as combination therapy What are the chances of it working? Nearly 3 out of 4 recipients of combination therapy show increased hair density How much benefit can I expect? Average increase: +35 hairs/cm 2. No change in hair diameter. Which people do worse with therapy? Patients with earlier-onset disease and lower baseline hair counts don t respond as well When will I see benefit? Usual response at 2-4 months, but may increase or decrease 25
26 When NOT to use PRP: presence of skin cancer on the head BCC on the scalp 26
27 Microneedling Clinical Trial at NYU Split scalp; one side MN Both sides receive Minoxidil 5% foam bid Single blinded study Hair counts and diameters Treatment every 2 weeks for 20 weeks
28 Microneedling (MN) Mechanisms of action: Neo-angiogenesis, growth factor production Breach of stratum corneum allows for more effective drug delivery
29 Skin Pen II Automated vibrating cartridge, stamp-like and fractionated Variable length needles, set for 1.5 mm in our study FDA registered as medical device Bellus Medical SkinPen
30 Microneedling half head study 30
31 Microneedling Journal of Cosm et ic and Laser Therapy Subjects were randomly allocated into 3 groups Topical 5% minoxidil (group 1, n = 20), Electrodynamic microneedle treatment (group 2, n = 20), Electrodynamic microneedle treatment with topical 5% minoxidil (group 3, n = 20). Patients received microneedle treatments every 2 weeks, for a total of 12 times. The best therapeutic effect was observed in group 3: nonvellus and the total hair counts, the hair thickness, investigator assessment, and patient self-assessment ISSN: (Print) (Online) Journal homepage: Randomized trial of electrodynamic microneedle combined with 5% minoxidil topical solution for the treatment of Chinese male Androgenetic alopecia Linlin Bao, Lin Gong, Menger Guo, Taoming Liu, Anyu Shi, Haifeng Zong, Xuegang Xu, Hongduo Chen, Xinghua Gao & Yuanhong Li J Cosmet Laser Ther Oct % of these patients showed greater than 50% improvement of hair growth
32 FPHL < 20% scalp involvement Androgenetic Alopecia 20-50% scalp involvement 51-90% scalp involvement 91% scalp involvement Cranial prosthesis 5% minoxidil solution/foam Consider Finasteride 2.5mg QD or Spironolacton e 50mg BID Improvement No improvement after 6 months Improvement 5% minoxidil solution/foam with: Finasteride 2.5mg QD +/- Spironolactone 50mg BID *PRP No improvement after 6 months Hair transplantation 5% minoxidil solution/foam Finasteride 2.5mg QD Spironolactone 100mg BID Dutasteride 0.5mg QD in post-menopausal women *PRP Cosmetic products Review 6 monthly Review 6 monthly *PRP: platelet rich plasma Increase the dose of Finasteride to 5mg QD or Spironolactone to 100mg BID Dutasteride 0.5mg QD in post-menopausal women *PRP No improvement after 6 months Improvement Hair transplantation Cosmetic products Review 6 monthly
33 Thank you
JERRY SHAPIRO, MD, FAAD PROFESSOR
The Ronald O. Perelman Department of Dermatology Novel treatments for hair regrowth Where are we? JERRY SHAPIRO, MD, FAAD PROFESSOR AAD Chicago 2018 Disclosures Consultant/Investigator for: Aclaris Samumed
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