Platelet-Rich Plasma: Advances and Controversies in Hair Restoration and Skin Rejuvenation

BACKGROUND

Platelet-rich plasma (PRP) and its combined therapeutic modalities have catalyzed new possibilities in dermatology; however, limitations in evidence and lack of consensus remain among clinicians regarding optimal composition, protocol, technique, and application.

OBJECTIVE

To provide an update and analysis of the evidence for PRP in hair restoration and skin rejuvenation through review of recent available data, highlighting controversies and expert insights to guide future studies, and stimulate discourse and innovations benefitting patients.

METHODS

A structured review and expert analysis of PubMed publications before October 2023, with a focus on recent literature from January 2020 through October 2023.

RESULTS AND CONCLUSION

Growing literature supports the utility and benefits of PRP and related autologous products for applications for skin and hair, with strongest evidence for androgenetic alopecia and skin rejuvenation. However, this is limited by lack of consensus regarding best practices and protocols. Randomized, controlled trials with uniform metrics comparing outcomes of various compositions of autologous blood products, preparation methods, dosimetry, and frequency of treatments are still required. This will allow the medical discourse to grow beyond the realm of expert opinion into consensus, standardization, and more wide spread adoption of best practices that will benefit patients.

Safety and Efficacy of Minoxidil Treatment in Scarring Alopecia: A Scoping Review

BACKGROUND

Topical minoxidil (TM) has been a cornerstone in treating various hair loss disorders, while low-dose oral minoxidil (LDOM) is emerging as an effective alternative. Despite their widespread use, there is a notable gap in the literature regarding their use in treating scarring alopecia.

OBJECTIVE

This study evaluates the efficacy and safety of TM and LDOM in managing scarring alopecia.

METHODS

A systematic literature search identified relevant studies on TM and LDOM use in central centrifugal cicatricial alopecia, frontal fibrosing alopecia, lichen planopilaris, and traction alopecia. Key metrics included disease stabilization, hair thickness improvement, hair regrowth, and side effect profiles.

RESULTS

Analysis of the selected studies revealed mixed outcomes. Most participants experienced benefits in terms of disease stabilization and hair regrowth with TM and LDOM. The majority of cases reported good tolerability of the treatment, although some side effects were noted.

CONCLUSION

TM and LDOM show promise in scarring alopecia treatment, demonstrating benefits in disease stabilization and hair regrowth. Despite these positive indications, the variability in results and reported side effects underline the need for further research to establish their consistent efficacy and safety profiles in scarring alopecia treatment. J Drugs Dermatol. 2024;23(3):     doi:10.36849/JDD.7743.

Medical and procedural treatment of androgenetic alopecia - Where are we?

Novel medical and procedural options for androgenetic alopecia have arrived. Low-dose oral minoxidil has made its clinical debut, while data on spironolactone, finasteride, and nutritional supplements have advanced. Minimally invasive technological advancements include photobiomodulation and platelet-rich plasma. Within hair transplantation, follicular unit extraction and robotics are now at the clinicians' fingertips.

Psychosocial impact of pediatric alopecia areata: A survey study

This study, which aimed to identify distress by sites of hair loss and psychosocial stressors for a pediatric alopecia areata population, enrolled 50 patients (32 females, 18 males, ages 7-17 years) from pediatric dermatology clinics, including a monthly hair disease clinic. Patients completed a 47-question survey. Scalp hair loss was rated as often or always bothersome in 34.7%; eyebrow loss in 24.3%; and eyelash loss in 21.6%, and 6 patients (12%) discontinued a social activity due to hair loss. Referral to behavioral/mental health specialists should be considered to improve psychosocial outcomes.

Current Treatment of Alopecia Areata

The number of alopecia areata (AA) clinical trials with Jak inhibitors of cytoplasmic tyrosine kinases, including Jak1, Jak2, Jak3, and tyrosine-protein kinase has increased significantly since the last Research Summit. This fact means that the conversation about current treatments for AA now also needs to include a discussion of traditionally used off-label therapies as well as evolving therapies as with Jak inhibitors.

Ruxolitinib cream for the treatment of patients with alopecia areata: A 2-part, double-blind, randomized, vehicle-controlled phase 2 study

BACKGROUND

There are currently no treatments for alopecia areata (AA) that are universally effective or approved by the US Food and Drug Administration. Oral ruxolitinib has shown efficacy in extensive AA. Ruxolitinib cream would potentially avoid systemic adverse effects.

OBJECTIVE

To assess the efficacy and safety of 1.5% ruxolitinib cream in patients with AA who had at least 25% hair loss by Severity of Alopecia Tool score.

METHODS

This was a 2-part study. Part A was an open-label, 24-week study of 1.5% ruxolitinib cream in patients with 25% to 99% hair loss followed by a 24-week extension period. Part B was a double-blind, vehicle-controlled, 24-week study of 1.5% ruxolitinib cream in patients with 25% to 100% hair loss, followed by a crossover to ruxolitinib cream in the vehicle group for 24 weeks and additional treatment time for the ruxolitinib cream group.

RESULTS

Although Part A results suggested potential efficacy of 1.5% ruxolitinib cream, there was no significant difference in hair regrowth based on 50% improvement in Severity of Alopecia Tool scores between patients receiving 1.5% ruxolitinib cream and vehicle in part B. There were no significant safety issues with 1.5% ruxolitinib cream.

LIMITATIONS

Single strength of ruxolitinib cream.

CONCLUSIONS

The 1.5% ruxolitinib cream did not have a significant effect in patients with AA.

Development of cutaneous squamous cell carcinoma after prolonged exposure to pegylated liposomal doxorubicin and hand-foot syndrome: a newly recognized toxicity

Pegylated liposomal doxorubicin (PLD) can be administered for prolonged periods with minimal toxicity. The risk of cutaneous squamous cell carcinoma (SCC) with this therapy has not been reported. We describe cutaneous SCC of the plantar foot in two patients exposed to high doses of PLD. A 50-year-old man with angiosarcoma received a total PLD dose of 1350 mg/m² and developed cutaneous SCC of bilateral plantar feet. A 45-year-old woman with cutaneous T-cell lymphoma was treated with a total PLD dose of 1142 mg/m² with subsequent diagnosis of cutaneous SCC of the right plantar foot. No risk factors for SCC of the plantar foot were identified in either patient. Cutaneous SCC is likely an unreported side effect of prolonged exposure to PLD. An extended duration of hand-foot syndrome from other anti-cancer drugs may also share this risk. Regular complete skin examination with early intervention for suspicious lesions is indicated in this patient population.

Evidence for neurogenic inflammation in lichen planopilaris and frontal fibrosing alopecia pathogenic mechanism

Lichen planopilaris (LPP) and frontal fibrosing alopecia (FFA) are lymphocytic scarring alopecias affecting primarily the scalp. Although both diseases may share some clinical and histopathological features, in the last decade, FFA has become an "epidemic" particularly in Europe, North and South America with unique clinical manifestations compared to LPP, thus, raising the idea that this disease may have a different pathogenesis. Symptoms such as scalp burning, pruritus or pain are usually present in both diseases, suggesting a possible role for nerves and neuropeptides in the pathogenesis of both diseases. Based on some previous studies, neuropeptides, such as substance P (SP) and calcitonin gene-related peptide (CGRP), have been associated with lipid metabolism and many chronic inflammatory disorders. In this study, we asked if these neuropeptides are associated with LPP and FFA scalp lesions. Alteration in the expression of SP and CGRP in affected and unaffected scalp skin from patients with both diseases was found with examination of sections using immunohistochemical techniques and confocal microscopy. We then quantitatively assessed and compared SP and CGRP expression from control, LPP and FFA scalp biopsies. Although LPP and FFA share similar histopathologic findings, opposite results were found in affected and unaffected scalp in the ELISA tests, suggesting that these diseases may have different pathogenic mechanisms. We also found presence of histopathological inflammation irrespective of evident clinical lesions, which raises the possibility that both diseases may be more generalized processes affecting the scalp.

The rise of transcutaneous drug delivery for the management of alopecia: a review of existing literature and an eye towards the future

Introduction: Fractional lasers and microneedling devices are increasingly used with topical drugs to treat various conditions, including alopecia, as they grant access to dermal structures such as hair follicles and cutaneous vasculature. Objective: To perform a comprehensive review on transcutaneous drug delivery for the management of alopecia. Methods: PubMed, Embase, and Ovid Medline databases were searched using terms including: alopecia, microneedling, lasers, androgenetic alopecia (AGA), alopecia areata (AA), drug delivery. Articles were examined for inclusion criteria: diagnosis of alopecia regardless of type, use of fractional laser or microneedling devices, and subsequent administration of topical medication. Results: 8 studies, 6 prospective clinical trials and 2 case series, examining either AA or AGA were identified. For AA, five studies examined microneedling together with topical triamcinolone in three of these, while two studies used photodynamic therapy. Regarding AGA, two studies used topical minoxidil plus microneedling, and one examined topical finasteride with fractional erbium glass laser. Improvement was seen in 6 of the 8 studies. Discussion: Transcutaneous drug delivery via fractional laser and microneedling is a promising modality with preliminary evidence for increased hair regrowth over topical therapy alone. Further studies are needed to elucidate treatment parameters and appropriate device selection for drug delivery.

Childhood alopecia areata-Data from the National Alopecia Areata Registry

BACKGROUND/OBJECTIVES

Alopecia areata may occur at any age and is the third-most-common dermatosis in children. The objective of this study was to investigate the clinical and epidemiologic features of children and adolescents with alopecia areata based on the data of the National Alopecia Areata registry on children and adolescents.

METHODS

Two thousand two hundred eighteen children and adolescents with alopecia areata self-enrolled in the National Alopecia Areata Registry and completed a web-based, self-administered, short-intake screening questionnaire (first tier). In the second tier, 643 patients participated in a clinical examination and completed a long-form questionnaire.

RESULTS

Mean age of onset was 5.9 ± 4.1 years. With a female to male ratio of 1.5:1, alopecia areata was more prevalent in girls, but boys were significantly more likely to have a severe type (P = .009). One-fourth of all children had a positive family history, with 8% having more than three affected relatives. The disease most commonly associated with alopecia areata was atopic dermatitis (32.7%).

CONCLUSION

Childhood alopecia areata is more prevalent in girls than in boys, but boys have more extensive alopecia areata. Despite the low prevalence, congenital alopecia areata is an important differential diagnosis for neonatal hair loss. Alopecia areata runs in families, suggesting an underlying genetic background. One-quarter of the children reported at least one affected first-degree relative; 8% had more than three affected relatives.

Building and Crossing the Translational Bridge: 2016 Alopecia Areata Research Summit Highlights

Alopecia areata (AA) is a common autoimmune skin disease that results in the loss of hair on the scalp and elsewhere on the body and affects over 146 million people worldwide at some point in their lives. Founded in 1981, the National Alopecia Areata Foundation is a nonprofit organization that supports research to find a cure or acceptable treatment for AA, supports those with the disease, and educates the public about AA. The National Alopecia Areata Foundation conducts research summits every 2 years to review progress and create new directions in its funded and promoted research. The Foundation brings together scientists from all disciplines to get a broad and varied perspective. These AA research summits are part of the Foundation's main strategic initiative, the AA Treatment Development Program, to enhance the understanding of AA and accelerate progress toward a viable treatment.

Alopecia Areata: The Clinical Situation

In the absence of an approved treatment by the US Food and Drug Administration, choosing one of the many off-label treatments available for a child, teen, or adult with alopecia areata (AA) can be challenging. The physician or midlevel provider treating a patient with AA needs to take into consideration the age of the patient, location of hair loss, disease extent and activity, and any ongoing medical or psychological issues. Many patients and their families have now also heard the "buzz" about evolving research, particularly with JAK inhibitors, for the treatment of AA. This means that today's clinic visit with the AA patient should include not only a discussion about traditionally used off-label treatments but also evolving therapies and clinical research opportunities.

Photobiomodulation therapy for androgenetic alopecia: A clinician's guide to home-use devices cleared by the Federal Drug Administration

The market for home-use photobiomodulation devices to treat androgenetic alopecia has rapidly expanded, and the Food and Drug Administration (FDA) has recently cleared many devices for this purpose. Patients increasingly seek the advice of dermatologists regarding the safety and efficacy of these hair loss treatments. The purpose of this guide was threefold: (1) to identify all home-use photobiomodulation therapy devices with FDA-clearance for treatment of androgenetic alopecia; (2) to review device design, features and existing clinical evidence; and (3) to discuss practical considerations of photobiomodulation therapy, including patient suitability, treatment goals, safety, and device selection. A search of the FDA 510(k) Premarket Notification database was conducted using product code "OAP" to identify all home-use devices that are FDA-cleared to treat androgenetic alopecia. Thirteen commercially available devices were identified and compared. Devices varied in shape, wavelength, light sources, technical features, price, and level of clinical evidence. To date, there are no head-to-head studies comparing the efficacy of these devices. Photobiomodulation therapy devices have an excellent safety profile and mounting evidence supporting their efficacy. However, long-term, high quality studies comparing these devices in diverse populations are lacking. As these devices become increasingly popular, dermatologists should be familiar with this treatment modality to add to their therapeutic armamentarium.

ABBREVIATIONS

AGA, androgenetic alopecia; FDA, Food and Drug Administration; IEC, International Electrotechnical Commission; LED, light-emitting diode; PBMT, photobiomodulation therapy.

Importance of Group Therapeutic Support for Family Members of Children with Alopecia Areata: A Cross-Sectional Survey Study

BACKGROUND/OBJECTIVES

The psychological effect of alopecia areata (AA) is well documented, but group interaction may help lessen this burden. We aimed to determine factors that draw patients with AA and their families to group events.

METHODS

Surveys were administered at the annual alopecia areata bowling social in 2015 and 2016. This event is a unique opportunity for children with AA and their families to meet others with the disease and connect with local support group resources from the Minnesota branch of the National Alopecia Areata Foundation. Data from 2015 and 2016 were combined. Comparisons of subgroups were performed using Fisher exact tests for response frequencies and percentages and two-sample t tests for mean values.

RESULTS

An equal number of men and women participated in the study (n = 13 each). The average age was 41.1 years. There were no significant differences (p > 0.05) in survey responses based on respondent age or sex. Twenty-three (88.5%) attendees sought to connect with others with AA and met three or more people during the event. Seventeen (65.4%) also attended other support group events. Twelve respondents (46.2%) came to support a friend or family member. One hundred percent of attendees identified socializing with others with AA as important.

CONCLUSIONS

Group interaction is an important source of therapeutic support for people with AA and their families.

Syphilitic Alopecia: Case Reports and Trichoscopic Findings

There has been a resurgence of syphilis in the last decade. Although alopecia is not a common manifestation of the disease, the "moth-eaten" pattern is considered patognomonic. However, diffuse hair loss, termed essential alopecia, sometimes can be the only sign of syphilis infection and mimic other conditions, such as alopecia areata and telogen effluvium. We describe three patients with syphilis in whom the pattern of alopecia was not typical. Although clinical, histopathological, and trichoscopic examinations may share some similar findings with other hair diseases, the inclusion of syphilis in the differential diagnosis of hair loss causes is fundamental to a correct screening and diagnosis.

Efficacy and Safety of Once-Daily Minoxidil Foam 5% Versus Twice-Daily Minoxidil Solution 2% in Female Pattern Hair Loss: A Phase III, Randomized, Investigator-Blinded Study

BACKGROUND

A once-daily minoxidil topical foam (MTF) has been developed to treat female pattern hair loss.<br/>

OBJECTIVE

Determine noninferiority of once-daily 5% MTF versus twice-daily 2% minoxidil topical solution (MTS) based on the change from baseline in target area hair count (TAHC) at 24 weeks.

METHODS

In a randomized, phase III trial, women with female pattern hair loss received once-daily 5% MTF (n=161) or twice-daily 2% MTS (n=161) for 52 weeks. Primary endpoint was change from baseline in TAHC at 24 weeks. Secondary endpoint was change from baseline in TAHC at 12 weeks. Exploratory endpoints included change in total unit area density and change in overall scalp coverage.<br/>

RESULTS

Once-daily 5% MTF increased TAHC from baseline (adjusted mean ± standard error) by 23.9 ± 2.1 hairs/cm² at week 24. Twice-daily 2% MTS increased TAHC 24.2 ± 2.1 hairs/cm² at week 24. The treatment difference was -0.3 hairs/cm² (95% CI = -6.0, 5.4). Since the lower bound of the 95% CI was less than -5.0, the prespecified noninferiority goal was not met. Both treatments were well tolerated.<br/>

CONCLUSIONS

Once-daily 5% MTF and twice-daily 2% MTS induced hair regrowth in female pattern hair loss, but prespecified noninferiority criteria were not met.<br /> ClinicalTrials.gov identifier: NCT01145625 <br /><br /> <em>J Drugs Dermatol.</em> 2016;15(7):883-889.

Overview of alopecia areata

Alopecia areata is a complex genetic, immune-mediated disease that targets anagen hair follicles. The disease affects children and adults and is characterized by round or oval patches of hair loss, loss of all scalp hair (alopecia totalis), body hair (alopecia universalis), or ophiasis pattern hair loss. Patients may also present with patchy loss in multiple hair-bearing areas. Commonly associated diseases include asthma, allergic rhinitis, atopic dermatitis, thyroid disease, and automimmune diseases, such as thyroiditis and vitiligo. Nail abnormalities may precede, follow, or occur concurrently with hair loss activity. Alopecia areata has no known age, race, or ethnic preponderance and in contrast to other autoimmune diseases such as thyroiditis or lupus, the hair follicle does not usually sustain permanent injury and maintains its potential to regrow hair. It is estimated that alopecia areata affects between six and seven million individuals in the United States. Genes, the immune and nervous systems have all been implicated in the pathogenesis of alopecia areata. Although many treatments are available, there is still no cure. Bolstered by new scientific and translational opportunities from recently published genome-wide association studies, an ambitious treatment development program has recently been initiated by the National Alopecia Areata Foundation.

Health-Related Quality of Life (HRQoL) in alopecia areata patients-a secondary analysis of the National Alopecia Areata Registry Data

Alopecia areata (AA) is a nonscarring and recurrent disease characterized by hair loss that may significantly affect patient health-related quality of life (HRQoL). Given the lack of reliable and accurate reporting of HRQoL status in patients with AA, we analyzed data from 532 AA patients from the National Alopecia Areata Registry whose registry record included HRQoL assessments using three validated instruments: Skindex-16, brief version of the Fear of Negative Evaluation Scale, and Dermatology Life Quality Index. The mean HRQoL scores were compared with previously reported HRQoL levels from healthy controls and patients with other skin diseases. Two-step cluster analysis of Skindex-16 scales divided patients into two groups: 481 (57%) with good HRQoL and 361 (43%) with poor HRQoL. Multivariate logistic regression modeling revealed a set of risk factors for poor HRQoL: age <50 years (odds ratio (OR) 3.99, 95% confidence interval (CI) 1.66-9.58), female gender (OR 2.74, 95% CI 1.73-4.34), hair loss 25-99% (OR 2.47, 95% CI 1.12-5.45), family stress (OR 1.8, 95% CI 1.13-2.86), and job change (OR 2.01, 95% CI 1.02-3.94). The current analysis provides an overview of the HRQoL status of AA patients and may guide patient care in the future.

A review of scalp camouflaging agents and prostheses for individuals with hair loss

Hair loss is a common problem for both men and women and may impact negatively on self-esteem. A variety of medical and surgical treatment options are available depending on the type of alopecia. Many patients also seek the advice of their physicians about options to hide or reduce the appearance of hair loss with hair prostheses (wigs, hairpieces, and extensions) or hair camouflaging agents (hair fibers, powder cakes, lotions, sprays, hair crayons, and scalp tattooing). Herein, we review current methods to hide or reduce the appearance of hair loss and discuss their associated costs, advantages, and disadvantages. Knowledge of products available to cover scalp, eyebrow, and eyelash hair loss may not only better equip clinicians to respond to questions from concerned patients, but may provide additional options to help these patients best cope with their hair loss.

Subcutaneous efalizumab is not effective in the treatment of alopecia areata

BACKGROUND

Alopecia areata (AA) is a T-cell-mediated autoimmune disease. Efalizumab is a T-cell-targeted therapy approved for the treatment of psoriasis.

OBJECTIVE

To assess the efficacy and safety of efalizumab in the treatment of moderate-to-severe AA.

METHODS

Sixty-two patients were enrolled into this phase II, placebo-controlled trial. The trial consisted of three 12-week periods-a double-blind treatment period, an open-label efalizumab treatment period, and a safety follow-up.

RESULTS

There were no statistical differences between treatment groups in percent hair regrowth, quality-of-life measures, or changes in biologic markers of disease severity after 12 or 24 weeks. In both groups, there was an approximately 8% response rate for hair regrowth (at 12 weeks). Efalizumab was well tolerated.

LIMITATIONS

Numbers were too small for certain analyses.

CONCLUSION

A 3- to 6-month trial of efalizumab was not effective in promoting hair regrowth in this small cohort of patients with moderate-to-severe AA.