Ilya Petrou, MD

Hair loss has a lengthening list of complex causes in male and female patients, ranging from genetic predisposition and androgen imbalances to physical and mental stress and COVID-19. In response, the mechanisms of action and scope of treatment options are expanding exponentially. However, not all these therapies demonstrate equal efficacy and safety, according to panelists presenting on full-cycle hair loss management at the Music City SCALE Symposium for Cosmetic Advances & Laser Education 16th Annual Meeting, August 18-22, 2021, in Nashville, Tennessee.

This track outlined the treatments which show the most promise, how to select and use these options, and how to prepare for further COVID 19-related impact on hair loss as the pandemic enters a new phase.

Harness Regenerative Medicine’s Potential


Regenerative medicine has “amazing,” untold potential as an emerging therapy, said Michael H. Gold, MD, founder of Gold Skin Care Center, Advanced Aesthetics Medical Spa, The Laser & Rejuvenation Center, and Tennessee Clinical Research Center located in Nashville, Tennessee during his presentations on hair loss at the SCALE conference.

 However, he cautioned that this potential could dissipate if dermatologists do not do in-depth homework.

For example, Gold pointed out that platelet-rich plasma (PRP) is a huge play in dermatology currently and while having demonstrated positive outcomes in other aesthetic rejuvenation procedures, the technique also has proven itself to be a very effective treatment for hair loss.

Although an ever-increasing number of companies offering PRP kits claim their product to be top shelf, Gold noted some do not back up their positions with peer-reviewed studies, publications, and authenticated scientific research. The FDA has cracked down on pseudo-science-oriented products, but physicians still need to be wary regarding which PRP products they choose, he added. 

“The products we choose need to be backed by sound science with clinical trials that are best performed by dermatologists and/or medical professionals in the field who specialize in hair and treatments for hair loss,” Gold said. “I believe the aesthetic and dermatology companies out there have slowly but finally understood that we as medical professionals demand this for our patients.”

Prescription medications such as finasteride, non-prescription remedies such as minoxidil, special diets—including high-dose protein, vitamin D, biotin, and iron supplements—can be useful adjunctive therapies in addressing alopecia, according to Gold. 

Nutraceuticals also have proven their efficacy in stemming hair loss and helping regrow hair, said Gold. However, he recommended that physicians search for nutraceutical products from reputable companies and use products that are backed by placebo-controlled clinical trials that include hair counts to back their claims.

Additionally, more innovation is on the horizon. In July, the FDA cleared an Investigational New Drug Application (NDA) for Kintor Pharmaceutical’s novel drug GT20029 for treatment of androgenetic alopecia (AGA) and acne subjects. GT20029 is the first topical Proteolysis Targeting Chimera (PROTAC) compound globally to have entered the clinical stage. 

“Hair loss therapy is a booming business today and for male and female patients with most types of alopecia, PRP, nutraceuticals, and other products in the pipeline are giving hope,” Gold said. “If you are going to be in the regenerative medicine space no matter if it’s injectables, topicals, or pills, you need to do [your] homework.”

Hospitalized patients with COVID-19 present and diagnosed with androgenetic alopecia are more frequently found than expected in an aged-matched control groups, and the underlying pathology is likely due to androgens, said Andy Goren, MD, chief medical officer at Applied Biology, Inc., in Irvine, California, in his presentation on hair loss at SCALE.

Recent data have shown that patients with higher tissue androgen levels are likely to suffer from more severe COVID-related symptoms according to Goren. This discovery has led to clinical trials, both of genetic and androgen assessment of COVID-19. Among key factors being studied are anti-androgens, specifically using androgen deprivation therapeutic drugs against COVID-19.

In his hair loss research, Goren noticed that male patients are disproportionately affected compared to female patients, but prepubescent pediatric patients are not affected at all. In his view, this appears to implicate an androgen level imbalance in affected individuals. 

Androgens play a pivotal role in hair loss but not in “COVID effluvium.” “Stress related to the pandemic can cause telogen effluvium or ‘COVID effluvium’, which in all likelihood will reverse itself to normal hair growth once the stress factor is gone,” Goren said.

Closer investigation suggested a link between androgen response and coronavirus. Goren and his team found that, in order to enter the type II pneumocytes in the lungs, SARS COVID-2 requires an enzyme to cleave the virus, mainly TMPRSS2.

“The only known promoter of this enzyme in humans is regulated by an androgen response element, and this honed our focus on androgens and androgen receptors, which is the first thing you think of in androgenetic alopecia,” Goren said.

, Goren and his colleagues found that men with COVID-19 who had been hospitalized with the virus, had less hair than expected in that corresponding patient population. As a result, baldness was established as an increased risk factor for more severe COVID-19 infection, re-enforcing the premise that pandemic-related hair loss is related to androgens, not stress. 

This finding led to the hypothesis that androgen receptor genetics—how androgens are regulated—might predict risk for COVID-19 severity. 

“From a dermatology perspective, this finding was incidental and is interesting because the connection to baldness and androgenetic state seems to impact the severity of COVID-19 disease,” Goren said. “Nevertheless, it is not surprising because the influenza virus is also thought to be influenced by androgens. In fact, studies demonstrated that androgens attenuate vaccine efficacy. So, it’s not just COVID-19.”

In a retrospective analysis, researchers then began working with the dual 5-alpha-reductase inhibitor dutasteride for potential COVID-19 treatment and studied the medication’s effect in a cohort of dermatology patients who were taking the drug for more than 6 months—imparting a protective effect—compared to patients who were not on the drug.

Following positive results from the analysis, the researchers then turned to using the drug in patients who were hospitalized for COVID-19 and taking androgen deprivation therapy, which offers a more potent and faster-acting means to reduce androgens in the body. 

Proxalutamide (Kintor Pharmaceuticals), a second-generation androgen receptor antagonist, as well as HC-1119 (Hinova Pharmaceuticals), an androgen receptor inhibitor, used in COVID-19 patients are currently in phase 3 trials (NCT04728802 and NCT04986176, respectively). If they gain FDA approval, these drugs could represent a completely new therapy for COVID-19 infection, according to Goren.

As a result of his research, Goren recommended that patients experiencing hair loss should speak with a dermatologist, as this could be a sign that they may be at a higher risk for COVID-19 severity. A multidisciplinary approach would be the best route for optimal patient care, he concluded.

Goren and Gold reported no relevant financial disclosures.

Gold MH, Goren A, Fisher J, et al. SCALE hair workshop: The full cycle of managing the hair loss patient. Presented at: Music City SCALE 16th Annual Meeting; August 18-21, 2021, in Nashville, Tennessee. 

Gold MH. PRP updates. Presented at: Music City Scale 16th Annual Meeting; August 18-21, 2021, Nashville, Tennessee.

Gold MH. Hair loss treatments—nutraceuticals and new medical treatments. Presented at: Music City Scale 16th Annual Meeting; August 18-21, 2021, Nashville, Tennessee.

Goren, A. What’s new in hair research, including COVID update. Presented at: Music City SCALE 16th Annual Meeting; August 18-21, 2021. 

Goren A, Vaño-Galván S, Wambier CG, et al. A preliminary observation: Male pattern hair loss among hospitalized COVID-19 patients in Spain - A potential clue to the role of androgens in COVID-19 severity. J Cosmet Dermatol. 2020 Jul;19(7):1545-1547. doi: 10.1111/jocd.13443. Epub 2020 Apr 23.

Wambier CG, Vaño-Galván S, McCoy J, et al. Androgenetic alopecia present in the majority of patients hospitalized with COVID-19: The "Gabrin sign". J Am Acad Dermatol. 2020 Aug;83(2):680-682. doi: 10.1016/j.jaad.2020.05.079. Epub 2020 May 22.

Articles

More options are available to address alopecia, but not all are backed by equally solid science. Strategies for choosing and using new treatments and procedures for full-cycle hair loss management were highlighted at the Music City Symposium for Cosmetic Advances & Laser Education 16th Annual Meeting. 

Game-Changers Advance Hair Loss Treatment

Futuristic hair restoration techniques are coming of age with the introduction of robotics, platelet-rich plasma (PRP), and photobiomodulation (low-level laser light) leading the way, according to experts presenting at the American Academy of Dermatology Virtual Meeting Experience (AAD VMX) 2021 annual meeting, April 23-25, 2021.

Providing an overview of some of the innovative therapeutic tools clinicians can use to slow hair loss and increase hair growth were Maria Hordinsky, MD, professor and chair of the Department of Dermatology at the University of Minnesota and the director of the department’s clinical research division in Minneapolis, who led the session; Marc R. Avram, MD, a Manhattan-based dermatologist and clinical professor of dermatology at New York-Presbyterian Hospital/Weill Medical College at Cornell Medical Center in New York, New York; and Neil S. Sadick, MD, FACP, clinical professor of dermatology at New York-Presbyterian Hospital/Weill Cornell Medical Center in New York, New York, and adjunct professor, Department of Dermatology, University of Minnesota in Minneapolis.

Transplant techniques used in hair restoration therapy have progressed from the use of large plugs to the harvesting of follicular units, allowing hair transplant surgeons to create undetectable, natural-looking results, Avram said. In his view, the robotic-assisted harvesting of follicular units has several advantages over manual harvesting.

“In the last few years, a novel approach has evolved to perform hair replacement robotically,” Avram said. “We take out each individual hair follicular unit from the back of the scalp with an incision that is less than 1 mm and then immediately place those follicular units at the front of the scalp where the hair is thinning. This has become state-of-the-art technology that can assist in achieving excellent treatment outcomes.”

Using the robot-assisted technique, the clinician can harvest 800 to 1000 follicular units in an hour with minimal transection. Robotic systems can do transplants in an automated fashion, saving much valuable time in a busy practice. Unless the clinician is very skilled, Avram said manual harvesting can not only be slow going but also may result in a higher transection rate, which can affect the growth of the transplant and lead to suboptimal aesthetic outcomes.

A central advantage of the robotic technique for patients is that it is minimally invasive. Historically, one of the major issues with hair transplant surgery is the 15- to 18-cm scars that would remain following follicular unit harvesting via donor ellipse.

According to Avram, today’s techniques using 0.9-mm punches do not require any suturing, allowing patients to wear short hairstyles without any visible scarring. However, Avram still performs elliptical donor harvesting for patients who never plan to have short hair and for whom donor scars are of no practical concern.

“Innovation is where you can move a few thousand hair follicles from the back of the head to the front without using a single stitch, and doing it robotically, making it a very popular procedure. The procedure has become very appealing and has opened up to a whole new group of patients who appreciate the quick, simple, and scar-free treatment technique,” Avram said.

PRP has also become a popular in hair restoration procedures, particularly when combined with transplant surgery. The autologous, minimally invasive treatment modality has been shown to encourage hair growth by promoting cellular maturation, differentiation, and proliferation while minimizing the risk of infection and immune rejection.

“There are several different devices available for PRP techniques. Some activate platelets before the PRP is injected while others are associated with activation of platelets with injection,” Hordinsky said. “However, it remains unclear whether the keys to success are platelet numbers or the release of growth factors by the platelets.”

When performing hair transplant surgery, a novel approach is to perform the PRP technique intraoperatively, injecting the solution before placing the grafts in the front. Clinically, this will help maintain the existing hair around the transplant sites and aid in making the transplanted grafts grow a little sooner, according to Avram.

It appears that PRP boosts the hair cycle, allowing patients to arrive at their desired outcomes sooner. It has even been shown to be effective in treating scarring alopecias, Avram added.

“The PRP is a way to combine robotics with medical techniques,” he said. “Performed intraoperatively, PRP gives a boost to the transplant hair and also treats and helps to maintain the already existing but thinning hair.”

Whether used as a monotherapy or in combination with minoxidil or PRP techniques, low-level laser light is also proving to be effective and a useful adjunctive therapy in hair replacement strategies.

“We often use photobiomodulation treatment to help initiate hair growth in patients who primarily have nonscarring hair loss,” said Hordinsky. “Several FDA-cleared home-use devices—including combs, bands, and caps that employ primarily red light or, in some cases, LED light or a combination— have been shown to be helpful in promoting hair growth,” Hordinsky added.

She advises patients to use these devices for a minimum of 4 months before evaluating treatment progress. She explains that patients need to adhere to the prescribed use of the devices because overuse could cause hormesis, which accelerates hair loss.

New generation noninvasive treatments such as PRP, low-level laser light, microneedling, fractional energy-based devices, and nutraceuticals have all been shown to be safe and effective in treating hair loss, but they also can be successfully combined with traditional medications such as minoxidil or oral finasteride, according to Sadick.

“The best and most comprehensive method for improving clinical outcomes and patient satisfaction in hair loss relies on combination therapies, as results are usually faster and treatments more effective than monotherapy, Sadick said. “Combination hair loss treatment strategies are typically personalized for each patient and depend on the type and severity of their hair loss as well as compliance level, time constraints, and budget.”

One of the key challenges when addressing patients with hair diseases is monitoring treatment success in the outpatient setting. Fortunately, Hordinsky said, new imaging systems enable clinicians not only to examine scalp health accurately with trichoscopy but also to get an assessment of the types of hair fibers present in the area being treated.

“Regrowing hair is a very slow process and people can become impatient with their results,” Hordinsky said. “Modern imagery can offer a quantitative assessment and precision evaluation that patients appreciate in following their improvement from therapy.”

Overall, Hordinsky sees more innovation ahead. “New and exciting technologies like photobiostimulation or PRP are proving useful in hair loss treatments. Physicians should recognize and embrace their therapeutic potential,” she said.

Avram reported no relevant or financial disclosures.

Hordinsky received 4 photobiomodulation devices for clinical research on the topic of photobiomodulation.

Sadick is a clinical researcher and chief medical adviser for Venus Concept.

1. Hordinsky M, Avram MR, Sadick N. Innovative technological and procedural advancements in managing alopecia. Presented at: American Academy of Dermatology Virtual Meeting Experience (AAD VMX) 2021. April 23-25, 2021.

Futuristic tools including robotics and new types of lasers are just some of the therapeutic innovations aimed at slowing hair loss and increasing hair growth.

Hair Restoration Goes High-Tech

Microneedling has become an increasingly popular treatment in clinical and aesthetic dermatology because of its minimally invasive nature, positive treatment outcomes, and minimal downtimes, according to Michael H. Gold, MD. Obtaining optimal results, however, requires the right training and device for practice needs.

Gold is the founder and medical director of Gold Skin Care Center, Advanced Aesthetics Medical Spa, The Laser & Rejuvenation Center, and Tennessee Clinical Research Center in Nashville, Tennessee. He provided a profile of microneedling advances and strategies at Maui Derm Live.1

Maximizing outcomes begins with an understanding of the device, its capabilities, and the science behind it, he said. The 4 microneedling techniques currently used, gradually increasing in the depth of skin penetration, include rollers, pens, radiofrequency (RF) pins, and RF needles.

In the procedure, miniature fine needles are superficially and uniformly introduced into the skin in a controlled manner. The resulting controlled skin injury induces rapidly healing micro-punctures and stimulates a wound healing with release of various growth factors, including platelet derived growth factor, transforming growth factor alpha and beta, connective tissue-activating peptide-III, cellular communication network factor 2, and fibroblast growth factor.

The subsequent stimulation of collagen and elastin fiber production leads to skin remodeling and visibly improved clinical outcomes. (Figure. 1)

“Microneedling is a very versatile treatment technique that can be effective in addressing a mosaic of cosmetic and medical concerns,” Gold said, including skin rejuvenation, acne, acne scars, posttraumatic/burn scars, alopecia, drug delivery, hyperhidrosis, and striae distensae.

Rollers are the simplest form of microneedling and can be used at home. Microneedling pens penetrate more deeply and are usually performed by physicians or relegated staff in clinic.

Microneedling pin devices typically only reach the upper dermis, whereas those with needles extend deeper into the dermis creating more dramatic effects. According to Gold, microneedling pins and needle techniques, particularly with the addition of RF, can lead to more robust collagen induction and enhanced clinical outcomes.

“There is a learning curve with microneedling RF pins and needle devices,” he said. “When maximizing their potential, you not only see improvement in collagen to treat scars or rejuvenate the skin, but [you] also get tightening, and lifting.”

Gold says the technique itself has a positive safety profile. Adverse events associated with the procedure, although not zero, are usually minimal and quickly resolve. The procedures also have minimal to no downtime in most cases.

“Training and skill level are paramount in helping to achieve positive outcomes,” said Gold. “Physicians should not expect to just turn these devices on and...get the most amazing results without understanding all the concepts behind them, how they work, and how the skin heals.”

Choosing the right microneedling device for the practice can be a daunting task because the market is imbued with an increasing number of competitive devices—all claiming to have the choice technology and best potential therapeutic abilities. When shopping for a cosmetic device, Gold said that it is important to “do your homework” and search for a device from a reputable company.

Some RF microneedling devices come with insulated and noninsulated tips, and some have both available in the system.

“Both needle types have benefits,” said Gold. “I like the noninsulated needle devices for many of the cases I see, but the insulated needle tips have proved to be very useful as well.”

In addition to achieving positive outcomes, practices also need to take into account the downtime required for the devices. When a patient is considering treatment with RF involved, Gold recommended asking them how much downtime they’ll allow—something he does routinely in his practice.

“Similar to the resurfacing days, the more aggressive the treatment, the more dramatic the cosmetic outcomes,” said Gold. “In my treatment plan discussion with patients, I will choose pen, RF pins, or RF needles, depending on how much downtime is available and making sure the patient understands this in advance.”

Gold said patients need to be informed in detail about the procedure and clear on expectations. “It behooves physicians who want to incorporate RF microneedling cosmetic procedures [into] their practice to learn the devices and their science well before proceeding,” Gold said. “This will help ensure positive treatment outcomes and very happy patients.”

Gold has consulted for, spoken for, or been an investigator for Crown Aesthetics, Collagen Pin, Strata Skin Sciences, Candela, Venus Concept, ENDYMED Medical, Lumenis, and InMode Ltd.

1. Gold MH. Microneedling RF & skin tightening—insulated and non-insulated needles—the case for each and new concepts in skin tightening without needles. Presented at: Maui Derm Live In-Person Dermatology CME Conference and Maui Derm Connect Virtual Dermatology CME Conference; January 25-29, 2021; Maui, HI; virtual.

Microneedling with or without radiofrequency has become a very popular cosmetic procedure. Understanding the science behind these versatile devices can help clinicians better harness their therapeutic potential and ensure positive treatment outcomes in their patients. 