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Platelet-Rich Plasma in Androgenic Alopecia: Myth or an Effective Tool

Swapna S Khatu, Yuvraj E More, Neeta R Gokhale, Dipali C Chavhan, Nitin Bendsure
Department of Dermatology, Venereology and Leprosy, Smt Kashibai Navale Medical College, Pune, Maharashtra, India
Address for correspondence: Dr. Swapna S. Khatu, Department of Dermatology, Venereology and Leprosy, Smt Kashibai Navale Medical College, Narhe,
Pune - 411 041, Maharashtra, India. E-mail: [email protected]

ABSTRACT
Platelet-rich plasma (PRP) has become a newer method for the treatment of various types of alopecia. In this
prospective study, safety, efficacy and feasibility of PRP injections in treating androgenic alopecia were assessed.
Eleven patients suffering from hair loss due to androgenic alopecia and not responding to 6 months treatment with
minoxidil and finasteride were included in this study. The hair pull test was performed before every treatment session.
A total volume of 2-3 cc PRP was injected in the scalp by using an insulin syringe. The treatment was repeated every
two weeks, for a total of four times. The outcome was assessed after 3 months by clinical examination, macroscopic
photos, hair pull test and patient’s overall satisfaction. Results: A significant reduction in hair loss was observed
between first and fourth injection. Hair count increased from average number of 71 hair follicular units to 93 hair
follicular units. Therefore, average mean gain is 22.09 follicular units per cm2. After the fourth session, the pull test
was negative in 9 patients. Conclusion: PRP injection is a simple, cost effective and feasible treatment option for
androgenic alopecia, with high overall patient satisfaction.

KEYWORDS: Androgenic alopecia, platelet rich plasma, hair pull test

REC Review: growth factor (PDGF), transforming growth factor (TGF),

Risk : 5 0 = maximum risk 5 = least risk vascular endothelial growth factor (VEGF), insulin-like
Efficacy : 2 0 = minimum efficacy 5 = maximum efficacy growth factor (IGF), epidermal growth factor (EGF)
Cost : 2 0 = very expensive 5 = least expensive and interleukin (IL)-1.[2,3] It is hypothesised that growth
factors released from platelets may act on stem cells in the
bulge area of the follicles, stimulating the development
INTRODUCTION of new follicles and promoting neovascularisation.[4] The
Androgenic alopecia or male pattern baldness is a very aim our pilot study was to evaluate the safety, efficacy
common type of hair loss observed in both males and and feasibility of PRP for treatment of androgenic
females. Platelet-rich plasma (PRP) is an autologous alopecia.
preparation of platelets in concentrated plasma.
Although the optimal PRP platelet concentration MATERIALS AND METHODS
is unclear, the current methods by which PRP is
prepared report 300-700% enrichment, with platelet Between August 2013 and November 2013, all patients
concentrations consequently increasing to more than suffering from androgenic alopecia and on topical
1,000,000 platelets/L.[1] PRP has attracted attention in minoxidil and finasteride for at least 6 months without
several medical fields because of its ability to promote much improvement were considered for PRP therapy.
wound healing. Activation of alpha granules of platelets Written informed consent was obtained. All included
releases numerous proteins, including platelet-derived patients were tested by ELISA for HIV, HBS Ag and
platelet count. Exclusion criteria were haematological
Access this article online disorders, thyroid dysfunction, malnutrition and other
Quick Response Code: dermatological disorders contributing to hair loss. A
Website:
www.jcasonline.com 1 cm × 1 cm square area was marked over right parietal
area in mid-pupillary line, 10 cm proximal to right
eyebrow in each patient. Baseline follicular units were
DOI:
10.4103/0974-2077.138352 manually counted with the help of trichoscan in this area
by dividing into four small quadrants [Figures 1 and 2].

Journal of Cutaneous and Aesthetic Surgery - Apr-Jun 2014, Volume 7, Issue 2 107
Khatu, et al.: Platelet rich plasma

Figure 1: Pre-treatment trichoscan image Figure 2: Post-treatment trichoscan image

Before each session, the hair pull test was performed cm apart) under proper aseptic precaution in minor
three times by the same clinician. All patients were operation theatre. A total volume of 2-3 cc was injected.
advised to avoid washing hair two days prior to the The treatment was repeated every two weeks for four
treatment. A bundle of approximately 50-60 hair was sessions. At each visit, hair count was noted over the
grasped between the thumb, index and middle finger prefixed square area. Subjective improvements of
from the base close to the scalp. The hair was firmly patients were noted on a scale of worst (1) to best (10).
tugged away from the scalp, and the extracted hair We evaluated all the patients at the end of 12 weeks.
was counted in every session. To evaluate overall hair
growth, hair volume, hair quality and fullness, global RESULTS
pictures were taken in every session from front, vertex,
Eleven male patients in the age group of 20-40 years
lateral and back view.
were included in the study. According to Hamilton
classification of male pattern baldness, 4 patients were
PRP was prepared by collecting 20 cc of fresh blood
in grade 2, 4 patients were in grade 3 and 3 patients were
in sodium citrate containing vaccutainers in minor
in grade 4 androgenic alopecia.
operation theatre under proper aseptic precaution.
The tubes were rotated in a centrifugation machine at
Before treatment, all our patients (100%) had a positive
1500 revolutions per minute for 6 minutes. The first
hair pull test with mean number of 10 hair. After the
centrifugation is called “soft spin”, which allows blood
fourth session, the pull test was negative in 9 patients
separation into three layers, namely bottom RBC layer
(81.81%) with average number of three hairs. A significant
(55% of total volume), topmost acellular plasma layer
reduction in hair loss was observed between first and
called platelet poor plasma (PPP, 40% of total volume)
fourth injection as noticed by patients. Global pictures
and an intermediate PRP layer (5% of total volume)
also revealed a moderate improvement in hair volume
called the “buffy coat”. Separated buffy coat with PPP
and coverage. [Figures 3 and 4] Hair count depicted
was collected with the help of Finn pipette in another
average number of 71 hair follicular units over marked
test tube. This tube underwent a second centrifugation,
area before starting the treatment, and after 4 sessions
which was longer and faster than the first, called “hard
of PRP, average number of follicular units was 93.09
spin”, comprising at 2500 revolution per minute for
follicular units. Therefore, average mean gain is 22.09
15 minutes. This allows the platelets (PRP) to settle at
follicular units per cm2. Overall, patient satisfaction was
the bottom of the tube. The upper layer containing PPP
high with a mean result rating of 7.0 on a scale of 1-10.
was discarded and the lower layer of PRP was loaded
in an insulin syringe containing calcium chloride (1 part
The side effects after PRP injections were minimal pain,
calcium chloride and 9 parts of PRP) as an activator.[5]
redness at the time of injections and pinpoint bleeding.
One hour prior to administration of PRP, anaesthetic
DISCUSSION
cream was applied over the bald area. Area of the scalp
to be treated was cleaned with cetavlon, spirit and Hair loss has a significant influence on psychological
povidone-iodine. With the help of insulin syringe PRP distress and is associated with low self-esteem and
was injected over affected area by nappage technique depression. Treatment options for androgenic alopecia
(multiple small injections in a linear pattern one- are very limited and include topical minoxidil and

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 Khatu, et al.: Platelet rich plasma

Figure 3: Pre-treatment clinical photograph Figure 4: Post-treatment clinical photograph

oral finasteride (FDA approved) either alone or in difference in the yield of follicular units on comparing
combination.[6,7] However, there are several reported the experimental with the control areas of the scalp.
side effects such as headache and increase in other The areas treated with platelet plasma growth factors
body hairs for minoxidil[6] whereas loss of libido has demonstrated a yield of 18.7 follicular units per cm2
been reported with oral finasteride. Finasteride also whereas the control areas yielded 16.4 follicular units
interferes with genital development in a male fetus and per cm2, an increase in follicular density of 15.1 percent.[4]
is contraindicated in pregnant women and those likely
to become pregnant.[7,8] Our study has some limitations. Trichoscopic hair
evaluation could have given more objective results.
PRP has already attracted attention in plastic surgery, Sample size is very small. Mean follow up of patients is
orthopaedic surgery and cardiac surgery because of its also short to draw conclusion regarding the long-term
potential use in skin rejuvenating effects, rapid healing, effectiveness of treatment. Thus, further studies are
reduced infection, decreased chance of hypertrophic needed with longer follow up and with large sample size.
keloids and scars.[9,10] Growth factors are known to activate
the proliferative phase and transdifferentiation of hair CONCLUSION
and stem cells and produce new follicular units. bFGF is PRP injection for androgenic alopecia is a simple, cost-
reported to promote the in vitro proliferation of papilla effective and feasible treatment option for hair loss
cells, and thereby plays a key role in elongating hair shaft.[11] and can be regarded as a valuable adjuvant treatment
modality for androgenic alopecia. Although PRP has
We prepared PRP by double spin method, in which sufficient theoretical scientific basis to support its use in
blood cell layers were manually separated. Activation hair restoration, hair restoration using PRP is still at its
of platelets through coagulation triggers the secretion infancy. Clinical evidence is still weak. Considering its
of various growth factors, which produce mitogenic excellent safety profile and relatively low cost, PRP hair
effects in various cell types. Activated PRP promotes treatment is a promising treatment option for patients
the proliferation of dermal papillary cells and prevents with thinning hair.
their apoptosis.
ACKNOWLEDGEMENT
In our study, the hair pull test became negative after
four sessions of PRP. This finding is comparable with the We would like to acknowledge Dr Vimal Arun Harke for
helping us in preparing PRP.
study conducted by Besti et al.[12] This study also observed
significant improvement in hair volume and coverage
in global pictures, but according to our study, only REFERENCES
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were pre-treated with platelet plasma growth factors of biology and applications in plastic surgery. Plast Reconstr Surg
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Commentary

Platelet Rich Plasma in Androgenic Alopecia: Where do we Stand?

Kiran Godse
Department of Dermatology, Dr. D. Y. Patil Medical College and Hospital, Nerul, Navi Mumbai, Maharashtra, India
Address for correspondence: Dr. Kiran Godse, Department of Dermatology, Dr. D. Y. Patil Medical College and Hospital, Nerul, Navi Mumbai - 400 706,
Maharashtra, India. E-mail: [email protected]

Dear Editor, In this issue an article titled ‘Platelet rich Methods of preparation vary with different kits and
plasma in androgenic alopecia: myth or an effective with manual methods. In addition there is no consensus
tool’ has shown favourable results with platelet for frequency of this procedure in various indications.
rich plasma (PRP) in androgenic alopecia. [1] There Once a month for three months seems to be appropriate
has been growing interest in PRP as a procedure in for hair growth. Automated kits seem to give better
dermatology. results. In general, platelet concentration should be four
to five times normal counts to achieve optimum results.
Literature review shows limited number of articles on Giusti et al., have showed optimum concentration of
PRP in various indications like androgenic alopecia, platelets around 15 lacs/mm3 for angiogenesis in human
healing in chronic ulcers and skin rejuvenation. PRP endothelial cells.[3]
seems to be rational therapy with science of growth
factors in tissue regeneration. Level of evidence of Precautions like using proper numbering of blood
various studies in androgenic alopecia is from low to samples, maintenance of sterile environment throughout
medium.[2] Well-defined double blind trials or split face the procedure, avoidance of infection and temperature
trials will definitely increase the confidence of clinicians control are important for consistent results. Transmission
in this procedure. of infections through this procedure is a theoretical
possibility. Patients with bleeding disorders, platelet
Access this article online dysfunction syndrome, anti coagulant therapy are
Quick Response Code:
contraindications for this procedure.

Website: PRP has shown reliable results in ulcer healing in an

www.jcasonline.com
Indian study.[4] PRP is also a useful adjuvant to fractional
laser therapy in skin rejuvenation.[5] In hair transplant
procedures, Ubel reported that enriching hair root grafts

110 Journal of Cutaneous and Aesthetic Surgery - Apr-Jun 2014, Volume 7, Issue 2
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