PracticalDermatology

Many patients with hair loss are intrigued by the possibility of taking a more personal role in their hair restoration treatment through the use of platelet-rich plasma (PRP) injections.

Platelet-rich plasma was initially described as “a small volume of plasma containing higher concentrations of platelets than those found in peripheral blood” that has now become a popular treatment for conditions in sports and regenerative medicine, as well as aesthetic medicine and hair loss, according to the authors of a recent review.1

Great Potential for PRP

In the review, Anon Paichitrojjana, MD, and Anand Paichitrojjana, MD, of Mae Fah Luang University and Mahidol University, both in Bangkok, Thailand, respectively, examined the mechanism of action for PRP and highlighted recent research regarding the use of PRP for managing hair loss.1

Although the method of preparation varies, PRP protocols involve preparing concentrated platelets from the patient’s own blood via centrifuge. The variation in PRP preparation may account for the variability in clinical benefits of PRP for hair loss reported in studies, according to the authors. The mechanism of action for PRP has not been fully explored, but data show that PRP can stimulate hair growth through the release of growth factors and cytokines including platelet-derived endothelial growth factor (PDGF), transforming growth factor Β (TGF-Β), fibroblast growth factor-2 (FGF-2), vascular endothelial growth factor (VEGF), epidermal growth factor (EGF), insulin-like growth factor1 (IGF-1), and glial cell line–derived neurotrophic factor (GDNF).

The reviewers identified recent clinical trials showing benefits for PRP across several hair loss conditions including androgenetic alopecia, female pattern hair loss, alopecia areata, cicatricial alopecia, and as an adjunct to hair transplantation. The reviewers noted that no major adverse side effects such as infections, scarring, or allergic reactions were reported after PRP treatment for hair conditions.

“PRP has been one of the most surprising and delightful additions to our hair loss treatment algorithm,” said Joel Schlessinger, MD, a dermatologist and cosmetic surgeon in private practice in Omaha, NE, and Chief Cosmetic Surgery Editor of Practical Dermatology, in an interview. “I was unsure that it could help these patients until I saw evidence from several studies, and I decided to try it in our clinic. The results have been extraordinarily rewarding, and patients seem to love the opportunity to spur their hair regrowth, at least for the short-term.”

Dr. Schlessinger has seen benefits for patients with a variety of hair disorders, such as androgenetic alopecia, telogen effluvium, and even some forms of scarring alopecia. He said he’s also been encouraged by reports of successful use of PRP for patients with skin of color and central centrifugal cicatricial alopecia (CCCA).

“These are some of the most challenging patients we encounter, and few treatments have been shown to help,” he added.

The main downside to PRP is the high cost, which can be a significant barrier to many patients. For those who can take advantage, according to Dr. Schlessinger, it is greatly appreciated as an option and the side effects are minimal. In his office, patients are offered nitrous oxide to help manage the discomfort of the injections, which are given in the scalp areas where regrowth is needed. Most of Dr. Schlessinger’s patients who undergo PRP for hair loss receive three to four injections separated by about 6 months.

“It doesn’t exactly start and end there, because many people do it over a longer period of time,” he explained. “Most patients understand the transient nature of it and would prefer something transient to other treatments such as oral minoxidil that may have more problematic side effects.”

He added: “We don’t necessarily start patients on PRP with the idea that it will be the only thing they do, but they may have tried other treatments without success. Generally, I also prescribe either spironolactone or low-dose finasteride, and in some cases, low-dose oral minoxidil. Additionally, we offer over-the-counter treatments such as Viviscal and ReTress in our office.”

Looking ahead, Dr. Schlessinger said he sees PRP as continuing to evolve as a hair loss treatment option.

“We have already seen focus on improving the yield from PRP and manufacturers are improving their product, so I think it’s safe to say that this area is still in early stages, and there is a lot of investigation that will be done in the future as to what it can and can’t do,” he noted.

Dr. Schlessinger also emphasized the importance of not overstating the benefits of PRP.

“PRP can create a nice improvement with short-term to medium-term longevity, but it certainly isn’t something that everyone has access to or would necessarily want,” he cautioned. “Also, clinicians must be mindful of the risks of over-promoting a therapy and be aware that patients may have heard overhyping from unscrupulous providers. Being on the bleeding edge is great until you are surrounded by charlatans and frankly dangerous practitioners who may be injecting PRP in unorthodox and inappropriate manners.”

Hope for CCCA

CCCA remains one of the most challenging forms of hair loss to manage, but research into PRP as a safe and effective option for this patient population is on the rise.

“Cicatricial or scarring alopecia often results in permanently damaged hair follicles that may be progressive, difficult to treat, and devastating for the patient,” said Porcia B. Love, MD, of River Region Dermatology and Laser in Montgomery, AL.

“I actively treat and newly diagnose various types of cicatricial alopecia in my clinic daily, predominantly among the skin-of-color community,” she said. “Due to the rapidly increasing prevalence of cicatricial alopecia, and CCCA in particular, it was important for me to conduct this research exploring alternative treatment options for patients with recalcitrant cicatricial alopecia.”

Dr. Love and her colleague, Chloe J. Walker, MD, also of River Region Dermatology and Laser, analyzed treatment outcomes for PRP in skin of color patients with CCCA at a single center between 2016 and 2022. They presented results of their retrospective study in a poster at the 2023 Music City Symposium for Cosmetic Advances & Laser Education (SCALE) in Nashville.

Their review included outcomes from 11 Black/African American women aged 40 to 72 years; 7 with a diagnosis of CCCA, 3 with Lichen planopilaris and frontal fibrosing alopecia (LPP/FFA), and 1 with nonspecific early scarring. Approximately two-thirds (64%) had concomitant androgenetic alopecia.

After an average of four sessions of PRP at intervals ranging from 4 to 6 weeks, 8 of the 11 patients showed significant improvement, including 6 with CCCA, 1 with LPP/FFA, and the patient with nonspecific scarring. The patients had failed both previous topical therapy and intralesional steroid injections.

“There is currently limited evidence to substantiate the efficacy of PRP in skin-of-color patients with cicatricial alopecia who have failed standard corticosteroid therapy,” Dr. Love told Practical Dermatology. “Given the limited data in the literature, I was surprised to see that the majority (73%) of my patients included in a subset of our study population demonstrated global improvement in hair density post-PRP therapy. Additionally, 64% had concomitant female pattern hair loss, which most likely contributed to positive treatment outcomes.”

Asked which patients might be mostly likely to succeed with PRP, Dr. Love said it is most effective for those patients with forms of non-scarring hair loss.

“However, PRP may be considered in those patients with mild cicatricial alopecia, coexisting female pattern hair loss, and those with unsatisfactory outcomes from conventional treatment,” she added.

Cost remains a barrier to PRP treatment because it is considered a cosmetic procedure, Dr. Love noted. Insurance does not cover the procedure.

“In addition to cost, procedural pain is another barrier to treatment,” she said. “Having more evidence-based research to substantiate PRP efficacy for select cicatricial alopecia patients may support insurance coverage as a medical treatment in the future.”

In the meantime, for patients who are able to undergo treatment, Dr. Love said that “providing proper education, appropriate expectations, spacing treatments at 4- to 6-week intervals and offering local or topical anesthetic support for the patient are some simple ways to help overcome procedural barriers to treatment.”

Following the preliminary study findings, Dr. Love said that next steps would include clinical trials involving larger study populations with various types and severities of cicatricial alopecia across ethnicities.

1. Paichitrojjana A, Paichitrojjana A. Platelet rich plasma and its use in hair regrowth: a review. Drug Des Devel Ther. 2022 Mar 10;16:635-645. Accessed July 3, 2023. doi:10.2147/DDDT.S356858.