Update on Approaches to Hair Restoration

What is the potential benefit for JAK inhibitors for the treatment of alopecia and hair loss?

Francisco Jimenez, MD: JAK inhibitors are a group of drugs used to treat autoimmune diseases, such as psoriasis, rheumatoid arthritis, and certain hematologic malignancies. A few years ago, it was found that some patients with alopecia areata who were treated with these drugs for other autoimmune diseases had striking hair growth in the previously bald areas. Since then, numerous studies have been done showing that these medications (tofacitinib and ruxolitinib) are indeed very effective in alopecia areata, even in their severe forms (alopecia totalis and alopecia universalis). These drugs are used orally and although they are well tolerated by most patients, they may yield unwanted long-term side effects.

Topical application of JAK inhibitors may be a desirable treatment option for alopecia areata. There are currently numerous clinical trials investigating other JAK inhibitors and topical formulations which may be an important option in the future.

What are the benefits and potential role for PRP in addressing hair loss?

Dr. Jiminez: Platelet-rich plasma (PRP) is basically an increased concentration of platelets found in whole blood. It has received a lot of attention and hype as a therapy for androgenetic alopecia. The ISHRS 2020 Practice Census gauged the frequency of prescribing PRP and other treatments to patients and found that PRP was one of the most commonly prescribed treatments, with 43.5 percent of ISHRS members reporting always or often prescribing PRP to patients in 2019.

The latest reviews published by ISHRS members (Gupta, et al.) have shown that, in general, PRP can be considered an effective therapy for AGA, but in my opinion it is not superior to other options, such as finasteride or topical or oral minoxidil.

One of the problems of PRP is the variability of results, which may be due to the different PRP systems used or different patient characteristics.

In my practice I use PRP as an adjuvant therapy and in combination with oral and topical medications in patients that do not improve enough with medical therapy alone. The current recommended dosage is three injections at once monthly intervals and then a maintenance regimen of one injection every six months, depending on the patient’s response.

Is hair restoration surgery the gold standard for hair restoration? Why?

Dr. Jiminez: Yes, hair restoration surgery has indeed passed the test of time and is now the main and most effective therapy for androgenetic alopecia and other forms of hair loss. It has been in our armamentarium since 1939 when Okuda published his seminal papers on punch grafting. Over the years the surgical technique has evolved and changed completely, but the basic concept remains pretty much the same, namely the redistribution of scalp hair follicles—removing follicles from areas where hair growth is almost certainly permanent and implanting them into areas of baldness.

Currently, the technique of hair transplantation using exclusively follicular units achieves completely natural results in just one or a few sessions. But it is important to know that this is not an easy surgical technique. It requires meticulous concentration, is very laborious, has to be performed by qualified doctors, and the training and experience of the surgeon are absolutely key to achieving good outcomes.

Hair restoration procedures continue to grow globally. What do you think accounts for the increasing demand?

Dr. Jiminez: The ISHRS 2020 Practice Census found that the worldwide volume of surgical hair restoration procedures performed in 2019 rose 16 percent from 2016, with 735,312 procedures performed last year alone. The most important reason for the increasing demand is, in my opinion, the progressive improvement of the surgical technique employed and the use of follicular units as hair grafts that are virtually undetectable. In addition, the appearance of a surgical technique known as FUE (follicular unit excision) in the early 2000s has made hair transplantation even more popular for the general public, as it is less invasive than the traditional strip harvesting FUT technique.

FUE is perceived by patients as a minimally invasive surgery because it does not involve sutures or an excision of a long strip. This has increased demand. The results of FUE when compared with strip harvesting FUT are identical if performed by qualified surgeons.

Non-scalp treatments have also increased. Are there risks associated with these types of treatments, and what are some guidelines to ensure best outcomes?

Dr. Jiminez: Yes, in recent years eyebrow and beard hair transplantation have increased in popularity substantially. Eyebrow transplantation requires sound knowledge and experience to get good results. The eyebrows are especially challenging, because the hairs need to match eyebrow hair quality and also because eyebrow hairs exit the skin at very flat angles. Excellent articles have been published by ISHRS members from China about this topic. We have to inform patients that hairs transplanted into the eyebrows need to be cut frequently, approximately every two weeks, because they grow more quickly and longer than original eyebrow hair—in fact at the same rate as if they were still on the scalp.

Current hipster fashion has also attracted many men to grow dense and long beards, and we are seeing increasing numbers of patients requesting hair transplantation into beards.

In addition, the beard may be used as a source of donor hair follicles in some patients with androgenetic alopecia that do not have enough donor hair on the occipital scalp and require more hair grafts. Studies have shown the hair growth survival is excellent.

What is the Fight the FIGHT campaign? Why is this initiative necessary?

Dr. Jiminez: The Fight the FIGHT campaign was launched a year ago due to the extensive complications that we were seeing in many patients who had received hair restoration surgery from non-doctors in clinics primarily motivated by commercial interests and with a very limited focus on proper patient care. The campaign is designed to be informative and educational. We want to make people aware of the consequences of being operated on by technicians with no medical licensure. We hope to make people realize that not everything they read on the Internet is true. It is vital that anybody considering hair restoration surgery thoroughly researches the credentials of the clinic and its doctors. They should know clearly in advance who will be performing the surgery. Knowing such things beforehand can save the patient from a lot of potential trouble.

Hair transplantation is a very rewarding treatment if done well and with good judgment, but it can have disastrous consequences which may even be permanent and impossible to undo, if performed by people with unethical conduct and attitudes whose primary interest lies not in the science or in the wellbeing of the patient, but in commercial gain.