Safe, Effective Treatments for Hair Loss 

Reena Jogi, MD, a Houston-based dermatologist and hair loss expert, is one of the leading practitioners in the field of hair loss disorders and treatments, and particularly in the use of platelet-rich plasma (PRP) therapy. Dr. Jogi spoke with Practical Dermatology® about how she started using PRP, important considerations for doing it effectively, and other issues in hair loss treatment. 

How did you come to specialize in hair loss? 

Dr. Reena Jogi: I fell into hair loss a bit serendipitously. When I started my practice about 8 years ago, I treated the same amount of hair loss that most dermatologists do. Like others, I did not feel like I had a lot to offer people because treatment options were a lot more limited than they are now. However, as we were deciding which cosmetic procedures to bring in, the representative for one of the microneedling devices we tried asked if I was interested in PRP therapy. I tend to be a bit of a late adopter, but this sounded very intriguing. First of all, it also sounded extremely safe and it sounded like the downside was pretty low. She gave me more information and connected me with another representative, and then I ended up training under Dr. Jeffrey Rappaport, who did perhaps more PRP than anyone in the country at that time. That is how I started doing PRP for hair loss. Of course, if you just do PRP for hair loss, then you don’t really distinguish yourself very much from a medical spa that does not know how to diagnose and treat hair loss conditions. As a result of adding PRP to my practice, I ended up seeing a lot more hair loss and becoming very comfortable very quickly.. 

Was the adoption process for PRP smooth or were there any bumps in the road? 

One thing that distinguishes board-certified dermatologists is that we all learn about hair loss extensively in residency, even if we don’t do a hair loss fellowship or anything extra. As a result, it’s just a matter of turning that switch to become someone who doesn’t dread seeing a hair loss patient. Hair loss patients can be challenging. It’s very emotional. Being able to offer PRP made seeing hair loss patients much more palatable because I had this extra tool that I could offer patients; even if they didn’t choose PRP, they at least left feeling more satisfied knowing that there was this additional option available. 

What makes PRP such a strong option? 

The approach is definitely not one-size-fits-all. Some patients don’t respond. What’s nice is that it’s fairly simple to do in the office. The injection technique is straightforward. Once you know how to do it, you know how to do it. With proper patient selection, it is effective. I have had great results. I do know doctors who have not had such strong results, so there is some variability in efficacy. The safety is almost unparalleled, however, and it’s very tolerable if you do it with certain modifications. We use cold air chiller devices to help take the edge off, and we also offer nitrous oxide. With those considerations, the tolerability, efficacy, and safety profile are what make PRP exciting. Additionally, the regenerative medicine aspect appeals to patients because they like the idea that their body is healing itself. 

Is it important to understand how PRP works and the technology behind it? 

It’s absolutely important. That basic scientific knowledge differentiates us from other people who did not go to medical school; we learn all that basic science for a reason. Also, patients are very savvy these days. I have yet to have the patient who has walked in and said, “Protein kinase B,” but I have patients who ask pretty challenging questions, and you need to be prepared to answer them. I also think it’s good for patients to understand—they don’t necessarily need to know specific pathways, but I explain that the platelets have a lot of growth factors that turn on these pretty complicated signaling pathways that then turn on the stem cells that are already there at the base of the hair follicle. That does help them appreciate the science behind it. 

What investment is necessary and what kind of return on that investment is possible? 

The initial outlay is far less than, for example, purchasing a laser. However, you do need to get a centrifuge and tubes. You need to use one of the more legitimate companies because if you have a problem, they will support you, and you also want tubes that have been put through pyrogen-free testing. You want to really make sure that you’re doing something that’s safe. Some companies offer a free centrifuge if you buy a certain number of tubes. If you’re not able to make it work and you find that these tubes are just sitting there and not getting use, it should not be difficult to find dermatologists nearby to buy them from you. So, the risk is low from a financial aspect, and the return on investment is quick because of the markup. When patients ask why it costs so much, the answer is expertise. It’s not just knowing how to inject because we’re not medical spas. We know your hair loss pattern and we know how to diagnose you. We know what to do if it doesn’t work. We know how to change gears very quickly. 

What are some of the important considerations as far as the actual procedure and technique? 

There are so many different ways to do PRP. There is not a standardized protocol; there is a lot of flexibility there. As long as you’re staying within the standard of care and you’re staying within certain parameters, you’re going to be fine. For example, when considering a single-spin or double-spin system, at the end of the day, the system that you use just needs to be able to work in your office setting and be practical to use. Some double-spin systems that orthopedic surgeons use are quite big and bulky and very, very, very pricey. They draw a lot larger volume of blood, which is not the easiest for every staff member to do. So, you must be able to make that work if you choose double-spin. We use a single-spin system in our office, and it’s been working very well. I also have some colleagues who activate and some who do not. Personally, I do not activate my PRP, and it seems to work well, but we do have a system that allows for activation for patients who request that. My theory is that platelets know what to do when they get to where they’re supposed to be, so I don’t feel the need to activate them outside of the body. However, if you talk to 50 dermatologists, probably half of them will say that their way is better. There’s no real wrong way to do it. You have to do what works and what’s practical for your office. 

What are some of the potential additives for PRP treatment? 

In my office, we really don’t add anything else, and that’s the appeal to patients. They like it to be their own body. I think it depends a lot on patient population, but mine tends to prefer to keep things as pure and clean as possible. Some dermatologists, however, add vitamins and other substances. Some people add ACell because they believe it increases the efficacy, though that is not supported by strong data. I think it adds to the expense to the patient and theoretically adds to the risk. Anything foreign brings the chance of an allergic reaction. Additionally, some people do PRP with exosomes. Exosome therapy is a big buzzword, and patients sometimes ask for it. I have tried exosomes on myself and on my colleague, and the jury’s still out for us. My issue with exosomes is that they are not FDA cleared yet, which is fine. Of course, we are using PRP off-label for this indication, but PRP does have FDA clearances; exosomes are not FDA cleared at all. They haven’t been studied enough. So far, the evidence seems to be very anecdotal, and it’s a bit of a hard sell because you have something coming from a foreign donor. Now, a few companies seem to be doing it right and trying to get FDA approval, but the jury is still out for me. I’m exosome curious, I should say, but I think that there’s still a lot of knowledge that needs to be there.