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Dermatologists comment that scalp hair loss seems to provoke more distress than many severe skin conditions. Unfortunately, hair loss may not be easy to remedy.

What causes hair loss?

Hair loss can be due to:

• Decreased growth of the hair
• Increased shedding of the hair
• Breakage of hairs 
• Conversion of thick terminal hairs to thin vellus hairs

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Hirsutism (or hirsutes) is the term used for increased hair growth in women. It refers to a male pattern of hair, i.e. in the moustache and beard areas (chin), or occurring more thickly than usual on the limbs. Hirsutism is very common.

There may be hairs on the chest or an extension of pubic hair on to the abdomen and thighs. What is considered normal for a woman, and what is considered hirsute, depends on cultural factors and race.

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The term alopecia means hair loss. In the form of alopecia known as alopecia areata, round bald patches appear suddenly, most often affecting the scalp. Alopecia areata can occur at any age, including in childhood.

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What is male pattern hair loss (androgenetic alopecia)?

Hair loss resulting in thinning is known as alopecia. When it is related to hormones (androgens) and genetics, it is known as androgenetic alopecia, or more commonly just balding. Male pattern alopecia is characterised by a receding hairline and/or hair loss on the top of the head. A similar type of hair loss in women, female pattern hair loss, results in thinning hair on the vertex (top) of the scalp but is generally less severe than occurs in males.

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What is Dutasteride?

Dutasteride is an oral medication that was initially used to treat benign prostatic hypertrophy in men. It blocks an enzyme called 5-alpha reductase (5AR), which is responsible in the conversion of testosterone to dihydrotestosterone (DHT). DHT is one of the implicated hormones responsible for male pattern hair loss in individuals that are susceptible to it. While used off-label for male pattern hair loss/androgenetic alopecia (AGA) in Ireland, oral dutasteride (0.5mg/day) is approved to treat androgenetic alopecia in South Korea, Japan, and Taiwan (2).

How does Dutasteride help with hair loss?

While both finasteride and dutasteride are (5AR) inhibitors, dutasteride blocks both type 1 and type 2 5AR, whereas finasteride is only 5AR type 2. Dutasteride lowers serum DHT to 98% compared to 71% for finasteride (1). In addition, it is more slowly metabolized than finasteride, as evidenced by its longer half-life (time required for metabolism of 50% of the dose) in the serum. The half-life is 5 weeks for dutasteride compared to 6-8 hours for finasteride.

Formulations

Oral Dutasteride

The most common form dutasteride available is in capsules of 0.5 mg .

Topical Dutasteride

Dutasteride is also available in the USA and Canada from multiple compound pharmacies in a topical liquid solution formulation. Sometimes, it is combined in a combination topical solution of both dutasteride and minoxidil.

Effectiveness of Dutasteride

Oral Dutasteride

Multiple studies have shown that oral dutasteride is superior to oral finasteride in improving AGA. A recent multicenter retrospective medical chart review study of 600 male patients with AGA showed that dutasteride given at 0.5 mg per day was superior at improving AGA compared to finasteride given at 1 mg per day and had a similar level of adverse events (2). Additionally, a randomized placebo controlled clinical trial of oral dutasteride in 20 to 50 year old men with AGA showed that dutasteride 0.5 mg significantly increased hair count and improved hair growth at week 24 compared with finasteride and placebo (3). Other randomized clinical trials also corroborated this data.

Topical Dutasteride

In addition to oral dutasteride, topical formulations of dutasteride may show clinical efficacy when applied either by itself or augmented with the addition of microneedling (mesotherapy). A 2022 randomized, double-blind, placebo-controlled study tested microneedling plus topical 0.01% solution of dutasteride versus microneedling plus saline solution alone in males with androgenetic alopecia (4). Male patients were randomly assigned to receive either 3 sessions of microneedling plus topical 0.01% solution of dutasteride or microneedling plus saline solution. At week 16, an expert dermatologist panel assessment of hair loss showed a significant improvement in 52.9% of the men in the microneedling-dutasteride group and 17.6% of those in the microneedling-saline group, with a statistical difference (p=0.037). Topical dutasteride is not considered very well absorbed into the skin so applying it as part of a mesotherapy is considered more effective than just topical solutions. When not combined with mesotherapy/microneedling, most studies of topical dutasteride show its efficacy when combined with other topical medications, but not by itself. More study is needed to assess whether topical dutasteride applied by itself is effective (5).

Dosage and Administration

Oral Dutasteride

The standard dosage of oral dutasteride is 0.5 mg per day, although some physicians prescribe it as a twice weekly dosing regimen, considering the long half-life of oral dutasteride. It is important to follow your doctor’s prescription regarding medication dosage and frequency of use.

Topical Dutasteride

Dosages of topical dutasteride solutions range from 0.1% to 0.3%.

Side Effects of Dutasteride

The side effects of dutasteride are similar to those reported for finasteride.

• Decreased libido (sex drive)
• Erectile dysfunction
• Male breast enlargement
• Psychological depression

In one double-blind study, 2 out of 70 patients on 0.5 mg daily had decreased libido, and 2 out of 70 had impotence. 3 of 70 on a placebo developed impotence. 9 of 71 taking dutasteride 2.5 mg daily had impotence, indicating a correlation with dosage.

Another study showed a 25-28% decrease in sperm count in a one-year trial. Six months after discontinuing dutasteride, the sperm count was still lower than the initial count by 23%. Semen volume followed these same percentages. The sperm morphology appeared normal.

Drug interactions reported from use of dutasteride include interference with some antibiotics, some anti-depression and anti-anxiety medications, and some drugs used to treat HIV/AIDS.

Precautions

As with finasteride, dutasteride should not be taken or handled by a woman who is pregnant or who may become pregnant because of the drug’s potential to cause abnormal development of a fetus.

Dutasteride vs Finasteride

Dutasteride has a longer half-life than finasteride and blocks both type 1 and type 2 5-alpha reductase enzymes, causing a significantly larger decrease in DHT. Dutasteride lowers serum DHT to 98% compared to 71% for finasteride. Given its effect on DHT, studies show that oral dutasteride may be more effective than oral finasteride in treating male pattern hair loss.

Dutasteride vs Minoxidil

Dutasteride targets the hormonal causes of hair loss by blocking DHT. Minoxidil is a medication that may help hair obtain growth factors by regulating blood flow to hair follicles. Dutasteride, in general, is thought to be more effective than topical minoxidil in preventing the progression of androgenetic alopecia and also in helping regrow hair. However, given the different mechanisms of action, oral dutasteride can be combined with topical minoxidil (and possibly with oral minoxidil). You must consult with your prescribing physician to discuss those options.

Combining other treatments with Dutasteride

As discussed above, topical and even oral minoxidil may be combined with oral dutasteride.

Purchasing Dutasteride

Oral dutasteride is best obtained as a prescription from your physician that specializes in hair loss. There are also various online services that may provide both oral dutasteride and compounded topical dutasteride prescriptions.

Expert Opinion

Since oral dutasteride is more effective at blocking DHT than oral finasteride and studies show that it is more effective at the treatment of male pattern hair loss, my decision to include this in a patient’s regimen is supported by the evidence.

This article is based on information from The International Society of Hair Restoration Surgery (ISHRS): www.ishrs.org

For further information contact:
Dr David Buckley
www.kerryskinclinic.ie
Email This email address is being protected from spambots. You need JavaScript enabled to view it.
Tel 066 7174066

References

Clark RV, Hermann DJ, Cunningham GR, Wilson TH, Morrill BB, Hobbs S. Marked suppression of dihydrotestosterone in men with benign prostatic hyperplasia by dutasteride, a dual 5alpha-reductase inhibitor. J Clin Endocrinol Metab. 2004;89:2179–2184.

Gwang-Seong Choi, Woo-Young Sim et al. Long-Term Effectiveness and Safety of Dutasteride versus Finasteride in Patients with Male Androgenic Alopecia in South Korea: A Multicentre Chart Review Study. Ann Dermatol. 2022 Oct; 34(5): 349–359.

Gubelin Harcha W, Barboza Martínez J, Tsai TF, Katsuoka K, Kawashima M, Tsuboi R, et al. A randomized, active- and placebo-controlled study of the efficacy and safety of different doses of dutasteride versus placebo and finasteride in the treatment of male subjects with androgenetic alopecia. J Am Acad Dermatol. 2014;70:489–498.e3

Microneedling plus topical dutasteride solution for androgenetic alopecia: a randomized placebo-controlled study. Sánchez-Meza E, Ocampo-Candiani J, Gómez-Flores M, Herz-Ruelas ME, Ocampo-Garza J, Orizaga-Y-Quiroga TL, Martínez-Moreno A, Ocampo-Garza SS. J Eur Acad Dermatol Venereol. 2022 Oct;36(10):e806-e808

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Hair Growth and the Role of Vitamins

All vital amino acids (Vitamins) are by definition essential nutrients that the body needs to maintain health overall, and hair health in particular. The complete absence of any vitamin will lead to illness and even death. However, outside of undeveloped countries, extreme diets and specific diseases, vitamin deficiency severe enough to cause disease is very rare, and this includes hair loss. Menstruating women who do not consume enough iron-containing foods are often iron deficient and should supplement, and people like me who live in Cleveland or similar cloudy locations should assume they are deficient in Vitamin D and supplement accordingly. Most vitamins are readily available in our diets, and inexpensive oral supplements can be used to ensure adequate levels are available for our bodily functions. Excess intake of vitamins can cause disease states as well or are eliminated from the body unused, so in spite of the availability of heavily promoted nutrient supplements claiming to improve hair growth and quality, the consumer should be cautious and seek the most cost-effective options. Also Read: Hair Supplements: Are They Worth the Hype?

Key Vitamins for Hair Growth

Biotin

Biotin is a critical vitamin for healthy hair growth, and deficiency will lead to thinning hair. However, biotin deficiency is very rare and almost always associated with an inherited disorder called biotinidase deficiency. Biotin deficiency has never been reported in healthy individuals with a normal diet, and there is no evidence that biotin supplements will help grow hair in the absence of a documented deficiency. Acquired biotin deficiency may occur with raw egg consumption, alcohol use disorder, pregnancy, and isotretinoin and antibiotic use. Notably, excess biotin intake may interfere with a number of important lab tests, including thyroid and other hormone tests such as pregnancy tests.[1]

Natural Sources

Biotin deficiency is very rare because biotin is found in eggs, liver, wheat and oat cereals, several vegetables, rice, and dairy products, so even vegetarians and vegans can fulfill their body’s need for this vitamin.

Recommended Daily Intake

The FDA does not have a recommended daily allowance (RDA) for biotin. However, most sources state that a daily intake of 30 mcg is sufficient to prevent deficiency. Biotin remains commonly recommended by hair loss specialists at doses up to 2.5 to 5 mg/day.

Excess Intake Risks

There are no reports of biotin toxicity even at very high doses of 100,000 mcg per day. However, there is also no evidence to support such doses for the treatment of hair loss or any other condition.

Vitamin D

Vitamin D plays an important role in healthy hair development as well as in many other physiologic processes, so deficiency may have detrimental effects. However, exactly how deficiency impairs hair growth is unknown. There are reports in the literature of successful hair regrowth after correcting Vitamin D deficiency, but in areas such as the northeast US, where Vitamin D deficiency is very prevalent, supplements rarely bring clinical benefits. Hair loss specialists who regularly screen for Vitamin D levels help patients attain normal levels for all of its potential benefits.[1]

Natural Sources

Dietary Vitamin D is most easily obtained through fortified foods such as milk, yogurt, orange juice, and cheese, in fatty fish including sardines, salmon and tuna, and in egg yolks and mushrooms. The prevalence of Vitamin D deficiency suggests that most people do not consume adequate dietary Vitamin D, nor have sufficient sun exposure for adequate skin conversion of Vitamin D.

Recommended Daily Intake

Most experts recommend a daily Vitamin D intake of 600 to 1000 IU/day for adults. Severe deficiency can be treated with high-dose prescription strength Vitamin D for short periods of time.

Excess Intake Risks

Severe Vitamin D deficiency is defined as blood levels of 20 ng/ml or less, mild deficiency at 30-50 ng/ml, and normal levels at 50-70 ng/ml. Levels above 80ng/ml are excessive, and severe toxicity, known as hypervitaminosis D or vitamin D intoxication occurs at levels above 150 ng/ml. This would require extremely high daily doses over a long period, with symptoms including bone pain and kidney problems, such as the formation of calcium stones. Progression to confusion, apathy, recurrent vomiting, abdominal pain, and dehydration may occur if supplements are not stopped.

Vitamin C

Vitamin C is another essential nutrient required for the biosynthesis of collagen, L-carnitine, and certain neurotransmitters, and is also involved in protein metabolism. Collagen and other proteins are important for healthy hair growth. Vitamin C helps the absorption of plant-based iron, another important nutrient for healthy hair growth. Severe Vitamin C deficiency produces scurvy, a life-threatening disease that includes follicular hyperkeratosis and corkscrew hairs. Interestingly, smokers have impaired Vitamin C absorption and need greater dietary intake.[1,4]

Natural Sources

Natural sources of Vitamin C include all citrus fruits, red and green bell peppers, tomatoes, broccoli, brussels sprouts, potatoes, spinach, green peas, cantaloupe and strawberries.

Recommended Daily Intake

The RDA for Vitamin C is 90 mg daily for men and 75 mg daily for women, with higher intake during pregnancy and lactation. This can usually be obtained from a healthy diet.

Excess Intake Risks

Excess Vitamin C intake does not generally cause toxicity, but can result in gastrointestinal distress, insomnia, headaches and rarely kidney stones. Most excess Vitamin C is excreted unmetabolized in the urine.

Key Minerals for Hair Growth

Iron

The most common nutritional deficiency in the world is iron deficiency, and iron deficiency is common in women with hair loss. However, the association between hair loss and low serum ferritin (iron) levels remains controversial. While testing for and correcting iron deficiency is always prudent, significant improvement in hair loss in these individuals cannot be assured.[1]

Natural Sources

Iron is found in many natural sources, including meat, fish, poultry, fruits, vegetables, grains, and more.

Recommended Daily Intake

The RDA for all age groups of men and postmenopausal women is 8 mg/day; the RDA for premenopausal women is 18 mg/day. This can usually be obtained from a healthy diet. If you suffer from hair loss you should have your blood tested for anaemia and low levels of vitamin B12, folate and ferretin (iron).

Excess Intake Risks

The upper limit for safe iron intake is 45 mg per day for adults. Excess iron is deposited in organs throughout the body and can cause organ damage due to the formation of reactive oxygen species. The liver, heart and endocrine glands are the most notable organs with iron deposition. Extremely high doses can cause organ failure, coma, convulsions and death.

Choosing the Right Supplements

With rare exceptions noted in this discussion, the availability of vitamins and minerals in a varied and healthy diet makes supplementation unnecessary for most individuals. When supplements are desired, there are many choices for multivitamins or individual vitamins that are readily available and inexpensive. There are also several heavily marketed “hair loss” supplements that are very expensive and that lack scientific credibility. The reader is cautioned to be skeptical of these products.

Anyone experiencing hair loss and interested in treatment should first see a health care professional such as a Board-Certified Dermatologist for a thorough examination and assessment. Early intervention with the correct medications and supplements should provide the best long-term benefits.

Expected Results and Timeline

Unfortunately, improvement in hair growth rate and quality can take months to become noticeable, as individual hair shafts grow only about 1 mm per day. Accordingly, when beginning a treatment program, patience is needed and one should only make status checks every three months or so.

Expert Opinion

As a hair loss specialist with over thirty years of experience, I have seen and tried just about every product, procedure, and supplement to help my patients with hair loss. As there are only two FDA-approved medications available to treat pattern hair loss (finasteride and minoxidil,) there has always been a desire and need for more choices. I have always recommended a healthy and varied diet, and when appropriate, hair-focused nutritional supplements for my patients. I have seen definite and sometimes dramatic improvement with the FDA-approved medications mentioned above, but only a tiny handful of patients have shown improvements with vitamins and nutraceuticals used as a monotherapy. As mentioned several times above, most of us obtain all of our nutrients from our diet, and true deficiencies are rare.

FAQs

What are the best vitamins for hair growth?

The available evidence supports the routine use of only three supplements: Vitamin D, Iron, and Vitamin C, mostly for its effects on improving iron absorption. Overuse of biotin can lead to dangerously false laboratory results, and while other supplements are unlikely to cause harm, there is little evidence that they will provide benefit.

Do vitamins really help hair growth?

All vitamins are essential for normal growth and development and that includes healthy hair, skin and nails. We obtain most of what the body requires through our daily diet, so supplements are rarely needed.

References

1. AlmohannaHM, AhmedAA, Tsatalis JP,Tosti The Role of Vitamins and Minerals in Hair Loss: A Review Dermatol Ther (Heidelb). 2019 Mar; 9(1): 51–70.
2. VanBuren CA,Everts Vitamin A in Skin and Hair: An Update. Nutrients. 2022 Jul; 14(14): 2952.
3. Khalil S, Bardawil T, Stephan C, Darwiche N, Abbas O, Kibbi AG, et al. Retinoids: a journey from the molecular structures and mechanisms of action to clinical uses in dermatology and adverse effects. The Journal of Dermatological Treatment. 2017 28 (8): 684–696.
4. Li Y, Schellhorn HE. New developments and novel therapeutic perspectives for vitamin C. J Nutr 2007;137:2171-84.
5. BeoyLA, WoeiJW,Hay Effects of Tocotrienol Supplementation on Hair Growth in Human Volunteers. Trop Life Sci Res. 2010 Dec; 21(2): 91–99.
6. JaripurM, Ghasemi-TehraniH, Askari G, Gholizadeh-Moghaddam M, Clark CT, Rouhani The effects of magnesium supplementation on abnormal uterine bleeding, alopecia, quality of life, and acne in women with polycystic ovary syndrome: a randomized clinical trial. Reprod Biol Endocrinol. 2022; 20: 110.

This article is based on information from The International Society of Hair Restoration Surgery (ISHRS): www.ishrs.org

For further information contact:
Dr David Buckley
www.kerryskinclinic.ie
Email This email address is being protected from spambots. You need JavaScript enabled to view it.
Tel 066 7174066

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Low Level Laser Therapy (LLLT)
(Photobiomodulation=PBM) and the Effectiveness of current Devices for Treating Hair loss

Photobiomodulation (PBM), also called low level laser therapy (LLLT), is a treatment used to stimulate hair follicles to grow. It is often used in conjunction with other hair loss therapies. While some patients have seen a benefit, others have not. There are many types of devices with varying energy output. Some devices may be purchased directly by consumers, and others are only to be used in the physician’s office. Despite a burgeoning array of such devices on the market today, important questions about dosing and efficacy remain unanswered.

Consumers should be aware of these unanswered questions in order to make an informed decision. Dr Buckley recommends seeking the advice of a hair loss specialist who is knowledgeable about various types of hair loss and the full array of options to appropriately and effectively treat them.

Frequently Asked Questions

Would I be a good candidate for Photobiomodulation Therapy

The answer is, there is much we don’t know about the optimal wavelengths and dosing for Photobiomodulation therapy to treat hair loss. Despite the studies that have been performed, important questions remain unanswered. For patients, it is advisable that prior to making the decision to purchase an OTC device to treat their hair loss all therapies and options should be reviewed with a hair loss specialist.

How does Photobiomodulation work for stimulating hair growth?

Researchers are not certain how PBM works to stimulate hair growth but believe it has to do with stimulating hair to enter the growth phase (anagen re-entry), prolongation of the growth cycle (prolongation of anagen), proliferation of hair in the active growth cycle (anagen), and prevention of premature catagen (the rest phase of hair growth).

It has even been postulated to have an effect on modulating 5 alpha reductase activity—the enzyme that converts testosterone into dihydrotestosterone (DHT)—with the latter considered to be a cause of hair loss in androgenetic alopecia (AGA). (5) Studies are ongoing to further identify cellular targets and the mechanisms of action for hair growth stimulation, as this will assist researchers to identify the optimal wavelengths and dosing.

Is there an optimal wavelength for stimulating hair growth?

The short answer is, probably, but it may not yet be available in current devices. Some researchers believe the chromophore responsible for PBM response in hair growth stimulation is Cytochrome C oxidase, found inside of mitochondria. Tissue culture experiments have shown peak DNA production in 4 wavelength ranges, felt to be a reflection of Cytochrome C oxidase activity : 614-624nm; 668-684n, 751-772nm and 813-846nm. (ref 1, 6) More recent research specific to hair growth evaluated the response of various wavelengths on the shaven backs of Sprague-Dawley rats using diodes of 632, 670, 785 and 830nm. The higher wavelengths of 830 nm and 785 nm resulted in a significant effect on hair growth stimulation, with 830 nm being most effective (ref Lasers Med Sci). The original study by Mester used a ruby laser with wavelength 694 nm to achieve the first hair growth resulting from PBM therapy.

Interestingly, none of the currently marketed devices use a wavelength of 694 nm, 785 nm or 830nm. To date most of the FDA cleared devices in the US use lower wavelengths varying from 635nm, 650nm, and 655nm with one at 678 nm. The reasons for this have little to do with the previously mentioned scientific studies, and everything to do with the cost of FDA pre market approval (PMA) vs the 510K clearance process for low risk medical devices. The impact of the regulatory process on device development will be further discussed below. Importantly, human study results from some of these available devices suggest a hair growth benefit for some patients. However, closer scrutiny raises questions about methodology and whether study conclusions can apply in real use settings, as well as whether any benefits identified would be greater if optical parameters were optimized.

What are the optimal dosing regimens for Photobiomodulation devices?

Important optical parameters for PBM include wavelength, as well as irradiance or power density (mW/cm2)—how bright the light is, distance of the target from the light source, and frequency and duration with which light is applied to the head/scalp (ex 3 times weekly for 20 minutes); as well as the duration or course of therapy (6 months, 12 months etc). Determining optimal dosing seems especially important given the characteristic of LLLT known as the biphasic dose response , a phenomenon believed to occur in both animals and humans—where too little energy results in no response, and too much energy could actually have a detrimental effect on target tissue.

Researchers investigating optimal dosing regimens for hair growth performed a review of 90 published studies and observed a confusingly wide array of dosing schedules and irradiance or power densities which varied by as much as two orders of magnitude—making it impossible to identify ” optimal” parameters. (ref) Furthermore, none of the OTC devices published any justification for their recommended dosing, nor did they address why there were no dosing adjustments based on Fitzpatrick skin typing. The latter classification was developed to aid in dosing for skin phototherapy based on the presence of the chromophore, melanin, in skin and hair which absorbs laser light.

The FDA apparently recognized this factor, however, and has only approved the OTC devices for Fitzpatrick Skin types 1-4 which does not include patients with darker skin and hair where melanin would be expected to absorb a considerable amount of the light before it could reach other cellular targets.

What is FDA 510K clearance and how does this impact LLLT or PBM device development?

For low risk medical devices, the US- FDA allows companies to go through a markedly faster and cheaper process to bring their products to the marketplace. This process is called 510K clearance, and is not the equivalent of “FDA approval.” For this clearance process, a company is required to establish their device as equivalent in safety to a previously approved device with similar characteristics (the predicate device). In contrast, the Pre-market “Approval “(PMA) process requires safety and efficacy studies, takes more time time, and usually costs millions of dollars.

Several of the PBM devices being marketed today with 510K clearance have no studies to prove efficacy. For companies that went through the PMA process to produce the first predicate device, there is little incentive to produce another novel device that may be used by another company as a predicate at a much lower development cost.

Because of this, the 510K clearance process encourages “copy cat” wavelengths and device styles, rather than novel and possibly more effective wavelengths or devices. For example, the first PBM device to achieve 510K clearance listed as predicates, a variety of FDA approved and unapproved laser based devices including non hair growth devices intended for hair removal and pain relief. Since then this first device has been listed on subsequently 510 K cleared PBM devices on the market to treat hair loss.

Another limitation of direct to consumer sales of PBM devices is the necessity to adhere to laser safety precautions for Class 3a or 3R lasers. The latter limits the device power to 5 mW(.005 W) to avoid eye hazards, regardless of whether a higher power device could be more effective. The incentive for companies to market direct to consumers for higher sales volume and profits is clear.

However, this may obviate the development of devices with higher and possibly more effective power levels because it would place them in a laser class that could not be sold directly to consumers. Currently there are many studies documenting PBM efficacy for various tissues and therapies, with devices exceeding 5 mW.

Are there any reliable studies on the effectiveness of the LLLT (PBM) devices?

There have been studies evaluating the effectiveness of a variety of PBM devices to treat hair loss, including 655 nm laser combs, and helmets which combined 650 nm, or 655 nm laser diodes with LED lights. However, questions have been raised about possible flaws in the methodology of these studies. First of all, while it is generally accepted the gold standard for evidence based medical studies is the randomized, controlled trial, where patients with the same medical condition are randomly selected to be treated with the real medical therapy vs a placebo (not real, but looks alike ) —the data required to prove effectiveness of a hair growth promoter is very specific.

Patient self report is deemed too subjective and found to be unreliable and is often positive in placebo groups. Even global photographs can have a degree of subjective bias if performed improperly. Strict adherence to standardized photo position, lighting, hair color and hair style do offer some measure of credible evidence. Nevertheless, while most studies do include the use of global photographs the gold standard for establishing hair growth is phototrichogram evidence. The latter are areas of treated scalp trimmed to approximately 1 mm so hairs do not overlap, but are not so short as to be unseen, and tattooed so the precise area is measured for hair counts at intervals to determine if an increase or decrease has occurred. New hairs generally take about 3 months to grow out from a follicle, so growth promoter assessment is often done at monthly intervals assessing the emergence of new hairs, as well as the possibility of improvements in hair fiber caliber.

Did these studies present photo-trichograms to prove effective increased hair growth?

Out of a sample size of 269 patients the laser comb study did present one very credible phototrichogram to document improved caliber and growth. However, skeptics point out there should have been more than one credible phototrichogram out of this sample to document efficacy. Other studies did not publish credible and easily assessed phototrichograms. Notably there were several patients in the placebo groups of all studies with equivalent and small hair count increases to many patients in the treated group. For example, there were reports of 100% increased hair counts among placebo patients in the helmet studies, suggesting some type of counting error. The helmet studies also suffered from small sample sizes.

Did the studies have sufficiently large sample size and study duration to provide adequate medical evidence to recommend them?

All sample sizes for each of the dfferent devices studied were <100 patients. (several different laser combs were used in the largest study) None of the studies were longer than 26 weeks (~6 months), with no published evidence to date to determine if any hair growth benefits from PBM devices would be enduring with long term use.

Were there any other concerns about the photobiomodulation studies?

There was no documented scientific justification behind the dosing schedules. Energy doses were highly variable. No adjustments were made for hair and skin color (Fitzpatrick skin type), and none of the devices were cleared for use on darker skin patients (Fitzpatrick Type 5-6). Furthermore, since areas of hair growth assessment had to be shaved for hair counts, and light was beamed directly on these areas, it necessarily provided added opportunity for a PBM effect that would not necessarily be expected on areas of the scalp covered by hair.

Computer models have calculated that hair coverage can impede light transmission by > 30%, especially with dark hair. This raises questions about whether patients who did respond to the PBM device under study conditions, would actually experience the same response without shaving the hair.

Defining Low level laser therapy light or PBM

Laser light is collimated, that is, it is not diffuse and light waves are focused in a beam or column until they hit a target that either reflects, transmits, scatters or absorbs it. A chromophore is a tissue target that absorbs a particular wavelength of light. Various tissue chromophores include water, hemoglobin, melanin or other cellular components such as mitochondria. The wavelength for various PBM therapies includes the visible light spectrum from 500nm-1100nm; the other defining characteristic is low power from 1mW-500mW and power density from 1mW-500mW/cm2.

This low power does not heat tissue. Two factors are most important for achieving an effect from photobiomodulation. First of all, in order for the PBM to cause bio-stimulation , light of a particular wavelength must reach and be absorbed by a particular tissue target or chromophore. Secondly, the wavelength must be carried by energy or power through the skin, to reach the target, such as a hair follicle. The range of low power which can biostimulate without tissue heating, as previously noted, is 1 mW-500 mW. However, all over the counter PBM devices are limited by laser safety regulations to just 5mW of power—in order to protect consumer’s eyes, not based on efficacy to achieve a tissue response.

A device with 100 times the power of over the counter (OTC) devices would still be considered a ‘cool’ laser– and would not burn or destroy tissue, but could not be sold direct to consumers in most countries because it exceeds regulated power limits for ocular safety. This limitation must be kept in mind as we review currently available OTC devices for treating hair loss.

References

Lasers Med Sci. 2015 Aug;30(6):1703-9. doi: 10.1007/s10103-015-1775-9. Epub 2015 Jun 6.

Evaluation of wavelength-dependent hair growth effects on low-level laser therapy: an experimental animal study.

Kim TH¹, Kim NJ, Youn JI.

References

1. Hamblin M.R. Mechanisms of laser induced hair regrowth, Source: Welllman Center for Photomedicine, March/April 2006, pp28-33
2. Avci, P., et al, LLLT for treatment of hair loss.  Lasers in Surgery and Medicine. 2013 9999:1,
3. Evaluation of wavelength-dependent hair growth effects on low-level laser therapy: an experimental animal study.  Kim, TH; Kim NJ; Youn, JI,  Lasers Med Sci  2015 Aug 30 (6):1703-9
4. Photobiomodulation devices for hair regrowth and wound healing: a therapy full of promise but a literature full of confusion, Mignon, Charles, Botchkareva, N.V., Uzunbajakava, N.E., Tobin, D.J.,  Experimental Dermatology, July 13, 2016, pp745-49Clin Diagn Res. 2015 Dec; 9(12): ZL01–ZL02.Published online 2015 Dec 1. doi:  7860/JCDR/2015/15561.6955PMCID: PMC4717791

Examples of US suppliers (not necessarily endorsed by Dr Buckley):

The Capillus Pro S1 features 304 medical-grade laser diodes delivering 0.87 J/cm² dose of light energy to the hair follicles (US discount price $2,124.15) The regular size caps fit most heads, with a head circumference of up to 23". If your head circumference is greater than 23" inches please contact customer service for ordering a larger size.
https://www.capillus.com/products/capillus-pro-s1

LaserCap HD+. FDA-cleared laser therapy for male and female pattern hair loss. The LaserCap HD+ contains 304 laser diodes, delivering 3.93 J/cm² dose of light energy to the hair follicles. (US price $2,995)
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This article is based on information from The International Society of Hair Restoration Surgery (ISHRS): www.ishrs.org

For further information contact:
Dr David Buckley
www.kerryskinclinic.ie
Email This email address is being protected from spambots. You need JavaScript enabled to view it.
Tel 066 7174066

Download this information as a PDF

What is Minoxidil?

Minoxidil is a medication used primarily to treat hair loss, specifically androgenetic alopecia, which includes male and female pattern baldness. It is available over-the-counter in topical forms such as liquids and foams, commonly in 2% and 5% concentrations. Minoxidil was originally developed as a treatment for high blood pressure, but its side effect of promoting hair growth led to its repurposing as hair loss treatment.

Historical Background

During clinical trials in the 1970s, researchers discovered that one of its side effects of the tablet version was excessive hair growth, known as hypertrichosis. This unexpected outcome led to further investigation into its potential as a hair loss treatment.

By the 1980s, Minoxidil had been reformulated for topical use to combat hair loss. Minoxidil received approval from the U.S. Food and Drug Administration (FDA) in 1988 as the first drug proven to promote hair regrowth.

How does minoxidil work to promote hair growth?

There have been a few proposed mechanisms to explain the effects of minoxidil on hair growth. We know today that it lengthens and prolongs the anagen (growth) phase of the hair cycle, which decreases hair loss and causes an overall effect of thickening. To be effective, however, minoxidil must be metabolized to minoxidil sulfate. The enzyme responsible for this conversion is present in the skin and the liver. Studies have shown that there is a large variation in the amount of the enzyme in the skin of different people and even in different areas of the scalp in the same person. This explains why topical minoxidil is more effective for some people and less for others. When taken orally, however, the conversion to minoxidil sulfate is done in the liver, which creates more consistent minoxidil sulfate, thereby making it more effective.

Minoxidil sulfate relaxes smooth vascular muscle, promoting vasodilation, which in turn decreases blood pressure. This also causes increased blood flow to the scalp, which is one of the mechanisms of action on the hair follicle. Minoxidil sulfate has also been shown to stimulate the production of certain growth factors, which may explain the increase in hair proliferation and hair cell multiplication. However, the exact mechanism of action of minoxidil is still not fully understood.

Formulations

The original topical minoxidil formulations include concentrations of 5% (recommended for men) and 2% (recommended for women, to decrease the possibility of facial hair growth). It is recommended that patients apply it twice a day to the scalp. These formulations still exist today, though women may have better results if they use the 5% concentration once a day. The most common side effects of the topical application are skin irritation, redness, and dryness. This is due to the presence of propylene glycol in the formula. Propylene glycol has a greasy feeling to it, and it can be a skin irritant.

To decrease this side effect, a foam formulation was developed, and it is overall better accepted by patients. It has no propylene glycol, so it is less greasy and less irritating. It is available in a 5% concentration for men and women. Another advantage of the foam preparation is that the foam melts when in contact with body heat, so most of the product reaches the skin. When the liquid formulation is used, a lot of it is wasted because it stays on the hair instead of reaching the scalp, where it needs to be.

In recent years, there has been a significant increase in the prescription of the oral formulation of minoxidil. When taken by mouth, minoxidil is usually more effective than when used topically, though side effects such as dizziness, tachycardia (fast heart rate), and increased facial and body hair tend to be more pronounced than when used topically.

Effectiveness

There is a plethora of review articles documenting the effectiveness and safety of both topical and oral minoxidil, and it continues to be a useful tool in the medical management of many types of hair loss, including genetic and auto-immune forms.

How do I apply topical minoxidil?

Topical minoxidil 5% foam should be applied to the scalp twice a day for men and once a day for women. It may be applied to all areas of the scalp, including the temples and the anterior hairline.

Dosage and Considerations

Oral minoxidil is normally used in doses varying from 0.625 mg a day to 5 mg per day. In determining the dose, consideration must be given to the patient’s age and concurrent use of other medications, particularly those for high blood pressure and cardiac arrhythmias, as well as patients with a history of heart failure.

Side Effects and Safety

The most common side effects of topical minoxidil application are redness and irritation of the skin. Rarely, patients have reported headaches, palpitations, and dizziness. Oral minoxidil side effects include palpitations, dizziness, low blood pressure, chest pain, headaches, and swelling of the legs.

Persons with a tendency for irritation of the scalp (psoriasis, seborrheic dermatitis, etc.) are more prone to irritation and redness. Oral minoxidil should be used carefully in older patients and in patients with a history of heart issues.

Combining Minoxidil with Other Treatments

Minoxidil is usually combined with other treatments for hair loss. For the most common genetic hair loss (androgenetic), minoxidil is usually combined with finasteride and or laser therapy. These treatments target the hair follicles differently, so their use in combination is usually more beneficial than when used alone.

Purchasing Minoxidil

In Ireland, 5% topical minoxidil can be purchased without a prescription. Brand name and generic equivalents are available. Oral minoxidil is only available by prescription in Ireland in the generic category.

FAQs

Is Minoxidil permanent?

Minoxidil needs to be used consistently to provide and maintain results. Any gain will be lost once the treatment is stopped. However, a common misconception is that if one uses minoxidil and stops it, the hair loss will worsen. This is not true. The hair loss will resume after stopping and will progress as it would normally without treatment.

Can I comb my hair after applying Minoxidil?

Yes. Minoxidil should be applied to the scalp and not to the hair shaft. Therefore, combing the hair after the application of minoxidil is not a problem.

Can you leave minoxidil on overnight?

Yes, you should. For men, minoxidil should be applied twice a day. For women, once a day. Leaving overnight is not a problem.

What happens if minoxidil touches the face?

It can cause hair growth in these areas. Therefore, women should not touch their face after applying topical minoxidil. Hands should be washed before touching other areas of the body. That being said, the most common reason women have secondary hair growth elsewhere is not inadvertent spillage of the product but instead absorption of minoxidil into the bloodstream, causing hair growth elsewhere other than the scalp

Is minoxidil a steroid?

No, it is not a steroid

Does minoxidil cause pimples?

It can cause irritation on the skin, and it can cause ingrown hairs by stimulating hair growth.

This article is based on information from The International Society of Hair Restoration Surgery (ISHRS): www.ishrs.org

For further information contact:
Dr David Buckley
www.kerryskinclinic.ie
Email This email address is being protected from spambots. You need JavaScript enabled to view it.
Tel 066 7174066

References

Gupta, A. K., Talukder, M., Venkataraman, M., & Bamimore, M. A. (2022). Minoxidil: a comprehensive review. Journal of Dermatological Treatment, 33(4), 1896–1906.

Adil, A., Godwin, M. (2017). The effectiveness of treatments for androgenetic alopecia: A systematic review and meta-analysis. Journal of the American Academy of Dermatology, 77(1), 136-141.

Randolph, M., Tosti, A. (2021). Oral minoxidil treatment for hair loss: A review of efficacy and safety. Journal of the American Academy of Dermatology, 84(3), 737-746

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What is PRP Therapy?

PRP (platelet-rich plasma) is a growth factor-based treatment for hair loss that falls under the regenerative medicine umbrella that also includes stem cell therapy. There are three potential sources for growth factors:

1. Synthetic, which is currently a proprietary product administered with an ultrasound device.
2. Exogenous, generally as exosomes, which are intercellular communication structures that are obtained from bone marrow or placenta, but exogenous also includes plant-based growth factors and other types of exogenous growth factors.
3. Endogenous, which is obtained from the patient’s own blood. It is the endogenous source that is most well-known as PRP, which is the subject of this page.

Platelets are blood-cell fragments that are critical to normal blood clotting function and that also contain several different growth factors. Growth factors are proteins that signal the body to generate specific tissues, such as blood vessels and skin, after an injury, as well as many other functions. With PRP, blood from a patient is centrifuged into separate layers, including red blood cells, plasma, and a buffy coat layer where all the platelets are concentrated. This layer is separated from the others along with a small quantity of plasma and is thus termed platelet-rich plasma, in which the growth factors reside.

Since there is a wide range for normal platelet levels (from 150 to 450 per mcl), some PRP samples will have much higher levels of growth factors than others, and this may account for the inconsistent results often seen with this therapy.

The PRP is injected very superficially into the skin of the scalp in areas of hair loss with the expectation that the growth factors will produce thicker, darker, healthier, and more cosmetically effective hair growth.

FDA Approval

Importantly, while several PRP preparation systems are FDA-cleared for orthopedic indications, their use for hair growth is “off-label“, as no data has been submitted to the FDA sufficient to grant clearance for this indication. Off-label treatments allow physicians to legally perform the procedure with adequate patient counseling about the nature of the procedure along with the pros, cons, and limitations associated with that kind of therapy.

An ongoing and possibly perpetual problem is a lack of standardization in terms of blood collection, preparation, and administration. There are literally dozens of permutations, and no attempts at standardization have achieved acceptance amongst practitioners.

How Does PRP Work for Hair Loss?

The exact mechanism of action for how PRP promotes hair growth is unknown. PRP contains at least six different growth factors, and the individual and synergistic effects of these proteins on hair growth cannot easily be identified. In addition, PRP contains at least 30 other substances, including chemokines, clotting factors, and immune mediators, all or some of which may influence hair growth as well. Growth factors in PRP that are most involved in hair growth include Fibroblast Growth Factor (FGF), Vascular Endothelial Growth Factor (VEGF), and Epidermal Growth Factor (EGF). Growth factors can increase the duration of the anagen, the growth phase of hair, and may increase the thickness of the hair shaft.

Who’s a Good Candidate for PRP?

As with almost all non-surgical treatments for hair loss, the best candidates are those with thinning hair rather than complete baldness and for those who have experienced more recent hair loss. Thinning hair is more common in younger individuals, but anyone with thinning hair loss may benefit from the treatment. As noted earlier, individuals with naturally high platelet levels have an advantage over those with lower platelet levels, as the quantity of growth factors administered will be greater in the former group.

PRP Treatment Process

• A PRP visit begins with a clear explanation of the procedure and the signing of an informed consent form. This signifies that the patient understands the risks, benefits, limitations, and alternatives to the procedure.
• Next, a quantity of blood will be drawn, the exact amount being dependent on the system used by the office. While the PRP is prepared, the patient will generally be moved to a treatment room, where local anesthesia will be administered if appropriate.
• The blood sample will be processed according to the protocol specific to the system used, which may involve a single or double spin, and transferred to test tubes or separation containers. When concluded, there will be three products: packed red blood cells, platelet-poor plasma (PPP), and platelet-rich plasma (PRP).
• Sometimes, but not always, a small sample will be tested to determine the exact concentration of platelets. The goal is to concentrate the platelet level 2–6 times higher than the starting level. There is no consensus on the ideal concentration.
• In some offices, the PRP will be injected as is, while other offices may add a porcine-based extracellular matrix as a stabilizer. This is done to stabilize the PRP proteins and enhance the results. Generally, at least 6 ml of PRP will be available to inject.

PRP is often administered along with microneedling, another method of stimulating growth factor release. If so, an anesthetic ring block may be administered, or nitrous oxide gas may be administered, to reduce any pain. The PRP is injected in small quantities of as little as 0.05 ml, allowing as many as 120 injection sites per procedure. Microneedling will generally follow the PRP injections, if they are administered.

Required Number of Sessions

PRP treatments will always need to be repeated to be effective. However, there is no standard treatment interval. A common program is one treatment session each month for three months, followed by a booster session every six months. Your practitioner will discuss your recommended treatment program and its rationale.

Post Treatment Care

Avoid using scalp products or camouflage products prior to the procedure. Patients should avoid anti-inflammatory agents such as NSAIDs and aspirin for up to 14 days after the procedure, as they may interfere with the beneficial effects of PRP.

Benefits and Effectiveness of PRP for Hair Loss

PRP, along with all non-surgical hair loss treatments, may decrease shedding or result in thicker-looking hair. Thicker-looking hair can be seen with either an increase in the actual number of hairs present, by an increase in the hair-shaft diameter, or by a combination of both. Not all patients will benefit from growth factor treatments, so some patients experience no benefit. As mentioned above, any benefits noted will only be maintained if ongoing treatments are maintained.

Multiple studies have been published on the effectiveness of PRP. While some have demonstrated benefits, others have not. This is not surprising due to the wide variability of protocols and patient characteristics.

In my opinion, PRP is best performed after other non-invasive treatments have already been enlisted, including minoxidil and finasteride.

Potential Risks and Side Effects

PRP injections are considered to be very safe. The substance injected is autologous, meaning it was obtained from the patient’s own body, eliminating the risk of blood or tissue borne pathogens. Assuming the procedure is carried out in an aseptic manner, there is little risk of infection from the injections themselves, although it is not possible to sterilize the surface of the scalp. Thus, local and temporary pain at the injection sites is the principal risk.

Cost and Considerations

The cost of PRP is quite variable and can be as little as $400 or as much as $1,500 or more per session in the USA. Comparing costs is difficult, as the equipment used and any additives have a significant impact on the cost to the provider. The skill and experience of the provider are also critical to success. Do not look for the cheapest or the most expensive office, but rather investigate experience and reputation above all.

Choosing the Right Provider

As with all aspects of hair loss management, finding an experienced and compassionate provider is critical to success and satisfaction. True hair loss specialists have mastered many approaches to hair loss. Some are very effective and very inexpensive, and when appropriate, these should be recommended first. Unfortunately, some providers see PRP as an easy way to make a profit and recommend this modality when other choices are preferred.

Take the time to determine if you have found an office that provides many treatments for hair loss, and be wary if only expensive treatments are recommended. Visiting the office and meeting with the provider is also critical to determining your best treatment approach. If you are unsure, take the time to meet with other practitioners.

For a consultation with a hair restoration surgeon, access our Find A Doctor tool, where you can search for an ISHRS member by location.

Expert Opinion

As a practitioner offering PRP treatments for over a decade, I have seen many successes and many failures. It is frustrating that no protocol standardization exists, and none is likely to exist in the future. The cost of properly studying all the variables is prohibitive, and we are thus left to arrive at our own best practices. In my practice, I have a cost-centric approach, meaning if I can effectively treat a patient’s hair loss for $10 per month, which is possible with minoxidil and finasteride, then I do so. For patients that do not respond to those treatments, I then offer PRP and other more expensive modalities, and that often takes place 6 to 12 months after our first visit. Hair loss can be a devastating condition, so above all, each patient must find a doctor that he or she feels comfortable with during what will be a very long journey.

FAQs

Does PRP actually regrow hair?

For most patients, the answer is yes. Some patients will only experience a decrease in shedding, and some patients will not experience any benefit. Unfortunately, there are no guarantees of success.

What are the side effects of PRP for hair loss?

Local pain and temporary swelling may occur at the sites of injection.

What is the disadvantage of PRP?

PRP is an expensive, invasive, and somewhat painful procedure that is not guaranteed to work. When it does work, ongoing treatments will be required to maintain benefits.

How successful is PRP for hair loss?

This is difficult to answer, as so many variables play a factor, and most have not been well studied. Available data suggests that at least 30–50% of patients will experience some benefit.

Who is not a good candidate for PRP?

Individuals who are completely bald in the area of concern are not likely to experience any benefit. Patients with active skin conditions such as skin cancer or pre-cancer, as well as certain systemic diseases, should not undergo PRP.

Can I comb my hair after PRP?

You will be able to gently style your hair immediately following the procedure.

Is PRP better than hair transplant?

There is no procedure that can produce long, thick, dense hair in the recipient zone as well as surgical hair restoration. PRP can be an effective adjunctive treatment for patients undergoing surgery, or using pharmacologic therapy or photobiomodulation therapy.

How many PRP sessions are needed for hair?

There are several commonly accepted protocols, with the most common being three sessions spaced one month apart, followed by booster sessions every six months.

What happens if you stop the PRP?

As with all effective treatments for hair loss, discontinuing the treatment will result in hair loss. Generally, you will only use the hair that the treatment helped grow.

How long does PRP take to regrow hair?

While visible growth can be seen as early as 1-2 months, it can take as long as six months to see a benefit.

Which age is best for PRP?

Patients with thinning rather than full baldness are better candidates for surgery. While younger patients are more likely to fit this criteria, patients of all ages can be considered for PRP.

Can I do shampoo after PRP?

Generally, it is recommended to shampoo gently the morning after the procedure.

Can we go to the gym after PRP?

Light exercise can begin the day after the procedure. Most offices suggest waiting several days before undergoing strenuous exercise.

References

Gupta Aditya K. MD, PhD, Cole John MD, Deutsch David P. MD, et al. Platelet-Rich Plasma as a Treatment for Androgenetic Alopecia. Dermatologic Surgery 45(10):p 1262-1273, October 2019.

Pavlovic Voja, Ciric Milan, Jovanovic Vladimir, Stojanovic Predrag. Platelet Rich Plasma: a short overview of certain bioactive components. Open Med (Wars). 2016; 11(1): 242–247.

Paichitrojjana Anon, Paichitrojjana Anand. Platelet Rich Plasma and Its Use in Hair Regrowth: A Review. Drug Design, Development and Therapy 2022:16 635–645

This article is based on information from The International Society of Hair Restoration Surgery (ISHRS): www.ishrs.org

For further information contact:
Dr David Buckley
www.kerryskinclinic.ie
Email This email address is being protected from spambots. You need JavaScript enabled to view it.
Tel 066 7174066