Special Feature: Managing Hair Loss

By Allie Anderson / 01 Mar 2016

There are numerous techniques and procedures available to restore thinning and declining hair. Allie Anderson speaks to practitioners about some of the options available and details how they work

Many people seek aesthetic treatment for hair loss that has occurred either as a result of ageing or an underlying condition. Various treatments are available, however unnatural-looking results have made some of them unappealing. Even with the development of more advanced technology, according to the practitioners interviewed for this article, the market for male hair loss treatments remained comparatively small until around five years ago, when there came a steady rise in demand, particularly among younger men. “I see a large proportion of men in their 20s, and that’s doubled in the last few years. I put that down to celebrities,” explains Dr Edward Ball, medical director of The Maitland Clinic. He is, of course, alluding to the likes of Wayne Rooney, who at the age of 25 famously (and openly) underwent hair transplant surgery in 2011,1 demonstrating impressive results. Such well-publicised successful treatments, revealing fuller-looking hair and restored hairlines,

have helped generate interest among the general public. In fact, research conducted by The Maitland Clinic found that one fifth of 2,000 men polled think hair transplants are more acceptable thanks to these high-profile endorsements.2 This is perhaps borne out in the numbers of people – both men and women – having treatment, with numbers of surgical treatments carried out in Europe increasing by 45% between 2008 and 2014.3 Dr Ball adds that, in his opinion, the rise of social media and ‘selfie’ culture is, in part, responsible for society’s increasing preoccupation with hair.

Causes of hair loss

Anecdotal evidence from those interviews suggests that the most common cause of hair loss in men who seek treatment is androgenic alopecia (male pattern hair loss). It is caused by oversensitivity of the hair follicles to dihydrotestosterone, a converted form of the testosterone hormone.4 Male pattern baldness also runs in families, most strongly in the mother’s side.4 This form of hair loss typically follows a predictable pattern, such that patients’ hair usually begin to recede at the temples or notice a thinning patch on the crown, followed by gradually increasing thinning and sometimes complete loss of hair on the top of the head.5 Women, too, can present with androgenic alopecia (female pattern hair loss). “Some women have hair that thins more as they age,” says Natasha Borciani, owner of Borciani London. “They tend to get a strip (of thinning hair) down the centre along the parting, which will widen over the years.” This diffuse thinning makes the scalp more visible and worsens with time. Androgenic hair loss in women is associated with the presence of testosterone, and, post-menopause, with a reduction in oestrogen levels.5 The most common problem in women with regards to hair loss is telogen effluvium, which presents as widespread yet gradual diffuse shedding or thinning of the hair, rather than in clumps or patches.6 
Other types of hair loss include:5,6

  • Alopecia areata – where coin-sized bald patches appear on the scalp
  • Scarring alopecia – also known as cicatricial alopecia, usually caused by complications from another condition (and consequently, hair won’t grow back)
  • Anagen effluvium – commonly a side effect of chemotherapy and other cancer treatments
  • Trichotillomania – self-inflicted hair loss caused by obsessive- compulsive pulling of the hair

Forms of treatment

Medication

Medical interventions can be effective to slow or halt the progression of androgenic hair loss in men and women, and is often the first line of treatment. “There are two FDA-approved medications for hair loss, the first of which is minoxidil,” says Dr Munir Somji, clinical director at Priors Clinic. He adds, “Although we’re not completely sure of its mechanism of action, it causes vasodilation, which could help hair growth.”7 The vasodilatory effects of minoxidil could, it is suggested, open potassium channels and thereby allow more oxygen, blood and nutrients to the hair follicle.7 Indeed, topical minoxidil has been indicated to generate ‘superior’ results compared with placebo controls in trials among both men and women, with 5% concentrations appearing to be more effective than 2% and eliciting no significant adverse effects.8,9

Fiigure 1: Patient with traumatic alopecia treated with minoxidil and tailored, topical solutions over a period of seven months. Images courtesy of Mandy Baldwin.

 

The second FDA-approved medication, says Dr Somji, is finasteride. “It is prescribed in 1mg doses for male pattern hair loss, and we see that it actually stops hair loss in about 65% of individuals,” he says. It works by blocking the conversion of testosterone to dihydrotestosterone, and it has been indicated to promote hair growth and prevent further loss, with improvements noted in 66% of male recipients after two years of treatment, with a good tolerability profile.10 

Mesotherapy

Mesotherapy is used in aesthetics to combat a number of concerns, including cellulite and signs of ageing skin,11 and its application in hair loss is gaining in popularity. “The science is limited, but essentially, mesotherapy is a term that describes a technique as opposed to a specific treatment,” explains Pam Cushing, aesthetic nurse prescriber and vice president of the Society of Mesotherapy UK. “You can do mesotherapy with different types of products; for example, we could use platelet-rich plasma (PRP), pure hyaluronic acid, or cocktails that combine natural products that would stimulate the hair to thicken by feeding the bulb of the hair follicle.” These ‘hair cocktails’ contain different pre-mixed ingredients that can be injected into the scalp. “Using very small, microinjections just underneath the scalp, small deposits of the product are delivered and evenly spaced out, to stimulate collagen production, but also to feed, nourish and hydrate the hair bulb,” says Cushing. “If you increase the nutrients, vitamins, trace elements and amino acids that the hair requires for growth, it stands to reason that the bulb will grow thicker.” She points out that different manufacturers will use different preparations, but an example cocktail might include:

  • Drugs – buflomedil, pentoxifylline, minoxidil, finasteride
  • Vitamins – dexpanthenol (B5), biotin (vitamin H), L-ascorbic acid (vitamin C), vitamins A, E, B1, B2, B6, B complex, and D
  • Trace elements – cobalt, copper, ginkgo biloba, lithium, magnesium, manganese, phosphorous, selenium, sulphur, zinc
  • Nutritional drugs – Centella asiatica, silicon
  • Hormone – calcitonin
  • Anaesthetic – procaine
This type of therapy has been the subject of comparatively few scientific studies, but some have demonstrated that mesotherapy can elicit good results in the treatment of acute diffuse hair loss, such as telogen effluvium, stress alopecia, androgenetic hair loss and alopecia areata.14 Patients typically undergo one treatment per month over three months, at which point Cushing would expect to see results. “The greatest limitation is patient expectation,” she says. “You have to be realistic, and some patients can be dissatisfied purely because the change has not been as rapid as they anticipated. Managing expectations is important.
Figure 2: Images following treatment with the Athrex ACP PRP system from Biotherapy Services Ltd 
Windsor. Images courtesy of Pam Cushing.



Platelet Rich Plasma

Dr Somji offers PRP treatment, in which the patient’s own blood is re-injected into the scalp via multiple, tiny injections around 1cm apart. This involves withdrawing blood – usually from the patient’s arm – and processing it through a machine to centrifuge it and separate out plasma containing a high concentration of platelets. This PRP is rich in growth factors – naturally occurring substances that stimulate cell growth and proliferation, and thereby promote tissue regeneration.12 Studies have demonstrated that injecting PRP preparations has a ‘positive therapeutic effect on male androgenic alopecia without major side effects’.13 “First, we do a trichoscopy, looking at the scalp under a microscope for areas of miniaturised follicles,” Dr Somji comments, adding, “We count the number of follicles per cm squared, so we have a quantitative analysis before treatment.” This gives both the patient and the practitioner a measurable assessment of the success of the treatment. An important factor, according to Dr Somji, is the depth to which you inject the scalp. “The length of the hair follicle underneath the skin is different for everybody. People of Indian origin have longer hair follicles than Caucasian people, for example,” he says. As a result, injection depth should be determined by the length of the individual patient’s hair follicle. “I surgically remove one follicle and look at it under the microscope to measure how far it goes down to the papillary dermis, which is where the PRP is injected. That gives me an accurate measurement of how deep to set the needle,” explains Dr Somji, adding, that this is typically between 1.5 and 2.5mm, with 0.5ml of PRP injected per cm squared, but, crucially, the depth is varied from patient to patient, where other practitioners may use the same depth across the board. According to consultant trichologist Mandy Baldwin from the Hair and Scalp Clinic, dormant hair follicles start to become fortified and reinvigorated almost immediately. “You can’t see anything straight away but there is lots happening underneath, just like when you plant a seed that eventually grows into a flower,” she says. “Patients normally begin to see a change at around three to six months post treatment.” Moreover, Baldwin adds, PRP can be used in combination with hair transplantation to help the implanted follicles to prosper, reduce inflammation, erythema, trauma, and the formation of scabs, and to aid healing.

Hair transplantation

When one thinks of hair loss treatments, transplantation might be the first thing that springs to mind. Dr Ball explains, “Hair transplant surgery is based around a principle known as ‘donor dominance’. That means the donor hair is dominant in its characteristics. So, you take hair from a donor area – that usually being the back and sides of the head – and the hair will retain the characteristic from that area regardless of where you put it.” Hair transplant surgery is said to produce ‘excellent’ results in the treatment of many forms of male and female hair loss, particularly androgenic alopecia.15
There are two methods of removing the donor hair: follicular unit transplantation (FUT) and follicular unit extraction (FUE). The former involves taking a strip of skin from the back of the head, usually around 1- 2cm wide, with the length dependent on both how much hair you need and the density of the donor hair. “You have to carefully dissect in between each hair follicle to maximise the donor yield, and the skin is then stitched up,” Dr Ball comments. “This can leave a scar, which although is usually barely noticeable and is easily covered by hair, can be a concern for some patients, particularly men who like to keep their hair short.” In such patients, the latter (and more advanced) technique – FUE – is advised. Dr Ball explains, “Here, instead of taking the whole piece of skin and stitching it up, you remove each hair individually using a device that makes tiny punches of around 0.8 to 1mm. From that point on, both techniques are the same.”

Figure 3: Patient in his 20s who underwent a single hair transplant surgery using the FUT method to the frontal half, following seven months on oral finasteride (1mg daily). Images courtesy of Dr Edward Ball.
The donor hair is examined under the microscope and separated into individual grafts of one or two hairs, which must be delicately handled and placed in a preservative solution to maintain their viability. The area of the scalp receiving the donor hair is then prepared: the practitioner makes a series of tiny incisions, into which the grafts will be positioned. “The placing of the hair takes a long time. Each graft must be laid out to match the angle, direction, and the density of the hair you want to create,” says Dr Ball. “It has to be natural-looking, in keeping with the patient’s age, face shape and hair line, and the whole procedure can take up to 10 hours.” People can, anecdotally, return to normal daily routine within one week, with no evidence of having had surgery, Dr Ball adds. Post-treatment care involves not touching the hair for the first six days, while the skin heals over to root the follicles into place, then washing, styling and treating the hair as normal thereafter. “The hair graft sits dormant waiting for new hair to grow, and that happens in stages very gradually. It’s subtle, and it normally starts about four to six months after surgery. Patients get most of the growth by 10 to 12 months. Beyond that, while they won’t get new hair growth, the quality, calibre and thickness of the hair tends to get better and better.”

 Hair follicle stimulation

Most solutions are aimed at restoring hair, but an alternative option is to conceal instead of ‘treat’ hair loss, by way of scalp micropigmentation (SMP). Borciani offers this ‘follicle simulation’ for men and women experiencing all types of hair loss. She says, “We create micro dots of pigment underneath the skin in the dermal layer, which mimics the appearance of real hair follicles or strands. It’s a more affordable and natural alternative to hair restoration.” While SMP can be an effective application for balding or thinning hair and can yield extremely pleasing results,16 this is largely reliant on the technical and artistic skills of the practitioner, whose careful selection of pigments and understanding of the hair loss process is crucial to the procedure’s success.17

Figure 4: Before and after two sessions of hair follicle stimulation over four weeks. Images courtesy of Natasha Borciani.

“I draw on a hairline template with a liner to get an idea of the shape we can work with and what the likely result will be,” Borciani explains. “Then we do some colour matching; we work with a large range of pigments that we blend together to find an exact match that’s as natural looking as possible.” After numbing the scalp for 20 to 30 minutes, the treatment is performed using one of two systems – or a combination of both – depending on the extent of the hair loss and the desired outcome. “The first is a roller system, which allows you to put in far more pigment far more quickly. It reduces the length of time the patient has to be in the chair, which, for a full head, could be from up to five hours down to about 60 minutes.” This roller is applied to large sections of the scalp, and around the front and sides the second system will usually be used. “This is a manual dotting technique, similar to a very fine tattoo pen, which allows me to blend into any remaining hair, and achieve a natural-looking hairline.” Patients normally undergo two or three treatments, each four weeks apart, to get optimum results, but the nature of the technique – placing pigment into the skin – means that you can see a distinct difference straight away. Borciani reports that anecdotally, the effect can last up to two or three years, with a maintenance session often required around 15 months post procedure. “There are factors that affect the longevity, such as sun exposure, lifestyle and general skin condition – oily skin doesn’t retain the pigment as well – but if patients look after their scalp, they should be happy for more than a year,” she says.

Conclusion

Hair loss for both sexes can be an emotional event and a source of great insecurity. The manifold treatments available can offer a solution, and as techniques become more sophisticated, they will undoubtedly produce increasingly better results. Scientists have been researching the potential to grow human hair using stem cells, whereby stem cells can turn dead hair follicles into healthy ones, and consequently promote new hair growth.18 The point in time when not only human hair can be grown in human tissue, but also when the science is routinely applied in clinics, may be closer than we think.   

References

  1. Harley Street Hair Clinic, Wayne Rooney’s hair transplant, (London, 2013). www.hshairclinic.co.uk/patients-gallery/wayne-rooney/
  2. The Maitland Clinic, Balding truth about hair loss in the UK, 2015. Data on file via The Maitland Clinic. 
  3. International Society of Hair Restoration Surgery, 2015 Practice Census Results, (USA, 2015) http://webcache.googleusercontent.com/search?q=cache:NxGrEwaoTNYJ:www.ishrs.org/sites/default/files/users/user3/report_2015_practice_census-final.pdf+&cd=1&hl=en&ct=clnk&gl=uk&client=safari
  4. Men’s Health Forum, Hair loss FAQs, (London, 2014) www.menshealthforum.org.uk/hair-loss-faqs
  5. The Institute of Trichologists, Hair conditions (London) www.trichologists.org.uk/index.php/conditions/hair-conditions
  6. NHS Choices, Hair loss (London, 2015) www.nhs.uk/Conditions/Hair-loss/Pages/Introduction.aspx#telogen
  7. Rossi A, Cantisani C, Melis L, Iorio A, Scali E, Calvieri S., ‘Minoxidil use in dermatology, side effects and recent patents’, Recent Pat Inflamm Allergy Drug Discov, 2 (2012), pp.130-6.
  8. Lucky AW, Piacquadio DJ, Ditre CM, Dunlap F, Kantor I, Pandya AG, Savin RC, Tharp MD., ‘A randomized, placebo-controlled trial of 5% and 2% topical minoxidil solutions in the treatment of female pattern hair loss’, J Am Acad Dermatol, 50 (2004), pp.541-53.
  9. Olsen EA, Dunlap FE, Funicella T, Koperski JA, Swinehart JM, Tschen EH, Trancik RJ., ‘A randomized clinical trial of 5% topical minoxidil versus 2% topical minoxidil and placebo in the treatment of androgenetic alopecia in men’, J Am Acad Dermatol, 47 (2002), pp.377-85.
  10. McClellan KJ, Markham A., ‘Finasteride: a review of its use in male pattern hair loss’, Drugs, 57 (1999), pp.111-26.
  11. Mesotherapy and Estetik, FAQ, testimonials, patient warning, (New York, 2006) www.mesotherapy.com/faq/
  12. El-SharkawyH,KantarciA,DeadyJ,HasturkH,LiuH,AlshahatM,VanDykeTE.,‘Platelet-richplasma: growth factors and pro- and anti-inflammatory properties’, J Periodontol, 78 (2007), pp.661-9. 
  13. Gentile, P et al, ‘The Effect of Platelet-Rich Plasma in Hair Regrowth: A Randomized Placebo- Controlled Trial’, Stem Cells Translational Medicine, 4 (2015), pp.1317–1323.
  14. Kutlubay Z, Karaku? Ö, ‘Hair Mesotherapy’, Hair Ther Transplant (2012) 2:e102. www.omicsgroup.org/journals/2167-0951/2167-0951-2-e102.pdf
  15. PaulTRose,‘ Hair restoration surgery: challenges and solutions’, Clin Cosmet Investig Dermatol,8 (2015), pp.361-370.
  16. William R Rassman, Jae P Pak, Jino Kim, ‘Scalp Micropigmentation: A Useful Treatment for Hair Loss’, Facial Plastic Surgery Clinics of North America, 21 3 (2013), pp.497-503.
  17. William R Rassman, Jae P Pak, Jino Kim, Norman Estrin., ‘Scalp Micropigmentation – A Concealer for Hair and Scalp Deformities’, J Clin Aesthet Dermatol, 8(3) (2015), pp. 35-42.
  18. Medic8,FutureTreatmentHairLoss–HairLosstreatments, http://www.medic8.com/healthguide/hair-loss/treatments/future-treatment-hair-loss.html

Comments

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