Hair Loss

[Michael Scally MD]

Reddy SK, Garza LA. The Thinning Top: Why Old People Have Less Hair. J Invest Dermatol 2014;134(8):2068-9. http://www.nature.com/jid/journal/v134/n8/full/jid2014172a.html
Changes in the hair cycle underlie age-related alopecia, but the causative mechanisms have remained unclear. Chen et al. point to an imbalance between stem cell-activating and -inhibitory signals as the key determinant of age-related regenerative decline. Further, they identify a secreted protein, follistatin, that may be able to shift the balance toward renewal.


Chen CC, Murray PJ, Jiang TX, et al. Regenerative Hair Waves in Aging Mice and Extra-Follicular Modulators Follistatin, Dkk1, and Sfrp4. J Invest Dermatol 2014;134(8):2086-96. http://www.nature.com/jid/journal/v134/n8/full/jid2014139a.html

Hair cycling is modulated by factors both intrinsic and extrinsic to hair follicles. Cycling defects lead to conditions such as aging-associated alopecia. Recently, we demonstrated that mouse skin exhibits regenerative hair waves, reflecting a coordinated regenerative behavior in follicle populations. Here, we use this model to explore the regenerative behavior of aging mouse skin. Old mice (>18 months) tracked over several months show that with progressing age, hair waves slow down, wave propagation becomes restricted, and hair cycle domains fragment into smaller domains. Transplanting aged donor mouse skin to a young host can restore donor cycling within a 3 mm range of the interface, suggesting that changes are due to extracellular factors. Therefore, hair stem cells in aged skin can be reactivated. Molecular studies show that extra-follicular modulators Bmp2, Dkk1, and Sfrp4 increase in early anagen. Further, we identify follistatin as an extra-follicular modulator, which is highly expressed in late telogen and early anagen. Indeed, follistatin induces hair wave propagation and its level decreases in aging mice. We present an excitable medium model to simulate the cycling behavior in aging mice and illustrate how the interorgan macroenvironment can regulate the aging process by integrating both "activator" and "inhibitor" signals.

 

[noah_k]

@Michael Scally MD

Thank you for continually combing through these studies for us.

Can I ask your personal opinion as informed individual and not as any official medical statement? Do you personally think making the transition from finasteride (with no complications) to dutasteride (as currently 'off-label' use) is an acceptable level of risk for the potential benefits and efficacy? Understand if you don't want to answer such a loaded question point blank

 

[ATodd]

@Michael Scally MD

Thank you for continually combing through these studies for us.

Can I ask your personal opinion as informed individual and not as any official medical statement? Do you personally think making the transition from finasteride (with no complications) to dutasteride (as currently 'off-label' use) is an acceptable level of risk for the potential benefits and efficacy? Understand if you don't want to answer such a loaded question point blank

Noah,
Awesome question. I've done a bit of research and was going to run both (Adovart, black market, my script for propecia). I also don't want to due to the possililty of sides. Hope the good Dr. will answer, even if it's in the form of a hypothetical situation. I realize that long term effects are still up in the air, but i value his opinion and would like to hear any insights.
atodd

 

[greenddog1]

While attempting to donate blood I found out if you are taking Avodart (dutasteride) you not allowed to donate. The waiting peroid is 6 months from the last dose. Propecia (finesteride),the waiting peroid is 1 month from the last dose. Wish I had known this before starting Avodart.

Puts a crimp in trying to manage hematocrit levels. Something to consider.

 

[Michael Scally MD]

Caserini M, Radicioni M, Leuratti C, Annoni O, Palmieri R. A novel finasteride 0.25% topical solution for androgenetic alopecia: pharmacokinetics and effects on plasma androgen levels in healthy male volunteers. Int J Clin Pharmacol Ther. http://www.dustri.com/nc/article-response-page.html?artId=12533&doi=10.5414/CP202119

Objective: Finasteride, a selective inhibitor of type 2 5-alpha reductase isoenzyme, inhibits the conversion of testosterone to dihydrotestosterone (DHT) and is indicated in the treatment of male androgenetic alopecia. The study objective was to evaluate a newly developed finasteride 0.25% topical solution in comparison to the marketed finasteride 1 mg tablet, with respect to finasteride pharmacokinetics and suppressive effects on plasma DHT.

Methods: 24 healthy men with androgenetic alopecia were randomized in a single center, open-label, parallel-group, exploratory study, and received either multiple scalp applications of the topical solution b.i.d. or oral doses of the reference tablet o.d. for 7 days. Plasma finasteride, testosterone and DHT concentrations were determined.

Results: After multiple doses, mean (+/- SD) finasteride Cmax and AUC00-t corresponded to 0.46 +/- 0.28 ng/mL and 6.64 +/- 7.50 ng/mL x h for the topical solution and to 6.86 +/- 1.78 ng/mL and 57.93 +/- 29.38 ng/mL x h for the tablet. Plasma DHT was reduced by ~ 68 - 75% with the topical solution and by ~ 62 - 72% with the tablet. No relevant changes occurred for plasma testosterone with either treatment. No clinically significant adverse events occurred.

Conclusions: A strong and similar inhibition of plasma DHT was found after 1 week of treatment with the topical and tablet finasteride formulations, albeit finasteride plasma exposure was significantly lower with the topical than with the oral product (p < 0.0001).

 

[Michael Scally MD]

@Michael Scally MD

Thank you for continually combing through these studies for us.

Can I ask your personal opinion as informed individual and not as any official medical statement? Do you personally think making the transition from finasteride (with no complications) to dutasteride (as currently 'off-label' use) is an acceptable level of risk for the potential benefits and efficacy? Understand if you don't want to answer such a loaded question point blank

_____
I see no risk other than those noted already for 5ARis.

 

[blazinshotguns]

Dr Scally help me recover my hair

 

[Michael Scally MD]

FGF5 Is a Crucial Regulator of Hair Length

The length of your eyelashes probably differs from the length of the hair on your head—and unlike your hair, your eyelashes can never reach your shoulders.

What controls how long hair can get?

To find out, Higgins et al. studied people with a rare disorder called familial trichomegaly, who have very long eyelashes and longer hair on the arms. They found that these people had a mutation in the gene that encodes fibroblast growth factor 5 (FGF5).

When human hair follicles produce FGF5, they stop growing hair.

FGF5 underlies trichomegaly and is a crucial regulator of hair growth in humans.

Targeting FGF5 could potentially control the growth and rest phases of hair follicles, preventing unwanted hair from sprouting or growing longer lashes and locks.

Higgins CA, Petukhova L, Harel S, et al. FGF5 is a crucial regulator of hair length in humans. Proc Natl Acad Sci USA. 2014;111(29):10648-53. http://www.pnas.org/content/111/29/10648.abstract

Mechanisms that regulate the growth of eyelashes have remained obscure. We ascertained two families from Pakistan who presented with familial trichomegaly, or extreme eyelash growth.

Using a combination of whole exome sequencing and homozygosity mapping, we identified distinct pathogenic mutations within fibroblast growth factor 5 (FGF5) that underlie the disorder. Subsequent sequencing of this gene in several additional trichomegaly families identified an additional mutation in FGF5.

We further demonstrated that hair fibers from forearms of these patients were significantly longer than hairs from control individuals, with an increased proportion in the growth phase, anagen.

Using hair follicle organ cultures, we show that FGF5 induces regression of the human hair follicle.

We have identified FGF5 as a crucial regulator of hair growth in humans for the first time, to our knowledge, and uncovered a therapeutic target to selectively regulate eyelash growth.

 

[flexx89]

read this whole thread and couldnt find an answer so ill ask it.

are reports of negative side effects on avodart less or the same as propecia/proscar?

 

[Michael Scally MD]

Schiavone G, Raskovic D, Greco J, Abeni D. Platelet-Rich Plasma for Androgenetic Alopecia: A Pilot Study. Dermatol Surg. http://www.ncbi.nlm.nih.gov/pubmed/25111436#

BACKGROUND: Androgenetic alopecia is a common condition, with severe attendant psychosocial implications, and for which it is difficult to obtain a satisfactory degree of clinical improvement.

OBJECTIVE: To explore the possible clinical benefit of injecting platelet-derived growth factors into the scalp of patients using a specific autologous blood concentrate.

MATERIALS AND METHODS: Two injections of a leukocyte platelet-rich plasma (L-PRP) with the addition of concentrated plasmatic proteins were administered at baseline and after 3 months (single spin at baseline and double-spin centrifugation at 3 months). Macrophotographs were taken at baseline and after 6 months, and 2 independent evaluators rated them using Jaeschke rating of clinical change.

RESULTS: Sixty-four consecutive patients were enrolled. Some improvement was seen in all patients by 1 evaluator and in 62 by the other. The mean change in clinical rating was 3.2 (95% confidence interval [CI], 2.9-3.5) and 3.9 (95% CI, 3.5-4.3), and the proportion of patients reaching a clinically important difference was 40.6% and 54.7%, according to the 2 evaluators, respectively.

CONCLUSION: Our pilot study may provide preliminary evidence that this treatment may induce some degree of clinical advantage for male- and female-pattern baldness. This may warrant the design of randomized controlled clinical trials to formally test this procedure.

 

[Michael Scally MD]

Gallicchio L, Calhoun C, Helzlsouer KJ. Aromatase inhibitor therapy and hair loss among breast cancer survivors. Breast Cancer Res Treat 2013;142(2):435-43. http://link.springer.com/article/10.1007/s10549-013-2744-2

The objective of this study was to examine the associations between aromatase inhibitor therapy and hair loss or hair thinning among female breast cancer survivors.

Data were analyzed from 851 female breast cancer survivors who responded to a hospital registry-based survey. Data on hair loss, hair thinning, demographic characteristics, and health habits were based on self-report; data on aromatase inhibitor therapy were collected on the survey and verified using medical record review. Logistic regression was used to estimate the odds ratios (ORs) and 95 % confidence intervals (CIs) for the associations between aromatase inhibitor therapy and the hair outcome variables adjusted for potential confounders, including age and chemotherapy treatment.

The results showed that 22.4 % of the breast cancer survivors reported hair loss and 31.8 % reported hair thinning. In the confounder-adjusted analyses, breast cancer survivors who were within 2 years of starting aromatase inhibitor treatment at the time of survey completion were approximately two and a half times more likely to report reporting hair loss (OR 2.55; 95 % CI 1.19-5.45) or hair thinning (OR 2.33; 95 % CI 1.10-4.93) within the past 4 weeks compared to those who were never treated with an aromatase inhibitor. Current aromatase inhibitor use for two or more years at the time of the survey and prior use were significantly associated with hair thinning (current users, >/=2 years: OR 1.86; prior users: OR 1.62), but not hair loss.

Findings from this study suggest that aromatase inhibitor use is associated with an increased risk of hair loss and hair thinning independent of chemotherapy and age; these side effects are likely due to the substantial decrease in estrogen concentrations resulting from treatment with this drug. Future research should focus on examining these associations in a prospective manner using more detailed and objective measures of hair loss and thinning.

 

[Michael Scally MD]

New Drug Helps Some Bald Patients Regrow Hair
http://www.nytimes.com/2014/08/18/health/alopecia-patients-in-study-grow-hair-with-new-drug.html

Brian, 34, who asked that his last name be withheld to protect his privacy, suffers from alopecia areata, an autoimmune disease afflicting about 1 percent of men and women, causing hair to fall out, often all over the body.

After trying various treatments, Brian enrolled this year in a study at Columbia University Medical Center testing whether a drug approved for a bone marrow disorder could help people with alopecia.

After successfully testing on mice two drugs from a new class of medicines called JAK inhibitors, which suppress immune system activity by blocking certain enzymes, the researchers began testing one of the drugs, ruxolitinib, on seven women and five men.

Some of their findings were published Sunday in the journal Nature Medicine.http://www.nature.com/nm/journal/vaop/ncurrent/full/nm.3645.html

The results for Brian and several other participants have been significant.

 

[Michael Scally MD]

Khatu SS, More YE, Gokhale NR, Chavhan DC, Bendsure N. Platelet-rich plasma in androgenic alopecia: myth or an effective tool. J Cutan Aesthet Surg 2014;7(2):107-10. http://www.jcasonline.com/article.a...me=7;issue=2;spage=107;epage=110;aulast=Khatu

Platelet-rich plasma (PRP) has become a newer method for the treatment of various types of alopecia. In this prospective study, safety, efficacy and feasibility of PRP injections in treating androgenic alopecia were assessed. Eleven patients suffering from hair loss due to androgenic alopecia and not responding to 6 months treatment with minoxidil and finasteride were included in this study. The hair pull test was performed before every treatment session. A total volume of 2-3 cc PRP was injected in the scalp by using an insulin syringe. The treatment was repeated every two weeks, for a total of four times. The outcome was assessed after 3 months by clinical examination, macroscopic photos, hair pull test and patient's overall satisfaction.

RESULTS: A significant reduction in hair loss was observed between first and fourth injection. Hair count increased from average number of 71 hair follicular units to 93 hair follicular units. Therefore, average mean gain is 22.09 follicular units per cm(2.) After the fourth session, the pull test was negative in 9 patients.

CONCLUSION: PRP injection is a simple, cost effective and feasible treatment option for androgenic alopecia, with high overall patient satisfaction.

 

[Michael Scally MD]

Platelet rich plasma in androgenic alopecia: Where do we stand?

Dear Editor, In this issue an article titled 'Platelet rich plasma in androgenic alopecia: myth or an effective tool' has shown favourable results with platelet rich plasma (PRP) in androgenic alopecia. There has been growing interest in PRP as a procedure in dermatology.

Literature review shows limited number of articles on PRP in various indications like androgenic alopecia, healing in chronic ulcers and skin rejuvenation. PRP seems to be rational therapy with science of growth factors in tissue regeneration. Level of evidence of various studies in androgenic alopecia is from low to medium. Well-defined double blind trials or split face trials will definitely increase the confidence of clinicians in this procedure.

Methods of preparation vary with different kits and with manual methods. In addition there is no consensus for frequency of this procedure in various indications. Once a month for three months seems to be appropriate for hair growth. Automated kits seem to give better results. In general, platelet concentration should be four to five times normal counts to achieve optimum results. Giusti et al., have showed optimum concentration of platelets around 15 lacs/mm 3 for angiogenesis in human endothelial cells.

Precautions like using proper numbering of blood samples, maintenance of sterile environment throughout the procedure, avoidance of infection and temperature control are important for consistent results. Transmission of infections through this procedure is a theoretical possibility. Patients with bleeding disorders, platelet dysfunction syndrome, anti coagulant therapy are contraindications for this procedure.

PRP has shown reliable results in ulcer healing in an Indian study. PRP is also a useful adjuvant to fractional laser therapy in skin rejuvenation. In hair transplant procedures, Ubel reported that enriching hair root grafts in PRP solution showed better results in the form of an increase in hair density.

Though PRP is a newer technique in a dermatosurgeon's armamentarium that can be combined with other therapies like fractional lasers, needle radiofrequency and microneedling, monotherapy is yet to show consistently good results in various studies.

Godse K. Platelet rich plasma in androgenic alopecia: Where do we stand? J Cutan Aesthet Surg. http://www.jcasonline.com/article.a...me=7;issue=2;spage=110;epage=111;aulast=Godse

 

[Michael Scally MD]

Is There Sufficient Research Data to Use Platelet-Rich Plasma in Dermatology?

We conducted our own pilot study in Dr. D.Y. Patil Medical College and Research Center, Nerul, Mumbai, to determine the efficacy of PRP therapy given for androgenic alopecia (AGA), without the use of any other adjuvant therapy. Ten male patients with AGA Grade 2 or 3 were treated with weekly PRP for six sessions, and results were studied with global photography. On assessing the photographs, there was clinical improvement in only two patients [Figure 1]. Rest of the patients showed no effect; however, all the patients were satisfied with the results. Hence, we concluded that subjective improvement is more than objective improvement in PRP. Hence, it can only be used as an adjuvant for therapy in hair loss and should not play a lead role in any treatment regime for AGA.

Despite these abundant studies in various peer-reviewed journals, we await evidence-based data regarding the exact concentration and dosing parameters. All the studies are conducted with different methodology. Questions such as, when to inject PRP? Will PRP work better if injected weekly, daily, or monthly? For how long post procedure? Still boggle the mind. For now, all we have are arbitrary guidelines. Instead of being helpful and encouraging, these studies can often be confusing and misguiding to a doctor planning to inculcate PRP in his daily practice. These unanswered questions, plus the time and cost of equipment setup, are obstacles to widespread implementation of PRP.

It is undoubtable that the use of platelet-based formulations in cutaneous medicine will continue to evolve. Hence to use PRP to the fullest extent, the principles, procedure and indications need to be understood, standardized and simplified; only then, we can trust this procedure completely and give maximum benefit to our patients.

Marwah M, Godse K, Patil S, Nadkarni N. Is there sufficient research data to use platelet-rich plasma in dermatology?. Int J Trichol 2014;6:35-6. http://www.ijtrichology.com/article...ume=6;issue=1;spage=35;epage=36;aulast=Marwah

Figure 1: (a) Before therapy, thinning of hair seen, (b) Posttherapy, increase in density of hair seen

 

[Michael Scally MD]

Rousso DE, Kim SW. A Review of Medical and Surgical Treatment Options for Androgenetic Alopecia. JAMA Facial Plast Surg. http://archfaci.jamanetwork.com/article.aspx?articleid=1900716

Importance: Androgenetic alopecia is a highly prevalent condition that can profoundly impair the quality of life in both men and women.

Objective: To provide the up-to-date medical and surgical treatment options for patients with androgenetic alopecia. Evidence Review: A Medline search of scientific literature was conducted from 1997 to 2013. Search terms included androgenetic alopecia, hair restoration, follicular unit transplantation, and follicular unit extraction.

Findings: Oral finasteride and topical minoxidil are the 2 mainstream medical treatments for androgenetic alopecia. These medications have different mechanisms of action and should be combined to have an additive effect in men. Follicular unit transplantation is the gold standard for surgical management. There are 2 types of graft harvest technique: donor strip and follicular unit extraction. Each technique has its own advantages and disadvantages and should be tailored to the individual patient. Understanding of the anterior hairline design is essential to achieving a natural-appearing result.

Conclusions and Relevance: Medical treatment should be used in conjunction with surgery to achieve a synergistic effect. For the right candidate, follicular unit hair transplantation can lead to a long-lasting, natural result with appearance of dense scalp hair.

 

[Michael Scally MD]

Munck A, Gavazzoni MF, Trueb RM. Use of low-level laser therapy as monotherapy or concomitant therapy for male and female androgenetic alopecia. Int J Trichology 2014;6(2):45-9. http://www.ijtrichology.com/article...lume=6;issue=2;spage=45;epage=49;aulast=Munck

BACKGROUND: Androgenetic alopecia (AGA) is the most common form of hair loss in men and in women. Currently, minoxidil and finasteride are the treatments with the highest levels of medical evidence, but patients who exhibit intolerance or poor response to these treatments are in need of additional treatment modalities.

OBJECTIVE: The aim was to evaluate the efficacy and safety of low-level laser therapy (LLLT) for AGA, either as monotherapy or as concomitant therapy with minoxidil or finasteride, in an office-based setting.

MATERIALS AND METHODS: Retrospective observational study of male and female patients with AGA, treated with the 655 nm-HairMax Laser Comb((R)), in an office-based setting. Efficacy was assessed with global photographic imaging.

RESULTS: Of 32 patients (21 female, 11 male), 8 showed significant, 20 moderate, and 4 no improvement. Improvement was seen both with monotherapy and with concomitant therapy. Improvement was observed as early as 3 months and was sustained up to a maximum observation time of 24 months. No adverse reactions were reported.

CONCLUSIONS: LLLT represents a potentially effective treatment for both male and female AGA, either as monotherapy or concomitant therapy. Combination treatments with minoxidil, finasteride, and LLLT may act synergistic to enhance hair growth.


Monotherapy in a 54-year-old male
(a) Before treatment, and improvement after
(b) 6 months, and
(c) 12 months of low-level laser therapy



Concomitant treatment with topical 5% minoxidil and 1 mg oral finasteride in a 34-year-old male
(a) Before,
(b) After 9 months treatment with 1 mg oral finasteride and topical 5% minoxidil solution bid, and
(c) After 3 months after adding on low-level laser therapy



Concomitant treatment with topical 5% minoxidil in a 55-year-old male adding on low-level laser therapy (LLLT) to 4 year pretreatment with 5% topical minoxidil solution
(a) Before, and
(b) After 3 months of added LLLT

 

[Michael Scally MD]

Celbek G, Turan H, Aydın Y, Ermiş F. A Case of Hypogonadism Presented with Alopecia Universalis. Balkan Med J 2013;30:345-6. http://balkanmedicaljournal.org/sayilar/39/buyuk/345-61.pdf

A 46 year-old male patient attended our outpatient clinic complaining of hair falling out all over his body. He had developed hair loss first on his whole scalp and subsequently on his body.

When the patient’s anamnesis was explored further, it was found that he had also experienced a decline in both his sexual drive and levels of physical activity, hot flushes, sweating, and erection problems. The patient had already had these complaints when his alopecia started.

His pubertal development was complete. He had no peculiarities in his personal and family history and was not using any medication. The physical examination was normal except for the total loss of hair all over his body.

Routine laboratory tests were within normal limits. His total testosterone level was low at 142.1 ng/dL (250-836 ng/dL). The follicle-stimulating hormone (FSH) and luteinising hormone (LH) levels were normal at 1.05 mIU/ml (0-12.4 mIU/mL) and 0.11 mIU/mL (0-8.6 mIU/ mL), respectively. His hypophysis MR and testis USG were normal.

Based on clinical and laboratory results, he was diagnosed with idiopathic hypogonadotropic hypogonadism (IHH). Following testosterone replacement treatment, his sexual drive and physical activity have increased.

However, no improvement was seen in his alopecia, so the patient started photochemotherapy to treat this.

 

[Michael Scally MD]

Mirmirani P, Consolo M, Oyetakin-White P, Baron E, Leahy P, Karnik P. Similar Response Patterns to 5% Topical Minoxidil Foam in Frontal and Vertex Scalp of Men with Androgenetic Alopecia: A Microarray Analysis. Br J Dermatol. http://onlinelibrary.wiley.com/doi/10.1111/bjd.13399/abstract

BACKGROUND: There are regional variations in scalp hair miniaturization seen in androgenetic alopecia (AGA). Use of topical minoxidil can lead to reversal of miniaturization in the vertex scalp. However, its effects on other scalp regions are less well studied.

METHODS: A placebo controlled double-blinded prospective pilot study of minoxidil topical foam 5% (MTF) vs placebo was conducted in sixteen healthy men ages 18-49 with Hamilton-Norwood type IV-V thinning. The subjects were asked to apply the treatment (active drug or placebo) to the scalp twice daily for eight weeks.

Stereotactic scalp photographs were taken at the baseline and final visits to monitor global hair growth. Scalp biopsies were done at the leading edge of hair loss from the frontal and vertex scalp before and after treatment with MTF and placebo and microarray analysis was done using the Affymetrix GeneChip HG U133 Plus 2.0.

RESULTS: Global stereotactic photographs showed that MTF induced hair growth in both the frontal and vertex scalp of AGA patients. Regional differences in gene expression profiles were observed before treatment. However, MTF treatment induced the expression of hair keratin associated genes and decreased the expression of epidermal differentiation complex (EDC) and inflammatory genes in both scalp regions.

CONCLUSIONS: These data suggest that MTF is effective in the treatment of both the frontal and vertex scalp of AGA patients.

 

[cazper]

Ty for this thread.
Appreciate the information.