ROLE OF PLATELET-RICH PLASMA IN ANDROGENETIC …

I

“ROLE OF PLATELET-RICH PLASMA IN ANDROGENETIC

ALOPECIA: A PROSPECTIVE STUDY”

by

Dr. RAMYA NARAHARI

Dissertation Submitted to the

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore

In partial fulfillment

of the requirements for the degree of

MASTER OF DENTAL SURGERY

IN

ORAL AND MAXILLOFACIAL SURGERY

Under the guidance of

Dr. RAMDAS BALAKRISHNA

Professor & Head Of the Department

DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY

K.L.E SOCIETY’S INSTITUTE OF DENTAL SCIENCES

BANGALORE -560022, KARNATAKA

2015-2018

:....:-,;· ..... ,~v ... ,....,'-..,'-...,,'....,'-..: .... ,......,,..:,/ .. }....,'-...,'.....:, '..:....: ..... ,....,,....,,....,,....:,./...:....:v .. _,. . ...,,....,,....,, ..:....,,....,,....:..,'......,',/ ...,'...,_;.' ,,,....,,....,,....,,....:....,, .... ,..._.,.,,..:....,'...._'....: .... , ...,'....:...: ...... ,....:...: .... '-..,'-..:-....'-...,'..: ..:...:-..,'-..,' ..,•....,1...:....,· .... '-.... '--..:..:..:-..: ... '-.... '-..: .... '-...,'-...,'--...,'-..,'-.... '-...,'-..,'-..,'-..,' .. : :

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA.

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation/thesis entitled "ROLE OF PLATELET-RICH

PLASMA IN ANDROGENETIC ALOPECIA: A PROSPECTIVE STUDY" is a

bonafide and genuine research work carried out by me under the guidance of Dr.

Ramdas Balakrishna, Professor and Head, Department of Oral and Maxillofacial

Surgery, K.L.E. Society' s Institute of Dental Sciences, Bangalore.

Date: ~ \LO\ t* Place: Bangalore Dr. Ramya Narahari

II

'

·,

·,

'

-'

' . ,

' ' · ·,

' . '

·,

' - ,

' . ,

' -,

' ··,

. ,

'

' .. ,

..; ... ·..; ... ·..; .... • ... ·...:-..· ..;..;"- ..;..; •, •, • , , . , ' , , . , , . , , , , , , , , , • , , , , , , , , , • , , , , , , , , . , , . , , , , , , ' , , ' ' . , ',. , -....; .. , .. , .:...:.:.:...:-.: .:.: .. • .:-.. -.:.:.:...:.:.:-..,.:,,,> .......... ... ...................... ..., ................. ................. ....................................................... .................. .., ...................................... ................ ... ......................... ................................ ........................ ....

..:-.... '-.:-...:-.: .... '-.:-.:..:-.... '-.:.:..:-..:-..:-..:-..:-..:-..:-.:..:-.:....:-.:.:v.: .... '.....:-.... '-.:-.:-..:-..:-..:-..:v..:-..:-.:.: .... '-.:-.... '....:-.:-....'-.... '-.: .... '-..:-.... '-..:-..:-.:..:-.... '-.:...,'-..:-..:-.... '-..:-..:-..:-.... '-.... '-..:-..:-..:-..:-..:-.: .... '-..:-..:-.: .... '- .... '-..:-.:.:-..:-.:-..: ...,'-..:-..:-.... '-.:.J .... '-.: .... '-..:-.: .... , .:..:-.... '-.• /...,'-.:...,'~-:

ENDORSEMENT BY THE HEAD OF THE DEPARTMENT,

PRINCIPAL/ HEAD OF THE INSTITUTION

This is to certify that the dissertation entitled "ROLE OF PLATELET-RICH

PLASMA IN ANDROGENETIC ALOPECIA: A PROSPECTIVE STUDY" is a

bonafide research work done by Dr. Ramya Narahari under the guidance of Dr.

Ramdas Balakrishna, Professor and Head, Department of Oral and Maxillofacial

Surgery, K.L.E. Society's Institute of Dental Sciences, Bangalore.

··, . · , .. ··, . .. ··, . ' · , ·, . ... .. ··, . ' ... ··, ··, · ·, ··, . ' .. ... ··, ··, . , · , ··, ··, . ··, .. ·, ··, ··, .. .. . . . ·, ··, ··, .. ··, ··, .. ··, .. , . ' .. ··, . ' . ,

. , ··, .. , ··, ··, . ' .. , .. , ··, •·, .. , . .. , · , . .. , ··, . ··, .. , .. , .. , .. , ... .. , ., .. , ··, .. , .. , .. , ' .. ,

Seal and signature of the HOD

.. , .. .. , e of the Principal : :

Dr. Ramdas Balakrishna

Date:

Place: Bangalore

Dr. RAMDAS BALAKRISHNA M.o.s. Professor & Head

Dept. of Oral & Maxillofacial Su!'Qery KLE Society's Institute of Dental Saencn

BENGALURU-560 022.

PRINCIPAL ::: . KJ..E. SOCIETY'S :::

Dr. Snvats~ UTE OF DENTAL SCIENCES :·: • BANGAL.ORE. :::

Date: ~ tol C.';f. Place: Bangalore

.. , ··, .. , ··, . , ··, •·, .. , ··, . . , ··, ·, .., ··, ·, , . · , ··, · , ··, .. , ·,

COPYRIGHT

Declaration by the Candidate

I hereby declare that the Raj iv Gandhi University of Health Sciences, Kamataka shall

have the rights to preserve, use and disseminate this dissertation / thesis in print or

electronic format for academic / research purpose,

Date: q [ \ D l 1::t--Place: Bangalore

.t~ Dr. Ramya Narahari

© Raj iv Gandhi University of Health Sciences, Karnataka.

V

,.,

, .,

,.,

--,

,.,

.. , ',

, .,

',

,,

.. ,

,, ,,

,., -,

·, , , • , , , , , , , , , '· • , , , , , , , , , ". '. '. '• '. '...,\,'...,,,''·...,"-..,/·.,,"-..,"-,/...,\,"-...,'-..;v•

,\ .: .. :..:..: ...,' .. :.: ..:-..:-....'-..; ..•. / ..;.....,'-...,"-,;...; ..,/-....,"...,' .. : ..; . .., .. .....,,...,; ..;...;.....,'...,:-...,' ...,"-...,' ...,-.... :.: ...,' ...,,' ...,"-...,"....,'....,'....; . ...,· . ...,'.,,:-...,·,:-...,·...,· ..• /,: ...:-....·-....·.....,·....,· ... · .... :-.... ·-....\;-..., ........ .... .................. " """"""'"' ........................................................ ....

I

ACKNOWLEDEMENT

“Above all I thank God; The Almighty for showering his blessings, and kind

graciousness upon me at every step.”

I owe the deepest gratitude to my mentor and guide, Dr. Ramdas

Balakrishna, Professor and Head of the Department, Department of Oral and

Maxillofacial Surgery, KLE Society’s Institute of Dental Science, Bangalore for his

inspiration, continuous support, encouragement, advice and constructive feedback

throughout my journey of Post-Graduation. Sir, I will be forever indebted to you

throughout my life for your valuable guidance and support.

I fall short of words to express my thankfulness towards my teachers Dr.

Sudarshan, Dr. Veena G.C., Dr. Anubhav Jannu, Dr. Bhuvaneswari, Dr. Suhas,

Dr. Shetty Hardik, Dr. Manju Shree and Dr. Thejus for their encouragement and

guidance during the course of my study. They always have been very approachable

and extended their helping hands.

I sincerely thank Dr. Srivatsa G., Principal of KLE Society’s Institute of

Dental Sciences, for his constant support during my study.

I would also like to thank Dr. Mohan Raja Thomas and Dr. Srinivas Ghosla

Reddy, who are masters in their fields and had enlightened me with their surgical

skills.

I am grateful to acknowledge Dr. Raison Thomas for his guidance and

coaching which helped me in stepping into the world of Oral & Maxillofacial

Surgery.

I

LIST OF ABBREVATIONS USED

AA Alopecia Areata

ACD-A Anticoagulant Citrate Dextrose Solution Formula A

AGA Androgenetic Alopecia

bFGF Basic Fibroblast Growth Factor

EDTA Ethylene Diamine Tetra Acetic Acid

FDA Food And Drug Administration

Fig. Figure

FPHL Female Pattern Hair Loss

GPA Global Physician Assessment

HDI Hair Density Index

HMI Hair Mass Index

IGF Insulin Like Growth Factor

IL-1 Interleukin- 1

PAF-4 Platelet Activating Factor-4

PDEGF Platelet Derived Endothelial Cell Growth Factor

PDGF Platelet Derived Growth Factor

PDRN Poly Deoxy Ribo Nucleotide

PRFM Platelet Rich Fibrin Matrix

PRGF Plasma Rich In Growth Factors

PRP Platelet Rich Plasma

RCF Relative Centrifugal Force

TGF Transforming Growth Factors

TrA Triamcinolone Acetonide

VEGF Vascular Endothelial Growth Factor

I

LIST OF TABLES

Sl. No. TABLES Page No.

1

Comparison of mean no. of hair follicles / cc between

different time intervals post administration of PRP using

Repeated measures of ANOVA

32

2

Multiple comparison of mean no. hair follicles /cc between

different time intervals using Bonferroni's post hoc

Analysis

32

3

Comparison of mean density of hairs [Sq.cm] between

different time intervals post administration of PRP using

Repeated measures of ANOVA

33

4

Multiple comparison of mean density of hair [Sq.cm]

between different time intervals using Bonferroni's post

hoc Analysis

34

5

Number of Hair Follicles/cm2 for a Patient in Various

Appointments at 'V' point

35

6

Density of hair follicles/cm2 for a Patient in Various

Appointments

35

I

LIST OF FIGURES

Sl. No. FIGURES Page No.

1 Blood withdrawn from Patient 26

2 Blood after First Spin 26

3 Separation of Plasma from Blood after First Spin 26

4 Plasma after Second Spin 26

5 ‘V’ (Kang’s point) 27

6 Centrifuge Machine 27

7 Dermatoscope 28

8 1 cc insulin syringe 28

9 Patient- I Scalp Area - Pre - Treatment 28

10 Patient- I Scalp Area - Post - Treatment 28

11 Patient- II Scalp Area - Pre - Treatment 29

12 Patient- II Scalp Area - Post - Treatment 29

13 Patient- III Scalp Area - Pre - Treatment 29

14 Patient- III Scalp Area - Post - Treatment 29

I

ABSTRACT

Background & Objectives:

Androgenetic alopecia (AGA) is a hereditary and androgen-driven disorder

which is the most common form of alopecia in humans. Androgenetic alopecia

(AGA) is also widely called as Androgenic alopecia, Male Pattern Baldness. It is

characterized by progressive hair loss, predominantly of the central scalp, with some

variation of patterned loss. Treatment options for Androgenetic alopecia are very

limited and include topical minoxidil and oral finasteride (FDA approved) either

alone or in combination. However, there are several side effects reported. Researchers

have discovered through in vitro studies that there is a dose response relationship

between platelet concentration and the proliferation of human adult mesenchymal

stem cells, the proliferation of fibroblasts, and the production of type I collagen.

Platelet-Rich Plasma (PRP) is an autologous preparation that concentrates platelets in

a small volume of plasma. Platelet rich plasma (PRP) is a potentially useful adjunct in

oral and maxillofacial bone reconstructive surgery.

Aim of the study is to evaluate the efficacy and safety of PRP injections in the

scalp of patients with androgenetic alopecia.

Methods:

Ten patients with androgenetic alopecia were selected to evaluate the efficacy

and safety of PRP injections in the scalp of patients. Our protocol involved six

treatment sessions with an interval of 3 weeks between injections. Post 6 months from

the beginning of the treatment, a booster session was also performed. We evaluated

hair pull test, number of hair follicles in desired area, dermoscopic photomicrographs,

II

macroscopic photographs, hair density (hair/cm2), and patient’s satisfaction. We also

noted any reported adverse effects.

Results:

Before treatment, all our patients had a positive hair pull test with mean

number of 10 hairs. After the fourth session, the pull test was negative in 9 patients

with average number of 3 hairs. A significant reduction in hair loss was observed

between first and fourth injection as noticed by patients.

Macroscopic pictures also revealed a moderate improvement in hair volume

and coverage. Hair count depicted average number of 57.50 hair follicular units over

marked area before starting the treatment, and after 7 sessions of PRP, average

number of follicular units was 93.90 follicular units. Therefore, average mean gain is

36.4 follicular units per cm2.

Patient satisfaction was evaluated on a scale of 1-10; results showed patient

satisfaction was high with a mean result rating of 8.0.

Conclusion:

Platelet-Rich Plasma injections for Androgenetic alopecia are a simple, cost-

effective and feasible with excellent safety treatment option for hair loss.

Keywords: Androgenetic alopecia, Platelet-Rich Plasma, Pattern Hair Loss,

Introduction

Page 1

“ROLE OF PLATELET-RICH PLASMA IN ANDROGENETIC

ALOPECIA: A PROSPECTIVE STUDY”

INTRODUCTION

A hereditary, androgen-driven disorder, Androgenetic alopecia (AGA) is the most

common form of alopecia in humans. It is an age-dependent disorder with prevalence of

23%-87%. Central alopecia is more severe in men; women are more likely to experience

diffuse thinning.

It is characterized by progressive hair loss, predominantly of the central scalp,

with some variation of patterned loss. Although the prevalence is high in elderly patients,

AGA may also start at puberty. In men with androgenetic alopecia, large caliber hairs

become progressively finer and thinner (miniaturized) leading to decreased coverage of

the scalp; in some cases the hairs become so fine that they are barely visible to the eye. In

those who are genetically susceptible, hair miniaturization can begin as early as the teens,

twenties and thirties. Interestingly, these changes occur only in certain regions of the

scalp, specifically the frontal hairline, the top of the scalp and the crown or vertex scalp.

The follicles along the sides and back of the scalp are spared even in men with extensive

balding. These regional variations in patterns of scalp hair thinning may reflect

differences in embryologic scalp patterning, levels of hormonal receptors or other factors

that may influence follicular growth. Pathophysiologically, androgens mediate and drive

the follicular transformation in androgenetic alopecia. There is a substantial increase in

the local or follicular transformation of testosterone to dihydrotestosterone by the enzyme

5α-reductase. Dihydrotestosterone, which has five times higher affinity to the androgen

Introduction

Page 2

receptor compared to testosterone, triggers specific genes that then lead to the gradual

miniaturization of genetically programmed hair follicles. 1-2

The acute onset of alopecia in those with inflammatory diseases of the scalp

suggests a variety of etiologies, including the impact of inflammatory cells, release of

cytokines, presence of growth factors and increased interaction of stromal cells.3-7

Patients who have prominent thinning of hair are perceived as older, which affects

self-esteem and leads to psychosocial morbidity. Therapeutic modalities, which are most

effective when used in combinations, utilize hair growth promoters, antiandrogens and

androgen blockade agents. In contrast to the high prevalence of AGA, approved

therapeutic options are limited.8

Researchers have discovered through in vitro studies that Platelet-Rich Plasma

(PRP) induces a significant initiation and prolongation of the anagen phase of the hair

growth cycle. There is a dose response relationship between platelet concentration and

the proliferation of human adult mesenchymal stem cells, the proliferation of fibroblasts

and the production of type I collagen.

Platelet-Rich Plasma (PRP) is an autologous preparation that concentrates

platelets in a small volume of plasma.

Platelets are cytoplasmic fragments of megakaryocytes, formed in the marrow and

approximately 2 mm in diameter. Platelets are very important in the wound healing

process. They arrive quickly at the wound site and begin coagulation. They contain more

than 30 bioactive proteins, many of which have a fundamental role in haemostasis or

tissue healing. They release multiple wound healing growth factors and cytokines,

Introduction

Page 3

including platelet derived growth factor (PDGF), transforming growth factors (TGF)/b1

and b2, vascular endothelial growth factor (VEGF), platelet derived endothelial cell

growth factor (PDEGF), interleukin- 1 (IL-1), basic fibroblast growth factor (bFGF) and

platelet activating factor-4 (PAF-4). These growth factors are thought to contribute to

bone regeneration and increased vascularity, vital features of a healing bone graft. PRP

also includes three proteins in blood known to act as cell adhesion molecules: Fibrin,

fibronectin and vitronectin.

Platelet rich plasma (PRP) is a new and potentially useful adjunct in oral and

maxillofacial bone reconstructive surgery.

Topically applied platelet-rich plasma (PRP) derived from autologous blood was

recently introduced to facilitate tissue healing and regeneration and widely used in almost

all fields of surgery for the acceleration of bone and soft tissue formation and for the

management of chronic non healing wounds.

Numerous studies have demonstrated the clinical application and notable results

of PRP in dentistry, oral maxilla facial surgery, plastic surgery, orthopedics,

rheumatology, and the treatment of different types of injuries that include chronic

wounds and muscle injuries.9-10

The utility of platelet-rich plasma in the treatment of androgenetic alopecia is

rooted in the presence of growth factors in plasma.

Objectives

Page 4

OBJECTIVES

The Objective of the current study is to evaluate the Efficacy and Safety of

Platelet-Rich Plasma (PRP) injections in the scalp of Patients with Androgenetic

Alopecia (AGA).

REVIEW OF LITERATURE

Page 5


Alves and Grimalt in their randomized, placebo-controlled double-blind study

evaluated the efficacy of androgenic alopecia treatment with PRP. Twelve men aged 18

to 65 with Hamilton-Norwood patterns II to VII and thirteen women aged 18 to 65 with

Stage I to III patterns of hair loss according to the Ludwig classification were studied.

Patients were randomized to receive a half head treatment with PRP and the other half

head with saline placebo. The prepared PRP solution was injected on four selected areas

of the scalp. Patients received a total of three treatments, administered at one month

intervals, and were evaluated at each session. The evaluation criteria were assessed in all

patients was by global photography and phototrichogram. The mean total hair density for

the treatment areas after three months showed a mean increase of 14.8 ± 32.1 hairs per

cm2 compared with baseline, whereas the control area showed a mean decrease of 0.7 ±

32.7 hairs per cm2

(p < 0.05). After six months, the PRP treated area had a mean increase

of 12.8 ± 32.6 hairs per cm2 and the control area showed a decrease of 2.1 ± 31.3 hairs

per cm 2 (p < 0.05). Furthermore, the authors found statistically significant differences in

the mean number of anagen hairs and telogen hairs after six months. With respect to the

number of total hair count, there were no significant differences between the PRP treated

area and the placebo area, and no differences in the vellus hair density between the PRP

and placebo areas were observed. Although the authors found statistically significant

differences in hair density, the small sample size and short follow-up duration presented

weaknesses to the study design. The authors concluded that PRP can be used as a safe

and complementary treatment option for androgenic alopecia.11


Page 6

A randomized controlled trial conducted by Gentile et al studied 23 male

patients, aged 19-63, with stage IIa to stage IV hair loss. The primary outcome was

assessment of residual hair count and hair density based on computerized trichogram.

Secondary outcomes were microscopic evaluation of the epidermis thickness in PRP-

treated skin and increase in the number of follicles compared with baseline value, as well

as an evaluation of safety and feasibility. PRP was injected three times in each patient at

intervals of 30 days, in select areas of the scalp. All patients were evaluated in 6 stages,

for up to 24 months after the initial injections. Phototrichograms were taken of all scalps

by a trained evaluator. Incisional punch biopsies were also obtained at baseline and after

2 months from the last PRP treatment in order to evaluate the thickness of epidermis and

number of follicles per mm2. Results showed a significant increase in the mean hair count

for the treatment area after 3 months, with a mean increase of 33.6 hairs in the target area

compared with baseline, while the control area showed a mean decrease of 3.2 hairs. A

mean increase in total hair density of 45.9 hairs per cm2 compared with baseline was

observed after 6 months, and the control areas displayed a mean decrease of 3.8 hairs per

cm2. Terminal hair density improved significantly by 40.1 hairs per cm

2 and decreased by

5.6 hairs per cm2 in the control areas. No significant differences in vellus hair density

between the study and the control area were seen after 3 months. Microscopically, there

was an increase of epidermis thickness and an increase in the number of follicles. There

was also an increase of Ki67+ basal keratinocytes of epidermis and of hair follicular

bulge cells compared with baseline, along with an increase in small blood vessels around

hair follicles in the treated skin compared with baseline. The authors demonstrated that


Page 7

use of PRP presents itself as a viable option for androgenic alopecia treatment due to the

positive clinical results obtained and lack of serious adverse effects. 12

Cervelli et al, in their clinical study “The effect of autologous activated platelet

rich plasma (AA-PRP) injection on pattern hair loss: clinical and histomorphometric

evaluation”, Half of the sites were treated with autologous activated PRP, and the other

half were treated with a placebo. Patients were evaluated at the beginning of the study, at

14 weeks, 6 months and 12 months. Global photography, physician's and patient's global

assessment scales, and standardized phototrichograms were used. Incisional punch

biopsies (3 mm in diameter) of the hair were obtained at baseline and after two months

from the last PRP treatment. Immunohistochemistry was performed using mouse

monoclonal antiKi67 and anti-CD31, with positive and negative controls. Results showed

a significant increase in the mean hair count for the treatment area after three months,

with a mean increase of 18.0 hairs in the target area compared to baseline, while the

control area showed a mean decrease of 2.0 hairs. The mean hair density also increased

by 27.7 hairs per cm2 after three months. Terminal hair density improved significantly by

27.0 ± 15.3 hairs per cm2, while decreasing by 2.1 ± 12.4 hairs per cm

2 in the control

area. There was no significant difference in hair density after 3 months. Microscopic

evaluation showed an increase of epidermis thickness, increase in the number of follicles,

increase in number of Ki67+ basal keratinocytes of epidermis and of hair follicular bulge

cells. PRP treatment was also associated with a slight increase of small blood vessels

around hair follicles in the skin treated compared to baseline. 13

Uebel et al conducted a study using implanted follicular units embedded with

platelet plasma growth factors. 20 patients with male pattern baldness in the frontal,


Page 8

parietal, or occipital area were studied. The authors obtained a hair-bearing flap from the

occipital area of each patient‟s scalp above the neck, from which follicular units were

harvested. The units were divided into two groups; the first was imbibed with plasma

growth factors, and the second was soaked with saline. On the right side of each patient‟s

head, follicular units embedded with platelet plasma growth factors were implanted; on

the left side, the untreated follicular units were implanted as controls. After seven

months, the authors observed a significant difference in the yield of follicular units when

comparing the experimental with the control areas of the scalp. The experimental group

with the platelet plasma growth factors showed a difference of 2.4 follicular units per cm2

compared to the control area, which was an increase in follicular density of 15.1%. The

authors found a range of increases in follicular density from 3% to 52% compared to

control areas. This study provides preliminary evidence for a promising, viable option for

combining hair transplant and PRP therapy. 14

Kang et al studied the effects of CD34+ cell-containing PRP with concomitant

finasteride treatment on pattern hair loss. The authors set out to study the angiogenic

effects of mobilized CD34+ cells compared to the bioactive properties of placental

extract. Placental extracts are enriched in bioactive molecules, including growth factors,

amino acids, nucleic acids, vitamins, fatty acids and minerals, and have been used for

various purposes. This randomized controlled trial evaluated 15 male and 11 female

patients with pattern hair loss. The patients were divided into two groups. The authors

prepared CD34+ cell-containing PRP and injected the solution into scalp areas affected

by hair loss on patients in the first group. This was performed twice with a 3-month

interval. The second group of patients was treated with interfollicular placental extract


Page 9

injection into affected scalp areas. Male patients were also treated with oral finasteride

therapy. Measurement was performed using a computerized handheld USB camera PT

system at baseline and 3 and 6 months after the first treatment. At 3 months after the first

treatment, the patients treated with CD34+ cell-containing PRP presented clinical

improvement of the mean number of hairs, mean hair thickness, and mean two-point

scores, compared with baseline values. These parameters were also improved in the

controls treated with placental extract. Hair thickness and hair count were greater in the

placental extract group. At 6 months, the continued trend of increases above baseline

were seen in all parameters in both groups, with hair thickness and two-point score

measures being greater in the CD34+ cell-containing PRP treatment group compared to

the placental extract group. The authors found that concomitant finasteride therapy did

not significantly affect hair count, hair thickness, or degree of disease progression in

either group. These results should be confirmed through the implementation of

optimized, prospective studies with a controlled or split-scalp design to confirm the

clinical efficacies of CD34+ cells in patients with pattern hair loss. Another study

examined the effects of a variation on a PRP formulation by using dalteparin and

protamine microparticles (D/P MPs). The material consists of a mixture of low-

molecular-weight heparin (dalteparin) with protamine, resulting in water-insoluble

microparticles. These microparticles are a carrier for controlled release of growth factors

such as FGF-2.23 FGF-2 containing D/P MPs have shown a substantial ability to induce

vascularization and fibrous tissue formation.15

Takikawa et al examined 26 volunteers with thin hair in frontal or parietal areas.

One group of patients received five local treatments of 3 ml PRP-D/P, and the other


Page 10

received PRP and saline injections at 2- to 3- week intervals. The groups were evaluated

for 12 weeks. Experimental and control areas were also photographed. Significant

increases in hair cross-section, but not in hair numbers, were seen in both groups at the

end of the 12-week period, with greater increases seen in the PRP-D/P group.

Microscopic findings showed thickened epithelium, proliferation of collagen fibers and

fibroblasts, and increased vessels around follicles in both groups. The authors concluded

that the addition of dalteparin and protamine microparticles enhanced the effects of PRP

in their patients and may be useful to explore further in future controlled studies.

Additional studies without control groups or split-head protocols have demonstrated the

clinical effects of PRP on treating androgenic alopecia.16

Gkini et al performed a prospective cohort study with 20 patients. The males in

the study demonstrated type II to type V androgenic alopecia, and the females

demonstrated type I and III. PRP was prepared and injected into the androgen-related

areas of the scalp in men and into the problematic areas in women. Three treatment

sessions were performed with an interval of 3 weeks. At 6 months from the beginning of

the treatment, a booster session was also performed. Outcome measures included hair

loss, hair density and patient satisfaction, measured through hair pull tests,

photomicrographs, photographs and patient questionnaire. Results showed that hair

density significantly increased throughout the study, with the highest density at 3 months.

However, the rate of increase began to slow after the third assessment. Macroscopic

photographs showed an overall improvement in hair density and quality, as laguno-like

hair became thicker. Patients reported a mean satisfaction rating of 7.1 on a linear

analogue scale of 1- 10. Patients reported an improvement in hair density and thickness,


Page 11

at the fifth assessment (at 6 months), 100% of patients indicated a need or want of a

booster session. Minimal side effects, including mild, transient pain and scalp sensitivity,

were reported. While the authors did not have a control group and utilized nonobjective

forms of evaluation, their findings suggested positive results and invite further study into

PRP treatments. The authors found that patients with grades II-III androgenic alopecia

have more favorable results when compared to those with more advanced alopecia.17

Parul Singhal et al in 2015 investigated the clinical efficacy of PRP in treatment

of androgenic alopecia on 10 patients. The males in the study demonstrated Hamilton-

Norwood score I to IV androgenic alopecia, and the two female‟s demonstrated Ludwig

alopecia score I and III. Area of the scalp is cleansed with spirit and povidone-iodine.

With the help of insulin syringe PRP is injected over affected area by nappage technique

(multiple small injections in a linear pattern 1-cm apart) under proper aseptic precaution

in the minor operation theatre. A total volume of 8-12 cc is injected. The treatment is

repeated every 2 weeks for four sessions. All the patients are evaluated at 1-week

intervals. The “hair pull test” is performed 3 times by the same clinician wherein a bundle

of approximately 50-60 hair is grasped between the thumb, index, and middle finger from

the base close to the scalp. The hair is firmly tugged away from the scalp, and the

extracted hair is counted in every session. To evaluate overall hair growth, hair volume,

hair quality, and fullness, global pictures are taken in every session from the front, vertex,

lateral, and back view. The treatment is repeated every 2 weeks for four sessions. All the

patients are evaluated at 1-week intervals. Hair growth was seen in six patients after 7

days and in four patients after 15 days. By the end of 3 months, all ten patients had good

hair growth. Three patients complained of a mild headache after the initial procedure


Page 12

which was alleviated after paracetamol 500 mg. None of the patients had any

inflammation or infection and the results of the hair pull test showing that the number of

hair pulled out has reduced by an average of 65%.The controls showed no improvement

in the hair pull test. No new hair growth was seen in the controls. Thus, concluded that

clinical improvement is seen in the hair counts, hair thickness, hair root strength, and

overall alopecia.18

Schiavone G et al in 2014 explained the possible clinical benefit of injecting

platelet-derived growth factors into the scalp of patients using a specific autologous blood

concentrate in 64 patients. Only patients whose blood test revealed a platelet count above

140,000 platelets per microliter and only patients who had never been treated with

finasteride or minoxidil, or patients who had used finasteride or minoxidil for at least 2

years were included in the study. A 2-injection approach was planned, with a 3-month

interval between the 2 interventions. At the time of the first procedure, 60 ml of venous

whole blood were drawn, and then processed through the GPS III Platelet Separation

System, thus obtaining 6 to 8 ml of a solution rich in leukocytes and platelets. This

solution was then injected through a 24-to 26-gauge needle in a 10 ml Luer-lock syringe

on the superficial cutaneous scalp layers. The amount injected, per each injection, was

approximately 0.2 to 0.3 ml. Three months after the first injection, a second procedure

was carried out, drawing 40 ml of venous blood, this time using a double-spin

centrifugation method. The concentrated solution of plasmatic protein was then added to

the obtained platelet concentrate, as described for the first procedure. Platelet

concentration after this procedure was estimated at approximately 4 times the baseline

concentration. Their photographic protocol required patients to wet their hair by wiping

http://www.ncbi.nlm.nih.gov/pubmed/?term=Schiavone%20G%5BAuthor%5D&cauthor=true&cauthor_uid=25111436


Page 13

their scalp with a sponge soaked with 5 ml of saline solution. No products were added to

the patient‟s hair. Pictures were taken at the time of the first injection, at the time of the

second procedure, and then at a 6-month follow-up (i.e., 3 months after the second

procedure). The clinical change between the first assessment and the end of the follow-up

was rated by 2 independent evaluators according to the 15-point scale proposed by

Jaeschke and colleagues. Patients were all affected by different degrees of male or

female-pattern baldness, ranging from Hamilton Class 2 to 5 for men, and Ludwig Class

1 and 2 for women. No immediate adverse effects, such as allergic reactions,

postoperative pain or fever, prolonged redness, nor were delayed side effects such as

telogen effluvium reported. Only 10 patients (15.6%) were classified as “severe or very

severe” according to the GPA at baseline. An improvement (i.e., positive scores) was

observed in 62/64 patients by Evaluator 1 and in all 64 patients by Evaluator 2. The

visible improvement at follow-up should not be attributed to increased hair length, but

rather to an increase in the hair thickness. Thus, they provided evidence that this

treatment may induce some degree of clinical advantage for male and female pattern

baldness.19

Tawfik et al (2017), in their double-blinded randomized placebo-controlled

study evaluated “The effect of autologous activated platelet-rich plasma injection on

female pattern hair loss”. Thirty female patients age ranged from 20 to 45 years, who had

received topical or systemic treatments for hair loss in the previous 3 months, were

excluded. Patients who are pregnant or those with a present history of keloids,

malignancies, bleeding disorders, and thyroid dysfunction were also excluded. Patient‟s

scalps with pattern hair loss were randomly assigned (using the tossing coin method) to


Page 14

receive autologous PRP injection into a selected area, and another area was injected with

normal saline as a placebo. Four treatments were given for each patient, with an interval

of 1 week between the sessions. Patients were followed up at 6 months after the last

session. The effects of the treatment on hair growth, hair density (number of hairs/cm2),

hair diameter, and volume were assessed in all patients with the help of global

photography, hair pull test, patient‟s satisfaction scale, and standardized

phototrichograms. The evaluation of results was performed by an independent evaluator

who was blinded regarding the treatment and control areas of the scalp and not involved

in the administration of PRP treatment. According to physician‟s assessment which was

performed by comparing macroscopic photographs at baseline and 6 months after the last

session, At 6-month follow-up, PRP area, a mean increase in hair density of 77.28

(number of hairs/cm2) was observed after 6 months and the placebo area displayed a

mean increase of 17.81 in hair density at the same time. In addition, hair thickness

improved significantly by 0.11 mm in PRP area compared to baseline, while increasing

by 0.03 mm in the placebo area of the scalp. Meanwhile, at 6-month follow- up, there

was a statistical significant difference between PRP and placebo areas (P<.005) regarding

both hair density and hair thickness. In PRP-injected sites, there was a high overall

patient satisfaction with a mean result rating of 7.0 on a scale of 1-10. They experienced

only temporary pain and pinpoint bleeding at the injection sites and these symptoms

disappeared within a day. No major side effects were reported during treatment. Thus,

PRP-injected sites showed an overall improvement in hair density and thickness, as

lanugo-like hair became thicker, normal hair. Moreover, a significant reduction in hair

loss was observed between first and fourth PRP injection as noticed by patients.20


Page 15

Puig et al (2016) conducted a double-blind, placebo-controlled pilot study on the

use of platelet-rich plasma in women with female androgenetic alopecia. A randomized

sample of 26 women (treatment group, n = 15; placebo group, n = 11), at least 18 years of

age, diagnosed with Ludwig II female androgenetic alopecia through history taking,

physical examination, and either biopsy or strong family history of female pattern hair

loss as defined by 2 or more female relatives known to have a similar Ludwig pattern of

hair loss, without known disease, were included in this study. None of the patients

received other hair loss treatments during the study and for 60 days before the study. Hair

mass was measured on the midline scalp using the Cohen hair check system, and the

exact distance from the glabella was recorded. Hair within the 4-cm2 hair check data box

was then clipped to a length of 1 mm, and the hair check data box was photographed

using Dermalight 1-cm reticule for independent hair count analysis. The patients were

anesthetized using a ring block method. Subcutaneous injection of 10 ml of either the

study solution or the placebo solution was injected in the hair check data box and within

10 x 10 cm of the immediate surrounding area. The patients were examined every 4

weeks to verify for possible complications or problems occurring after the treatment. At

26 weeks, the patients also completed a patient survey. The data collection end points are

hair count (through photography), hair mass index (measured using the Cohen hair check

system) and patient survey. All photographs were forwarded to the primary investigator,

who had the hair counting performed by an experienced hair restoration technician

trained in working with strip graft dissection and slivering and did not participate in any

of the patient treatments. Hair mass index (HMI) or hair count did not statistically

significantly differ between the study and placebo groups. However, 13.3% of the


Page 16

treatment subjects (vs 0% of the placebo subjects) experienced substantial improvement

in hair loss, rate of hair loss, hair thickness, and ease of managing/styling hair and 26.7%

(vs 18.2% of the placebo group) reported that their hair felt coarser or heavier after the

treatment and concluded that platelet-rich plasma failed to demonstrate any statistically

significant improvement in HMI or hair count in women with congenital female pattern

hair loss. The patient survey results suggest a therapeutic advantage of PRP as perceived

by patients but not according to hair count or HMI the treatment.21

Shah et al, in their Comparative Study of Microneedling with Platelet‑rich

Plasma plus Topical Minoxidil (5%) and Topical Minoxidil (5%) Alone in Androgenetic

Alopecia. Their aims was to compare the efficacy of topical minoxidil (5%) alone and

topical minoxidil (5%) + microneedling with PRP in men between 18 and 50 years with

AGA Grade III to V vertex (Norwood–Hamilton scale) and to perform objective and

subjective evaluation based on clinical improvement and photographic evidence. The

study was conducted in the outpatient department of dermatology, venereology, and

leprology in tertiary care hospital. It was open, prospective study. Fifty patients with

AGA were selected on the basis of inclusion and exclusion criteria. These patients were

randomly divided into two groups of 25 patients each and were given following

treatment: (i) Group A: topical minoxidil (5%) alone and (ii) Group B: topical minoxidil

(5%) + microneedling with platelet‑rich plasma (PRP). Patients were assessed before

starting the treatment and at the end of 6 months on the basis of patient‟s self‑assessment

based on standardized seven‑point scale compared with baseline. Physician‟s assessment

based on standardized seven‑point scale of hair growth compared with baseline. There

was a significant improvement (P < 0.05) in both patient‟s assessment and investigator‟s


Page 17

assessment in Group B as compared to Group A at the end of 6 months. Microneedling

with PRP is safe, effective, and a promising tool for the management of AGA. 22

Jha AK et al in their study “platelet-rich plasma with microneedling in

androgenetic alopecia along with dermoscopic pre- and post-treatment evaluation” to

ascertain the role of platelet-rich plasma with microneedling and to compare the pre- and

post-treatment dermoscopic features in androgenetic alopecia. Patients aged 18-45 years

with Hamilton-Norwood score 1-5 were included in both study and control group.

Dermoscopy was performed using Dermlite II hybrid m; 3Gen dermoscope at 10X

magnification in polarized mode, and photographs were taken. Those not responding or

those not having any new hair growth to conventional therapy for at least 1 year were

included. The study group were given autologous platelet-rich plasma injections with

microneedling over a period of 3 months at 3 weekly intervals. Baseline and post

treatment photographs were taken. Hair growth started after the first session. The

patient‟s satisfaction was more than 75% in 18 patients, on their subjective hair growth

assessment scale. In post-PRP-treated patients of AGA, increase in the number of vellus

and total hairs, increased hair shaft diameter, and reduction in yellow dots were

appreciated after 3 sessions. Hair pull test was negative after treatment in 14 patients

(70%). Thus, they reinforce the importance of dermoscopy in not only aiding in the

diagnosis, but also in evaluation of pre- and post-treatment response of AGA along with

excellent response to PRP with microneedling in patients not responding to conventional

therapy. 23

Anitua et al, in their pilot study “the effect of plasma rich in growth factors on

pattern hair loss” evaluated the biologic potential of PRGFs, a specific type of platelet-


Page 18

rich plasma, for the treatment of AGA. Nineteen patients suffering from AGA were

treated with five intradermal injections of PRGF over a 1-year period. Results regarding

baseline and post-treatment statuses were evaluated by clinical macro photograph

comparison, patient satisfaction score, histomorphometric analysis and quantitative

phototrichogram data. After PRGF therapy, mean hair density/diameter increased and

terminal/vellus hair ratio also improved. Patients presented epidermal thickness, peri-

follicular neoangiogenesis, cell proliferation and terminal/miniaturized hair ratio

improvement. Plasma rich in growth factors seemed to reduce the perivascular

inflammatory infiltrate, promote the remodelling of dermo-epidermal tissue, and increase

bulge stem cell niches. Patients declared an overall positive satisfaction and a high

clinical improvement score was achieved when comparing pre macro photographs and

post macro photographs and they concluded that randomized clinical trials are needed,

this study provides preliminary data supporting the positive therapeutic effect of

autologous growth factors on hair follicle regeneration.24

Sclafani et al, conducted a prospective cohort study on Platelet-Rich Fibrin

Matrix (PRFM) for androgenetic alopecia. 15 subjects diagnosed with androgenetic

alopecia for past 1 year were treated with intradermal injections of autologous PRFM

three times on a monthly basis. Hair density indices were measured in triplicate in the

same area of the scalp before the treatment and 1, 2, 3 and 6 months after initial

treatment. Hair density index (HDI) measurements were obtained and compared with pre-

treatment values for each subject. A series of intradermal injections of autologous PRFM

increased the HDI in patients with androgenetic alopecia at 2 and 3 months after initial

treatment, this improvement approached statistical significance at 6 months after


Page 19

initiating treatment. Most subjects described mild-moderate pain during treatment, but all

subjects completed all planned treatments. Adverse effects were limited and treatment

was tolerated by all subjects. Thus, they concluded that PRFM may be a valuable tool in

the treatment of androgenetic alopecia.25

Trink et al, performed a randomized, double-blinded, placebo and active-

controlled, half-head, parallel group study on 45 patients to evaluate the efficacy and

safety of PRP in Alopecia areate. Forty five AA patients were randomized to receive

intralesional injections of PRP, triamcinolone acetonide (TrA) or placebo on one half of

their scalp. The other half was not treated. A total of three treatments were given for each

patient, with an interval of one month from each other. The endpoints were hair regrowth,

hair dystrophy as measured by dermoscope, burning/itching sensation and cell

proliferation as measured by Ki-67 evaluation. Patients were followed for 1 year. PRP

was found to significantly increase hair regrowth and decrease hair dystrophy and

burning/itching sensation when compared with TrA or placebo, and Ki-67 levels, which

served as markers for cell proliferation, were significantly higher. No side effects were

noted during treatment. This pilot study, which is the first to investigate the effects of

PRP on AA, suggests that PRP may serve as a safe and effective treatment option in AA,

and calls for more extensive controlled studies with this method.26

Swapna S Khatu et al in 2014 did prospective study on safety, efficacy and

feasibility of PRP injections in treating AA in eleven patients suffering from hair loss due

to androgenic alopecia and not responding to 6 months treatment with minoxidil and

finasteride. 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


Page 20

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. They concluded that, 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. 27

El Taieb et al conducted a randomized controlled study to evaluate the efficacy

of PRP versus topical minoxidil 5% in the treatment of AA by clinical evaluation and

trichoscopic examination. Ninety patients were allocated into three groups; the first was

treated with topical minoxidil 5% solution, the second with platelets rich plasma

injections, and the third with placebo. Diagnosis and follow up were done by serial digital

camera photography of lesions and dermoscopic scan before and every 1month after

treatment for 3 months. Patients treated with minoxidil 5% and platelets rich plasma both

have significant hair growth than placebo (p<.05). Patients treated with platelets rich

plasma had an earlier response in the form of hair regrowth, reduction in short vellus hair

and dystrophic hair unlike patients treated with minoxidil and control (p<.05). Thus, they

concluded that platelets rich plasma is more effective in the treatment of alopecia areata

than topical minoxidil 5% as evaluated by clinical and trichoscopic examination.28

Sukhbir Singh in 2014 evaluated the efficacy of platelet-rich plasma (PRP) in

the treatment of chronic alopecia areata (AA) in 20 patients. All patients had history of

patches and taken various line of treatments for a duration of 2 years. The patient‟s age

ranged from 25 to 35 years, and none of them had any co-morbidities. All the patients

received 6 sessions of PRP at 4 weekly intervals. Patients were reviewed every month for

6 months and then at the end of 1 year. Of 20 patients, only one patient had a relapse.

http://www.ncbi.nlm.nih.gov/pubmed/?term=Singh%20S%5Bauth%5D


Page 21

None of the patients had any side effects. So they concluded that PRP has a definite role

in treating AA infections. 29

Lee et al in 2015 conducted a study on „Therapeutic efficacy of autologous

platelet-rich plasma and polydeoxyribonucleotide (PDRN) on female pattern hair loss

(FPHL)‟. Twenty FPHL patients were treated with a single session of PRP injection,

followed by 12 sessions of PDRN intra-perifollicular injection, along the scalp at weekly

intervals. Additionally, another 20 FPHL patients were treated with 12 sessions of PDRN

injection only. Meanwhile, one half of the backs of two rabbits were injected with the

PRP preparation, while the other half was injected with phosphate-buffered saline as a

control. Tissue samples from the rabbits were analysed by real-time polymerase chain

reaction and Western blotting. Compared with baseline values, patients treated with PRP

and PDRN injections exhibited clinical improvement in mean hair counts (23.2 ± 15.5%;

P < 0.001) and mean hair thickness (16.8 ± 10.8%; P < 0.001). As well, patients treated

with the 12 sessions of intra-perifollicular PDRN injection alone also showed clinical

improvement in mean hair counts (17.9 ± 13.2%; P < 0.001) and mean hair thickness

(13.5 ± 10.7%; P < 0.001). Comparison analyses between the two groups revealed that

combined therapy with PRP and PDRN induces greater improvement in hair thickness

than treatment with PDRN therapy alone (P = 0.031), but not in hair counts (P > 0.05).

The pilot animal study revealed significant up regulation of Wnt, platelet-derived growth

factor and fibroblast growth factor expression in rabbit skin treated with the PRP

preparation, compared to control skin. In conclusion, an intra-perifollicular injection of

autologous PRP and/or PDRN generates improvements in hair thickness and density in

FPHL patients. 30

Methodology

Page 22

Methodology

METHODOLOGY

Method of Data Collection

This in-vivo study was conducted on the randomly selected patients reporting

to the Department of Oral and Maxillofacial Surgery of K.L.E. SOCIETY’S

INSTITUTE OF DENTAL SCIENCES, BANGALORE.

Patients with androgenetic alopecia (AGA) were selected for the study.

Diagnosis of AGA was made in all patients based on detailed medical history, clinical

examination and laboratory tests.

Inclusion Criteria

Patients under ASA-I category.

Willing to comply with the study related procedures.

Patients aged between 18-50 years.

Exclusion Criteria

Patients under ASA- II and above category.

Unwillingness to commit to long term post therapy maintenance programme.

Dermatological conditions where skin needling is contraindicated which

include

Keloid Scarring

Diabetes

Neuromuscular disease

Bleeding disorder

Methodology

Page 23

Collagen vascular disease

Acute or chronic corticosteroid therapy

Acute or chronic anticoagulant therapy

Presence of skin cancers

Warts

Solar keratosis

Skin infection

Pregnancy

Laboratory Tests

a. Complete blood count

b. Serum iron, serum ferritin, TIBC (Total Iron-Binding capacity)

c. Folic acid

d. T3, T4, TSH, fT3, fT4, anti-TPO

e. VDRL

Sample Size and Sampling Procedure

Sample size - 10 patients

Sample procedure - Random sampling

Duration of Study

Duration of study is 2 years.

Methodology

Page 24

PREPARATION and INJECTION of PRP

Two-step centrifugation is generally used to prepare PRP. Various

centrifugation techniques and the heterogeneous nature of PRP according to different

preparation methods or commercial preparation devices have been reported. In the

present study, PRP was prepared by using a 2-step centrifugation with a table top

centrifuge machine, in which step 1 centrifugation (separating centrifugation) used

relative low g force (200g-500g) for 10 minutes so that erythrocytes are sedimented

but platelets remain in suspension, and step 2 centrifugation (condensation

centrifugation) used relative high g force (1500g) for 10 minutes to condense the

platelets. After step 1 centrifugation, upper plasma layer was transferred to another

plain tube for the condensation centrifugation and the remaining lower cell layer was

discarded. After step 2 centrifugation, supernatant layer (platelet-poor plasma) was

discarded and lower 3 ml plate-rich plasma was preserved, in which the platelet pellet

was suspended. The concentration of platelets in PRP was approximately 5.8 times as

great as that in whole blood.

All patients were informed about the process and its adverse effects and they

signed an informed consent form. They did not have their hair washed two days prior

to the treatment. None of the patients received any other treatment for hair loss during

PRP treatment. PRP (0.05-0.1 ml/cm2) was injected with a 27-G needle into the

androgen-related areas (frontal, parietal, occipital) of the scalp in men. 1 ml syringes

were used. Nappage technique was performed in a depth of 1.5-2.5 mm. Our protocol

involved six treatment sessions with an interval of 3 weeks between injections. Post 6

months from the beginning of the treatment, a booster session was also performed.

Methodology

Page 25

In our study, we evaluated hair pull test, number of hair follicles in desired

area, dermoscopic photomicrographs, macroscopic photographs, hair density

(hair/cm2), and patient’s satisfaction. We also noted any reported adverse effects.

In order to check the same area every time, we used ‘V’ (Kang’s point), as

proposed by Lee et al. ‘V’ is the point of intersection between the midsagittal line and

the coronal line connecting the tips of the tragus. By using a plastic headband and a

tapeline, ‘V’ can be measured conveniently because the headband presents the coronal

line connecting the roots of the ear Tagus and the tapeline easily shows the

midsagittal line. We measured 1 cm2, which is located roughly 1cm in front of the

anterior margin of the headband and recorded the distance from the headband to the

midpoint of the line connecting the lower margins of the eyebrows for reproducibility.

All patients were evaluated at seven time points: A(Appointment)1 -

beginning of study; A2 - 3 weeks; A3 - 6 weeks; A4 - 9 weeks; A5 - 12 weeks; A6 -

15weeks and A7 - 6 months.

SAMPLE SIZE ESTIMATION

Page 1

F tests - ANOVA: Repeated measures, within factors

Analysis: Compromise: Compute implied α & power

Input: Effect size f = 0.30

β/α ratio = 1

Total sample size = 10

Number of groups = 1

Repetitions = 6

Corr among rep measures = 0.5

Nonsphericity correction ε = 1

Output: Noncentrality parameter λ = 10.800000

Critical F = 1.686063

Numerator df = 5.000000

Denominator df = 45.000000

α err prob = 0.157460

β err prob = 0.157460

Power (1-β err prob) = 0.842540

Results

Page 30

RESULTS

The present study was undertaken on ten patients with androgenetic alopecia, who

reported for treatment to the Department of Oral and Maxillofacial Surgery, KLE

SOCIETY’S INSTITUTE OF DENTAL SCIENCES, YESHWANTHPUR,

BANGALORE.

Ten male patients in the age group of 20-40 years were included and were

classified according to Hamilton classification of male pattern baldness. 4 patients were

in grade-2, 4 patients in grade-3 and 2 patients in grade-4 androgenetic alopecia.

Before treatment, all our patients had a positive hair pull test with mean number

of 10 hairs. After the fourth session, the pull test was negative in 9 patients with average

number of three hairs. A significant reduction in hair loss was observed between first and

fourth injection as noticed by patients.

Macroscopic pictures also revealed a moderate improvement in hair volume and

coverage. Hair count depicted average number of 57.50 hair follicular units over marked

area before starting the treatment and after 7 sessions of PRP, average number of

follicular units was 93.90 follicular units. Therefore, average mean gain is 36.4 follicular

units per cm2. Patient satisfaction was evaluated on a scale of 1-10; Results showed

patient satisfaction was high with a mean result rating of 8.0.

The test results demonstrated that there was a significant increase in the mean no.

of hair follicles with every administration (7 sessions) of PRP [P<0.001].

Results

Page 31

The mean no. of hair follicles on first appointment was [57.50 ± 10.30], there was

significant increase over the next appointments like in case of 2nd

appointment [61.70 ±

11.41] at P=0.04, 3rd

appointment [66.40 ± 8.97] at P=0.005, 4th

appointment [71.80

±9.76] at P=0.001, 5th

Appointment [77.00 ±13.74] at P=0.002, 6th

appointment [82.50 ±

13.94] at P<0.001 and 7th

appointment [93.90 ± 12.58] at P<0.001.

Significant improvement in the number of hair follicles was observed from

appointment 2 to appointment 7 with P=0.02 to P<0.001 respectively, except for

appointment 3 [P=0.13] and similarly, a significant increase in the mean no. of hair

follicles was observed between the appointments 3 vs. 6 [P=0.006], 3 vs. 7 [P<0.001], 4

vs. 5 [P=0.007], 4 vs. 7 [P<0.001], 5 vs. 7 [P<0.001] and 6 vs. 7 [P=0.007]. However, the

significant differences were not observed between appointments 3 vs. 4 [P=0.10], 3 vs. 5

[P=0.07], 4 vs. 5 [P=0.19] and between 5 & 6 [P=0.10].

Results

Page 32

Table-1 Comparison of mean no. of hair follicles / cc between different time intervals

post administration of PRP using Repeated measures of ANOVA

Appt. N Mean SD Std. Error

Greenhouse Geisser

F P-Value

No. 1 10 57.50 10.30 3.26

62.024 <0.001*

No. 2 10 61.70 11.41 3.61

No. 3 10 66.40 8.97 2.84

No. 4 10 71.80 9.76 3.09

No. 5 10 77.00 13.74 4.34

No. 6 10 82.50 13.94 4.41

No. 7 10 93.90 12.58 3.98

* - Statistically Significant

Table-2 Multiple comparison of mean no. hair follicles /cc between different time

intervals using Bonferroni's post hoc Analysis

Appts. A1 Vs A2 A1 Vs A3 A1 Vs A4 A1 Vs A5 A1 Vs A6 A1 Vs A7

P-Value 0.04* 0.005* 0.001* 0.002* <0.001* <0.001*


P-Value 0.13 0.02* 0.01* 0.002* <0.001* 0.10


P-Value 0.07 0.004* <0.001* 0.19 0.007* <0.001*

Appts. A5 Vs A6 A5 Vs A7 A6 Vs A7

Results

Page 33

Table -3 Comparison of mean density of hairs [Sq.cm] between different time intervals

post administration of PRP using Repeated measures of ANOVA

Appt. N Mean SD Std. Error

Greenhouse Geisser

F P-Value

No. 1 10 61.60 10.61 3.35

52.943 <0.001*

No. 2 10 64.30 10.67 3.37

No. 3 10 65.30 12.07 3.82

No. 4 10 70.40 11.68 3.69

No. 5 10 74.10 11.75 3.72

No. 6 10 80.50 12.70 4.02

No. 7 10 90.80 14.94 4.72


P-Value 0.10 <0.001* 0.007*


Note: A - Appointment no.

Results

Page 34

Table-4 Multiple comparison of mean density of hair [Sq.cm] between different time

intervals using Bonferroni's post hoc Analysis

Appts. A1 vs. A2 A1 vs. A3 A1 vs. A4 A1 vs. A5 A1 vs. A6 A1 Vs A7

P-Value 0.31 0.31 0.01* 0.01* 0.001* <0.001*


P-Value 1.00 0.06 0.02* 0.001* <0.001* 0.27


P-Value 0.08 0.004* <0.001* 0.09 0.002* <0.001*

Appts. A5 Vs A6 A5 Vs A7 A6 Vs A7

P-Value 0.006* 0.001* 0.002*


The test results demonstrated that there was a significant increase in the mean

density of hairs between different time intervals post administration of PRP [P<0.001].

The mean density of hairs from first appointment [61.60 ± 10.61] showed significant

increase over the next time intervals of 4th




Appointment [90.80 ± 14.94] at P<0.001. Significant improvements in the number of hair

density was observed from appointment 2 when compared with appointment 5 to 7 with

P=0.02 to P<0.001 respectively, except for appointment 3 [P=0.13] & appointment 4

[P=0.06] and similarly, a significant increase in the mean no. of hair follicles was

Results

Page 35

observed between the appointments 3 vs. 6 [P=0.004], 3 vs. 7 [P<0.001], 4 vs. 6

[P=0.002], 4 vs. 7 [P<0.001], 5 vs. 7 [P=0.001] and 6 vs. 7 [P=0.002]. However, the

significant difference was not observed between appointments 3 vs. 4 [P=0.27], 3 vs. 5

[P=0.08] and between 4 vs. 5 [P=0.09].

Evaluation of side effects after PRP injections revealed minimal pain,

redness at the time of injections and pinpoint bleeding.

Table-5 Number of Hair Follicles/cm2 for a Patient in Various

Appointments(A) at 'V' point

Patient\Appt. No A1 A2 A3 A4 A5 A6 A7 (Booster Dose)

Patient 1 40 44 58 62 68 72 93

Patient 2 54 62 68 72 76 78 92

Patient 3 74 79 82 96 114 118 125

Patient 4 62 65 64 67 73 71 93

Patient 5 59 69 72 75 79 84 97

Patient 6 56 57 64 69 75 86 96

Patient 7 66 70 70 72 76 85 92

Patient 8 62 64 69 75 75 78 90

Patient 9 60 65 69 69 70 84 86

Patient 10 42 42 48 61 64 69 75

Table-6 Density of hair follicles/cm2 for a Patient in Various Appointments

Patient\Appt. No A1 A2 A3 A4 A5 A6 A7 (Booster Dose)

Patient 1 53 59 52 64 72 81 91

Patient 2 58 65 68 72 73 82 96

Patient 3 78 82 85 98 104 111 121

Patient 4 74 74 75 76 74 78 95

Patient 5 65 68 73 71 75 88 102

Patient 6 64 65 64 68 70 78 93

Patient 7 62 67 69 68 75 78 87

Patient 8 64 62 65 71 74 75 82

Patient 9 58 60 60 64 66 72 72

Patient 10 40 41 42 52 58 62 69

Results

Page 36

DISCUSSION

Page 37

DISCUSSION

AGA remains the most common hair disorder without a satisfactory treatment.

In AGA, a progressive stepwise miniaturization of the entire follicular apparatus

occurs, usually accompanied by apoptotic cell death and decreased proliferation of

epidermal keratinocytes and follicular fibroblasts.31

During the prolonged telogen

phase of the hair cycle, healthy terminal follicles result in finer miniaturized hairs

with vellus-like appearance.32

In addition, the reduction of the anagen growing phase

provokes the failure of small follicles to reach the scalp surface which is translated

into a reduction of hair density (follicles per cm2).

33

Hair loss has a significant influence on psychological distress and is associated

with low self-esteem and depression. Treatment options for androgenetic alopecia are

very limited and include topical minoxidil and oral finasteride (FDA approved) either

alone or in combination. However, there are several reported side effects such as

headache and increase in other body hairs for minoxidil, 34

whereas loss of libido has

been reported with oral finasteride. Finasteride also interferes with genital

development in a male foetus and is contraindicated in pregnancy.

We obtained PRP by double spin method, in which blood cell layers were

manually separated.

Factors influencing PRP yield

Various factors influence the yield of PRP such as draw of blood; speed, time

and temperature at time of centrifugation and use of anticoagulants.

Draw of blood

The clotting process is influenced from the time of the draw. To avoid

unintentional activation of platelets, most protocols use large bore needles (>22) to

draw the blood.

DISCUSSION

Page 38

Centrifugation

The earth’s gravitational force is sufficient to separate many types of particles

over time. A tube of anticoagulated Whole blood left standing on a bench top will

eventually separate into plasma, RBC and WBC fractions. However, the length of

time required precludes this manner of separation for most applications. In addition,

the potential degradation of biological compounds during prolonged storage means

faster separation techniques are needed. Hence, to accelerate sedimentation, the effect

of gravity is amplified using ‘centrifugal force’ provided by a centrifuge machine,

which is thousand times higher to the force of gravity.

Separation of cellular constituents within blood can be achieved by differential

centrifugation. In differential centrifugation, acceleration force is adjusted to sediment

certain cellular constituents and leave others in suspension.

In centrifugation, RCF is the force required to separate two phases, this force

also called relative centrifugal field. It is expressed as multiples of the earth’s

gravitational field (g). By accelerating the g, speedy sedimentation can be achieved.

‘g’ is the actual force exerted on the contents of the spinning rotor, which separates

the aqueous solutions in the centrifuge. Revolutions per minute (rpm) is calculated

using the following equation.

Formula

g = (1.118 × 10-5

) R S2

Where ‘g’ is the Relative Centrifugal Field, R is the radius of the rotor (from

centre of rotor to sample) in centimetres and S is the speed of the centrifuge in

revolutions per minute. It is important to remember that calculation of RCF is

dependent on the radius of the centrifuge rotor used. The same centrifuge machine

with different rotors can produce different acceleration forces.

DISCUSSION

Page 39

Temperature

Temperature during processing is crucial to prevent platelet activation.

American Association of Blood Banks (AABB) manual recommends 21°C–24°C for

centrifugation of blood for obtaining PRP.37

Macey et al.38

also stated that cooling

may retard platelet activation and this may be essential in obtaining PRP with viable

platelets. Many authors have used a temperature level of 12°C-16°C during

centrifugation for best platelet recovery. This is germane to those who use an ordinary

centrifuge to develop PRP, which are mainly developed for diagnostic purposes and

not for PRP processing and hence may not produce a sufficient platelet yield.

Anticoagulants

The importance lies in choosing an anticoagulant capable of preserving the

platelets best possible functionality, integrity, and morphology. With regard to the

type of anticoagulant for use, most authors agree on not using EDTA because it could

damage the platelet membrane. Therefore, anticoagulants with citrate and dextrose of

sodium citrate are recommended. Dhurat R et al 39

compared the effects of sodium

citrate and ACD-A on platelet aggregation, pH and extracellular iCa concentration.

The anticoagulant ACD-A is the choice for collection of platelets by apheresis,

whereas trisodium citrate (3.2% or 3.8%) is the anticoagulant most commonly used

for diagnostic evaluations of platelets. Trisodium citrate and ACD-A solutions differ

markedly in pH, with ACD-A having a pH of 4.9 and 3.8% sodium citrate having a

pH of 7.8. In addition, the citrate ion concentration in ACD-A is 15.6 mg/ml, whereas

3.8% sodium citrate contains 24.4 mg of citrate ion/ml. It has been reported. In

several species that alterations in the pH and extracellular iCa concentration of PRP

can affect platelet aggregation in vitro, with aggregation typically impaired at acidic

pH and lower extracellular iCa concentrations.

DISCUSSION

Page 40

Alternatively, citrate phosphate dextrose–adenine can be used. It is similar to ACD-A

but has fewer supportive ingredients and therefore is 10% less effective in

maintaining platelet viability.

Activation of PRP

PRP activation prior to injection is another parameter that requires further

discussion. PRP can be activated exogenously by thrombin, calcium chloride or

mechanical trauma. Collagen is a natural activator of PRP, thus when PRP is used in

soft tissue, it does not need to be exogenously activated. Once PRP is activated,

(fibrinogen–fibrin) a fibrin network begins to form, solidifying the plasma and

creating a fibrin clot or membrane. According to Weibrich et al., 40

there are no

significant changes in the platelet concentration or on the concentration of growth

factors in relation to age and gender, although there are studies that report that the

hematocrit and total platelet count influence the platelet concentration of PRP

After PRP injection, an autologous fibrin mesh is formed beneath the

epidermal layer that gradually releases a wide variety of biomolecules, such as TSP-1,

Ang-1, PDGF, fibroblast growth factor (FGF), TGFb1, VEGF, hepatocyte growth

factor, insulin-like growth factor-I (IGF-I), and EGF.38

After 6 months period of PRP

treatment, results demonstrated a significant increase in hair count (follicles per cm2).

These findings are consistent with other studies in which hair density, hair

pull test were also improved after platelet-rich plasma intradermal injections.

In our study, the hair pull test became negative after six sessions of PRP. This

finding is comparable with the study conducted by Besti et al.56

This study also

observed significant improvement in hair volume and coverage in global pictures, but

according to our study, only moderate improvement in hair volume and coverage was

observed.

DISCUSSION

Page 41

In fact, some clinical studies have demonstrated that these positive therapeutic

effects are closely related to the up regulation of the Wnt pathway and the

overexpression of PDGF and FGF-9 after platelet-rich plasma therapy, which have

been proved to promote hair canal formation and follicle neogenesis, respectively.42

As in other platelet-rich plasma–based clinical trials, PRP also showed to

increase the terminal/vellus-like hair ratio.43

These results could be explained by a prolongation of the anagen phase and the

increased differentiation of bulge stem cells into active hair follicle cells by FGF-7/b-

catenin pathway after platelet rich plasma treatment. A higher activity of hair follicle

cells may finally lead to an increased anagen/telogen hair ratio, thus allowing healthy

terminal hairs to reach the scalp surface.44

Moreover, platelet-rich plasma has been shown to activate several antiapoptotic

regulators such as Bcl-2 protein, thus exerting an important cell-death preventive

effect as one of the major contributing factors stimulating hair growth.21

PRP also seemed to reduce the perivascular inflammatory infiltrates when

comparing prebiopsies and postbiopsies, which might be a consequence of the

attenuation of the inflammatory nuclear factor kB pathway.45, 46

In addition, PRP

showed to improve the involution of the vascular plexus around hair follicles,

enhancing the neovascularization process that has been further outlined in other

clinical studies.44

In fact, several growth factors released by a-granules of platelets such as

VEGF, IGF, and FGF have proved to be involved in angiogenesis mediated hair

regrowth.47

Other growth factors, including EGF and PDGF, directly bind to

undifferentiated cell receptors of bulge stem cell niches, whose population increased

DISCUSSION

Page 42

after PRGF treatment, thus leading to the activation of new hair follicle

development.48

In patients with AGA, an increased dermal deposition of loose and densely

packed collagen bundles takes place resulting in marked perifollicular fibrosis that

sometimes ends by complete destruction of the affected follicles.36

Moreover,

testosterone has proved to induce the overexpression of TGFb-1 in human scalp

dermal fibroblasts resulting in a rapid fibrotic response that increases the deposition of

fibrillary collagens and fibronectin.49

After PRP treatment, newly formed and better

organized collagen and reticular fibers showed an improvement of the perifollicular

matrix disposition along with an increase in rete ridge number and a marked recovery

of the dermo-epidermal elastic fiber mesh. These results demonstrate the biologic

potential of PRP to induce the renewal of balding scalp connective tissue which had

already been proved in other dermatological disorders such as photo-damaged skin

regeneration.51

PRP might play an important role against AGA derived perifollicular fibrosis

development, as it is considered an antifibrotic treatment because of its ability to

counteract the effect of TGFb-1 in other tissues such as the ocular surface or gingival

regeneration.52, 53

Patient satisfaction after PRP treatment resulted in an overall positive feedback.

These results are consistent with others in which intradermal platelet-rich plasma

injections for pattern hair loss have demonstrated an improvement in the subjective

self-perception after this autologous therapy.17, 27

The correct macro photograph identification demonstrated a clinical improvement

score similar to other studies, suggesting that platelet-rich plasma may induce clinical

advantage for male pattern baldness.19

DISCUSSION

Page 43

In this study, patient’s subjective statements regarding noticeable hair loss

decrease and improvement in hair quality/appearance are supported by negative hair

pull tests and increased hair density index achieved after platelet-rich plasma therapy.

Conclusion

Page 44

CONCLUSION

Platelet-rich plasma injection for Androgenetic alopecia is a simple, cost-

effective and feasible with excellent safety treatment option for hair loss and can be

regarded as a valuable adjuvant treatment modality for androgenetic alopecia in males

without remarkable adverse effects. They were accompanied by a high patient’s

satisfaction rate.

Furthermore, other clinical trials that include a larger sample of patients with

AGA simultaneously treated with PRP and other topical and/or oral medications for

hair growth would also help define the efficacy of PRP as an adjuvant treatment of

AGA.

Considering its excellent safety profile and relatively low cost, PRP hair

treatment for AGA is a promising treatment option for patients with thinning hair.

SUMMARY

Page 45

SUMMARY

A hereditary, androgen-driven disorder, Androgenetic alopecia (AGA) is the

most common form of alopecia in humans. It is an age-dependent disorder with

prevalence of 23-87%. Central alopecia is more severe in men; women are more

likely to experience diffuse thinning. It is characterized by progressive hair loss,

predominantly of the central scalp, with some variation of patterned loss. Hair loss

has a significant influence on psychological distress and is associated with low self-

esteem and depression. Treatment options for androgenetic alopecia are very limited

and include topical minoxidil and oral finasteride (FDA approved) either alone or in

combination. However, there are several reported side effects such as headache and

increase in other body hairs for minoxidil whereas loss of libido has been reported

with oral finasteride. Finasteride also interferes with genital development in a male

foetus and is contraindicated in pregnancy.

Researchers have discovered through in vitro studies that PRP induces a

significant initiation and prolongation of the anagen phase of the hair growth cycle.

There is a dose response relationship between platelet concentration and the

proliferation of human adult mesenchymal stem cells, the proliferation of fibroblasts,

and the production of type I collagen.

Platelet-Rich Plasma (PRP) is an autologous preparation that concentrates

platelets in a small volume of plasma. They contain more than 30 bioactive proteins,

many of which have a fundamental role in haemostasis or tissue healing.

PRP also includes three proteins in blood known to act as cell adhesion

molecules: Fibrin, Fibronectin and Vitronectin.

SUMMARY

Page 46

Platelet rich plasma (PRP) is a new and potentially useful adjunct in oral and

maxillofacial bone reconstructive surgery.

Ten patients with androgenetic alopecia were selected to evaluate the efficacy

and safety of PRP injections in the scalp of patients.

Our protocol involved six treatment sessions with an interval of 3 weeks

between injections. Post 6 months from the beginning of the treatment, a booster

session was also performed.

We evaluated hair pull test, number of hair follicles in desired area,

dermoscopic photomicrographs, macroscopic photographs, hair density (hair/cm2),

and patients’ satisfaction. We also noted any reported adverse effects.

The test results demonstrated that there was significant increase in the mean

no. of hair follicles with every administration (7 sessions) of PRP [P<0.001].

Before treatment, all our patients had a positive hair pull test with mean

number of 10 hairs. After the fourth session, the pull test was negative in 9 patients

with average number of 3 hairs. A significant reduction in hair loss was observed

between first and fourth injection as noticed by patients.

Macroscopic pictures also revealed a moderate improvement in hair volume

and coverage. Hair count depicted average number of 57.50 hair follicular units over

marked area before starting the treatment, and after 7 sessions of PRP, average

number of follicular units was 93.90 follicular units. Therefore, average mean gain is

36.4 follicular units per cm2.

Patient satisfaction was evaluated on a scale of 1-10, results showed patient

satisfaction was high with a mean result rating of 8.0.

SUMMARY

Page 47

Thus we concluded that, Platelet-Rich Plasma injections for androgenetic

alopecia is a simple, cost-effective and feasible with excellent safety treatment option

for hair loss and can be regarded as a valuable adjuvant treatment modality for

androgenetic alopecia in males without remarkable adverse effects.

Bibliography

Page 48

BIBLIOGRAPHY

1. Mirmirani P. Age-related hair changes in men: Mechanisms and management of

alopecia and graying. Maturitas (2014), In: Badin HP, ed. Dermatologic Capsule

and Comment. New York: HP Publishing Co, 1988: l-10.

2. Bergfeld WF. Androgenetic alopecia: an overview. Seventh symposium on

alopecia. In: Badin HP, ed. Dermatologic Capsule and Comment. New York: HP

Publishing Co, 1988: l-10.

3. Bergfeld WF. Diffuse hair loss in women. Cutis 1978; 22: 190-5.

4. Hamilton JB. Patterned loss of hair in man: types and incidence. Ann NY Acad

Sci 1951; 53: 708-28.

5. Ludwig E. Classification of the types of androgenetic alopecia (common

baldness) occuring in the female sex. Br J Dermatol 1977; 97: 247-54.

6. Aghaloo TL, Moy PK, Freymiller EG (2002) Investigation of platelet rich plasma

in rabbit cranial defects: a pilot study. J Oral Maxillofac Surg 60:1176–1181.

7. Amanda G. M. Perez, José Fábio S. D. Lana, Ana Amélia Rodrigues, Angela

Cristina M. Luzo, William D. Belangero, and Maria Helena A. Santana,

“Relevant Aspects of Centrifugation Step in the Preparation of Platelet-Rich

Plasma,” ISRN Hematology, vol. 2014, Article ID 176060, 8 pages, 2014.

8. Whitman DH, Berry RL, Green DM. Platelet gel: an autologous alternative to

fibrin glue with applications in oral and maxillofacial surgery.

9. Eppley BL, Pietrzak WS, Blanton M: PlateletRich Plasma: A Review of Biology

and Applications in Plastic Surgery. Plast Reconstr Surg 118:147e, 2006.

10. Amable et al. Platelet-rich plasma preparation for regenerative medicine:

optimization and quantification of cytokines and growth factors, Stem Cell

Research & Therapy 2013, 4:67

Bibliography

Page 49

11. Alves R and Grimalt R: Randomized Placebo Controlled, Double-Blind, Half-

Head Study to Assess the Efficacy of Platelet-Rich Plasma on the Treatment of

Androgenetic Alopecia. Dermatol Surg 42:491-497, 2016

12. Gentile P, Garcovich S, Bielli A, et al: The Effect of platelet-rich plasma in hair

regrowth: a randomized placebo-controlled trial. Stem Cells Transl Med 4:1317–

23, 2015.

13. Cervelli V, Garcovich S, Bielli A, et al: The effect of autologous activated

platelet rich plasma (AA-PRP) injection on pattern hair loss: clinical and

histomorphometric evaluation. BioMed Res Int 2014.

14. Uebel CO, da Silva JB, Cantarelli D, Martins P: The role of platelet plasma

growth factors in male pattern baldness surgery. Plast Reconstr Surg 118:1458–

67, 2006.

15. Kang J-S, Zheng Z, Choi MJ, et al: The effect of CD34+ cell-containing

autologous platelet-rich plasma injection on pattern hair loss: a preliminary study.

J Eur Acad Dermatol Venereol 28:72–9, 2014.

16. Takikawa M, Nakamura S, Nakamura S, et al: Enhanced effect of platelet-rich

plasma containing a new carrier on hair growth. Dermatol Surg 37:1721– 9,

2011.

17. Gkini M-A, Kouskoukis A-E, Tripsianis G, et al: Study of platelet-rich plasma

injections in the treatment of androgenetic alopecia through a one year period. J

Cutan Aesthetic Surg 7:213–9, 2014.

18. Parul Singhal, Sachin Agarwal, Paramjeet Singh Dhot, and Satish K. Sayal

Efficacy of platelet-rich plasma in treatment of androgenic alopecia Asian J

Transfus Sci. 2015 Jul-Dec; 9(2): 159–162.

Bibliography

Page 50

19. Schiavone G, Raskovic D, Greco J, Abeni D. Platelet-rich plasma for

androgenetic alopecia: a pilot study. Dermatol Surg. 2014 Sep;40(9):1010-9.

20. Tawfik AA, Osman MAR. The effect of autologous activated platelet-rich plasma

injection on female pattern hair loss: A randomized placebo-controlled study. J

Cosmet Dermatol. 017;00:1–7.

21. Puig CJ, Reese R, Peters M. Double-blind, placebo-controlled pilot study on the

455 use of platelet-rich plasma in women with female androgenetic alopecia. 456

Dermatol Surg 2016;42(11):1243–7.

22. Shah KB, Shah AN, Solanki RB,Raval RC. A comparative study of

microneedling with platelet-rich plasma plus topical minoxidil (5%) and topical

minoxidil (5%) alone in androgenetic alopecia. Int J Trichol 2017;9: 14-8.

23. Jha AK, Udayan UK, Roy PK, Amar AKJ, Chaudhary RKP. Original article:

Platelet-rich plasma with microneedling in androgenetic alopecia along with

dermoscopic pre- and post-treatment evaluation. J Cosmet Dermatol. 2017;00:1–

6.

24. Anitua E, Pino A, Martinez N, Orive G, Berridi D. The Effect of Plasma Rich in

Growth Factors on Pattern Hair Loss: A Pilot Study. Dermatol Surg. 2017

May;43 (5):658-670.

25. Sclafani AP (2014) Platelet-rich fibrin matrix (PRFM) for androgenetic alopecia.

Facial Plast Surg 30(2):219–224.

26. Trink A, Sorbellini E, Bezzola P, Rodella L,et al. A randomized, double-blind,

placebo- and active-controlled, half-head study to evaluate the effects of platelet-

rich plasma on alopecia areata.BJD.2013;169:690-694.

27. Khatu SS, More YE, Gokhale NR, et al. Platelet-rich plasma in androgenic

alopecia: myth or an effective tool. J Cutan Aesthet Surg. 2014;7:107–10.

Bibliography

Page 51

28. El Taieb MA, Ibrahim H, Nada EA, Seif Al-Din M. Platelets rich plasma versus

minoxidil 5% in treatment of alopecia areata: a trichoscopic evaluation. Dermatol

Ther 2017;30(1).

29. Sukhbir Singh. Role of platelet-rich plasma in chronic alopecia areata: Our centre

experience Indian J Plast Surg. 2015 Jan-Apr; 48(1): 57–59.

30. Lee S-H, Zheng Z, Kang J-S, Kim D-Y, Oh SH, Cho SB. Therapeutic efficacy of

autologous platelet-rich plasma and polydeoxyribonucleotide on female pattern

hair loss. Wound Repair Regen 2015;23(1):30–6.

31. Rahnayake D, Sinclair R. Male androgenetic alopecia. Expert Opin Pharmacother

2010;11:1295–304.

32. Whiting DA. Possible mechanisms of miniaturization during androgenetic

alopecia or pattern hair loss. J Am Acad Dermatol 2001;45:S81–6.

33. Sinclair R. Male pattern androgenetic alopecia. BMJ 1998;317:865–9.

34. Olsen EA, Weiner MS, Delong ER, Pinnell SR. Topical minoxidil in male pattern

baldness. J Am Acad Dermatol. 1985;13:185–92.

35. Kaufman KD, Olsen EA, Whiting D, Savin R, DeVillez R, Bergfeld W, et al.

Finasteride in the treatment of androgenic alopecia. J Am Acad of Dermatol.

1998;39:578–89.

36. El-Domyati M, Attia S, Saleh F, Abdel-Wahab H. Androgenetic alopecia in

males: a histopathological and ultrastructural study. J Cosmet Dermatol

2009;8:83–91.

37. Sweeny J, Grossman BJ. Blood collection, storage and component preparation

methods. In: Brecher M, editor. Technical Manual. 14th ed. Bethesda MD:

American Association of Blood Banks (AABB) 2002;955-8.

Bibliography

Page 52

38. Macey M, Azam U, McCarthy D, Webb L, Chapman ES, Okrongly D,et al.

Evaluation of the anticoagulants EDTA and citrate, theophylline, adenosine, and

dipyridamole (CTAD) for assessing platelet activation on the ADVIA 120

hematology system. Clin Chem 2002;48:891-9.

39. Dhurat R, Sukesh MS. Principles and methods of preparation of platelet-rich

plasma: A review and author’s perspective. J Cutan Aesthet Surg 2014;7:189-97.

40. Weibrich G, Hansen T, Kleis W, Buch R, Hitzler WE. Effect of platelet

concentration in platelet-rich plasma on peri-implant bone regeneration. Bone

2004;34:665-71.

41. Anitua E, Prado R, Azkargorta M, Rodriguez-Suárez E, et al. High throughput

proteomic characterization of plasma rich in growth factors (PRGF–Endoret)-

derived fibrin clot interactome. J Tissue Eng Regen Med 2015;9:e1–12.

42. Anitua E, Zalduendo M, Prado R, Alkhraisat M, et al. Morphogen and

proinflammatory cytokine release kinetics from PRGF-Endoret fibrin scaffolds:

evaluation of the effect of leukocyte inclusion. J Biomed Mater Res A

2015;103:1011–20.

43. Navarro M, As´ın M, Mart´ınez A, Molina C, et al. Plasma rich in growth factors

(PRGF) for the treatment of androgenetic alopecia. Eur J Plast Surg

2015;38:437–42.

44. Rastegar H, Ahmadi Ashtiani H, Aghaei M, Ehsani A, et al. Combination of

herbal extracts and platelet-rich plasma induced dermal papilla cell proliferation:

involvement of ERK and Akt pathways. J Cosmet Dermatol 2013;12:116–22.

45. Anitua E, Pascual C, P´erez-Gonzalez R, Orive G, et al. Intranasal PRGF-Endoret

enhances neuronal survival and attenuates NF-kBdependent inflammation

Bibliography

Page 53

process in a mouse model of Parkinson’s disease. J Control Release

2015;203:170–80.

46. Anitua E, Zalduendo M, Troya M, Padilla S, et al. Leukocyte inclusion within a

platelet rich plasma-derived fibrin scaffold stimulates amore pro-inflammatory

environment and alters fibrin properties. PLoS One 2015;10:e0121713.

47. Paus R, Cotsarelis G. The biology of hair follicles. N Engl J Med 1999; 341:491–

7.

48. Yano K, Brown LF, Detmar M. Control of hair growth and follicle size by

VEGF-mediated angiogenesis. J Clin Invest 2001;107:409.

49. Akiyama M, Smith LT, Holbrook KA. Growth factor and growth factor receptor

localization in the hair follicle bulge and associated tissue in human fetus. J

Invest Dermatol 1996;106:391–6.

50. Yoo HG, Kim JS, Lee SR, Pyo HK, et al. Perifollicular fibrosis: pathogenetic role

in androgenetic alopecia. Biol Pharm Bull 2006;29:1246–50.

51. D´ıaz-Ley B, Cuevas J, Alonso-Castro L, Calvo M, et al. Benefits of plasma rich

in growth factors (PRGF) in skin photodamage: clinical response and histological

assessment. Dermatol Ther 2015;28:258–63.

52. Anitua E, Muruzabal F, Alcalde I, Merayo-Lloves J, et al. Plasma rich in growth

factors (PRGF-Endoret) stimulates corneal wound healing and reduces haze

formation after PRK surgery. Exp Eye Res 2013;115:153–61.

53. Anitua E, Troya M, Orive G. Plasma rich in growth factors promote gingival

tissue regeneration by stimulating fibroblast proliferation and migration and by

blocking transforming growth factor-b1-induced myodifferentiation. J

Periodontol 2012;83:1028–37.

Bibliography

Page 54

54. Inui S, Fukuzato Y, Nakajima T, Yoshikawa K, et al. Identification of androgen-

inducible TGF-b1 derived from dermal papilla cells as a key mediator in

androgenetic alopecia. J Investig Dermatol Symp Proc 2003; 8:69–71.

55. Miao Y, Sun YB, Sun XJ, Du BJ, et al. Promotional effect of platelet rich plasma

on hair follicle reconstitution in vivo. Dermatol Surg 2013; 39:1868–76.

56. Besti EE, Germain E, Kalbermatten DF, Tremp M, Emmenegger V. Platelet-rich

plasma injection is effective and safe for the treatment of alopecia. Eur J Plast

Surg. 2013;36:407–12.

57. Takakura N, Yoshida H, Kunisada T, Nishikawa S, et al. Involvement of platelet-

derived growth factor receptor-a in hair canal formation. J Invest Dermatol

1996;107:770–7.

CONSENT FORM

Page 1

CONSENT FORM

Patient Name: __________________________ Age: _______

Sex: ____

1. My condition has been explained to me as: _________________________

2. The procedure necessary to treat the condition has been explained to me and I

understand the nature of the treatment to be

_____________________________________________________________________

_________________________________.

I certify that I have been informed about all the above points in my own language, and I

fully understand this consent for surgery, have had my questions answered and that all

blanks were filled prior to my signature.

Patients Signature / thumb impression Place:

Doctor’s Signature Date:

CASE HISTORY PROFORMA

Page 55

DEPARTMENT OF ORAL & MAXILLOFACIAL SURGERY

CASE HISTORY

Date: _ _ / _ _ /_ _ _ _

Name:……………………………………………………………………………………..

Age: ………. Sex: M / F

Address:……………………………………………………………………………………

………………………………………………………………………………………………

…………………………………………………………………Pincode…………………

Email………………………………………………………………..@...............................

Mobile: …………………….. Alternate Num: ……………………………………

Occupation:

Main Complaints -

Hair Loss

Site : Scalp / Beard/ Moustache/ Body (Specify area)

Onset (Specify duration) :

Hair coming out by

the roots/Breaking :

If Scalp, number of hair

lost per day : Less than 60/ 60-80/80-100/More than 100

Pattern : Diffuse/ Localized/ Patterned Thinning


Page 56

Associated Symptoms

Itching Scaling Burning Pain

Associated Conditions

Skin Disorders (Specify Site/Duration/Treatment)

Acne, Hirsuism, Photosensitivity, Others

Medical Conditions (Specify duration/ Active /Resolved)

Weight Loss / Gain : Kgs/ Duration

Chronic Illness : #Hypertension #Diabetics #Hypothyroidism

#Fever

Anemia : Fatigue/ Blood Loss/ Lethargy/ Palpitations

Family History

Baldness

Other Conditions

Family History of Premature Baldness:


Page 57

Previous Treatment Taken:

Personal History

Diet:

Hair-Care routine :

Stress : Work Hours, Night Shift, Work Environment, Stress at Home, Stress of

any chronic illness, Frequent Travelling, Sleep pattern

Habit :Smoking/Tobacco/Alcohol Intake

Others: Keloidal tendency Epileptie tendency Bleeding tendency

GI Symptoms

Physical Examination

General Physical Examination

Weight - Blood Pressure- Edema- Mucosa- Pulse-

Pallor- Nails- Thyroid Gland Normal / Enlarged-

Lymphadenopathy-

Systemic Examination (complete examination of the system with

complaints/suspected involvement)

Skin examination:


Page 58

Hair Examination:

Bald

Area/Thinning

Front Back Right Left

Site

Size

Shape/Pattern

Borders

Underlying Skin

Erythema

Scaling

(greasy/silvery

white/adherent)

Scarring

Pustules

Papules

Pigmentation

Telangiectasia

Surrounding Skin

Surrounding Hair

Provisional Diagnosis:

Your hair analysis findings

your hair loss is: Male ( I II III IV V VI VII VIII )

Lab findings:


Page 59

Final Diagnosis:

Treatment plan:

Evaluation of hair follicles

S.No Date Number of follicles/c.c Density

1

2

3

4

5

6

7 (Booster)

MASTER CHART

Table-6 Density of hair follicles/cm2 for a Patient in Various Appointments

PatienfAppt. No Al A2 A3 A4 A5 A6 A 7 (Booster Dose) Patient 1 53 59 52 64 72 81 91 Patient 2 58 65 68 72 73 82 96 Patient 3 78 82 85 98 104 111 121 Patient 4 74 74 75 76 74 78 95 Patient 5 65 68 73 71 75 88 102 Patient 6 64 65 64 68 70 78 93 Patient 7 62 67 69 68 75 78 87 Patient 8 64 62 65 71 74 75 82 Patient 9 58 60 60 64 66 72 72

Patient 10 40 41 42 52 58 62 69

Table-5 Number of Hair Follicles/cm2 for a Patient in Various

Appointments(A) at 'V' point

Patient'Appt. No Al A2 A3 A4 A5 AG A 7 (Booster Dose) Patient 1 40 4-l 58 62 68 72 93 Patient 2 5-l 62 68 72 76 78 92 Patient 3 74 79 82 96 114 118 p· ... ) Patient 4 62 65 64 67 73 71 93 Patient 5 59 69 72 75 79 84 97 Patient 6 56 57 64 69 75 86 96 Patient 7 66 70 70 72 76 85 92 Patient 8 62 64 69 75 75 78 90 Patient 9 60 65 69 69 70 84 86 Patient 10 42 42 48 61 64 69 75

\ I

, l;Y STU~TURE STAFF SIGNATURE

Photographs

Page 26

PHOTOGRAPHS

Fig (i) - Blood withdrawn from

Patient

Fig (ii) – Blood after First Spin

Fig (iii) – Separation of Plasma

from Blood after First Spin

Fig (iv) – Plasma after Second

Spin

Photographs

Page 27

Fig (vi) – Centrifuge Machine

Fig (v) – ‘V’ (Kang’s point)

Photographs

Page 28

Fig (ix) – Patient- I Scalp Area

Pre - Treatment

Fig (x) – Patient- I Scalp Area

Post - Treatment

Fig (vii) – Dermatoscope

Fig (viii) – 1 cc insulin syringe

Photographs

Page 29

Fig (xi) – Patient- II Scalp Area

Pre - Treatment

Fig (xii) – Patient- II Scalp Area

Post - Treatment

Fig (xiii) – Patient- III Scalp Area

Pre - Treatment

Fig (xiv) – Patient- III Scalp Area

Post - Treatment

ROLE OF PLATELET-RICH PLASMA IN ANDROGENETIC …

Documents

Transcript of ROLE OF PLATELET-RICH PLASMA IN ANDROGENETIC …