Innovations in Non-Surgical Hair Restoration

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In this interview, Dr Neil S. Sadick discusses the latest advancements in non-surgical hair restoration, including platelet-rich plasma (PRP) therapy and low-dose oral minoxidil, and offers tips on evaluating and managing patient expectations for optimal treatment outcomes.

The Dermatologist: Can you provide an overview of the most effective non-surgical treatments currently available for hair restoration?

Dr Sadick: The 2 major advances in non-invasive techniques and technologies to prevent hair loss and stimulate hair growth are the utilization of PRP and low-dose oral minoxidil. In PRP therapy, we draw your blood (about 15 cc), spin it down, isolate the platelets that contain growth factors, and then we re-inject them directly into the scalp to try to stimulate the stem cells for your hair follicles. It can also be introduced after microneedling, but I like to use direct targeted injection of the PRP. It is usually done as 3 treatment sessions as an induction, usually spaced at 4- to 6-week intervals, and then 1 treatment is done for maintenance every 3 to 6 months. We have some major advances in being able to monitor the results of these treatments. HairMetrix allows us to give a computer analysis of how much hair is growing, how much hair is being transitioned from a resting phase into a growth phase, and how much inflammation there is in the hair at the time that it is evaluated. This lets us know how effective our treatments are and allows us to optimize maintenance treatment programs.

We just wrote the first textbook on PRP and there have now been over 50 peer-reviewed publications showing the efficacy of PRP therapy. It does not work in everybody, and we do not tell our patients that it is going to grow an entire new head of hair. But most of our patients usually have between 10% and 20% hair regrowth after 1 year of utilizing PRP treatments. It is an excellent new modality that we use commonly in conjunction with low-dose oral minoxidil. We know topical minoxidil has been popular for years and that many individuals were compounding off-label higher concentrations of minoxidil. But now we have low-dose oral minoxidil at 1.25 mg to 5 mg, which is effective in slowing down hair loss and can lead to significant hair regrowth in many individuals.

Although PRP and low-dose minoxidil are the advances we most commonly use, we also utilize other technologies because in hair treatments it is always a multimodal approach. Other modalities include photo modulation or utilization of low-energy light using technologies like Omnilux to decrease inflammation and stimulate the cytokines or stem cells to try to regrow more hair. It is based on research that we performed where we identified a significant number of both women and men as having low-range chronic inflammation associated with hair loss. If you cut off the inflammation or lower the inflammation, we have found that we can stimulate new hair and slow down the hair loss process. Remember, our first goal is to prevent hair from being shed. Indeterminate hairs that can be shed under genetic influence are the ones we want to keep actively growing.

Another more recent advance is the utilization of a nonablative fractional laser called the FoLix, which is US Food and Drug Administration (FDA)-approved for hair stimulation. We have just completed our research studies that show its ability to regrow 10% to 15% of hair in individuals with hair loss. We have also finished a study on a new trichoceutical product called Revive, which is a natural product like Nutrafol that has also been shown to increase hair count numbers and decrease inflammation. We know what cosmeceuticals are for skin, but now we have a new generation of products called trichoceuticals. And lastly, we have a a new cleansing technology called Keravive for scalp health and decreasing inflammation that we utilize as part of our treatment program for patients with hair loss.

The Dermatologist: How do you determine the most suitable non-surgical hair restoration treatment for a patient and how do you manage patient expectations?

Dr Sadick: When I evaluate patients, particularly in women, I like to do small biopsies, 2-, 3- or 4-mm biopsies, to see whether the hair loss is associated with inflammation. If there is significant inflammation associated with the hair loss, I like to use anti-inflammatory approaches. Sometimes I will mix topical minoxidil with a low-potency topical corticosteroid, and then I will also introduce photo modulation that has excellent anti-inflammatory capabilities. For most individuals as a starting point, I like to start them on low-dose minoxidil and PRP.

We tell patients if they opt into a non-surgical program that it is not going to grow as much hair in most individuals as a hair transplantation. It does not grow the same thickness of diffuse hair as surgery does. But again, it is a lifelong process and even if you do hair transplantation surgery, you still need to maintain the residual hairs that are still present on the scalp, which includes non-surgical approaches as part of the treatment program.

Our number one goal in non-surgical programs is first to slow down or stop hair loss and that usually occurs within the first 6 months. Once we do that, a large majority of patients will have some degree of hair regrowth. Our secondary goal is to stimulate between 10% and 20% hair regrowth, which we commonly can do if patients stay on these treatment programs for a long period of time. We give them realistic expectations. Because of hair cycle characteristics, it can take up to a year before you see a significant improvement, so we tell patients not to give up after the initial 3 treatments of PRP or after taking oral minoxidil for a few months. You need to wait 6 months to a year to really assess the efficacy of these non-surgical programs.

The Dermatologist: What emerging non-surgical treatments or technologies do you find promising for the future of hair restoration?

Dr Sadick: We are now seeing the utilization of energy-based devices, such as the ultrasound device called TED and the FoLix laser, and I think those are playing an increasing role. We have found from our clinical studies that there is an added effect to using PRP and laser together. We are getting better results in terms of slowing down hair loss and growing new hair using a combination technology. We just completed a large study of using the FoLix laser in this type of treatment program.

As we look to the future, I think the small microparticles called exosomes that contain active growth factors, which our research group is now studying, will play an important role in hair loss treatment as more research comes to the forefront. Exosomes are not FDA-cleared and not utilized now for anything but research trials. We are trying to better understand the optimal concentration of these particles and the most active growth factors that can be utilized to stimulate hair regrowth and slow down hair loss. We may also see hair cloning in the future where we can clone hair follicles and bank them to be used at any time during an individual’s life for hair care stimulation or hair loss prevention products.

Of course, we always want to rule out secondary causes of hair loss when we initially see our patients, such as medications that cause hair loss, anemia, or excess androgens, but I would like to emphasize that our major target is inflammation—a lot of the newer approaches are anti-inflammatory.