Cosmetic Dermatology

Nonsurgical Hair Restoration Treatment

Cutis. 2019 July;104(01):17-24

References

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Price VH, Roberts JL, Hordinsky M, et al. Lack of efficacy of finasteride in postmenopausal women with androgenetic alopecia. J Am Acad Dermatol. 2000;43(5, pt 1):768-776.
Yeon JH, Jung JY, Choi JW, et al. 5 mg/day finasteride treatment for normoandrogenic Asian women with female pattern hair loss. J Eur Acad Dermatol Venereol. 2011;25:211-214.
Oliveira-Soares R, André MC, Peres-Correia M. Adverse effects with finasteride 5 mg/day for patterned hair loss in premenopausal women. Int J Trichol. 2018;10:48-50.
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Shanshanwal SJ, Dhurat RS. Superiority of dutasteride over finasteride in hair regrowth and reversal of miniaturization in men with androgenetic alopecia: a randomized controlled open-label, evaluator-blinded study. Indian J Dermatol Venereol Leprol. 2017;83:47-54.
Eun HC, Kwon OS, Yeon JH, et al. Efficacy, safety, and tolerability of dutasteride 0.5 mg once daily in male patients with male pattern hair loss: a randomized, double-blind, placebo-controlled, phase III study. J Am Acad Dermatol. 2010;63:252-258.
Olszewska M, Rudnicka L. Effective treatment of female androgenic alopecia with dutasteride. J Drugs Dermatol. 2005;4:637-640.
Nickel JC. Comparison of clinical trials with finasteride and dutasteride. Rev Urol. 2004;6(suppl 9):S31-S39.
Olsen EA, Hordinsky M, Whiting D, et al. The importance of dual 5alpha-reductase inhibition in the treatment of male pattern hair loss: results of a randomized placebo-controlled study of dutasteride versus finasteride. J Am Acad Dermatol. 2006;55:1014-1023.
Gómez R, Núñez L, Caballero R, et al. Spironolactone and its main metabolite canrenoic acid block hKv1.5, Kv4.3 and Kv7.1 + minK channels. Br J Pharmacol. 2005;146:146-161.
Huffman DH, Kampmann JP, Hignite CE, et al. Gynecomastia induced in normal males by spironolactone. Clin Pharmacol Ther. 1978;24:465-473.
Sinclair R, Patel M, Dawson TL Jr, et al. Hair loss in women: medical and cosmetic approaches to increase scalp hair fullness. Br J Dermatol. 2011;165(suppl 3):12-18.
Sinclair R, Wewerinke M, Jolley D. Treatment of female pattern hair loss with oral antiandrogens. Br J Dermatol. 2005;152:466-473.
Brough KR, Torgerson RR. Hormonal therapy in female pattern hair loss. Int J Womens Dermatol. 2017;3:53-57.
Fabbrocini G, Cantelli M, Masarà A, et al. Female pattern hair loss: a clinical, pathophysiologic, and therapeutic review. Int J Womens Dermatol. 2018;4:203-211.
Sinclair RD. Female pattern hair loss: a pilot study investigating combination therapy with low-dose oral minoxidil and spironolactone. Int J Dermatol. 2018;57:104-109.
Camacho-Martinez FM. Hair loss in women. Semin Cutan Med Surg. 2009;28:19-32.
Mackenzie IS, Macdonald TM, Thompson A, et al. Spironolactone and risk of incident breast cancer in women older than 55 years: retrospective, matched cohort study. BMJ. 2012;345:E4447.
Farivar S, Malekshahabi T, Shiari R. Biological effects of low level laser therapy. J Laser Med Sci. 2014;5:58-62.
Jimenez JJ, Wikramanayake TC, Bergfeld W, et al. Efficacy and safety of a low-level laser device in the treatment of male and female pattern hair loss: a multicenter, randomized, sham device-controlled, double-blind study. Am J Clin Dermatol. 2014;15:115-127.
Lanzafame RJ, Blanche RR, Bodian AB, et al. The growth of human scalp hair mediated by visible red light laser and LED sources in males. Lasers Surg Med. 2013;45:487-495.
Kim H, Choi JW, Kim JY, et al. Low-level light therapy for androgenetic alopecia: a 24-week, randomized, double-blind, sham device-controlled multicenter trial. Dermatol Surg. 2013;39:1177-1183.
Banga AK. Transdermal and Intradermal Delivery of Therapeutic Agents: Application of Physical Technologies. New York, NY: CRC Press; 2011.
Dhurat R, Sukesh M, Avhad G, et al. A randomized evaluator blinded study of effect of microneedling in androgenetic alopecia: a pilot study. Int J Trichol. 2013;5:6-11.
Jha AK, Vinay K, Zeeshan M, et al. Platelet-rich plasma and microneedling improves hair growth in patients of androgenetic alopecia when used as an adjuvant to minoxidil [published online January 28, 2019]. J Cosmet Dermatol. doi:10.1111/jocd.12864.
Anitua E, Pino A, Martinez N, et al. The effect of plasma rich in growth factors on pattern hair loss: a pilot study. Dermatol Surg. 2017;43:658-670.
Puig CJ, Reese R, Peters M. Double-blind, placebo-controlled pilot study on the use of platelet-rich plasma in women with female androgenetic alopecia. Dermatol Surg. 2016;42:1243-1247.
Mapar MA, Shahriari S, Haghighizadeh MH. Efficacy of platelet-rich plasma in the treatment of androgenetic (male-patterned) alopecia: a pilot randomized controlled trial. J Cosmet Laser Ther. 2016;18:452-455.
Maria-Angeliki G, Alexandros-Efstratios K, Dimitris R, et al. Platelet-rich plasma as a potential treatment for noncicatricial alopecias. Int J Trichol. 2015;7:54-63.
Gkini MA, Kouskoukis AE, Tripsianis G, et al. Study of platelet-rich plasma injections in the treatment of androgenetic alopecia through an one-year period. J Cutan Aesthet Surg. 2014;7:213-219.
Landesberg R, Roy M, Glickman RS. Quantification of growth factor levels using a simplified method of platelet-rich plasma gel preparation. J Oral Maxillofac Surg. 2000;58:297-300; discussion 300-301.
Weibrich G, Kleis WK, Hafner G. Growth factor levels in the platelet-rich plasma produced by 2 different methods: curasan-type PRP kit versus PCCS PRP system. Int J Oral Maxillofac Implants. 2002;17:184-190.
Alves R, 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. 2016;42:491-497.
Hou A, Cohen B, Haimovic A, et al. Microneedling: a comprehensive review. Dermatol Surg. 2017;43:321-339.
Singh A, Yadav S. Microneedling: advances and widening horizons. Indian Dermatol Online J. 2016;7:244-254.
Asif M, Kanodia S, Singh K. Combined autologous platelet-rich plasma with microneedling verses microneedling with distilled water in the treatment of atrophic acne scars: a concurrent split-face study. J Cosmet Dermatol. 2016;15:434-443.
Kumar MK, Inamadar AC, Palit A. A randomized controlled single-observer blinded study to determine the efficacy of topical minoxidil plus microneedling versus topical minoxidil alone in the treatment of androgenetic alopecia. J Cutan Aesthet Surg. 2018;11:211-216.
Hausauer AK, Jones DH. Evaluating the efficacy of different platelet-rich plasma regimens for management of androgenetic alopecia: a single-center, blinded, randomized clinical trial. Dermatol Surg. 2018;44:1191-1200.
Kang JS, 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. 2014;28:72-79.
Soltani-Arabshahi R, Wong JW, Duffy KL, et al. Facial allergic granulomatous reaction and systemic hypersensitivity associated with microneedle therapy for skin rejuvenation: adverse reactions with microneedle therapy. JAMA Dermatol. 2014;150:68-72.
Bak DH, Choi MJ, Kim SR, et al. Human umbilical cord blood mesenchymal stem cells engineered to overexpress growth factors accelerate outcomes in hair growth. Korean J Physiol Pharmacol. 2018;22:555-566.
Bu ZY, Wu LM, Yu XH, et al. Isolation and characterization of in vitro culture of hair follicle cells differentiated from umbilical cord blood mesenchymal stem cells. Exp Ther Med. 2017;14:303-307.
Kim JE, Oh JH, Woo YJ, et al. Effects of mesenchymal stem cell therapy on alopecia areata in cellular and hair follicle organ culture models [published online October 29, 2018]. Exp Dermatol. doi:10.1111/exd.13812.
Elmaadawi IH, Mohamed BM, Ibrahim ZAS, et al. Stem cell therapy as a novel therapeutic intervention for resistant cases of alopecia areata and androgenetic alopecia [published online March 6, 2018]. J Dermatolog Treat. 2018;29:431-440.
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Glynis A. A double-blind, placebo-controlled study evaluating the efficacy of an oral supplement in women with self-perceived thinning hair. J Clin Aesthet Dermatol. 2012;5:28-34.

Finasteride

Finasteride is an oral medication that is FDA approved at a dose of 1 mg daily for the treatment of AGA in men. It competitively inhibits the type I and type II 5α-reductase enzymes, with a strong affinity for the type II enzyme, thereby inhibiting the conversion of testosterone to dihydrotestosterone (DHT), the potent androgen responsible for terminal hair follicle miniaturization and transformation of terminal hair into vellus hair.^21,23

Finasteride has demonstrated efficacy and high tolerability in large-scale, placebo-controlled, randomized trials with only rare complications of sexual dysfunction, supporting its status as a first-line agent.^24,25 One study found that in a population of 3177 Japanese men, an overall increase in hair growth was seen in 87.1% of men receiving oral finasteride 1 mg daily, with AEs such as decreased libido occurring in only 0.7% of patients.²⁶ However, postmarketing studies described more severe complications in men taking finasteride to treat AGA or benign prostatic hyperplasia, even after the discontinuation of medication, described as postfinasteride syndrome.^27,28 These side effects include decreased libido, reduction in penis size, gynecomastia, erectile dysfunction, and ejaculation disorder, in addition to psychologic impairments, including decreased concentration, depression, and suicidal ideation, presumably due to the role of 5α-reductase interacting with the γ-aminobutyric acid (GABA_A) receptor within the central nervous system.²⁹ The incidence of persistent erectile dysfunction was reported to be as low as 1.4% in a study assessing 11,909 men prescribed up to 5 mg once daily of finasteride to treat benign prostatic hyperplasia and AGA. The incidence was higher in patients using higher doses of finasteride and longer treatment courses as well as in patients with prostate disease.²⁹ These potential side effects should be discussed with male patients prior to prescribing finasteride.

Finasteride is not FDA approved for use in women and is considered category X in pregnancy due to animal studies that demonstrated external genital abnormalities in male fetuses exposed to type II 5α-reductase inhibitors.³⁰ Despite this potential teratogenicity, finasteride is prescribed off label to treat FPHL and hirsutism. A meta-analysis of 2683 women participating in 65 studies found that finasteride, when used at dosages of 0.5 to 5 mg daily, may improve FPHL and frontal fibrosing alopecia after 6 to 12 months.³⁰ However, available studies have used varying treatment methods, yielding differing results. For example, one randomized trial of 137 postmenopausal women with FPHL and normal androgen levels found no benefit with 1 mg daily³¹; however, another trial of 87 women with normal levels of androgens found that 5 mg daily of finasteride showed significant improvements in hair quantity and thickness after 12 months (P<.01).³² Further studies are needed to assess the appropriate female population that may benefit from use of finasteride. Premenopausal women interested in this therapy should be counseled about the risk of teratogenicity, as well as potential breast tenderness, loss of libido, and menstrual irregularities.³³ Furthermore, finasteride use in women may pose a theoretical risk of breast cancer, as DHT inhibition results in conversion of excess testosterone to estrogen, thereby altering the estrogen to androgen ratio.³⁴

Dutasteride

Dutasteride is 100-times more potent than finasteride as an inhibitor of type I 5α-reductase enzyme and 3-times more potent as an inhibitor of type I 5α-reductase enzyme.³⁵ Therefore, it has been hypothesized that dutasteride may be more effective than finasteride for restoring hair loss, though it is not yet FDA approved for this indication.

Research evaluating the efficacy of dutasteride is emerging. Randomized controlled trials in men with AGA are promising and suggest reversed hair miniaturization.³⁶ One randomized trial of 153 men found that dutasteride 0.5 mg daily was superior to placebo for the treatment of hair loss, as evidenced by an increase in hair counts in dutasteride patients (12.2/cm²) compared to controls (4.7/cm²). Furthermore, 0.5-mg dutasteride resulted in significantly increased new hair growth after 24 weeks compared to a placebo control (23/cm² vs 4/cm²; P<.05).³⁷

Dutasteride also is now being used off label to treat FPHL. Little evidence-based research exists regarding the use of dutasteride in women, though 1 case report described successful treatment of FPHL after 6 months of treatment with 0.5 mg daily of dutasteride in a 46-year-old woman who showed only minimal improvement on oral finasteride.³⁸

The side-effect profile is similar to finasteride, and research in the urologic literature demonstrated that the rate of AEs is comparable between the 2 drugs, with reports of sexual side effects occurring in 11% of patients taking dutasteride 0.5 mg daily vs 14% of patients taking finasteride 5 mg daily.³⁹ In the dermatologic literature, there was no statistically significant difference between the rate of AEs, specifically sexual AEs, in patients taking dutasteride 0.5 mg daily vs finasteride 1 mg daily.³⁶ Safety of dutasteride in women is not well established. The side-effect profile described for finasteride, including the risk of potential fetal anomalies, should be discussed with women receiving dutasteride therapy.

Spironolactone

Although topical minoxidil is still considered first-line therapy for women experiencing hair loss, spironolactone is growing in popularity as an off-label treatment of FPHL, though it is not FDA approved for this indication. Spironolactone is a synthetic steroid that has been used as a potassium-sparing diuretic for more than 60 years. Its primary metabolite, canrenone, competitively inhibits aldosterone.³⁷ It is FDA approved for the treatment of essential hypertension (25–100 mg), congestive heart failure (25 mg), diuretic-induced hypokalemia (25–100 mg), and primary hyperaldosteronism (100–400 mg).^37,40 Spironolactone was serendipitously discovered to treat hirsutism, acne, and seborrhea associated with polycystic ovary syndrome.⁴¹

Nonsurgical Hair Restoration Treatment

References

Finasteride

Dutasteride

Spironolactone

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