role of platelet-rich plasma in androgenetic …
TRANSCRIPT
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
II
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
REVIEW OF LITERATURE
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
REVIEW OF LITERATURE
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
REVIEW OF LITERATURE
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,
REVIEW OF LITERATURE
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
REVIEW OF LITERATURE
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
REVIEW OF LITERATURE
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,
REVIEW OF LITERATURE
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
REVIEW OF LITERATURE
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
REVIEW OF LITERATURE
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
REVIEW OF LITERATURE
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
REVIEW OF LITERATURE
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
REVIEW OF LITERATURE
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
REVIEW OF LITERATURE
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-
REVIEW OF LITERATURE
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
REVIEW OF LITERATURE
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
REVIEW OF LITERATURE
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.
REVIEW OF LITERATURE
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*
Appts. A2 Vs A3 A2 Vs A4 A2 Vs A5 A2 Vs A6 A2 Vs A7 A3 Vs A4
P-Value 0.13 0.02* 0.01* 0.002* <0.001* 0.10
Appts. A3 Vs A5 A3 Vs A6 A3 Vs A7 A4 Vs A5 A4 Vs A6 A4 Vs A7
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
* - Statistically Significant
P-Value 0.10 <0.001* 0.007*
* - Statistically Significant
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*
Appts. A2 Vs A3 A2 Vs A4 A2 Vs A5 A2 Vs A6 A2 Vs A7 A3 Vs A4
P-Value 1.00 0.06 0.02* 0.001* <0.001* 0.27
Appts. A3 Vs A5 A3 Vs A6 A3 Vs A7 A4 Vs A5 A4 Vs A6 A4 Vs A7
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*
* - Statistically Significant
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 [70.40 ± 11.68] at P=0.01, 5th
appointment [74.10 ± 11.75] at P=0.01, 6th
appointment [80.50 ± 12.70] at P=0.001, 7th
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
CASE HISTORY PROFORMA
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:
CASE HISTORY PROFORMA
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:
CASE HISTORY PROFORMA
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:
CASE HISTORY PROFORMA
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