One Patient’s experience with PRP/ACell treatment for hair growth
Patient JK is a 35 year old male who is interested in getting his hair back. We first met at the beginning of May in 2015 and he had lost much of his frontal area and his crown – a Norwood Class IVa in hair loss terms. Like most hair loss patients, his hair loss snuck up on him. He is a successful guy, owns his own business, never thought much about his hair until he started to lose it. Also, like most regular guys, he was surprised how much this loss bothered him
So, also like most guys, he started to research on the Internet. “Dr. Google” was, as usual, pretty generous with misinformation, so he tried several shampoos, supplements and methods of camouflage before the lack of improvement made him come to see me.
During our initial consultation, it was clear that he had early androgenetic alopecia. He had miniaturized hair visible under microscopic analysis, a family history of baldness, and an appearance consistent with pattern hair loss. His goals were realistic, too; halt the loss, improve it if possible, and to try every non-surgical means possible before considering hair transplantation. In short; JK was an excellent hair loss patient.
THE ARMAMENTARIUM OF AVAILABLE TREATMENTS:
So we stated talking about the basics for medical treatment. Finasteride, minoxidil 5% foam, Low Level Light Therapy (LLLT), and the medicated shampoos (ketoconazole, zinc pyrithione, selenium, and coal tar) were all acceptable treatment options for him. He had heard about this new treatment called PRP, though, and wanted to give it a try first.
I explained that PRP stands for Platelet Rich Plasma and that it is obtained by drawing a patient’s own blood, removing the red cells and concentrating the platelets, and re-injecting it back into the patient’s scalp (after numbing of course). The reason re-injecting one’s own platelets is even considered a good idea, is that platelets contain growth factors – at least 3-5X that of native plasma (although 8-10X may be preferable for injecting for hair growth). PRP is known to speed wound healing and have a host of other positive effects on the growth of tissues throughout the body. If it sounds too good to be true, it just might be. Even experts in the “hair world” agree that at this point, the science is still developing.
In my practice, we like the scientific evidence for adding a protein matrix before re-injecting. We use one known as ACell or MatriStem) because it has some independent evidence for its use in hair. ACell is a product of extracellular matrix derived from porcine urinary bladder tissue. It is stripped of cells (AKA “acellular,” hence the name) and thus does not cause a reaction in the body of humans and is postulated to provide the “scaffolding” or matrix on which cells can build or regenerate tissue. ACell+ PRP injections possibly help the growth of the native hair (and maybe even grafts if surgery was done) in the area. Not all practitioners do this, and PRP alone treatments are an (cheaper) option, but if PRP alone is the treatment chosen, the evidence seems to support more frequent dosing (every month) to gain benefit, so fewer patients opt for it.
Since the use of PRP and ACell (MatriStem) for encouraging hair growth is not yet fully tested, it is impossible to know how much of an effect it would have. Patients with thinning but not completely bald areas are the best candidates. Women are typically good candidates for this reason – it is rare that women go slick bald at all. However, the earlier someone starts on any treatment the better (i.e. Norwood types I-IV or Ludwig types 1-II), and that seems to include PRP/ACell treatment. But other than the financial risk of paying for an experimental treatment that might not meet the patient’s goals, it is not likely to be detrimental, and may in fact help growth (a good reference can be found at http://www.ncbi.nlm.nih.gov/pubmed/25111436).
That being said, in some patients there are great results and in others the results are not as significant. Plus, like all medical hair treatments it will very likely require ongoing maintenance treatments, and this may be a financial burden. We reviewed the pros and cons, risks and benefits, and the methods we use to monitor patient progress (including global photographs, and HairCheck cross sectional measurements). Given that he still had hair remaining in the areas he wanted to treat, we decided that this treatment did have a reasonable chance of helping him, and he decided he wanted to go ahead with a set of PRP/ACell injections before trying anything else.
So, at the end of May, we scheduled our first PRP/ACell session. He arrived on time and we took photographs and performed a “HairCheck” to establish his baseline. The HairCheck test consists of measuring the width of a bundle of hair at each of three precisely measured locations. Any increase in the size of this bundle’s diameter correlates with either additional (new) hair growth, or increased hair shaft size – both what you would expect for hair regrowth! His numbers were:
We then drew his blood, spun it down (sterile vials in a centrifuge), and using special equipment to “harvest” the PRP, placed the clear yellow into a syringe with the ACell in powdered form. During this time we also numbed JK’s head (which most patients call “The worst part of the whole thing!”) so he would not feel the PRP/ACell injections. After wetting the hair down with some saline so we could see, we then injected the PRP/ACell into the scalp in the areas we wanted to improve the growth. The PRP should be injected as precisely as possible at the depth of the “bulge” (i.e. where the hair stem cells are located in the follicle 2-3m below the surface) and “activating” the PRP with the addition of calcium gluconate or other PRP “activator” is also a common step before injecting. Injecting is the last part of the whole process, and it takes all of about 5 minutes – which is almost anticlimactic at this point in the procedure. When I tell them we are finished, most patients ask, “You mean you did it already?”
Post-operatively, I told JK to keep his hair clean (i.e. go ahead and shower normally), watch for swelling or a mild headache. There was some pinpoint bleeding immediately after the procedure, and we took photos again for documentation, but overall he was pleased that the procedure was as short and mildly uncomfortable as it was. In order to minimize any potential swelling, he planned to sleep slightly upright the first few days, but this is not strictly needed for most patients. As he left I once again gave him my cell number and told him to call if there were any problems. We set up our next appointment for 3 months later, and I did not hear from him at all except at our call confirming his next appointment…
In mid-September, JK returned for his “booster” PRP/ACell treatment. He said he had not had any swelling whatsoever. His head had been mildly sore for the first day or so (likely from being stuck with a needle!) and his business had been so busy that he was coming in actually at the 3.5 month mark so he was concerned that the treatment would not work. I reassured him that hair follicles follow a general timeframe, but they are NOT punctual to the day when you expect them to grow. In fact, if hair was a country, it would be more like Italy and the Italians than the Swiss…
We first took another set of photographs in the same poses and with the same lighting as the previous visit. We also performed another HairCheck at precisely the same locations we had at the initial visit (NB-we have one staff member perform these so no one else – including me – can bias the results). These numbers were telling, and so I asked him how he felt his hair was growing and overall he noted less hair falling out and an overall thicker feeling to the hair. JK’s numbers were consistent with this assessment. His HairCheck showed:
With this initial hopeful sign that he might be part of the estimated 60-80% of patients who gets a benefit from PRP/Acell, we again drew blood, prepared the PRP, numbed his scalp, and injected the PRP with ACEll into the same areas as previously. JK planned to go work out later that day, and refused the Tylenol we offered. He also asked if it was ok for him not to sleep upright since he had no swelling the last time, and I told him that that was fine since any swelling would probably be mild anyway. He left the office with another visit scheduled for 3 months later (at the 6 month mark since his treatments began) and my cell number/email in case of problems.
THE SIX MONTH CHECK-UP:
JK came back for his 6-month check up at the beginning of January, 2016. My staff had already re-taken his standard set of photos and performed a HairCheck and they handed me his chart as I was walking in the room to see him. I was running a little behind so before reviewing the paperwork, I asked him how he felt things were going with his hair. “I think it worked,” he said. He did not see as much shedding, it felt fuller, and other people noticed. I looked at his HairCheck readings and showed him the improvement:
Which means his hair growth looks like this I you track it in a chart:
Now, charts look good, but 6 months is a short time to expect improvement in the world of hair medicine. Most experts around the world will tell you it takes at least that long to even begin to see a change one way or another. But, even accounting for any small variability in taking the measurements, this seemed to confirm JK’s hair growth and observations with solid evidence.
There was a catch, though – JK was not as excited as I would have anticipated. He felt that even with the improvement, this would not be the treatment plan that would fit his goals.
I had to admit that this was a realistic view of the situation. JK had indeed had an amazing response to the PRP/ACell, but overall he could probably do even better. We discussed that this would mean starting on medical therapy, and even considering hair transplantation surgery. JK had thought about all this even before I brought it up. He knew he had aggressive hair loss in his family, and as time had gone on, he began to see the logic of getting aggressive right back. He now wanted to develop a long term plan that included doing everything he could, both medically and surgically to arrest the ongoing miniaturization and replace the hair mass that had been lost before we started treating him.
To that end, we decided to suspend the remaining PRP/ACell treatment in favor of starting finasteride, minoxidil, and scheduling a surgery with the traditional “strip” approach to maximize the number of grafts possible in a single surgery. At the end of January, we performed this surgery and transplanted 4205 grafts to the frontal, mid-bridge, and a little into the vertex areas of his scalp. We have yet to see the final results – I warned him that it would take 6-12 months to grow so be a “a patient patient.” He also took several opportunities to mention (humorously) that my numbing skills had deteriorated, but that my staff was more caring than I was and deserved a big fat raise (and I agreed!).
All in all, this case is an excellent example of the process that patients go through as they decide the best course of action for treating their hair loss. Sometimes the long-term benefits of a treatment are not justified by the maintenance routine necessary to keep them. Different treatments meet different goals for the wide variety of patient situations out there, and in the long view, the best thing a patient can do is to develop an overall plan for their hair loss with their doctor.
2) Review of Factors Affecting the Growth and Survival of Follicular Grafts
3) Fernandez-Barbero JE, Galindo-Moreno P, Avila-Ortiz G, Caba O, Sanchez-Fernandez E, Wang HL. Flow cytometric and morphological characterization of platelet-rich plasma gel. Clin Oral Implants Res. 2006;17:687–693.
5) Miao, Y MD et al.. Promotional effect of PRP on Hair Follicle Reconstitution in Vivo. Derm Surg 2013;39:1868-1876.
6) Use of porcine urinary bladder matrix in hair restoration surgery applications. AND Early results in the use of injectable ACell suspended in arterial blood serum/PRP in retarding hair loss/re-growth of miniaturizing scalp hairs. Hair Transplant Forum Int’l June 2011
Notes From the Editor Emeritus, Hair Transplant Forum Int’l. Jan 2014
Good search engines like pubmed.gov will have the search terms “PRP” and “autologous plasma” as well as “hair loss” and “androgenetic alopecia” if you would like to look for yourself!
Additional Suggested reading:
- Stenn KS, Cotsarelis G. Bioengineering the hair follicle: fringe benefits of stem cell technology. Curr Opin Biotechnol 2005;16:493–7.
- Miteva M, Tosti A. Treatment options for alopecia: an update, looking to the future. Expert Opin Pharmacother 2012;13:1271–81.
- Eppley BL, Pietrzak WS, Blanton M. Platelet-rich plasma: a review of biology and applications in plastic surgery. Plast Reconstr Surg 2006;118:147e–59e.
- Uebel CO, da Silva JB, Cantarelli D, Martins P. The role of platelet plasma growth factors in male pattern baldness surgery. Plast Reconstr Surg 2006;118:1458–66.
- Li ZJ, Choi HI, Choi DK, Sohn KC, et al. Autologous platelet-rich plasma: a potential therapeutic tool for promoting hair growth. Dermatol Surg 2012;38:1–7.
- Weinberg WC, Goodman LV, George C, Morgan DL, et al. Reconstitution of hair follicle development in vivo: determination of follicle formation, hair growth, and hair quality by dermal cells. J Invest Dermatol 1993;100:229–39.
- Perez-Meza D. Part II The use of autologous rich and poor plasma to enhance the wound healing and hair growth in hair restoration. In programs and Abstracts. 13th ISHRS annual meeting; Sydney, Australia 2005.
- Uebel C. A new advance in baldness surgery using platelet-derived growth factor. Hair Transplant Forum Int 2005;15:77–84.
- Perez-Meza D, Leavitt M, Mayer M. The growth factors Part 1: clinical and histological evaluation of the wound healing and revascularization of the hair graft after hair transplant surgery. Hair Transplant Forum Int 2007;17:173–5.
- Greco J, Brandt R. Preliminary experience and extended applications for the use of autologous platelet rich plasma in hair transplantation surgery. Hair Transplant Forum Int 2007;17:131–2.
- Greco J, Brandt R. The effects of autologous platelet rich plasma and various growth factors on non-transplanted miniaturized hair. Hair Transplant Forum Int 2009;19:49–50.
- Zheng Y, Du XB, Wang W, Boucher B. Organogenesis from dissociated cells: generation of mature cycling hair follicles from skin-derived cells. J Invest Dermatol 2005;124:867–76.
- Jahoda CA, Horne KA, Oliver RF. Induction of hair growth by implantation of cultured dermal papilla cells. Nature 1984;311:560–2.
- 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.
- Yano K, Brown L, Detmar M. Control of hair growth and follicle size by VEGF-mediated angiogenesis. J Clin Invest 2001;107:409–17.