Mechanical and Controlled PRP Injections in Patients Affected by Androgenetic Alopecia

Summary

This paper aims to describe the interfollicular autologous platelet-rich plasma injections (0.20 mL x cm²) in the scalp of 23 patients affected by androgenetic alopecia at a depth of 5 mm using a medical injector gun equipped with a 30 gauge needle, in three sessions.

Abstract

23 patients (18 male and 5 female) aged 21-70 years who displayed male pattern hair loss (MPHL) in Stage 1 to Stage 5 as determined by the Norwood-Hamilton classification scale, and female pattern hair loss (FPHL) in Stage 1 to Stage 2 as determined by the Ludwig classification scale, were treated with non-activated autologous platelet-rich plasma (A-PRP). Autologous blood (55 mL) was harvested using sodium citrate as an anticoagulant. A-PRP (23 mL) was produced for all cases using a closed system according to the transfusion service protocol. Following centrifugation (260 x g for 10 min) the A-PRP was inserted in a laser light selector device, and after the centrifugation, 9 mL of A-PRP was collected.

The scalp of the patients affected by androgenetic alopecia (AGA) was divided into four areas (frontal, parietal, vertex, and occipital); local anesthesia was not performed. Interfollicular A-PRP injections (0.2 mL x cm²) were performed by controlled and mechanical injections scheduled at a depth of 5 mm using a medical injector gun. Treatment sessions were performed with a 30-day interval. For each patient, three treatment sessions were performed.

PRP was injected in the androgen-related areas of scalp affected by hair loss. Placebo (normal saline solution) was loaded in another syringe (10 mL) and injected on the adjacent side in a similar fashion.

Introduction

The clinical injection of non-activated A-PRP has become an attractive resource for targeting hair growth. Here, the protocol of the A-PRP application in AGA is reported, using mechanical and controlled injections. Currently, only oral selective 5-α-reductase inhibitor, topical diaminopirimidilpiperidin-N-ossido (2.0% and 5.0%), and low-level laser therapy (LLLT) are approved by the US Food and Drug Administration (FDA) to combat MPHL^1,2.

Diaminopirimidilpiperidin-N-ossido 5% foam is also approved by the FDA for FPHL. The selective 5-α-reductase inhibitor has proven largely ineffective in treating FPHL³, and, given that the drug may cause abnormalities in the external genitalia of male fetuses, is unsuitable for use by pre-menopausal women⁴. Conversely, daily treatment with 1 mg of selective 5-α-reductase inhibitor has been shown to reduce serum dihydrotestosterone (DHT) levels by 70% and promotes hair growth of anagen hair leading to gradual increase in hair diameter and hair elongation in male AGA patients^5,6, through significant improvements in hair density. The use of oral selective 5-α-reductase inhibitor may require up to one year of treatment and users may develop loss of libido, which may persist after the medication is discontinued⁷.

Recently, the use of LLLT has been proposed to stimulate hair regrowth. Afifi et al.⁸ reviewed the existing research studies to determine whether LLLT was an effective therapy for AGA. The topical application of activated autologous platelet-rich plasma (AA-PRP) to harvested follicles prior to implantation has already been shown to increase their survival rate by 15% in patients affected by AGA⁹, as well as exhibit increased hair density 3 months post-surgery with terminal hair density increasing by 19% during that time¹⁰. These findings were confirmed in a study following AGA patients treated with calcium-activated PRP over the course of one year¹¹.

Given the positive results of AA-PRP¹² and A-PRP¹³ as an alopecia treatment, and the lack of data for the clinical injections system, the primary aim of this work is to show mechanical and controlled PRP injections protocol.

18 male and 5 female patients aged 21-70 years who displayed MPHL in Stage 2 to Stage 5 as determined by the Norwood-Hamilton classification scale, and FPHL in Stage 1 to Stage 2 as determined by the Ludwig classification scale, were treated with mechanical and controlled injections of A-PRP. AGA diagnoses were made by a medical history, trichoscopic analysis, clinical evaluation with negative hair pull test, laboratory tests, and urinalysis.

The stage of AGA was evaluated using the Norwood-Hamilton and Ludwig scale. All of the participants included in this study were assessed by a medical doctor specialized in dermatology and two plastic surgeon experts in regenerative plastic surgery and alopecia. The authors considered localized and systemic exclusion criteria for all patients. Systemic criteria were represented by blood and/or platelet disorders, anticoagulant and/or antiaggregation therapy, sepsis, immunosuppression, cancer, use of oral selective 5-α-reductase inhibitor or antiandrogens in the previous 12 months.

Localized exclusion criteria were represented by use of diaminopirimidilpiperidin-N-ossido (2.0% and 5.0%) or corticosteroids for topical treatments in the previous 12 months.

Protocol

The study protocol complied with the Declaration of Helsinki, and all patients provided written informed consent before participating in the study.

1. Non-activated A-PRP Preparation

1. Harvest 55 mL of autologous blood from a peripheral vein of the arm using a tube with butterfly needle according to the local blood collection protocol.
2. Add 7 mL of acid citrate dextrose (ACD) solution (112 mM of citrate) to the blood tube as an anticoagulant.
3. Centrifuge the blood collected in the tube at 260 x g for 10 min.
   Note: 23 mL of A-PRP + Autologous Platelet-Poor Plasma (A-PPP) and 20 mL of Red Blood Cells suspension (RBCs) were produced.
4. Take out the tube containing A-PRP + A-PPP and RBCs from the centrifuge and insert it in a laser light selector device.
5. Separate A-PRP + A-PPP in a sterile bag by mechanical suction performed by the laser selector in which the kit is placed. RBCs are automatically removed by mechanical suction.
   Note: 14 mL of A-PPP was manually harvested and removed by the sterile bag from the kit. 9 mL of A-PRP was obtained.

2. Non-activated A-PRP Injections

1. Divide the scalp of the patients affected by AGA into frontal, parietal, vertex, and occipital areas.
   Caution: Do not perform anesthesia (local or systemic).
2. Perform interfollicular A-PRP injections (0.20 mL x cm²) by the medical injector gun (see Table of Materials) to selected areas of the scalp.
   1. In patients with hair loss localized to the frontal and parietal areas, perform A-PRP injections exclusively to the frontal area and use saline as placebo in the parietal area.
   2. In patients with hair loss localized to the parietal and vertex areas, inject A-PRP in the parietal area, and use saline as placebo in the vertex area.
3. Perform an equal number of A-PRP and placebo injections for each patient.
4. Perform interfollicular A-PRP injections at a depth of 5 mm using the medical injector gun equipped with a 30G needle and 10 mL syringe.
5. Perform three sessions spaced 30 days apart.

Results

The hair growth parameters measured three months after the third A-PRP injections by tricoscopic analysis were compared with the baseline measurements and between the A-PRP treatment area and the control area, which received physiological saline injections as placebo. Before the first treatment, at baseline, no statistical differences in hair count (122 ± 10) and hair density (218 ± 17) were reported between the targeted area and controlled area (126 ± 9 baseline hair count controlled area), (225 ± 15 baseline hair densi...

Discussion

The authors demonstrated that mechanical and controlled injections of A-PRP represent viable AGA treatment options, with reduction of pain during the procedure compared with manual injection performed by the hands of the surgeon. Patients treated with this protocol were found to have greater increases in hair count and total hair density than patients treated with manual injections.

The most important aspect to obtain an improve...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
C-PunT system	Biomed Device, Modena, Italy	www.biomeddevice.it	a closed system medical device to obtain autologous concentrated platelet-rich plasma from the blood
Ultim Gun	Anti-Aging Medical System	www.aamedicalsystems.fr	a gun medical device to perform a mechanical and controlled injections of autologous platelet-rich plasma in a selected area of the scalp
Trichoscan	Tricolog GmbH, Freiburg, Germany).	www.tricholog.de	trihoScan is a digital software-supported epiluminescence technique for measuring hair count (number of hairs per 0.65 cm2), hair density (number of hairs per cm2), hair diameter, anagen-to-telogen ratio, and vellus hair-to-terminal hair ratio.
sodium citrate ACD-A	S.A.L.F.	SAAS2205GPO	anticoagulant for PRP preparation
30-Gauge needle	Becton Dickinson	Z192368	needle for injections
10 mL mL Luer-Lock syringe	Becton Dickinson	BD309695	syringe for PRP collection