Accepted Article

DR MARGIT JUHASZ (Orcid ID : 0000-0002-5723-6167)

Article type : Research Letter

Stratifying clinical response to adjuvant platelet-rich plasma in androgenetic alopecia patients

M.L.W. Juhasz,1,2 K. Sukhdeo,2 K. Lo Sicco2 and J. Shapiro 2

1 University of California, Irvine, Department of Dermatology, Irvine, CA

2 New York University, The Ronald O. Perelman Department of Dermatology, New York, NY

Corresponding Author: Margit Juhasz, MD, MSc

Email: mjuhasz@uci.edu

The authors have no conflicts of interest to disclose.

The authors did not receive any funding for this research.

Keywords: platelet-rich plasma, hair loss, androgenetic alopecia, treatment efficacy

This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process, which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
10.1111/BJD.19064
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 Platelet-rich plasma (PRP) is a promising treatment for androgenetic alopecia (AGA), but is not efficacious in
Accepted Article
all patients. Dynamic, quantitative trichoscopy can longitudinally follow hair regrowth during and after
treatment,1-4 thus characterizing clinical response to PRP as continued, non-productive treatment sessions
may lead to large patient burden. To appropriately counsel patients on adjuvant PRP treatment success,
clinical results must be accurately described. The objective of this study is to determine if AGA patient
response to adjuvant PRP can be stratified based on quantitative hair counts after two treatment sessions.
This retrospective review was approved by the New York University School of Medicine Institutional
Review Board. AGA patients who received adjuvant PRP therapy (RegenKit-BCT-1, RegenLab USA, New York,
NY) as part of their treatment regimen at a single, tertiary, academic medical center from January 2012 to
May 2019 were identified. PRP was prepared after venipuncture of 8 or 16 mL of blood, followed by
centrifugation (5 minutes, 1500 g), resulting in 5 or 10 mL, respectively, of supernatant with 1.6-fold
increased platelet concentration. Intradermal scalp injections (0.1 mL, 1 cm apart) were directed to clinically
affected areas. Trichologic assessment of hair density and hair shaft diameter was obtained using the
Folliscope (Anagen Corp, Seoul, South Korea); the location of baseline measurement was recorded, and all
follow-up measurements were taken in the same area. After two PRP sessions completed at four to six-week
intervals, patients were assessed for clinical response, defined as an increase in hair density by 10 hairs/cm2
from baseline. If patients were “PRP-responders” they received a further four monthly PRP sessions and
maintenance injections every three to six months.4 Statistical analyses of trichoscopic measurements were
completed using unequal t-tests.
104 (17.7%) of 588 identified AGA patients received adjuvant PRP. Most patients were female (71.2%,
n=74); the mean age was 46.0 ± 16.9 years. 93.3% (n=97) of patients were using other AGA-directed therapies
prior to initiating PRP including 79.4% (n=77) topical minoxidil, 61.9% (n=60) oral 5α-reductase inhibitor
(finasteride/dutasteride), and 42.3% (n=41) each oral minoxidil or spironolactone, amongst others. Of these
97 patients, 17 only had one PRP treatment and could not be evaluated for response; three patients with
concomitant scarring alopecia did not have trichologic measurements.
A positive response to adjuvant PRP was reported in 70.1% (54/77) of patients after two sessions.
After two PRP treatments, mean change in hair density from baseline demonstrates a significant 21.2±12.3%
increase in “PRP-responder” hair density versus a -2.5±6.2% decrease in “PRP-non-responders” (p < 0.0001)
(Figure 1). Of PRP-responders, 14.8% (n=8) demonstrated < 10% increase in hair density over baseline, 42.6%
(n=23) a 10-19.9% increase, 20.3% (n=11) a 20-29.9% increase, 16.7% (n=9) a 30-39.9% increase, 3.7% (n=2) a

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 40-49.9% increase and 1.9% (n=1) > 70% increase. Of non-responders, 52.2% (n=12) demonstrated a decrease
Accepted Article
in hair density from baseline, 13 % (n=3) demonstrated no change, and 34.8% (n=8) a < 10% increase.
Interestingly, despite lack of trichologic response, 12 non-responders opted to continue PRP therapy.
PRP-responders sub-group analysis showed a non-significant increase in regrowth after two sessions
between patients with baseline lower hair density (< 180 hairs/cm2), compared to those with normal density
(≥ 180 hairs/cm2) and subjective thinning (p = 0.0520); men were minimally more responsive to treatment
than women, however this difference did not reach significance. Forty-five PRP-responders received over
three PRP sessions. There was no significant improvement in hair shaft diameter after two PRP sessions in
either PRP-responders or non-responders. There was also no difference in the type(s) or number of AGA-
directed therapies used by PRP-responders or non-responders. Study limitations include retrospective design,
data obtained from a single-center possibly biased for patients with more severe AGA, lack of blinding and
proper control, as well as operator-dependent variation in hair counting.
Although PRP is reported as a monotherapy for AGA, it is unlikely that patients are not using multiple
treatment modalities by the time they or their physician decide to pursue adjuvant PRP. Hair specialists
disagree regarding the number of PRP treatments needed before assessing clinical efficacy,1,3 however these
arguments are often based on anecdotes. Our data reveals that it is possible to use quantitative trichoscopy
to stratify therapeutic response to adjuvant PRP after two treatment sessions (i.e. two months after initial
PRP injections). Many factors affecting PRP efficacy and treatment response (e.g. platelet and growth factor
concentration, leukocyte content, platelet activation, centrifugation protocols, total treatment sessions,
duration between sessions, and maintenance therapy) are unknown, and it is possible that initial “non-
responders” may respond to PRP therapy with continued sessions. Future directions include further
characterization of patient response to adjuvant PRP based on response to prior AGA therapies, disease
duration prior to PRP initiation, and amount of PRP delivered per treatment. We hope our findings will help
physicians counsel patients on the therapeutic benefit(s) of adjuvant PRP, as well as inform patient decisions
regarding further treatment.

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 REFERENCES
Accepted Article
1. Hausauer AK, Jones DH. Evaluating the Efficacy of Different Platelet-Rich Plasma Regimens for
Management of Androgenetic Alopecia: A Single-Center, Blinded, Randomized Clinical Trial. Dermatol Surg
2018;44(9):1191-1200.
2. Stevens HP, Donners S, de Bruijn J. Introducing Platelet-Rich Stroma: Platelet-Rich Plasma (PRP) and
Stromal Vascular Fraction (SVF) Combined for the Treatment of Androgenetic Alopecia. Aesthet Surg J
2018;38(8):811-822.
3. 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 2018;17(1):47-53.
4. Ho A, Sukhdeo K, Lo Sicco K, Shapiro J. Trichologic response of platelet-rich plasma in androgenetic
alopecia is maintained during combination therapy. J Am Acad Dermatol 2020;82(2):478-9.

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 FIGURE LEGENDS
Accepted Article
Figure 1. Mean increase in hair count from baseline of patients using two or more sessions of adjuvant PRP
(n=77). There is a significant difference in clinical response between PRP-responders versus non-responders
after two PRP sessions (p < 0.0001).

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Accepted Article

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