Regenerative Medicine - PRP/PRFM in Hair Loss Treatment 

PictureVials with centrifuged and separated blood. The golden liquid in the upper part is plasma
Platelet Rich Plasma (PRP) is a product of a patient's own blood, a golden color liquid that is obtained after centrifugation of the blood. PRP is activated and typically injected with a syringe, triggering body's own healing and rejuvenating processes at the injection site. 
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​PRP is currently used in the regenerative and sports medicine for wound and injury healing and tissue regeneration, in the face and skin rejuvenation; and it has been studied in the treatment of the hair loss (Maria-Angeliki, 2015), mostly for the androgenetic alopecia, to a lesser extent - for the alopecia areata; there are also some studies of the effectiveness for the telogen effluvium.
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Before and a follow-up after six once-a-month PRP sessions

PRP/PRFM - what it is and how it works

mechanism of action
​The precise mechanisms behind PRP action are not fully established, but it is generally accepted that PRP derives its regenerative qualities from bioactive proteins and peptides, called growth factors.
After a patient's blood is drawn in vials and separated in a centrifuge, the growth factors in the remaining plasma are activated by adding special compounds.

Once injected in the scalp, growth factors in platelets' granules of PRP bind to the bulge area of hair follicle (Maria Angeliki, 2015).
They revive dormant and dying fair follicles and facilitate hair growth and hair strength in those follicles. For this reason, a PRP treatment is unlikely to restore hair in an area where there has been no hair for years, and hence no hair follicles are left. ​
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Activated PRP secrets growth factors for about an hour after activation. Activated PRFM may secret growth factors for about 72 hours. 
procedure at a high level
  • PRP treatments are relatively non-invasive and regarded as safe.
  • The patient's own blood, 30 - 100 ml, is drawn from the vein into vials. Then the vials with the blood are spun in a special centrifuge to separate red blood cells, white blood cells, and plasma with platelets. The former are all discarded. Some preparation techniques include a second centrifugation. The remaining golden-color PRP liquid is activated typically with thrombin and calcium and is either injected with a syringe in multiple spots in the treated area or, alternatively, it can be applied topically during a micro-needling treatment; read more about the procedure here;
  • The regenerative potential of PRP/PRFM depends on the degree of the growth factors release (Wiebrich, 2002; Eppley, 2004), platelet concentration (Giusti, 2009), blood quality, how fast PRP is injected after activation (Garg, 2017); read more about PRP effectiveness here;
  • Some results are likely to be visible even after one treatment (2 to 6 months after the treatment). However, a series of 3 - 4 treatments is typically recommended;
  • The cost is $500 - $1,200 per treatment, and a series of 3-4 treatments is recommended to achieve a significant result.
PRP vs PRFM
Platelet-Rich Plasma (PRP) and Platelet-Rich Fibrin Matrix (PRFM) are both made mostly of a patient's own blood. It's a golden color liquid left after the blood is centrifuged, and white blood cells, red blood cells, and platelet poor plasma are discarded. 

PRP, that more people are familiar with, is a more 'standard' version. 
PRFM can be thought of as a more advanced version of PRP.

Platelet-rich fibrin matrix (PRFM) is different from PRP in the following:
  • the concentration of platelets is lower than in PRP;
  • sustained release of growth factors is much longer (about 72 hours vs one hour). That sustained release is achieved by addition of calcium chloride to the plasma with platelets. The small quantity of calcium initiates creation of the fibrin matrix, a scaffold, that binds platelets and growth factors at the injection site. ​Physiologically, this 'structure' resembles more what happens during a natural wound healing process (Sclafani, 2011). 

PRP Effectiveness in Hair Loss Treatment 

Types of hair loss treated with prp
PRP is thought to work by activating dormant hair follicles that are in the resting, telogen stage. 

  • Effectiveness of the PRP has been studied the most and found effective for the androgenetic alopecia;
  • Some studies have been conducted for the alopecia areata, and PRP has also been found effective.;
  • It has also been studied in the treatment of telogen effluvium; however, results are inconclusive. The likeley reason for that is that telogen effluvium is an 'umbrella' name for a number of very different health imbalances that lead to hair loss.
(Garg, 2017)
studies
Most studies of the the PRP/PRFM treatments for the hair loss with a minimum of three sessions demonstrate PRP effectiveness and improvements that commence at 2-3 months after the treatment and continue improving even more up to 6 months after the treatment.
  • “ A 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. Therefore, average mean gain is 22.09 follicular units per cm2. After the fourth session, the pull test was negative in 9 patients" (Khatu, 2014)
  • A review of 10 studies that used the minimum of 3 PRP sessions for the treatment of androgenetic alopecia showed positive “ therapeutic potential of PRP for the treatment of AGA. Among them, 6 studies demonstrated a statistically significant improvement following treatment with PRP using objective measures and 4 additional studies showed hair improvement (e.g., hair density, diameter) with PRP” (Cervantes, 2018)
  • Two more studies (one PRP treatment for women with AGA; two PRP treatments for men with AGA) showed no significant improvement (Cervantes, 2018). 
what impacts PRP effectiveness
Factors:
  • PRP/PRFM is a biological material, and its quality depends on the blood quality. Healthy diet is recommended before the blood is collected, and smoking is a relative contra-indiction for the procedure. 
 
  • The activating compound can make a difference if it impacts the duration of the growth factors release. PRP and PRFM are very similar, but differ in the type of compounds added to the drawn blood to activate the growth factors. PRFM provides a longer sustained release of growth factors after the activation and injection in the scalp and may be more effective in the treatment of hair loss. 
 
  • The effectiveness of PRP depends on the platelet concentration. The optimum concentration is 1.5 million platelets/µL, which is 5 - 10 times more than the level of platelets concentration in whole blood (Giusti, 2009). Concentrations less than 1.5 mln are less effective (and the level of concentration higher than the optimum level may inhibit rejuvenation). To achieve the required level of platelets concentration, normally the second centrifugation is required. In that centrifugation, platelets are concentrated in Platelet Rich plasma, and Platelet Poor Plasma is discarded.  It's worth noting that while concentration of platelets in PRFM is lower than the stated level, it is likely to be at least as effective as PRP with higher concentrations due to a much longer platelet release;
 
  • Finally, the effectiveness of the injections depends on how fast after activation PRP is injected. PRP should be used within 10 minutes after activation. "The platelets actively secrete growth factors within 10 minutes after activation and more than ninety five percent of the presynthesized growth factors are secreted within 1 hour" (Garg, 2017).

Preparation of the activated PRP is not standardized across the medical aesthetics industry, for example the number of centrifugations, the compounds activating growth factors, concentration of the platelets in the injected product, how fast PRP is injected and how much per injection site. 
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Therefore, the difference in the outcomes can be most likely attributed to the above factors, particularly to the differences in the PRP/PRFM preparation (Wiebrich, 2002; Eppley, 2004). 
​A patient may want to ask the medical provider about the precise technique/methods that the provider uses for the PRP preparation and injection. 

Just like any other non-surgical procedure, PRP/PRFM is only going to work in the places where hair follicles are still alive (even though there may be no visible hair on the skin surface). ​​

How the Procedure is Performed 

STEPS
  • Numbing/local anesthetic is typically applied to the treated area, because the injections are somewhat painful;
  • The patient's own blood (some 30 to 100 ml) is drawn from a vein into vials;
  • The vials with the drawn blood are spun in a centrifuge to separate red blood cells and white blood cells from plasma. The golden color plasma is left, everything else is discarded;
  • Some PRP preparation techniques include the second round of centrifugation that yields more effective PRP. In that second step, plasma with platelets is transferred into sterile tubes, centrifuged again to concentrate platelets at the bottom (for the truly platelet rich plasma), and platelet poor plasma is discarded (Dhurat R, 2014);​
  • The remaining golden-color PRP liquid is activated with, for example, thrombin or calcium chloride;
  • All the above steps take 15 to 30 minutes; 
  • PRP/PRFM is injected with a syringe in multiple spots in the treated area. For the most effectiveness, PRP should be injected within 10 minutes after activation;
  • Except for the marks on the injection site, there is no recovery or downtime.

PRP/PRFM for the Hair Loss Treatment Summary and Pros and Cons

Considerations.
The effectiveness of the procedure is affected by:
  • the blood quality,
  • the level of platelet concentration that depends on the PRP preparation technique, particularly the number of centrifugations;
  • activating compounds used, and
  • how fast PRP is injected after blood is drawn. 

Pros:
  • Autologous (patient's own) biomaterial is used for the procedure - no risk of rejection or allergic reaction;
  • Proven effectiveness;
  • Relatively non-invasive (blood is drawn, plasma is injected or applied along with the microneedling), no recovery, no downtime.
Cons:
  • ​Cost. The cost per session starts at $500 and can be as high as $1,200. A series of 3 - 4 treatments is required to see satisfactory results, and the total cost is between $1,500 to $4,800.
  • PRP works by reviving dormant/dying hair follicles. It is unlikely to work (well) on the areas where hair has been gone for years. 
Full list of references and literature on hair loss treatment and management is here