Does Platelet‐Rich Plasma Have a Therapeutic Role in Hair Restoration?

Platelet-rich plasma (PRP) is an innovative technology for hair restoration. PRP is created as an autologous substance from the centrifugation of patients' own blood. Growth factors found within platelets can allow for cell angiogenesis and proliferation. Androgenetic alopecia (AA) as well as female pattern hair loss (FPHL) can have significant impacts on patient quality of life, wellbeing, and perception of overall appearance.1 Many treatment options for patients with AA/FPHL exist, ranging from non-invasive to invasive. The most invasive current option for hair restoration is hair transplantation, which can lead to potential complications and is costly for patients. From a minimally invasive perspective, PRP has emerged as a novel hair restoration technique in the literature and gained popularity amongst patients and providers alike. Currently, there is a question regarding the true efficacy of and correct preparation protocols for PRP for hair restoration. Literature has been published on PRP for hair restoration, however, individual studies have been somewhat underpowered and inconclusive. Hence, by using recent systematic reviews/meta-analyses, this article aims to clarify if PRP has a therapeutic role in hair restoration. The literature was searched for all articles involved in PRP for hair restoration. Most relevant to this best practice summary, multiple recent systematic reviews published within the last 5 years were found, highlighting the primary literature on PRP for hair restoration. There was some overlap in the included studies between these reviews. Across these reviews 56 unique original studies were included with 2,114 unique patients. (Table I). Cervantes et al.2 conducted a review on the effectiveness of PRP for AA. Twelve studies were included, six of which were randomized controlled trials. The number of PRP sessions ranged from 1 to 6, with an interval of 2 weeks to 3 months in between sessions. Centrifugation speeds ranged from 580 to 3,300 rpm, with a range of platelet enrichment from x2–7. Activators used included Calcium chloride, plasma rich growth factor activator, and no activators. Blood volume ranged from 9 to 60 ml and PRP volume ranged from 1.5 to 20 ml. Side effects of PRP were commented on, including mild headaches, itching, and temporary pain. They concluded that 10/12 of the reviewed studies showed the therapeutic effectiveness of AA by increasing terminal hair density/diameter. Based on the included studies, they recommend a double-spin centrifugation method at 1,700 rpm and then 2,500 rpm, using a calcium containing activator, with a range of 3–12 ml of PRP with mean platelet enrichment of 3–6x. Finally, a minimum of three sessions at 1 month intervals was recommended. Giordano et al.1 wrote a systematic review and meta-analysis on PRP for AA. The primary outcome of interest for their meta-analysis was number of hairs per cm2. They included six articles in their analysis, all of which had either a low or unclear risk of bias. A total of 117 patients were included in these studies. There was a mean difference of 17.90 number of hairs per cm2 in the PRP patients versus controls (p = 0.004). Blood volume range was 15−60 ml. PRP injection sessions ranged from 1–6 times, with 15–60 ml of blood used. Centrifugation rates were 1700−3000 rpm. Gupta et al.3 completed a systematic review and meta-analysis on the efficacy of PRP for hair restoration and facial aesthetics. Twenty three studies met their inclusion criteria, including seven randomized controlled trials (RCTs). Most commonly among the studies, PRP was delivered 1x/month for 3 months. Forty seven percent of studies used calcium gluconate for activation. Platelet concentrations ranged from 2–6x baseline count. Twenty six percent of the included studies were considered high quality. They found that PRP showed greater efficacy over placebo with regards to terminal hair density (p = 0.003), hair diameter (p < 0.05), increased epidermal thickness (p < 0.05) as well as hair density (p < 0.05). They commented that it is unclear if there is sufficient evidence to support activator use, the number of sessions needed, the number of platelets injected, or the platelet concentration. They did find evidence to support more frequent PRP sessions (every 4 weeks) compared to less frequent. Mao et al.4 conducted a systematic review evaluating PRP for treating AA. Eleven articles were included with the 262 AA patients. The extracted outcomes include hair density, hair cross section, terminal hair density, and vellus hair density. In addition, some studies reported on patient satisfaction. Some studies included controlled clinical trials (CCTs) and others were RCTs. The risk of bias was assessed, and there was a low-unclear risk of bias for the included studies. Among studies, there was no uniform frequency and interval of PRP injection. Injection methods ranged from one to six injections. Centrifugation speeds ranged from 1100 to 3500 rpm. Hair density was lower for single-spin centrifugation compared to double-sin (p < 0.0001), and there was no difference between using activation or without. There was no relationship found between treatment frequency/interval and effects. They found a significant increase in hair number per cm2 after PRP injections compared to the control group (p < 0.00001), as well as hair density (p = 0.05). Zhou et al.5 conducted a systematic review and meta-analysis looking at PRP in FPHL patients. Forty two studies with 776 female patients were included. There were 16 RCTS and 26 observational studies included. There was variation in the preparation strategies used in each included study. All studies added calcium gluconate and sodium citrate. Platelet concentrations ranged from 1.5 to 7x whole blood. Mostly 3–5 injections across 4–6 treatment intervals were performed. Centrifugation ranged from 450 to 4,000 rpm. PRP was efficacious in improving hair density compared to control groups (OR 1.61) and compared to baseline (OR 1.11). Most trials included had a low risk of bias, with only a few studies including some concerns/high risk. Based on this review of the current literature on PRP and hair restoration, PRP does have a therapeutic role in hair restoration. Regarding effective regimens, multiple treatments with an inter-treatment interval of 4 weeks can be recommended. Most studies used an activator, and there was some benefit to double-centrifugation. There is still a significant gap in knowledge regarding a defined, evidence-based, and standardized preparation technique for PRP use in hair restoration. All of the included studies called for the need for further rigorous, randomized double-blinded trials assessing PRP and hair restoration.

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