MICRONEEDLING WITH PLATELET-RICH PLASMA VERSUS MICRONEEDLING WITH TOPICAL 5% MINOXIDIL IN PATIENTS WITH ANDROGENETIC ALOPECIA- A COMPARATIVE STUDY Kallappa C. Herakal 1, Pehani Parag Vallabhbhai 2, Karjigi Siddalingappa 3, Mouryabha Shale 4, Deepika M. G 5, Kusuma M. R 6 1Professor & HOD, Deparmen of Dermaology, Navodaya Medical College & Research Cenre, Raichur. 2Junior Residen, Deparmen of Dermaology, Navodaya Medical College & Research Cenre, Raichur. 3Professor, Deparmen of Dermaology, Navodaya Medical College & Research Cenre, Raichur. 4Junior Residen, Deparmen of Dermaology, Navodaya Medical College & Research Cenre, Raichur. 5Junior Residen, Deparmen of Dermaology, Navodaya Medical College & Research Cenre, Raichur. 6Senior Residen, Deparmen of Dermaology, Navodaya Medical College & Research Cenre, Raichur. ABSTRACT BACKGROUND Androgeneic alopecia (AGA) is he mos common ype of alopecia in men, which is an androgen mediaed even. The FDA approved reamen for male AGA are Finaseride and Minoxidil. Plaele-rich plasma (PRP) is a newer mehod for he reamen of various ypes of alopecia by providing growh facors in simulaing dermal papilla associaed sem cells. Minoxidil helps in new hair growh by causing vasodilaaion of scalp blood vessels. Treamen wih microneedling showed an acceleraed response leading o significan increase in scalp densiy. MATERIALS AND METHODS Tweny five paiens wih AGA had undergone microneedling monhly wice followed by Topical 5% minoxidil soluion daily. Minoxidil should be applied 24 hours afer microneedling. Anoher Tweny five paiens were subjeced o microneedling wih Plaele-rich plasma monhly wice. Paiens were assessed wih he use of he sandardised 7-poin evaluaion scale and paiens' subjecive hair growh assessmen scale before he procedure and even afer he procedure. The paiens were followed up for 6 monhs afer pos-microneedling procedure. Saisical Analysis- Afer he daa collecion, i is enered in MS excel shee 2007. Calculaed and Sandard Deviaion for Quaniaive daa, Frequency and percenage for qualiaive daa, analysed by using SPSS V 16.0 sofware. Paired -es applied for pre-es and pos-es of PRP and opical 5% Minoxidil. Independen sample -es applied for PRP and opical 5% Minoxidil. The difference is considered saisically significan whenever p value is 0.05. RESULTS All paiens showed a response of + 2 o + 3 on a sandardised 7-poin evaluaion scale. The response in he form of new hair growh sared afer 10-12 sessions. Boh reamen modaliies were comparably effecive in improving hair densiy and alopecia grade. CONCLUSION PRP is a safe and effecive modaliy in AGA. Even microneedling wih minoxidil has good and early response. Thus, boh he procedures augmen he response even in poor responders o convenional herapy. KEYWORDS Androgeneic Alopecia, Minoxidil, Finaseride, Microneedling, Plaele-rich Plasma. HOW TO CITE THIS ARTICLE: Herakal KC, Vallabhbhai PP, Siddalingappa K, e al. plaele-rich plasma versus microneedling wih opical 5% minoxidil in paiens wih androgeneic alopecia- A comparaive sudy. J. Evoluion Med. Den. Sci. 2017;6(26):2182-2186, DOI: 10.14260/Jemds/2017/473 BACKGROUND Androgeneic alopecia (AGA) refers o he loss of hair seen wih increasing age in geneically predisposed individuals. Since physiological amouns of circulaing androgens are needed o express his geneic rai, i is called androgeneic Financial or Oher, Compeing Ineres: None. Submission 04-02-2017, Peer Review 19-03-2017, Accepance 25-03-2017, Published 30-03-2017. Corresponding Auhor: Dr. Kallappa Herakal, Professor& HOD, Deparmen of Dermaology, Navodaya Medical College Hospial & Research Cenre, Raichur. E-mail: paragpehani@gmail.com DOI: 10.14260/jemds/2017/0473 alopecia. I is so common ha in geneically predisposed Individuals, common baldness is considered physiological. 1 I commonly begins by 20 years of age and affecs nearly 50% of men by he age of 50 years. 2 Hair follicle has a very complex biologic srucure and growh of he hair process is regulaed by specific growh cycles. The maure follicle undergoes successive ransformaion from anagen (acive hair shaf producion) o caagen (apoposis-driven regression) o elogen (resing phase wih he involuion of hair follicle). 3 Role of apoposis (by he pahway of caspases cascade) in deermining he passage from anagen o caagen is well known. Many growh facors play a fundamenal role in he lifelong cyclic ransformaion of he hair follicle funcioning as biologic swiches ha are urned on and off during he differen J. Evoluion Med. Den. Sci./eISSN- 2278-4802, pissn- 2278-4748/ Vol. 6/ Issue 26/ Mar. 30, 2017 Page 2182
phases, conrolling he acive phase and promoing apoposis o induce caagen and elogen. 4 Plaele-rich plasma (PRP) is an auologous preparaion of plaeles in concenraed plasma. Alhough he opimal PRP plaele concenraion is unclear, he curren mehods by which PRP is prepared repor 300-700% enrichmen, wih plaele concenraions consequenly increasing o more han 1,000,000 plaeles/l. 5 PRP has araced aenion in several medical fields because of is abiliy o promoe wound healing. Acivaion of alpha granules of plaeles releases numerous proeins, including plaele-derived growh facor (PDGF), ransforming growh facor (TGF), vascular endohelial growh facor (VEGF), insulin-like growh facor (IGF), epidermal growh facor (EGF) and inerleukin (IL)- 1. 6,7 I is hypohesised ha growh facors released from plaeles may ac on sem cells in he bulge area of he follicles, simulaing he developmen of new follicles and promoing neovascularisaion. 8 A Dermaroller is a skin needling device wih many small surgical needles. Dermaroller wih needle lenghs beween 0.5 mm o 1.5 mm are suied for Androgeneic Alopecia. The needle diameer (hickness) is 0.25 mm a heir base. Sudies on repeaed Microneedling simulaion by Jeong e al 9 and Kim e al showed he enhanced expression of hair relaed genes and simulaion of hair in mice. Kim e al also noed earlier and faser hair re-growh wih more shiny exure of he hair in microneedle reaed group han he unreaed mice group. The auhors also suggesed ha microneedle roller could be useful o rea hair loss refracory o Minoxidil herapy. Minoxidil and Finaseride are he only FDA approved reamen modaliies for AGA. The realisaion of is affeciviy came hrough a serendipious observaion by Zappacosa in 1980 while reaing a paien wih hyperension. 10 Minoxidil, an orally effecive vasodilaor, was hen used opically for alopecia areaa (AA) and AGA. I may perhaps ac as a poassium channel opener hereby enhancing he growh of subopimal follicles in vivo and in viro. 11 I is used in concenraion of 2% in females and 5% in males applied 1 ml wice daily. MATERIALS AND METHODS Mehods of Allocaion I included weny-five paiens in each group, Men beween 25 years and 35 years of age wih mild o moderae (III or IV) AGA, according o Norwood-Hamilon grading scale were enrolled in he sudy. Tweny-five paiens wih AGA had undergone microneedling monhly wice followed by Topical 5% minoxidil soluion daily which should be applied 24 hours afer microneedling. Anoher Tweny-five paiens were subjeced o microneedling wih Plaele-rich plasma monhly wice. Boh groups, microneedling was done wih Dermaroller of 1.5 mm sized needles, rolled over he affeced areas of he scalp in a longiudinal, verical, and diagonal direcions unil mild eryhema. Duraion of sudy is 6 monhs wih 18 monhs of followup. PRP was prepared by drawing 10 ml of paien s own blood and cenrifuging i for 5 min.-1500 rpm, 15 min.-2500 rpm by double spin mehod and plaele-rich plasma colleced. The procedure was carried ou wih informed consen, under asepic condiion afer applicaion of opical anaesheic. Saisical Mehod Hair Couns The arge hinning area of 1 cm diameer, on he verex was defined by wo diagonally placed aoos o ensure reproducibiliy. Then, he hair couns were obained from colour phoographs of remnans of he shaven hair in he arge area. Colour Phoographs of arge area were aken before reamen, afer 6 and 18 monhs of reamen and paiens were assessed wih 7-poin evaluaion scale Paired baseline and pos-reamen phoographs were independenly reviewed by a blinded evaluaor. Baseline follicular unis were manually couned wih help of TrichoScan in his area by dividing ino small quadrans. Paiens were assessed wih he use of he sandardised 7-poin evaluaion scale and paien s subjecive hair growh assessmen scale. 3 = grealy decreased, 2 = moderaely decreased, 1 = slighly decreased, 0 = no change, +1 = slighly increased, +2 = moderaely increased, +3 = grealy increased. The procedure was repeaed every 15 days for duraion of six monhs. The paiens were followed up for 18 monhs afer pos microneedling procedure o assess he susainabiliy. Saisical Analysis Afer he daa collecion, i is enered in MS excel shee 2007. Calculaed and Sandard Deviaion for Quaniaive daa, Frequency and percenage for qualiaive daa, analysed by using SPSS V 16.0 sofware. Paired -es applied for pre-es and pos-es of PRP and opical 5% Minoxidil. Independen sample -es applied for PRP and opical 5% Minoxidil. The difference is considered saisically significan whenever p value is <0.05 and p value is <0.01 is highly significan. RESULTS Before reamen all our paiens (100%) had a posiive hair pull es wih mean number of 15 hairs. Afer 6 monhs of herapy, hair pull es was negaive in 21 (82%) paiens in PRP group and 20 (80%) paiens in microneedling wih opical 5% minoxidil group. Hair coun depiced average no. of 62 hair follicular unis over marked area before saring he reamen and afer 18 monhs, average no. of follicular unis was 94 in PRP group and 92 in microneedling wih opical 5% minoxidil group. J. Evoluion Med. Den. Sci./eISSN- 2278-4802, pissn- 2278-4748/ Vol. 6/ Issue 26/ Mar. 30, 2017 Page 2183
Hair Growh Assessmen Scale No. of Paiens showing Grealy Increased in Hair Growh (+3 response) No. of Paiens showing Moderaely Increased in Hair Growh (+2 response) PRP 11 (44%) 14 (56%) 5% Minoxidil 9 (36%) 16 (64%) Table 1 Paired Samples Saisics For PRP N Sd. Deviaion PRP Pre-reamen 62.0400 25 3.97366.79473 PRP 18 monhs afer reamen 94.0000 25 3.51188.70238 Table 2 Paired Samples Tes for PRP PRP Pre-reamen- PRP 18 monhs afer reamen Sd. Deviaion Paired Differences 95% Confidence Inerval of he Difference Table 3 30.28973 33.63027 (2-ailed) Paired Samples Saisics 5% Minoxidil Pair 2 N Sd. Deviaion 5% Minoxidil pre reamen 62.0400 25 3.97366.79473 5% Minoxidil afer 18 monhs of reamen 92.0000 25 3.96863.79373 Table 4 Paired Samples Tes 5% Minoxidil 5% Minoxidil prereamen - 5% Minoxidil afer 18 monhs of reamen Sd. Deviaion Paired Differences 95% Confidence Inerval of he Difference 29.9600 5.98944 1.19789 27.48768 32.43232 25.011 24 Table 5 (2-ailed).000<0.01 Highly Sig Group Saisics Pos Group N Sd. Deviaion PRP 25 94.0000 3.51188.70238 5% Minoxidil 25 92.0000 3.96863.79373 Table 6 PRP- 5% Minoxidil 1.887 48 (2-ailed).065>0.05 No Sig Table 7 -es for Equaliy of s Difference Difference 95% Confidence Inerval of he Difference 2.00000 1.05987 -.13102 4.13102 J. Evoluion Med. Den. Sci./eISSN- 2278-4802, pissn- 2278-4748/ Vol. 6/ Issue 26/ Mar. 30, 2017 Page 2184
All paiens in each group showed a response of + 2 o + 3 on sandardised 7-poin evaluaion scale. Ou of Tweny five paiens wih microneedling followed by Topical 5% minoxidil soluion, 16 (64%) paiens showed moderaely increased and 9 (36%) paiens showed grealy increased hair growh in 7-poin evaluaion scale. And anoher Tweny five paiens wih microneedling followed by PRP, 14 (56%) paiens showed moderaely increased and 11 (44%) paiens showed grealy increased hair growh in 7-poin evaluaion scale. While he response in he form of new hair growh sared afer 8-10 sessions in PRP group. Boh reamen modaliies were comparably effecive in improving hair densiy and alopecia grade. Among paiens using minoxidil, 5 developed irriaion, 2 headache and 2 conac dermaiis. Among paiens on microneedling and PRP, 3 developed discomfor over scalp, 2 developed eryhema. a) Before & b) 6 Monhs afer Treamen wih PRP a) Before b) One monh afer & c) 6 monhs afer 5% Minoxidil DISCUSSION Hair loss has a significan influence on psychological disress and is associaed wih low self-eseem and depression. Treamen opions for androgenic alopecia are very limied and include opical minoxidil and oral finaseride (FDA approved) eiher alone or in combinaion. 12, Local side effecs of Minoxidil include aggravaion of local inflammaory scalp dermaoses (seborrhoeic dermaiis, psoriasis), allergic conac dermaiis, irriaion and pain. Sysemic side effecs of Minoxidil are Hypoension, Headache and hyperrichosis. Growh facors are known o acivae he proliferaive phase and ransdiffereniaion of hair and sem cells and produce new follicular unis; bfgf is repored o promoe he in viro proliferaion of papilla cells, and hereby plays a key role in elongaing hair shaf. 13 Mechanisms of hair re-growh induced by Microneedling include Release of plaele derived growh facor, epidermal growh facors are increased hrough plaele acivaion and skin wound regeneraion mechanism; acivaion of sem cells in he hair bulge area under wound healing condiions which is caused by a Dermaroller; overexpression of hair growh relaed genes vascular endohelial growh facor, B caenin, Wn3a, and Wn10b. 9,14 In our sudy, Microneedling is a safe and promising ool in hair simulaion. PRP wih microneedling and Minoxidil wih microneedling is simple, cos effecive has good safey profile and promising reamen opion for AGA. Sample size is very small. followup of paien is also shor o draw conclusion regarding he long-erm effeciveness of reamen. A sudy done by Dura R e al on 50 paiens wih microneedling wih Minoxidil and 50 paiens only wih Minoxidil showed ha in Microneedling group 41 (82%) versus 2 (4%) in he Minoxidil group repored more han 50% improvemen afer 12 weeks. This sudy showed ha Minoxidil reaed group was saisically superior o Minoxidil reaed group in promoing hair growh in men wih AGA. 15 CONCLUSION PRP is a safe and effecive modaliy in AGA. Even microneedling wih minoxidil has good and early response. Thus, boh he procedures augmen he response even in poor responders o convenional herapy. PRP wih microneedling is simple, cos-effecive, has good safey profile and is a promising reamen opion for paiens wih androgeneic alopecia. Furher sudies are needed wih longer followup wih larger sample size. REFERENCES [1] Wadhwa SL, Khopkar U, Nischal KC. Hair and Scalp disorders. In: Valia RG, Valia AR. eds. IADVL exbook of dermaology. 3 rd edn. Bhalani Publishing House 2008:864-949. [2] Ellis JA, Sinclair R, Harrap SB. Androgeneic alopecia: pahogenesis and poenial for herapy. Exper Rev Mol Med 2002;4(22):1-11. [3] Kaufman KD, Olsen EA, Whiing D, e al. Finaseride in he reamen of men wih androgeneic alopecia. Finaseride male paern hair loss sudy group. J Am Acad Dermaol 1998;39(4 P 1):578-89. [4] Price VH. Treamen of hair loss. N Engl J Med 1999;341(13):964-73. [5] Li ZJ, Choi HI, Choi DK, e al. Auologous plaele rich plasma: a poenial herapeuic ool for promoing hair growh. Dermaol Surg 2012;38(7 P 1):1040-6. [6] Marx RE. Plaele-rich plasma: evidence o suppor is use. J Oral Maxillofac Surg 2004;62(4):489-96. [7] Eppley BL, Pierzak WS, Blanon M. Plaele-rich plasma: a review of biology and applicaions in plasic surgery. Plas Reconsr Surg 2006;118(6):147e-59e. J. Evoluion Med. Den. Sci./eISSN- 2278-4802, pissn- 2278-4748/ Vol. 6/ Issue 26/ Mar. 30, 2017 Page 2185
[8] Uebel CO, da Silva JB, Canarelli D, e al. The role of plaele plasma growh facors in male paern baldness surgery. Plas Reconsr Surg 2006;118(6):1458-67. [9] Jeong K, Lee YJ, Kim JE, e al. Repeaed microneedle simulaion induce he enhanced expression of hairgrowh-relaed genes. In J Trichology 2012;4(2):117-30. [10] Zappacosa AR. Reversal of baldness in a paien receiving minoxidil for hyperension. N Engl J Med 1980;303(25):1480-1. [11] Buhl AE. Minoxidil s acion in hair follicles. J Inves Dermaol 1991;96(5):73S-4S. [12] Olsen EA, Weiner MS, Delong ER, e al. Topical minoxidil in early male paern baldness. J Am Acad Dermaol 1985;13(2 P 1):185-92. [13] Kasuoka K, Schell H, Wessel B, e al. Effecs of epidermal growh facor, fibroblas growh facor, minoxidil and hydrocorisone on growh kineics in human hair bulb papilla cells and roo sheah fibroblass culured in viro. Arch Dermaol Res 1987;279(4):247-50. [14] O Toole EA, Mellerio JE. Wound healing. In: Burns TB, Cox N, Griffihs C, eds. Rook's exbook of dermaology. 8 h edn. Blackwell Publishing 2010:14.1-14.27. [15] Dhura R, Sukesh M, Avhad G, e al. A randomized evaluaor blinded sudy of effec of microneedling in androgeneic alopecia: a pilo sudy. In J Trichology 2013;5(1):6-11. J. Evoluion Med. Den. Sci./eISSN- 2278-4802, pissn- 2278-4748/ Vol. 6/ Issue 26/ Mar. 30, 2017 Page 2186