Original Article

Study of Platelet-Rich Plasma Injections in the Treatment of Androgenetic
Alopecia Through an One-Year Period
Maria-Angeliki Gkini, Alexandros-Efstratios Kouskoukis, Gregory Tripsianis1, Dimitris Rigopoulos2,
Konstantinos Kouskoukis
Department of Dermatology and Venereology, Medical School, Democritus University of Thrace, Alexandroupolis, 1Laboratory of Medical Statistics,
Democritus University of Thrace, Alexandroupolis, 2Department of Dermatology and Venereology, Medical School, Attikon Hospital, Universityof Athens, Athens, Greece
Address for correspondence: Dr. Maria-Angeliki Gkini, 6th km Alexandroupolis-Makris, 68100, Alexandroupolis, Greece. E-mail: gkinimargo@gmail.com

ABSTRACT
Background: Platelet-rich plasma (PRP) is defined as an autologous concentration of plasma with a greater countof platelets than that of whole blood. Its action depends on the released growth factors from platelets. It has been
investigated and used in numerous fields of medicine. Recently, PRP has received growing attention as a potential
therapeutic tool for hair loss. Aims: To evaluate the efficacy and safety of PRP injections in the scalp of patientswith androgenetic alopecia. Settings and Design: Prospective cohort study. Materials and Methods: 20
patients, 18 males and 2 females, with androgenetic alopecia were enrolled in the study. PRP was prepared using
a single spin method (Regenlab SA). Upon activation, it was injected in the androgen-related areas of scalp. Threetreatment sessions were performed with an interval of 21 days and a booster session at 6 months following the onsetof therapy. Statistical Analysis: Statistical analysis of the data was performed using the Statistical Package for
the Social Sciences (SPSS), version 19.0 (IBM, NY, USA). Results: Hair loss reduced and at 3 months it reachednormal levels. Hair density reached a peak at 3 months (170.70 ± 37.81, P < 0.001). At 6 months and at 1 year, it
was significantly increased, 156.25 ± 37.75 (P < 0.001) and 153.70 ± 39.92 (P < 0.001) respectively, comparing
to baseline. Patients were satisfied with a mean result rating of 7.1 on a scale of 1-10. No remarkable adverse effects
were noted. Conclusions: Our data suggest that PRP injections may have a positive therapeutic effect on male andfemale pattern hair loss without remarkable major side effects. Further studies are needed to confirm its efficacy.
KEYWORDS: Androgenetic alopecia, hair loss, platelet-rich plasma
REC Review:
Risk
: 5.0
Efficacy : 2.5
Cost
: 2.5

0 = maximum risk,
5 = minimum risk
0 = minimum efficacy, 5 = minimum efficacy
0 = maximum cost,
5 = minimum cost

INTRODUCTION
Androgenetic alopecia (AGA) is a common chronic hairloss disorder. It is characterised by progressive hairloss, affecting both sexes. It affects up to 80% Caucasianmen and 40% women. Its frequency increases withage, despite the fact that it may start at puberty. [1,2]Access this article online
Quick Response Code:
Website:www.jcasonline.com

DOI:
10.4103/0974-2077.150743

Independent of age and gender, patients diagnosed with
AGA may undergo significant impairment of quality oflife, since hair is considered to be an important featureof self-image.[3] Hair loss affects self-esteem, personal
attractiveness and may lead even to depression and othernegative effects of life, especially in women.[2-4]A number of products have been proposed as hair loss
therapies. Drug therapies specifically approved by Foodand Drug Administration (FDA) for treating AGA are
limited to minoxidil and finasteride. Both can be usedalone or combined.[5] Despite the therapeutic options
available, low patient compliance and satisfaction rate
as well as the plethora of topical and often importantsystematic adverse effects lead to the search of newtreatment options for AGA.[1,5]PRP is defined as a volume of the plasma fractionof autologous blood with an above baseline plateletconcentration. [6] The regenerative potential of PRP

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Gkini, et al.: PRP in androgenetic alopecia

depends on the levels of growth factors released uponactivation.[7,8] Main growth factors (GFs) involved inandrogenetic alopecia are platelet-derived growth factor(PDGF), transforming growth factor (TGF),vascularendothelial growth factor (VEGF) and insulin-likegrowth factor (IGF) with their isoforms.[9-12] GFs appear
to act in the bulge area of the follicle, where they bindto their respective receptors located in stem cells. In thebulge area, primitive stem cells of ectodermal origin arefound, giving origin to epidermal cells and sebaceous
glands. In matrix, germinative cells of mesenchymal
origin are found at the dermal papilla (DP). Interactions
between these two kind of cells as well as with binding
growth factors (PDGF, TGF-b and VΕGF) activate
the proliferative phase of the hair, giving rise to the
future follicular unit.[13] Therefore, PRP could serve as apotential treatment of AGA.
Aim of our study was to investigate the clinical efficacy
and safety of PRP injections in the scalp of patientswith AGA.
MATERIALS AND METHODS
From October 2012 to September 2013, 22 volunteers(20 men, 2 women) enrolled our study. All participants
were ≥18, who had not received any topical orsystematic treatment for their hair loss during thelast 6 months. Patients with present or a history of
immunosuppression (malignancy, chemotherapy,
steroid therapy), dermatological diseases affecting
the scalp, autoimmune disorders, hematologic
disorders, platelet dysfunction syndrome and on
anticoagulation therapy were excluded from ourstudy. Patients with a tendency for keloids werealso excluded. Patients taking aspirin or othernon-steroidal anti-inflammatory drugs (NSAIDs)
discontinued their use 7 days before treatment.
Diagnosis of AGA was made in all patients based on adetailed medical history (any drugs causing hair loss),clinical examination and laboratory tests. Laboratory
tests included:a. CBC;b. Serum iron, serum ferritin, TIBC (Total Iron-Binding
capacity);c. Folic acid;d. T3, T4, TSH, fT3, fT4, anti-TPO;
e. VDRL andf. For women, female hormone profile (DHEAS,
testosterone, and rostenedione, prolactin, follicle
stimulating and leutinising hormone).
Laboratory tests were assessed in order to exclude otherhair loss causes, such as anaemia, poor nutrition, thyroid
dysfunction, syphilis or polycystic ovary syndrome.

214

The stage of alopecia was evaluated according to the
Hamilton-Norwood scale for men and Ludwig scale
for women.
For the preparation of PRP, RegenKit BCT-3 (Regenlab®)
was used. Initially, whole blood was collected from theantecubital vein of the patient (16 ml). The blood was thenintroduced into two tubes (RegenBCT) and centrifugatedfor 5 min at 1500 g using the laboratory centrifuge
RegenA-PRPCentri. Each tube contained a thixotropic
gel composed of a mixture of polymers for plasma
separation (elimination of red blood cells) and sodium
citrate solution, as an anticoagulant, located above theseparator gel. Therefore, after centrifugation, the blood
was fractionated with the red blood cells being trapped
under the gel and cellular elements settling on the surfaceof the gel. After removal of 2 ml of upper supernatant
plasma (PPP, platelet-poor plasma) from each tube, 3 mlof PRP was yielded, which was resuspended by gentle
inversions of the tube. Total amount of yielded PRP was
about 6 ml and it was loaded in 1 ml syringes, ready for
injections. The activation process included the addition of
calcium gluconate in a 1:9 ratio (0.1 ml calcium gluconate
per 0.9 ml of PRP). The platelets in whole blood and PRP
were microscopically counted and mean platelet counts
were 1.9 × 105 and 1.102 × 106 platelets/μl, respectively.
The concentration of platelets in PRP was approximately
5.8 times as great as that in whole blood.
Before the PRP applications, all patients were informed
about the process and its potent adverse effects andthey signed a consent form. They did not have their
hair washed two days prior to the treatment. Local
anaesthesia was applied in the treatment area and scalp
was cleaned using 0.1% octenidine hydrochloride spray.
None of the patients received any other treatment forhair loss during PRP treatment.
PRP (0,05-0,1 ml/cm2) was injected, with a 27-G needle,
into the androgen-related areas (frontal, parietal,
occipital) of the scalp in men and into the problematic
areas in women, using BD-Luer LokTM 1 ml syringes.
Nappage technique was performed in a depth of
1.5-2.5 mm [Figure 1]. Our protocol proposed threetreatment sessions with an interval of 3 weeks. At
6 months from the beginning of the treatment, a booster
session was also performed.
In our study, we evaluated hair loss, hair density (hair/cm 2) and patients’ satisfaction. We also noted any
reported adverse effects. The evaluation of results was
performed by two independent evaluators, who were
not involved in the administration of PRP treatment.
Evaluation methods included hair pull test, dermoscopic
photomicrographs, macroscopic photographs and asatisfaction questionnaire. All patients were evaluated

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Gkini, et al.: PRP in androgenetic alopecia

at six time points: T1, beginning of study; T2, 3 weeks;
T3, 6 weeks; T4, 3 months; T5, 6 months; and T6, 1 year.
In order to check the same area at all time points, we used‘V’ (Kang’s point), as proposed by Lee et al.[14] ‘V’ is thepoint of intersection between the midsagittal line and thecoronal line connecting the tips of the tragus. By usinga plastic headband and a tapeline, ‘V’ can be measured
conveniently because the headband presents the coronalline connecting the roots of the ear vagus, and the tapeline
easily shows the midsagittal line [Figure 2]. We measured‘V’, which is located roughly 1 to 1.3 cm in front of theanterior margin of the headband and record the distancefrom the headband to the midpoint of the line connecting
the lower margins of the eyebrows for reproducibility.

Figure 1: Injecting activated PRP

Statistical analysis of the data was performed using theStatistical Package for the Social Sciences (SPSS), version
19.0 (IBM, NY, USA). The normality of quantitative
variables was tests by Kolmogorov-Smirnov test. Hairdensity was expressed as mean ± standard deviation (SD).
Hair density differences between the different time points
were assessed by one-way repeated measures ANOVA(rmANOVA); post hoc analysis was performed using
the Sidak test. All tests were two tailed and statisticalsignificance was considered for P values less than 0.05.
RESULTSA total of 22 patients enrolled in the study. Nevertheless,there was a dropout of two patients, who did notcomplete the therapy protocol and were not included in
the statistical analysis. Therefore, 20 patients (18 men, 2
women) were finally included in the study. In Table 1,
a summary of patients’ characteristics is presented.
The mean age of patients was 34 years (24-72). Amongmen, according to the Hamilton-Norwood scale, fivepatients suffered from type II androgenetic alopecia,
eight from type III, four from type IV and one from type
V alopecia. Both women suffered from I-3 androgenetic
alopecia, according to the Ludwig scale. Six patients
had previously soughtb medical help for their hair loss
and they had been treated with topical minoxidil lotion
5%. During the last 6 months since the onset of PRP
therapy, they had not received any medication. None had
undergone hair transplantation. Two male patients had
been taking NSAIDs due to musculoskeletal problems
and they stopped those 8 days before PRP injections.
In Figure 3, we present the number of hairs taken at
the hair pull test. It was performed in a standardisedmanner by the two evaluators. Despite the fact that it is
not an objective evaluation method, it gives a satisfactory
general image of hair loss. At T1, the mean number ofhairs pulled was eight while at T3 and at T4 reachednormal levels, since less than three hairs pulled are

Figure 2: Defining V point using a headband and a tapeline

Figure 3: Number of hairs pulled during hair pull test

considered to constitute normal hair loss. At T5 and at
T6, the mean hair loss increased with a number of fiveand six hairs respectively pulled during hair pull test.
Hair density (hair/cm2) significantly increased at T3(154.80 ± 34.39), at T4 (170.70 ± 37.81) at T5 (156.23 ±Journal of Cutaneous and Aesthetic Surgery - Oct-Dec 2014, Volume 7, Issue 4215

Gkini, et al.: PRP in androgenetic alopecia

37.75) and at T6 (153.70 ± 39.92) (P < 0.001) comparedto the onset of therapy (T1). The highest hair density
recorded was at T4 [Table 2, Figure 4]. The % increase
rate from baseline (T1) was 0.45%, 8.18%, 19.9%, 9.19%
and 7.41% at T2, T3, T4, T5 and at T6, respectively.
Regarding failure rate, at T3 and T4, none of thepatients presented decreased hair density comparedto that of baseline and only one of them presented
no change (5%). At T5, one patient (5%) presented adecrease of 1 hair/cm2 in hair density comparing tothat of T1, while at T6 30% presented a mean decreaseof 2 hair/cm2.
Table 1: Patients’ characteristics
Case

Sex

Age

1

M

38

Alopecia Stage
4

2

M

24

3v

3

F

58

I-3
3v

4

M

25

5

M

30

4

6

M

38

2

Patients filled in the patients’ satisfaction questionnaire
and reported any adverse effects. They were satisfied
with a mean result rating of 7.1 on a linear analogue scaleof 1-10 (1 = no result, 10 = best result). 85% of patients
reported an improvement in hair quality and thickness
flash»), while 65% reported an increase in hair density.
At T5, all patients (100%) claimed that they want and/or need the booster session, while, at T6, 75% of neededthem.
Regarding PRP›s safety profile, in the satisfaction
questionnaire patients reported any adverse effects.
During application, 100% of them felt mild pain, despite
local anaesthesia. After application, 25% of them felt amild pain feeling, which subsided after 4 hours, while
60% had scalp sensitivity during first hair wash after
treatment injections. None reported any worsened hair
shedding, infection or ecchymosis.

7

M

35

2

DISCUSSION

8

M

34

3v

9

M

28

4

10

M

25

3v

AGA remains the most common hair disorder withoutsatisfactory treatment. Since androgenetic alopecia

11

F

72

I-3

12

M

26

3a

13

M

29

2

14

M

40

4a

15

M

29

2a

16

M

32

3v

17

M

25

3v

18

M

31

5a

19

M

27

2

20

M

34

3v

Figure 4: The effect of activated platelet-rich plasma
injections on hair density through a 1-year period. Statisticalsignificance is considered for P values less than 0.05

216

Macroscopic photographs showed an overall
improvement in hair density and quality, as laguno-likehair became thicker, normal hair [Figures 5-8].

Table 2: Hair density (mean ± SD) in different time points
Time points

Hair density (hair/cm2)

T1

143.10±31.07

T2

143.75±31.27

T3

154.80±34.39

T4

170.70±37.81

T5

156.25±37.75

T6

153.70±39.92
P<0.001

Figure 5: Male, 29-year-old, before treatment

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Gkini, et al.: PRP in androgenetic alopecia

Except scalp surgery, which is a surgical treatment option,
FDA-approved drug therapies include finasteride andminoxidil.[1,5,15] Minoxidil appears to prolong anagen
phase and to promote survival of dermal papilla cells andincrease in hair follicle size.[16,17] Finasteride also promotes
hair growth of anagen hairs leading to gradual increasein hair diameter and hair elongation[18] and appears toactivate anagen hair growth.[19,20]

Figure 6: The same patient at 6 months following the onsetof PRP treatment

Figure 7: Male, 26 years old, before treatment

Figure 8: The same patient at three months after treatment

is characterised by a shortened anagen phase andminiaturisation of terminal to vellus hair, [5] current
therapeutic strategies target cellular proliferation anddifferentiation during the hair cycle.

Presently, there are limited published data regarding
PRP’s potential effect on hair. Activated PRP seems topromote differentiation of stem cells into hair follicle cells
through the upregulation of transcriptional activity of
β-catenin. It also induces in vitro proliferation of dermal
papilla cells, and increases dermal papilla cell growth byactivating ERK signalling. PRP also appears to prolong
anagen phase of hair growth cycle through increased
expression of FGF-7 and to increase cell survival byinhibiting apoptosis (associated with increased Bcl-2
protein levels as well as activated Akt signalling).[21] It
also appears to increase the perifollicular vascular plexus,
through the increase of VEGF and PDGF levels, whichhave an angiogenic potential. Therefore, it constitutes apotent useful tool for androgenetic alopecia treatment.[12]In our study using non-invasive evaluation methods,
such as dermoscopic photomicrographs, [Figures 9
and 10] a significant increase rate in hair density of 19,29%
and 9,19% was noted at 3 and 6 months respectively
with large variability in results (from no improvement
to significant improvement). Hair density followed an
upward curve, reached a peak at 3 months, decreased at
6 months but its value was significant higher than thatof baseline (T1). At 1 year (T6), hair density continued
its downward trend although remaining significantly
higher than that of T1. Hair loss after the second
treatment session (T3) decreased and at T4 reachednormal levels. Nevertheless, at 6 months (T5), number ofhairs pulled during hair pull test were increased to five,
without, however, reaching the number of eight hairsof T1. Taking these in account, the booster session at 6
months was necessary, in order to maintain and improve
the results achieved. Finally, at 1 year (T6), number ofhairs pulled increased to six, less than eight (T1).
Patients with grade II-III alopecia according to the
Norwood-Hamilton scale had better results comparedto patients with more advanced alopecia. Both women
were satisfied with the results. Furthermore, patientswith vellus hair had better results compared to those
who had few but normal hair, as PRP appeared to act
on hair diameter causing thin hair to become thicker.
Advantage of our study was that we used a standardised
approved PRP preparation kit (Regenkit-BCT-3), since
automated kits appear to give better results as mentioned

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Gkini, et al.: PRP in androgenetic alopecia

Figure 9: Dermoscopic photomicrographs from a male,
32-year-old, with grade III androgenetic alopecia, before theonset of treatment (x10 magnification)

Figure 10: Dermoscopic photomicrographs, from thesame 32-year-old patient, at 3 months following treatment(x10 magnification)in the literature. Furthermore, we described in detail our
protocol of PRP preparation and application, making our
results reproducible. Our follow-up, also, was longer(1 year) compared to most other studies.

were accompanied by a high patients’ satisfaction rate.
Nevertheless, more randomised, controlled, double-blindstudies with approved devices for PRP preparation, details
in PRP preparation and application, with larger sample
size, longer follow-up and objective evaluation methods
are needed. The questions are whether PRP will provide
as much benefit as existing treatment options, such as
minoxidil and whether it could be used as monotherapy
or in combination with other treatments. Nevertheless,it seems to be a good choice especially for women ofchildbearing age, who cannot take oral medication suchas finasteride, and for patients with adverse effects and/or no results from finasteride or minoxidil.

Nevertheless, our study was not a randomised, doubleblind, controlled trial and potent bias might be present.
In our case, for instance, most of our patients had vellus
hair and were non-smokers. Smoking is mentioned since
PRP promotes and improves hair follicle vascularisation.
Therefore, smoking as well as other factors affecting
microcirculation may play a role in trial results.
Apart from these, hair evaluation methods were notobjective. Hair pull test was performed in a standardisedmanner by the two evaluators, but it remains a subjective
evaluation method. Macroscopic photographs showed
an overall image of hair growth and hair density.
Dermoscopic photomicrographs showed an increase inhair density as number of hairs were counted manuallyby the evaluators twice and was the most objective
method. Phototrichogram, a more objective evaluation
method was not performed as it needs to be performed ona shaven part of the patient’s scalp which is not acceptedby most patients, particularly women. Nevertheless, anadequate means of measuring hair growth over time ina reproducible, economical and non-invasive manner is
not available and all the above methods give a relatively
fair assessment of the results after treatment.
Finally, sample size was small, despite the fact that we
had statistical significant results.

1.
2.
3.

4.

5.

6.
7.

8.

CONCLUSION
In conclusion, PRP injections appeared to be effective inthe treatment of androgenetic alopecia in both males andfemales, without remarkable adverse effects, while they218

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How to cite this article: Gkini MA, Kouskoukis AE, Tripsianis G,
Rigopoulos D, Kouskoukis K. Study of platelet-rich plasma injections in
the treatment of androgenetic alopecia through an one-year period. J
Cutan Aesthet Surg 2014;7:213-9.
Source of Support: Nil. Conflict of Interest: None declared.

Journal of Cutaneous and Aesthetic Surgery - Oct-Dec 2014, Volume 7, Issue 4219

Reproduced with permission of the copyright owner. Further reproduction prohibited without
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