Please forgive us. Sometimes when we don our BFT host hats, it’s impossible to remain entirely dispassionate about our daytime work. Today is one of those days. We are enthused and encouraged and can’t contain ourselves. There’s news to report and results to share. But as is our style, in the process you will learn a bit of science with enough bedtime reading references to induce REM sleep in even the worst insomniacs.
Recall that by age 50 over 80% of men are experiencing significant hair thinning with many of them opting to spend anywhere from $3000 to $20,000 for a hair transplant procedure. Annual expenditures for hair transplantation in the United States is a staggering $800 million. Perhaps more shocking, in excess of $250 million is spent on toupees and hairpieces. Nineteen percent of women experience significant hair loss sometime during their lifespan. Obviously, an effective option that “awakens” quiescent hair follicles has a large eager and waiting market.
It’s fairly certain some readers suspected we might be busy developing a hair regrowth product when we did three prior posts on hair a while back. We were, but early in the process. Much has happened since. As we explained before, hair physiology is very complex. A combinatorial (“multi-prong”) approach to hair regrowth was the strategy we adopted to give us the best odds at stirring slumbering hair follicles into action.
HERETOFORE LIMITED NON-SURGICAL OPTIONS
For many years, the market has had limited offerings with which to coax quiescent hair follicles to change their ways and resume producing visible hair. Minoxidil (Rogainâ) exploits the hair growth side-effect noticed when the anti-hypertensive drug was first being tested. The accepted mechanism of action is that minoxidil shortens telogen, the resting phase of the hair growth cycle, and has a vasodilatory effect that improves peri-follicular blood flow. Finasteride (Propeciaâ), the only other FDA approved drug for hair loss, is a 5-alpha reductase inhibitor which inhibits the transformation of testosterone into dihydrotestosterone, the metabolite of testosterone that causes pattern baldness in both sexes. A significant number of people taking finasteride discontinue due to side effects, particularly reduced libido and erectile dysfunction. The effect of both minoxidil and finasteride appears to be more to slow hair loss, than to significantly increase hair growth.
PRP (platelet rich plasma) has been injected into the scalp but with mixed results. The purported mechanism of action being localized increased levels of growth factors and cytokines including transforming growth factor (TGF), platelet-derived growth factor (PDGF), vascular endothelial growth factor (VEGF), epidermal growth factor (EGF), insulin-like growth factor (IGF), and interleukin-1. PRP involves blood aspiration from a vein, centrifugation of the blood and activation of the derived platelets, followed by injection of PRP into multiple sites in the balding scalp. There is substantial associated cost.
Low level laser therapy (LLLT) has increased hair counts in both men and women, albeit with modest improvement and with the requirement that the LLLT devices be worn often and for significant periods of time.
WHAT WE’RE DEALING WITH – MINIATURE HAIR FOLLICLES
Androgenetic alopecia is the result of progressive cyclical miniaturization of the hair follicle due to the influence of dihydrotestosterone on the hair follicle over time. Eventually, the follicle may disappear altogether. Totally obliterated hair follicles are impossible to resurrect although methods of regeneration with stem cell technology may one day evolve. We are not there now. Even miniature follicles give us something to work with.
On a substantially bald pate, most follicles have become miniaturized but continue to produce tiny wisps of hair. Progressively get small enough and one sees velus hair, the near colorless tiny hair of childhood. These miniature in size, yet functioning follicles may still respond to the proper physiologic signals. Our efforts have focused on identifying which signals are most important based on peer reviewed published literature, and our own research.
COMBINATORIAL “MULTI-PRONG” APPROACH
Not surprising, at least to us, many of the signals are ones that can be produced using laboratory culture of our old friends, bone marrow derived mesenchymal stem cells. This is especially true when specialized protocols are used to coax the cells to produce certain types of bio-signals (discussed below.)
Much of the published hair research over the past decade or so has focused on the role individual growth factors and cytokines play in hair follicle physiology. Some of these include the major bio-signals one finds in PRP. Unlike our usual refrain of “focus on anti-inflammatory bio-signals for chronic skin use”, there is a role for certain cytokines one usually associates with the genesis of inflammation including VEGF which helps increase localized blood flow. Improving blood flow to follicles is a good thing.
Another class of bio-signals proven effective in hair follicle stimulation is extracts derived from botanical source. Our innovative system includes nearly two dozen of these botanicals which are used in alternating (every other day) fashion with stem cell-derived and synthetic bio-signals.
Finally, there are certain molecules that have proof of efficacy in hair follicle stimulation that are included in our system.
THE USE OF MICRONEEDLING
The creation of thousands of tiny shallow perforations in the surface of the skin of the scalp serves multiple purposes. It enhances penetration through the normal surface barrier and increases availability of topically applied stem cell and synthetic bio-signals to peri-follicular tissues. It is not used with botanical extracts. Only naturally occurring substances, ones that are normally found within human tissues, should be administered using microneedling. This includes bio-signals produced by stem cell culture and synthetic versions which are molecularly identical to those produces by our own cells.
UNIQUE ROSTER of ACTIVE INGREDIENTS
The wnt//b-catenin signaling pathway enables activated cell surface receptors to influence gene transcription at the nuclear level; they are universally required for cell proliferation, differentiation and migration. Hence, they are integral to hair follicle development and growth. Prolonged ectopic Wnt-mediated β-catenin activation causes regenerating anagen hair follicles to grow larger in size with dramatically enhanced proliferation within the matrix, dermal papilla and hair shaft. Wnt proteins are lipid-modified, constraining them to act as short-range cellular signals only.
Stem cells fuel tissue development, renewal and regeneration, activities controlled by the local microenvironment, or “niche.” The locality of Wnt controls how stem cells differentiate, indeed enabling the self-organization of patterned tissues. The signaling pathway is an ancient evolutionary program dating from when Wnt signals arose in the simplest multicellular organism. Hair follicle genesis, function and phase transitioning is impossible without Wnt signaling. We manipulate our human bone marrow mesenchymal stem cell cultures, employing proprietary specialized techniques, enable harvesting of conditioned media with a “wnt emphasis.”
Another regulator of gene expression that controls cellular processes including growth and cycle progression is PAK1, a serine/threonine kinase that regulates both physiologic and disease processes. PAK1 blockers, such as cucurbitacin B, have been shown to be anti-oncogenic, anti-melanogenic and anti-alopecia i.e. promoting hair growth. Among the many known PAK1-inhibitors, cucurbitacin B from bitter melon is the most potent in its ability to promote the growth of hair cells.
Hair follicles produce hair fibers during the anagen growth phase. In a culture of dermal papilla cells in vitro, adenosine stimulated proliferation and activated and prolonged the anagen phase. Adenosine also promotes the expression of several growth factors responsible for hair growth, including fibroblast growth factors (FGF)-7, FGF-2, insulin-like growth factor (IGF)-1, and vascular endothelial growth factor (VEGF). β-catenin is a co-activator of Wnt/β-catenin signaling that induces morphogenesis and differentiation of hair follicles and also acts to transactivate downstream signaling pathways. Transcriptional activation of β-catenin in dermal papilla cells is increased by adenosine.
Double-blind, randomized, placebo-controlled studies of Japanese men and women confirm adenosine improves androgenic alopecia. Volunteers used either 0.75% adenosine lotion or a placebo lotion topically twice daily for 12 months. Adenosine significantly increased the anagen hair growth rate and hair thickness.
Metabolic reprogramming is necessary for regulating the fate of stem cell populations. It is now acknowledged that stem cells use a wide variety of substrates, such as glucose, glutamine, and fatty acids to support production of biosynthetic intermediates and/or energy during proliferation or differentiation. Recent findings point to pyruvate as one of the key metabolites controlling stem cell function. The metabolic fate of pyruvate, toward lactate production or mitochondrial metabolism, is a key aspect of the regulation of the stem cell compartment as it participates in the decision between the maintenance of self-renewal or the promotion of clonal expansion and differentiation. Substances regulating pyruvate metabolism are reported to alter the balance between self-renewal and differentiation states.
In cultures of male human hair follicles, caffeine counteracts the suppression of hair shaft production by testosterone. A study of male and female scalp hair follicles showed the caffeine effect was even more pronounced in female hair follicles. In both sexes, caffeine enhanced hair shaft elongation, prolonged anagen duration and stimulated hair matrix keratinocyte proliferation.
Caffeine counteracted the testosterone-enhanced TGF-β2 protein expression seen in male and female hair follicles, enhanced IGF-1 protein expression, stimulated cell proliifer-ation, inhibited apoptosis/necrosis, and upregulated IGF-1 gene expression and protein secretion.
The flavonoid baicalin is known to have multiple biological functions including activation of the Wnt/β-catenin signaling pathway. The hair growth promoting effects of baicalin in human follicular dermal papilla cells was studied. Evaluated was its effect on β-catenin signaling and growth factor expression levels. Results indicated that baicalin activates Wnt/β-catenin signaling in a dose-dependent manner in human DP cells and it induces the mRNA expression of growth factors, such as insulin-like growth factor-1 (IGF-1) and vascular endothelial growth factor (VEGF). Compared to vehicle treatment, baicalin treatment induced an earlier conversion from telogen to anagen. The results strongly suggest that baicalin promotes hair growth by regulating the dermal papilla cell activity.
Testosterone is necessary for the development of male pattern baldness (androgenic alopecia) yet the mechanisms for decreased hair growth are unclear. It is known that prostaglandin D2 synthase and prostaglandin 2 are elevated in bald scalp compared to haired scalp of men with androgenic alopecia. Prostaglandin D2 inhibition has been discovered as a pharmacological mechanism for treating androgenic alopecia. A study of 12 traditional herbal treatments for baldness concluded that a common mechanism of action was inhibition of prostaglandin D2 synthase although most botanicals had unacceptable side-effects such as skin irritation, sensitization, corrosiveness or poor absorption. Quercetin in particular shows good pharmacokinetic properties including anti-inflammatory effect and minimal adverse skin reaction.
The amino acid l-carnitine plays a key role in the intramitochondrial transport of fatty acids for beta-oxidation and thus serves important functions in cellular energy metabolism, making supplementation of potential value by increasing the energy supply in the proliferating and energy-consuming anagen hair matrix. Hair follicles in the anagen stage of the hair cycle were cultured in the presence of l-carnitine-l-tartrate for 9 days. At day 9, treated hair follicles showed a moderate, but significant stimulation of hair shaft elongation compared with vehicle-treated controls. Apoptosis was down regulated, and proliferation up regulated.
Vitamin E Acetate
Studies have shown an association between oxidative stress and alopecia. Patients with alopecia exhibit lower levels of antioxidants in their scalp as well as a higher lipid peroxidation index. Tocotrienols belong to the vitamin E family and are known to be potent antioxidants. A placebo-controlled study investigated the effect of tocotrienol supplementation on hair growth in volunteers suffering from hair loss. The number of hairs in the tocotrienol supplementation group increased significantly as compared to the placebo group, with the former recording a 34.5% increase at the end of the 8-month supplementation as compared to a 0.1% decrease for the latter. This observed effect was most likely to be due to the antioxidant activity of tocotrienols that helped to reduce lipid peroxidation and oxidative stress in the scalp.
Traditional medicine has used botanical agents in promoting hair growth with centuries of anecdotal success. Soph-isticated methods were used to investigate many of these botanical agents to evaluate their benefits in improving balding.
The expression levels of 5α-reductase were analyzed using quantitative real-time reverse transcription polymerase chain reaction in the human follicular dermal papilla cells. The 5α-reductase mRNAs and proteins were detected in the cultured cells and the expression level in the presence of the herbal extracts was gradually decreased. Herbal extracts were found to significantly increase the proliferation of human dermal papilla cells. These results suggest herbal extracts exert positive effects on hair proliferation and could be a valuable therapy for increasing hair proliferation.
Synthetic Bio-identical Growth Factors & Bio-signals
A growing medical literature confirms the value of topically applied growth factors and cytokines for skin anti-aging prophylaxis, repair and wound healing. Additionally, topical bio-signals have proven efficacy in modulation of inflammation following energy-based aesthetic treatments and microneedling, leading to enhanced healing with reduced likelihood of inflammation related sequelae such as hyper-pigmentation and fibrosis. Indeed, the popular use of platelet rich plasma (PRP) for a myriad of aesthetic indications, including hair regrowth, is due to the cytokines and growth factors PRP contains, most notably PDGF, VEGF, EGF, KGF, among others. Although PRP contains several bio-signals important for follicle stimulation and hair re-growth, there are certain others known to be of benefit which PRP lacks. Understanding which cytokines and growth factors are important and helpful in hair follicle stimulation makes it possible to create a “cocktail” of synthetic bio-signals capable of surpassing PRP in efficacy. Important biosignals to include are: IGF-1, IGF-2, aFGF, bFGF, KGF, KGF-2, SCF, CSF-1, PDGF, EPO, Noggin, and VEGF.
CLINICAL TRIAL (12-week and 24-week duration)
Men and women between 30 years and 65 years of age (average 47) with mild to moderate pattern baldness according to the Norwood-Hamilton and Ludwig-Savin grading scales and of less than 10 years duration were enrolled in the study. Subjects on finasteride or minoxidil within the past 6 months, or with any known systemic illness were excluded.
A total of 33 subjects (30 men and 3 female) were enrolled after providing written informed consent. Volunteers received six microneedling sessions of the scalp, each two weeks apart, using specially formulated bio-signals (cytokines and growth factors) derived from culture of adult human stem cells and synthesized in the laboratory.
Subjects also received 2 take-home products to be used on their scalp in an alternating fashion, and an at-home roller of needle size 0.25 mm to be used twice a week. One product contained human bone marrow stem cell culture and synthetically derived growth factors and cytokines and was used in conjunction with the home dermaroller. The other product contained botanical extracts and was used without the dermaroller.
Volunteers filled out questionnaires at the beginning and end of the study and gave permission to take high resolution photographs of their scalp before, during and at the end of the study.
Because of inconvenience and/or the time commitment required, five participants elected to drop out during the 12- week study. Of those that completed the 12-week study, twelve elected to participate for an additional 12 weeks (the 24-week study) which was conducted in identical fashion.
In-Office Microneedling Procedure
In-office microneedling was performed after the scalp was prepared with benzocaine, lidocaine, tetracaine topical anesthetic on the treatment area for 30 minutes and disinfected with 70% isopropyl alcohol. The scalp was needled in longitudinal, vertical and diagonal directions using either 1.0 mm electric “pen” devices or 1.0 mm dermarollers. Topical product specially formulated for hair regrowth was applied during and immediately after microneedling treatments.
Two primary efficacy parameters were assessed: Patient assessment of hair growth at 12 and 24 weeks, and investigator assessment of hair growth at 12 and 24 weeks. Subjects who completed all 12 weeks or all 24 weeks of the trial were considered in the respective evaluations. Five subjects dropped out during the twelve-week study and their results were not included in the summaries.
Patient self-assessment: Patients assessed their hair growth through a series of questionnaires evaluating differences in overall hair growth, new hair growth, and rate of continuing hair loss.
Investigator assessment: Standardized color high-resolution photographs of the affected area were taken in the same position at each visit. Paired baseline and post-treatment photographs were independently reviewed by the same evaluator, with the use of a standardized 7-point scale describing the amount of visible hair in balding areas (-3 = greatly decreased, -2 = moderately decreased, -1 = slightly decreased, 0 = no change, +1 = slightly increased, +2 = moderately increased, +3 = greatly increased).
Efficacy assessment: 12-week study
Patient subjective evaluation of hair growth at week 12 was a primary efficacy variable. 23 of 28 subjects (85%) reported a reduction in rate of hair loss or no hair loss during the course of the 12-week study. 14 of 28 subjects (50%) reported visible new hair growth. 26 of 28 patients (93%) reported either less hair loss or new hair growth.
Investigator evaluation of hair growth at week 12 was a primary efficacy variable. 18 of 28 patients in the study had a +2 to +3 response on a 7-point visual analogue scale (moderately increased or greatly increased amount of visible hair in balding areas.)
No significant adverse events were reported during the course of the 12-week study.
Efficacy assessment: 24-week study
Patient subjective evaluation of hair growth at week 24 was a primary efficacy variable. 9 of 11 subjects (82%) reported a reduction in rate of hair loss or no hair loss during the course of the 24-week study. 7 of 12 subjects (58%) reported visible new hair growth. 11 of 12 patients (92%) reported either less hair loss or new hair growth.
Investigator evaluation of hair growth at week 24 was a primary efficacy variable. 9 of 12 patients in the study (75%) had a +2 to +3 response on a 7-point visual analogue scale (moderately increased or greatly increased amount of visible hair in balding areas.)
No significant adverse events were reported during the course of the 24-week study.
|12 WEEKS TWENTY-EIGHT SUBJECTS|
|REDUCED OR NO HAIR LOSS||85% (23 of 28)|
|VISIBLE NEW HAIR GROWTH||50% (14 of 28)|
|LESS HAIR LOSS OR NEW HAIR||93% (26 of 28)|
|24 WEEKS TWELVE SUBJECTS|
|REDUCED OR NO HAIR LOSS||83% (10 of 12)|
|VISIBLE NEW HAIR GROWTH||58% (7 of 12))|
|LESS HAIR LOSS OR NEW HAIR||92% (11of 12)|
SELECTED PHOTOS of STUDY PARTICIPANT
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JAK/STAT Signaling. MedChem Express
Adenosine stimulates growth of dermal papilla and lengthens the anagen phase by increasing the cysteine level via fibroblast growth factors 2 and 7 in an organ culture of mouse vibrissae hair follicles. Int J Mol Med. 2012 Feb;29(2):195-201.
Mechanism of action of minoxidil in the treatment of androgenetic alopecia is likely mediated by mitochondrial adenosine triphosphate synthase-induced stem cell differentiation. J Biol Regul Homeost Agents. 2017 Oct-Dec;31(4):1049-1053.
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Stem Cell Metabolism in Cancer and Healthy Tissues: Pyruvate in the Limelight. Front. Pharmacol., 04 January 2018
Lactate dehydrogenase activity drives hair follicle stem cell activation. Nature Cell Biology 14 August 2017
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Prostaglandin D2 inhibits hair growth and is elevated in bald scalp of men with androgenetic alopecia. Sci Transl Med. 2012 Mar 21;4(126):126ra34.
L-carnitine-L-tartrate promotes human hair growth in vitro. Exp Dermatol. 2007 Nov;16(11):936-45.
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Hair growth-promoting effect of Carthamus tinctorius floret extract. Phytother Res. 2014 Jul;28(7):1030-6
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Changes in hair properties by Eucalyptus extract. J Cosmet Sci. 2008 Nov-Dec;59(6):481-96
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Malva verticillata seed extracts upregulate the Wnt pathway in human dermal papilla cells. Int J Cosmet Sci. 2016 Apr;38(2):148-54.
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Response to Microneedling Treatment in Men with Androgenetic Alopecia Who Failed to Respond to Conventional Therapy. Indian J Dermatol. 2015 May-Jun;60(3):260-3.
The Concise Guide to Dermal Needling – Expanded Medical Edition. Lance Setterfield, M.D., email@example.com