Treatment of Hair Loss

Treatment of Hair Loss Prof.Dr. Hoda Rasheed Professor of dermatology Faculty of medicine Cairo University Causes of hair loss Androgens Aging of the follicles Decreased blood supply Decresed thickness of the SC fat Damaged follicles Decreased sulphur containing amino acids 1

Androgenic alopecia (male- and femalepattern baldness) Alopecia areata Telogen effluvium Anagen effluvium Traction alopecia Trichotillomania Cicatricial alopecia Causes of hair loss History Diagnosis of hair fall Physical or emotional stress Child birth, surgery.. YES NO Telogen effluvium lab. Work Iron, thyroid, ANA,vit D 2

Diagnosis of hair fall lab. Work Iron, thyroid, ANA, vitd NO YES Correct the underlying cause accordingly Search for physical signs YES scalp biopsy and treat accordingly Diagnosis of hair fall Search for physical signs YES Scalp biopsy and treat accordingly NO Gradual history of thining YES Female pattern hair loss 3

Androgenetic alopecia Testosterone DHT 5 α Reductase enz. Anti androgens Nuclear receptor Proliferation Conversion of anagen into telogen Biological modifiers : Minoxidil Melatonin Growth factors Miniature hair & fibrosis Androgenetic alopecia Telogen anagen Prolongation of anagen Aim of treatment androgen effect on hair growth 4

Androgenetic alopecia Treatment Medical treatment Methotherapy Low level light therapy OTC drugs Hair transplantation Hair pieces and camuflage Minoxidil Antiandrogens Growth factors Topical retinoids Melatonin Iron, folic acid, biotin, zinc, vit B, vit D 5

Minoxidil Angiogenesis VEGF T cells K+ channel opener & Ca ++ Changes Telogen Mode anagen Prolong anagen of Anti- androgen action effect Initiate proliferation of keratinocytes : Telogen anagen Prolong anagen Vasodilator PGD2 & prostacyclin prolongatio n of anagen Antiandrogen effect Minoxidil Forms : 2% & 5% Response : 6 month 6

Minoxidil Hypertrichosis in females & children Irritation allergic C.D Seb. Dermatitis Systemic absorption (effect is low but it explains hypertrichosis) Sexual potency in males is very rarely affected Category C in pregnancy, may cause systemic hypertrichosis in fetus Minoxidil Uses: Androgenetic alopecia Alopecia areata Biological modifier proliferatio of Keratiocytes convert telogen into anagen and prolong anagen T-cell proliferation and activation 7

Minoxidil Uses: Cytotoxic drug induced alopecia ( prolong anagen ) Hair transplantation :»Prevents post operative telogen effluvium»prolongs anagen Telogen effluvium (converts telogen anagen) Anti-androgens Finastride Dutastride ketoconazole Spironolactone Yasmine (drospirenone) Ciproterone acetate Flutamide 8

Anti-androgens 1. Finastride : 5 α reductas e inhibitor Mode of action Prolongs anagen Converts telogen into anagen Anti-androgens 1. Finastride(Propecia) : Dose : 1 mg / day for life Side effects : Loss of libido Erectile dysfunction Decreased spermatogenesis Contraindications: In females in the fertile period as it causes hypospadius of the male fetus 9

Anti-androgens 1. Finastride (Propecia 1mg): Response: 60 % of users develop new hair The rest cessation of hair loss Anti-androgens 2. Dutastride : Mechanism of action Inhibits type I & type II 5 α reductase enzyme 3 times more potent on type II than finastride 100 times more potent on type I than finastride 10

Anti-androgens 2. Dutastride : Dose 1 tab / day for 2 weeks then 2 tab / week for life Response Faster effect & better results ( more hair density) than finastride Much better results In females Anti-androgens 2. Dutastride : Side effects (Can stay up to 6 months after cessation of therapy ): Increased incidence of» Erectile dysfunction» Loss of libido» spermatogenesis 11

Anti-androgens 3. Ketoconazole : Topical ( Nizoral shampoo ) Used as adjuvant Mode of action effect of DHT on the scalp Anti-inflammatory effect It removes pityrosporum (source of inflammation) Anti-androgens 4. Spironolactone ( good adjuvant therapy) Mode of action : Competitive inhibition of DHT receptors Dose Aldactone 100 200 mg/day Side effects Irregular menses breast size & tenderness Headache libido 12

Anti-androgens 5. Yasmine (Drospirenone): Side effects Mode of action : Competitive inhibition of DHT receptors Less than spironolactone Anti-androgens 6 -Ciproterone acetate : Mode of action : Competitive inhibition of receptors Testosterone production Dose : As contraceptive pills (with EthinyloestradiolBoth Diane 35 and Diane 50 contain 2 mg of cyproterone. Diane 35 contains 0.035 mg of estradiol. Diane 50 contains 0.050 mg of estradiol) ( Effective, good as contraception during ttt) 13

Anti-androgens 7. Flutamide Mode of action : The most potent anti androgen Used in prostatic cancer Dose 250 mg/day (one tab / day) Side effects liver enzymes Na & K irregularities Contraindications Fertile females in child bearing period Anti-androgens Topical 5 α -reductase inhibitors : Finasteride Saw palmetto linolenic acid (and other unsaturated fatty acids) Caffeine 14

Topical Retenoids : (retinol lotion) Nuclear Retinoid R apoptosis prolongation of anagen Mode of action Immunological modifiers Helps absorption of minoxidil and potentiates its action Melatonin ( adjuvant therapy ) Dose 6 mg / night Mode of action : Prolong anagen phase 15

VIT. D: Vitamin D analogs can stimulate the growth of hair in nude mice that normally do not have visible hair (Vegesna et al., 2002 ) Aim for a minimum of 600 IU of vitamin D per day, 800 IU if you re over 71 years old. Fortified milk and orange juice has 115 to 135 IU VIT. D: The role of vitamin D in hair can be explained by the fact that an optimal concentration of vitamin D has been suggested to be necessary to delay the aging phenomena, including hair loss (Balland et al., 2008). Moreover extensive data from animal models clearly show that the vitamin D receptor activation plays an important role in the hair follide cycle, specifically anagen initiation (Korrie et al., 2010). 16

VIT. D: Serum Ferritin and Vitamin D in Female Hair Loss: Do They Play a Role?. Rasheed H, Mahgoub D, Hegazy R, El-Komy M, Abdel Hay R, Hamid MA, Hamdy E. Skin Pharmacol Physiol. 2013 Feb 20;26(2):101-107. VIT. D: 80 patients with TE and FPHL were included. Diagnosis was confirmed using both the trichogram and dermoscopy. The role of ferritin and Vit. D was evident from their significantly lower levels in the cases in comparison to the controls, reaching their lowest levels in the most severe cases. 17

Trental and Vitamin E Procyanidins (purified from grape seeds) Ginkgo Biloba Mode of Action : Mesotherapy Restore and increase local microcirculation. Provide nutritional input. Slow down the programmed process of follicular involution. Stimulate hair growth and new hair production 18

Ingredients : Mesotherapy Finastride Dutastride Minoxidil Hair growth promoters Vitamin B5, B1, B2, B3, B6 or B8 Biotin Vit. A & Vit. C Trace elements Side effects : Mesotherapy Secondary infection Alopecia Minoxidil & finasteride edema Possible systemic side effects 19

Growth factors Vascular endothelial growth factor (VEGF) Epidermal growth factor Insulin like growth factor Stem cell factor & C kit Fibroblastic growth factors Keratinocyte growth factor Growth hormone Transforming growth factor beta Hepatocyte growth factors Growth factors How to deliver hair growth factors : Local application and rubbing Iontophoresis Derma roller injection 20

Growth factors Insulin like growth factor insulin like growth factor Antiapoptotic Anabolic proliferation & differentiation 3 Converts telogen into anagen Growth factors Keratinocyte growth factor Improves hair growth secondary to improved follicular proliferation & differentiation If given prior to cytotoxic drugs it can protect against hair loss Inhibits follicular aging process 21

Growth factors Vascular endothelial growth factor (VEGF) angiogenesis Apoptosis Potentiates the effect of minoxidil Growth factors Vascular endothelial growth factor (VEGF) Overexpression of VEGF in outer root sheath (ORS) keratinocytes resulted in enhanced perifollicular vascularization, accelerated hair regrowth after depilation, and increased size of hair follicles and hair shafts. 22

Growth factors Vascular endothelial growth factor (VEGF) Studies reported that changes in VEGF levels are related to fourfolds increase in perifollicular vessel size during the anagen growth phase and a rapid decrease during catagen and telogen phases. The changes in vessel size coincided with cyclic changes in follicle size. Trace elements Skin remodelling Copper peptide (SRCP) : Blood supply Follicular thickness Thickness of SC fat Conversion of telogen anagen Tyrosinase reduce hair graying 23

Low level light therapy Source Low powered ruby red laser (694 nm) Mode of action Mitochondrial production of ATP Wound healing Hair growth Message Proper identification of the type of Alopecia Before starting treatment is mandatory Treat according to the cause 24

Message Treatment for androgenetic alopecia should include : Anti-androgen ( it is better to use a combination of several antiandrogens to act on different levels ) Biologic modifiers Growth factors Trace elements (Iron, zinc & copper) Message To improve Minoxidil action : Add : Retinoids VEGF Anti-oxidants 25

26