Expert Perspectives: Hair Loss Management in Dermatology Practice

This presentation explores the rising prevalence of hair loss and the expanding range of treatment options available to dermatologists. It outlines the most common hair loss conditions and highlights the emotional and psychological impact on patients. The presentation reviews both established and emerging pharmacological treatments and non-pharmacological approaches, including innovative technologies. Additionally, the discussion touches upon market trends, increased patient demand, and common barriers to care, such as cost and treatment compliance. The goal of the video is to equip dermatology practices with effective strategies to improve outcomes. 

Video Transcript: 

Moderator: Hello and welcome to today's webinar on The Dermatologist. Today's presentation is Expert Perspectives Hair Loss Management in Dermatology Practice. My name is Cynthia Cooley, Themm for The Dermatologist. We're happy to have you join us today for this non-accredited, independent medical education program. Today, we are pleased to welcome our featured speakers, Dr Glynis Ablon and Dr Neil Sadick. Dr Glynis Ablon is a board-certified dermatologist with 30 years of experience in medical, surgical, and aesthetic dermatology. She's an associate clinical professor at UCLA and a national educator and investigator for pharmaceutical companies. Dr Ablon was the first US author to publish on mesotherapy and has contributed over 60 peer-reviewed articles, two book chapters, and three books. She is an on-camera medical expert for major networks, including ABC, CBS, NBC, and the Doctor's Show. Dr Ablon is a fellow of multiple professional societies, including the American Academy of Dermatology and the American Society for Dermatologic Surgery.

As director of the Ablon Skin Institute Research Center, she has led more than 50 clinical trials. Notably, in 2010, she received the MCA research award for innovative work on botulinum toxins. Dr Sadick is among the world's most influential and renowned dermatologists and researchers. He holds board certifications in internal medicine, dermatology, cosmetic surgery, and hair restoration surgery, and he is a diplomat of the American Board of Venus and Lymphatic Medicine. Dr Sadick is one of the world's most respected dermatologists, the medical director and owner of Sadick Dermatology, and the director of Sadick Research Group, which runs multiple FDA clinical trials annually. Dr Sadick has authored over 300 journal publications and 20 books on hair disorders, facial rejuvenation, lasers, sclerotherapy, and cosmetic surgery, as well as 70 book chapters on cosmeceuticals, hair transplantation, lasers, and sclerotherapy. He has also presented more than 500 major academic presentations throughout the world. With that, I will turn it over to our esteemed presenters. We're so glad to have them join us today.

Glynis Ablon, MD: Well, I'm excited to be here for The Dermatologist, and we're going to talk about the learning objectives today for this talk on alopecia. The first one is to identify and differentiate common hair loss conditions and to improve early diagnosis and patient management. The second is to evaluate the clinical effectiveness and suitability of various hair loss treatments options, including pharmacological therapies and laser therapies. And finally, it's to recognize how integrating specialized hair loss treatments can differentiate a dermatology practice, enhancing patient satisfaction and patient growth. I think it's really important to understand that the rise and prevalence of hair loss in the US is just skyrocketing. The idea, of course, is that we are living longer, we have more patients on planet earth, and so there are many more people having this issue of hair loss. It's interesting to note that two-thirds of men actually experienced hair loss by the age of 35, and we're seeing it even younger and younger these days.

And, basically, 50 million people in the US who experienced hair loss are men. But you have to remember that a lot of men can shave their heads and don't mind being bald. So, we have to think about the female experience as well. And what we're seeing now is that about 20% of women actually suffer from female pattern hair loss as early as the age of 21. That number where we see 50 million men experiencing male pattern hair loss, there are 30 million women in the US experiencing hair loss, not quite one-to-one, but you're seeing that the numbers are quite similar, getting closer. So, it's something that we really need to address and understand that we have treatment options available.

Let's go over now the common hair loss causes and conditions, and you can see that there are seven of them listed here. In dermatology residencies, oftentimes, we're taught to basically break it down into scarring alopecias and nonscarring alopecias, but this is a little bit different breakdown. Let's start with androgenic alopecia, or male and female pattern hair loss. It's the most common cause of hair loss in both males and females. The second one to talk about is alopecia areata. This is actually the third most common form of hair loss, and it affects about 20% of patients as children. It's also known to be an autoimmune basis, and about 2% of the population experiences alopecia areata. Then you get into the effluvium, and effluvium, of course, just means a byproduct in the form of waste, but we're talking about the anagen and telogen effluviums. Actually, 10% of patients with cancer will decline chemotherapy because of the fear of hair loss. So, it's a very big deal. 

Then you have the scarring alopecia. It's kind of a category all its own; we call it cicatrical alopecia, and it affects up to about 3% of people who are experiencing hair loss. I'll go into more detail about the scarring alopecia in a bit. Then you get three other categories, and those can kind of fall under both scarring and nonscarring alopecia. Let's talk about the hair shaft defects, and this is a structural abnormality of the hair shaft. This can be due to genetics, or it can be due to trauma or physical injury. The genetic portion of it that can have increased fragility or no increased fragility, and those include things like reis nodosa, loose anagen syndrome, monilethrix, and pili torti, to name a few. The external injuries are where we think of the physical injuries to the hair, fractures, and chemical injuries, and that includes things like traction alopecia or the pulling of the hair.

Then we have the category of medication use, and we do know that there are many medications that can lead to hair thinning or hair loss, and these include anticoagulants, antihypertensives, antidepressants, and of course the cancer medications. Finally, we have the infectious agents, and it's important to understand that all forms of infection can lead to hair loss. We know the fungal components, such as tinea capitis, can lead to hair loss or hair thinning. We know that bacterial infections such as syphilis, as well as folliculitis and folliculitis decalvans, can lead to both scarring and nonscarring alopecia. Then, of course, the viruses, and many of us know from the recent COVID outbreak that COVID is something that is a virus that can lead to hair loss, as well as things like shingles.

Now let's talk about the key features of hair loss conditions. Again, we're not naming every single hair loss condition, but we're going to name the majority of the most common things that we do see in dermatology. The first thing we talk about is androgenic alopecia. In the male patients, it's important to note that we see a little bit different type of hair thinning. We'll notice that kind of bitemporal thinning of the scalp. You can see the vertex thinning of the scalp, and patients can go as far as having complete hair loss or hair thinning. In females, however, we see this more diffuse hair thinning. It tends to retain the frontal hairline and a diffuse thinning on the top of the hair on the head, although it can appear everywhere on the scalp. When it comes to the effluvium, as I mentioned, telogen effluvium, this is where the hairs have basically gone into, usually a stressor that takes up a large portion of the anagen hairs and throws them into the telogen or resting phase.
Patients will notice that clumps of hair are coming out in the shower, in their hairbrush, and on their pillow at night. So, you can see again, a lot of hair shedding. Normal hair, we say, is about a hundred hairs a day; with patients who are having telogen effluvium, that can be up to 300 hairs a day or more. Typically, with telogen effluvium, about 4 to 6 months after the stressor, the hair will grow back, as this is a nonscarring alopecia. The anagen effluvium, basically, is hair shedding where the hairs are in the anagen phase or growth phase, and they just stop growing. This is usually due to an acute injury of the hair follicles. This is, again, endogenous or exogenous causes. This diffuse thinning and patients have this hair loss usually due to chemicals—usually due to chemotherapy—but also colchicine, thallium, gold, and arsenic can also play a part, and there can be an autoimmune part to the loss of hair with anagen effluvium as well.

Then you get into the alopecia areata, and as I mentioned, this is typically believed to be a T-cell abnormality, so autoimmune. About 2% of the population has it, and about 40% of patients will actually see hair loss due to alopecia areata before the age of 20. This really is a collapse of the bulb immune privilege of the anagen hair follicle, and this is a real big driver of the alopecia areata. High risk of comorbidities like thyroid disease, atopy, the iron deficiency, and of course vitamin B deficiency—as well as psychiatric disorders—can be seen in addition to the alopecia areata as comorbidities with alopecia areata. Again, you can see these short vellus hairs, broken hair shafts; it can be acute and patchy or diffuse. You can have that universalis or totalis, where you're also involving the eyebrows, eyelashes, and all the body hair. 

Trichotillomania, this is the patches of alopecia that we can see, and again, this too can include the eyebrows and eyelashes. Trichotillomania is also known as a focused repetitive behavior or impulse control issue, and it does warrant psychological evaluation and treatment. This is a nonscarring alopecia. Typically, if you can deal with the causes of the trichotillomania and can resolve it, patients can have their hair fully grow back. Trichorrhexis nodosa, this is something I mentioned under the hair shaft defect; it can be secondary to trauma. You get this fragile hair, and the patients can have excessive scalp scratching, which can also lead to trauma of the hair. Trichorrhexis nodosa is known to be a congenital abnormality seen with Argininosuccinic aciduria, or it can be due to hair straighteners and chemicals, too much dyeing, swimming, et cetera. This is believed to be a temporary or nonscarring alopecia that can be resolved. 

Finally, we have scarring alopecia, and this affects about 3% of the hair loss that we see. It's not a common issue, but when it happens, scarring alopecias are permanent. We like to treat these very aggressively and very acute situations as soon as possible because that's where we really can see some improvement. Once the progression has gotten to a completely scarred-down scalp, there is no great treatment at that point. Patients can notice that they have these irregular edges of bald patches. It can be smooth, there can be redness, scaling—again—depending on what type of scarring alopecia. There are many different ones, including these central centrifugal cicatrical alopecia, frontal fibrosing alopecia, folliculitis decalvans, lupus erythematosus or discoid lupus erythematosus, alopecia mucinosa, and those are just a few of the scarring alopecia that we do see.

Finally, I just want to mention that hair loss really can have a negative impact on quality of life. I have this discussion when I'm talking with all of my patients with alopecia areata on a regular basis, but hair really is an important component of identity and self-image. So, it's important to address how patients are feeling as they're dealing with their hair loss. There can be many psychological issues, including depression and anxiety, loss of self-confidence, lower self-esteem, and a heightened self-consciousness. I try to talk about the fact that we address it with the patient themselves, but it really is the surrounding family members that should be brought into this conversation. Quality of life is affected not only for the patient dealing with the hair loss, but also with the family members around them. Studies report that patients with very mild or moderate hair loss tend to experience more distress than those with severe hair loss, and we really don't know the reason why, but I think it's important, again, to address quality of life, to address how the alopecia is affecting each patient, and what we can do.
The fact that we have many treatment options, and again, the earlier the better that we address them. We are in better shape and the patients have better results, and we have happier, less depressed, less anxious patients.

Neil Sadick, MD: Let's talk about some current pharmacologic treatment options for hair loss. Those can be either segregated into FDA-approved drugs or select off-label type drugs. Adverse drug reactions or inconvenience leading to long-term compliance issues are something that is considered by the FDA when they make these decisions. The FDA-approved drugs include topical minoxidil, both for male as well as for female pattern hair loss. Oral finasteride has been approved for the treatment of male pattern hair loss. I was involved in those trials. Then, the JAK inhibitors, which are gaining increased popularity for treatment of more severe alopecia areata. The off-label products include topical finasteride, oral minoxidil, which is gaining increased popularity, and oral dutasteride. These off-label type products are more unclear in terms of their efficacy and their side effect profile.

Now, let's look at the emerging pharmacologic treatment landscape options for hair loss. They can be separated into three classes. On the left, as you can see, phytomedicine; in the middle, the neurotoxins; and then lastly, these novel androgen receptors, clascoterone. For phytomedicine, there are topical and subcutaneous administration of plant extracts. A number of them have shown favorable outcomes in clinical studies. These products include niacin, ascorbic acid, vitamin B complex, tocopherol, grape seed, rosemary oil, and sage. The neurotoxin botulinum toxin A is primarily used for relaxation of muscles, but again, it's hypothesized to have some effect due to its inhibition of TGF β1. Clinical trials have reported an increase in hair counts and/or patient satisfaction with the utilization of botulinum toxin. However, these studies are somewhat unclear, and further studies would be necessary to establish a more definitive relationship of improvement. Clascoterone is a new novel androgen receptor inhibitor that competes with DHT binding sites, and it's been approved by the FDA for the treatment of acne and is receiving more attention in trials that are being utilized for hair restoration. Currently, there are phase two clinical trials ongoing as a topical agent to be utilized for treatment of androgenic alopecia.

Then there are non-pharmacologic interventions. The two major ones I've outlined are platelet-rich plasma and hair transplantation surgery. As we know PRP, or platelet-rich plasma, involves the injection subcutaneously in the scalp of cytokines, which activate genes associated with tricostimulation. It's shown to in multiple studies to be effective in the treatment of female pattern hair loss. However, it may be somewhat less than minoxidil, although I'd say that this statement would require further substantiation to state its actual place. Not every patient can be a candidate for PRP; you cannot have any blood problems. Again, you can have to tolerate a little bit of discomfort during the procedure, and there is a higher cost associated with PRP since it's not commonly covered by insurance plans. Hair transplantation surgery has really emerged, and what we do is take donor hair follicles from the donor area and then insert them into the affected balding area of the scalp. It's only a partial solution due to the remaining non-transplant follicles, which can either be present in terms of the initial hair transplantation and require further treatment options or can progress with time. Hair transplantation has no effect on the progression genetically of the biologic process and still requires concomitant antiandrogenetic alopecia therapy again to be utilized. So, it's really, even if you transplant an area of balding, usually there's some necessity again for a nonsurgical approach to try to stimulate other areas on the scalp that have not yet lost their hair.

So, what are some of the emerging non-pharmacologic therapies for hair loss? This brings us into the next generation: nanotechnology used for wound healing, tissue regeneration, et cetera. Again, these systems have been proposed for the treatment of hair follicle disorders, including nanoparticles, these very small particles, nano-structured lipid carriers, which act again as karyotype agents. What's really new is nanotranserosomes. These serosomes also play a role in delivering and bringing cytokines to the area of balding. Basically, the aim of nanotechnology is to have more precise control over drug release and enhance the drug release, which will lead to improved delivery to the balding targets and subsequently improve clinical outcomes. Tissue engineering and 3D bioprinting techniques are also extremely new, and what it challenges are in constructing hair follicles. This has been somewhat of an issue that still has not been totally resolved because of the complexity in terms of mesenchymal epithelial cell interactions that occur again in the balding process and the attempt to stimulate the stem cells of the hair follicle. 3D bioprinting enables the creation of structures that actually closely resemble the true appearance and true effect of biological tissues, even when those structures are highly complex.

There are some initial studies showing promising results on these techniques in the treatment of hair loss. However, more sophisticated studies need to be conducted. Recent studies in the mouse model have shown hair growth, but again, this is really in the earlier phases of this type of approach. Low-level laser therapy—another area that I've been interested in—also called photomodulation, delivers near-infrared light with wavelengths between 600 and 1100 nm. It is felt, at least its mechanism is felt to be improved; elongation of the anagen phase of the hair follicle, decrease inflammation, prevention of premature catagen development or movement of hair into a resting phase, and increasing rates of proliferation in active anagen hair follicles. Now, on the right, there are multiple types of these products on the market. The one on the right shows a brush type of technology. Again, that's been FDA cleared. This phototherapy low-energy light source and the iGrow®, which is the other FDA-cleared agent, which is a helmet that encompasses the entire scalp.

So there've been a number of trials looking at these low-energy devices. They can be combs, helmets, sports caps, or headbands. We've published several papers on this along with our colleagues from the University of Minnesota. Studies have shown an increase in hair density with the low-energy light treatment group compared to the shams. Again, no significant differences in males or females, but significant improvement in hair numbers using these technologies. These low-energy light sources alone, and the combination with LED technologies have again shown an improvement in significant difference in terms of hair density. So, what we can say is that there's a statistically significant increase in hair density in studies looking at the combination of minoxidil and low-energy light. Certainly, in my patients, this is a common combination to be utilized: topical oral minoxidil and low-energy light therapy. Again, in studies that have been performed and published, 90% of these combination treatments showed improvement. What's more importantly, and always the most important facet, is 100% of patients actually reported patient satisfaction.

What's new in terms of emerging laser-based therapy? This is the most exciting new advance. Ablative lasers, which cause microdestruction to the skin and allow vaporization of tissue. These are in the ablative zone. Then, also, the other component, nonablative zone, which causes less, again, epidermal damage, preserves the epidermal surface, allowing rapid, decreased downtime and less problems with hypopigmentation. You can see here at the bottom, the fractional lasers act only on a percentage of the skin surface, but there's less downtime, better wound healing, and more rapid results. The only FDA-cleared fractional laser is FoLix, which is an Erbium glass laser. Again, the ablative lasers, which have been used in the past, clinical studies have shown an increase in shaft diameter and density using the CO₂ laser in combination with topical therapies. In preclinical murine studies, the effect of Erbium: YAG lasers were greatest again, when used in combination with minoxidil.

The new nonablative fractional lasers are really the state of the art and the state of modern treatment. The studies have shown significant improvement in hair density and growth rate as a monotherapy, and  looking at the folium laser, which showed significant improvement over the laser alone when used with topical treatments. 

The important points to remember is that there are both ablative and nonablative lasers. Nonablative lasers are associated with good results, positive hair growth, decreased downtime, and again, this is something that is being used more commonly by patients and trichologist physicians who are treating patients with hair disorders. The nonablative fractional laser induces an inflammatory response, which upregulates cytokines, such as gene expression of Sonic Hedgehog, which can be associated with increased hair growth and a significant improvement in inflammatory response. So, what you're doing is stimulating the stem cells of the hair follicle in the hair follicle structural unit.

As you can see on the right, there is no significant difference in coagulation. Infiltration of immune factors and complete tissue repair occurs comparable to the control group. So this is a great way to upregulate growth factors associated with hair stimulation, both from a physiologic point of view and from a genetic point of view as well. Again, with very rapid tissue repair, which doesn't show any significant difference when compared to control groups—a really important point—and that's why these nonablative fractional lasers are gaining such increased popularity because of their combination of safety and efficacy. In its retrospective study looking at FoLix, the nonablative fractional laser showed significant results. One hundred and thirty-two patients completed three of six laser treatments. As you can see here, there was a good combination of men and female, and there was a 97.9% success rate in terms of increased hair growth and patient satisfaction in men and 96.1% success rate in women. And with most importantly, there were no significant adverse events that were associated with this. On the right, you can see the application of the Erbium glass laser, which is the first and only FDA-cleared fractional laser for treatment of hair loss.

What are the barriers to hair loss treatment access? Again, with the oral agents, finasteride has been associated with an high percentage of individuals with side effects. So it's not also, because of this, been shown to be approved in female pattern hair loss, only in male pattern hair loss. Then topical products need to be applied three times a day and can lead to messiness of the hair on the scalp, and they need to be left on for hours. This has been associated with decreased patient compliance. The financial burden of low-energy light on patients, because they're looking at a long-term usage of this, although the price is not that significant, there is a high price range variability from $279 to almost $3,000. Hair transplants can run anywhere between 4,000 to 15,000, even up to $20,000, depending on the average. You can see here in the US being $13,600 depending on where you get the treatment performed.

Here's the financial burden, low-energy light, which needs to be continued indefinitely, also associated with a financial burden. Remember what we talked about before, even if you have a transplant, commonly, you also need to utilize again some other therapy to treat the remaining hair. 
So, what are the key takeaways? Remember my major comment to say, we've come a long way in the treatment of hair disorders. Finally, for the last couple of years, we now have some new innovative and FDA-approved technologies. Again, hair loss is a condition that affects men and women of all ages, and it's becoming increasingly prevalent. Now because we have these increased tools that are extremely effective, it's gaining increased popularity for our patients. The market is expanding exponentially because of the increasing growing demand and the knowledge that we now have effective treatments for this, and hair loss can present in various forms.

There are various clinical presentations. Some of it is genetic, others can be related to inflammatory disease, but the most common type is androgeneic alopecia, or male pattern or female pattern hair loss. The various medication interventions that we've talked about, pharmacotherapies and other treatment procedures, can combat alopecia in many cases. However, access to treatment is often hindered by multiple barriers. The number one barrier is really cost. These are expensive procedures, not most commonly covered by our insurance carriers. There are some adverse side effects, but they're relatively safe. Patient convenience of getting on a long-term program also is another barrier that people have to face if they're going to begin a hair treatment program. Many therapies, such as nanotechnology, that we've talked about. The new exciting nonablative fractional laser, are emerging, and these have helped to achieve more effective and personalized outcome for patients.

I'd like to say that when we treat hair disorders, it's usually a combination of treatment modalities that gives the greatest effect. For example, you can use the nonablative fractional laser. You can use some topical or low dose oral minoxidil. You can use photomodulation. PRP also is part of this treatment algorithm that can be utilized as well. But the important point to understand, it's usually a multimodality approach that gives the best results. What's really nice is that we can state that these are safe treatments. There's a relatively low adverse treatment outcome protocol that is associated with this. So thank you very much. We've come a long way. Remember, hair is hot. We have new great pharmacologic, technologic, and the therapeutic armamentarium is expanding to give better results and improve patient satisfaction. Thank you so much.