Much like a perfectly fitting pair of jeans; abundant, healthy-looking hair is the one thing we would all want to ‘wear’ everyday and never take off. In addition to genetic predisposition, the stress of city living, harsh chemical treatments and even over-styling can damage hair, leading to a greater incidence of irritated scalps, dull and breaking hair, and indeed, pronounced hair loss. For many, hair still stands as a sign of success, losing hair is one of the most distressing experiences for individuals, who often deal with a great deal of emotional stress.

With more men and women worldwide seeking medical help to deal with hair loss, the industry is experiencing a huge increase in size, with the total market for hair restoration surgery rising by almost 48% between 2008 and 2012, according to the International Society of Hair Restoration Surgery (ISHRS). This is an increase from around $1.3 billion to $1.9 billion USD in the 4 years to 2012. Regionally, the Asian market is overtaking the US in terms of volume, with 102702 procedures in Asia alone during 2012 compared to 88304 procedures in the US; while the Middle East is seeing strong growth as its economy continues to grow steadily, with around 35086 procedures¹.

Hair restoration surgery: the gold standard

Greater social acceptability and steadily reducing costs continue to support the popularity of hair restoration surgery (HRS) among patients.

Around 285425 surgical patients were treated worldwide in 2012, according to ISHRS, an increase of around 12% since 2008. The bulk of hair restoration surgery is still made up of 85% men, with women making up the remaining 15%. Regarding age groups, most patients (30.4%) find themselves in the 30–39 bracket, followed by around 26.3% in the 40–49 bracket, and 19.3% in the 20–29 age group, according to ISHRS¹.

Surgeries include follicular unit transplantation (FUT), follicular unit extraction (FUE), strip or linear harvesting, and micrografting among others. Follicular unit transplantation, currently the most popular technique, involves the cutting of a donor strip from a discreetly placed area in the back of the head. The strip is harvested and the follicles are then re-implanted in the identified recipient sites. According to Dr Ziering, a transplant surgeon with offices in the US, UK, and Spain, FUT requires ‘good surgical technique and trychophytic closure for reducing scar appearance’.

Follicular unit extraction, a more recent method, yields a reduced number of follicles, but has the advantage of not leaving behind such a large, visible scar. The follicular units are removed with a hollow punch, cultivated and re-implanted one by one.

‘Our practice does a large number of FUE cases, whether by ARTAS Robot or manual extraction. Both FUT and FUE can yield great results,’ said Dr Ziering. ‘Patients that desire a shorter hairstyle are especially good candidates for the FUE extraction method’.

The arrival of Artas, the robotic transplant system, is going to change the face of surgery. ‘It’s going to speed up the process somewhat and make it more uniform, it will allow it to have natural patterns, less transaction of the units, less cutting, so it should provide potential for a slightly better growth’, said Dr Sadick.

The system uses computer assistance including an image-guided robotic arm and special imaging technologies that co-ordinate to harvest hair follicles during the actual process of FUE hair replacement.

Non-invasive approaches: the first port of call

Alternatives to hair transplantation can provide cosmetic improvement for those who do not feel ready to jump into the deep end of invasive procedures. The market remains strong owing to the ease and convenience of the treatments, their smaller price tag and the fact most patients approach non-invasive treatments as a first port of call before headed for surgery should the treatment not succeed. Around 686035 non-surgical patients were treated worldwide in 2012, ISHRS data shows, more than twice the amount of those that underwent surgery¹.

The non-invasive approach has an arsenal of products ranging from topical medication such as minoxidil, systemic medications such as finasteride, and steroids such as triamcinolone or spironolactone (off label), as well as certain birth control options for women.

Minoxidil is an interesting example of how these drugs have moved from the medical realm to capture the mass market; it is now being sold in stores from Walgreens in the US to Tesco in the UK, with different strengths and targeting both genders effectively.

‘Minoxidil is still the leading topical treatment for non-scarring alopecia hair loss. Minoxidil has been used for many years and is safe, effective for a certain degree of prevention of hair miniaturisation, easy to use, and affordable,’ says Dr Ziering.

However, despite their proven efficacy, patients looking for a more holistic approach are increasingly turning their attention towards alternative treatments. These include injectable cocktails such as mesotherapy and skin needling, as well as non-injectables with other topical delivery systems, such as electroporation and ultrasonophoresis.

Mesotherapy

Mesotherapy is gaining greater acceptability globally, having already been well established in Europe owing to standard treatments being valued for their ability to add radiance back to weakened hair. They are designed to help with hair loss, both hormonal and hereditary, as well as hair loss related to stress, fatigue, and pregnancy.

A typical mesotherapy cocktail contains around forty actives, such as vitamins, amino acids, and minerals, while more in-depth coctails, largely produced in Asia, can contain flavonoids, antioxidants, hyaluronic acid, and adipose derived stem cells (ADSCs).

Other popular mesotherapy cocktails include formulations rich in peptides and growth factors, as well as autologous cocktails including platelet-rich plasma (PRP), herbal cocktails or formulas mixed with active ingredients such as minoxidil. Mesotherapy, together with skin needling, are typically used to stimulate the hair follicle and revitalise hair by improving hair structure, stimulate hair regrowth, slow down and prevent hair loss, improve irrigation to the hair follicle, hydrate and nourish the scalp, and even regulate seborrhea.

Dr Ziering offers PRP in his practice, ‘We do offer PRP/Acell injections in conjunction with dermarollers as an effective prevention therapy or to maximise the results of transplant surgery. It can be useful, especially in patients that do not want to have a daily routine in terms of a topical preparation or take a prescription medication like finasteride,’ he says.

ACell works at the cellular level to repair and remodel damaged tissues and organs; it recruits adult stem cells as well as the blood supply in the area, then changes these inactive adult stem cells back into activated progenitor cells (embryonic stem cells) resulting in the regeneration of native tissue, in this case, new hair follicles.

Lasers

On the laser front, the most popular treatments are those from low level light therapy (LLLT), light-emitting diode (LED), and photodynamic therapy (PDT). These cold lasers are lauded for their safety as they do not produce heat, nulling the possibility of thermal injury to the tissue. They work
by photomodulation, modulating cell activity so that cells work better and become healthier.

The laser energy delivered to the scalp increases microcirculation by mobilising calcium stores. The increased Adenosine-5′-triphosphate (ATP) production cascades into increased protein and nutrient production, which is delivered upstream to the hair follicle site. Laser treatments are typically in-office procedures lasting about 10 minutes each and are often combined with injections or other treatment formats. However, the rise of competitively priced at-home devices is also gaining traction, with tools such as the iGrow or Hair Max having cleared FDA approval and gaining currency. The protocol requires these devices to be used for around 30 minutes, three times daily, combined or followed by a maintenance phase of usage once or twice a week.

Holistic: the part no longer works for the whole

There is no ‘one-stop’ fix for thinning hair.  Rather, hair health is a by-product of the patient’s energy, nutrition, stress, endocrine system, genetic makeup, and androgenic sensitivity.

‘I would say that it’s impossible to treat hair loss without changing your lifestyle,’ says Dr Izabela Tilszer from Poland, who combines hair mesotherapy and LED to treat the scalp, as well as a mesotherapy cocktail against stress. ‘If stress is high in your life, it’s recommended to treat [it] as well’. She injects in the back along the spine up to the shoulders with a cocktail using magnesium, laroxyl, and procaine, injecting both the hair as well as the back in one session.

This concern with holistic treatments has supported the huge surge in popularity of trichology clinics in the UK, a move that is now expected to cross to the other side of the Atlantic.

According to Anabel Kingsley, head of product development at Philip Kingsley, the importance of diet cannot be emphasised enough. ‘Unfortunately, all hair gets finer as we age. Using a weekly stimulating scalp mask and eating a healthy, well-balanced diet will help boost the health of the hair, and keep it looking youthful and luscious,’ she says. ‘Proteins with breakfast and lunch are key here — It’s what your hair is made of. Making sure your iron and ferritin (stored iron) levels are good is also essential. Deficiencies in either of these can cause various problems such as hair loss and brittle hair.’

In 2013, the Philip Kingsley clinics saw an average growth rate of 15.5%, with an average 30 new consultations per week and a total of 130 treatments per week.

This rising popularity has also transposed the hairdressing market, which is showing greater demand for extra training from trichologists. ‘More salons want training in how to best take care of their clients’ hair; we hold teaching academies for 2 days every 4–6 weeks’, according to founder Philip Kingsley.

His eponymous product line has left the specialist shelves of clinics and is taking over pharmacies, drugstores, and even department stores. In July, Kingsley launched Tricho 7 — a new holistic three-step protocol to care for hair and scalp. Combining zinc sulphate, azelaic acid, and B6, these ingredients work together to create an ideal scalp environment for healthy hair. The formula is rich in antioxidants, has soothing effects, protects against environmental degradation, and immediately gives the appearance of more volume with increased density improvement over time. The kit contains three products: ‘Volumizing Protein Spray: Hair Density Formula’, ‘Volumizing Hair & Scalp Treatment Daily Scalp Drops’, and ‘Hair Nutrition Formula’.

The more holistic approaches tend to focus on natural and organic ingredients. Trichologist guru Ricardo Vila Nova only uses natural ingredients such as biotin, zinc, hyaluronic acid, lactic acid, protein, and trace elements.

Scalp: the new face

One of the most sought-after treatments for patients are those targeting the health of the scalp. After all, a healthy scalp equals healthy hair.

‘Many people with hair loss complain of burning and itching in scalp and that is part of the inflammatory process,’ Dr Sadick says. ‘Chronic inflammation leads to long term lack of functional fibroses, so if you have inactivity of growing healthy cells, they die, and that leads to hair fall out, therefore, if you can cut down the inflammatory cycle then you can cut down hair loss.’

Masks, serums, toners, and other products that aim to exfoliate the scalp are among the most popular on the market, while more treatments in clinics and hair dressers are also appearing under the ‘scalp facial’ tag.

Products: the camouflage

Those not willing to go into surgery, or for those occasions when it does not work, can find consolation in an increase array of camouflage products, such as artificial hair fibres, powder applicators or even permanent micro-pigmentation.

‘I recommend a number of hair camouflages like Toppik, Bumble and Bumble spray, and Joan Rivers compact applicator,’ according to Dr Rogers, who works at the Old Metairie Dermatology, Hair Restoration of the South. ‘These help reduce the contrast between hair colour and scalp colour, while we are waiting for the medications to work, or for the hair to grow in after hair transplant surgery.’

Conclusion

Despite the growing sophistication in research and techniques, thinning hair remains a big concern for men and women worldwide. Surgery and other non-invasive techniques constitute a robust market for practitioners that has shown steady growth despite the financial crisis.

Still, further breakthroughs are avidly awaited by patients that will help avoid the loss of their crowning glory, and the subsequent emotional stress it implies.

Cloning is one area where many MDs are looking to for hope. ‘More and more research is being done in the area of hair cloning. When we are able to successfully regrow 1000 or 10000 hair follicles from a single biopsy, this will be amazing’, says Dr Rogers. ‘This will allow us to help many more people than we currently can with existing techniques. That being said, cloning is still probably at least 10 to 20 or more years away.’