In September I attended the FUE Europe conference in Istanbul, Turkey. During the meeting, I oversaw two studies evaluating differences in PRP – Platelet Rich Plasma kits and different instruments to prepare adipose-derived mesenchymal stem cells. I asked the 95 attendees to bring the PRP kits that they use so that we could compare the platelet concentrations and platelet yields. Of the 95 attendees, two brought their kits. We compared these two kits to two kits commercially available in Europe. We found significant differences.
The truth is most physicians tend to look at the cost to them to provide PRP. The overwhelming majority have no idea what they are providing and don’t seem to care. If they did care, they would bring their PRP kit so we could tell them.
DR. COLE AT THE FUE EUROPE MEETING 2021
To evaluate the results, we brought a hemoccult machine that uses light to differentiate cells and quantify them. These machines are expensive, so it is understandable that most physicians don’t have one in their offices. It is curious why physicians don’t seem to care. One reason may be that they don’t under why it is important to know.
HEMOCCULT COULTER COUNTER
Growth factor concentration increases in a linear fashion as the platelet concentration increases. In 1998 Robert Marx, a maxillofacial surgeon, first describe how to make PRP. He also defined PRP as 1 million platelets per milliliter. Dr. Marx used PRP for bone grafts. He found the best benefit with around 1 million platelets per milliliter in dental surgery. Higher concentrations were of no additional benefit. We find a similar concentration is more valuable in treating hair loss. In our studies, 1 million platelets per milliliter improved hair density by 50% at 6 months. Lower concentrations resulted in decreased hair densities at 6 months. All the kits we evaluated in Istanbul resulted in platelet counts significantly below 1 million platelets per milliliter.
THE CRP PROTOCOL VS. PRP
Platelet counts normally are between 250,000 to 350,000 per milliliter, but the normal range is 150,000 to 450,000 per milliliter. Our goal in making PRP is to reach concentrations about 5 times the baseline count so that we can exceed 1 million platelets per milliliter. Both platelet kits we use exceed 1 million platelets per milliliter. When platelets are activated, the alpha granules release growth factors. Around 70% of the growth factors are released in the first 10 minutes and almost all the growth factor release is seen at 90 minutes. However, there are more growth factors in the platelets that never get out. They are trapped in the clot made up of fibrin, fibronectin, and vitronectin, which are good for cell migration and healing, but serve no benefit to improving hair coverage or graft growth. We found that lysing the platelets results in five times the concentration of the heavier growth factors. Higher growth factors are stimulatory to the hair, but also speed up the growth of grafts. We call lysed platelets Cytokine Rich Plasma (CRP). I developed a protocol using high-frequency sound energy to burst or lyse the platelets. This protocol takes one hour to lyse the platelets. The entire process to make and administer CRP takes two hours. CRP is highly stimulatory to the dermal papilla.
WHAT DID WE FIND IN ISTANBUL?
First, we measured the baseline platelet count of our patient. We then prepared four different types of PRP from the patient. The baseline platelet count was 238,000 platelets per milliliter. The highest kit produced 488,000 platelets per milliliter while the worst kit produced 33,000 platelets per milliliter. This kit is used by a physician in Turkey, and it is not PRP. It is platelet-poor plasma (PPP) and offers no benefit to the patient. We also measured the platelet yield. The highest was 90% and the lowest was 0.04%. Hence, there was no kit that met the ideal platelet count we want to treat hair loss with PRP. These are all platelet kits used by well-known and respected physicians, but these are not optimal kits to use to treat patients with hair loss or post-hair transplant surgery. In fact, the majority of PRP kits don’t benefit hair loss suffers at all.
I measure cell counts on almost all my patients. There are cells we want in the PRP and cells we do not want in PRP. There are two sources of non-nucleated cells, red blood cells, and platelets. We want very few red blood cells, but we want as many platelets as possible. A 90% platelet yield is very good. Lower platelet yields are acceptable provided we draw a larger volume of blood. Mononuclear white blood cells are beneficial, but we want very few of the rest of the white blood cells. However, in surgery, a small quantity of granulocyte white blood cells protect against infection. It would be advantageous to patients and physicians if cell counts were routinely evaluated in making PRP.
WHAT IS THE RIGHT PRP PROCEDURE TO BENEFIT PATIENTS?
There is cost-benefit patients are looking for. When the PRP kit contains an inadequate number of platelets, the patient will have cost with no benefit. This can sour patients on PRP. Patients with advanced hair loss will show improvement, but they are not likely to regrow a full head of hair. Furthermore, the treatment must be repeated at least annually. I recommend repeating the treatment every nine months. Treatment with good quality PRP works best with early hair loss and can increase hair mass by 50% in these patients. Unfortunately, in early hair loss patients see less benefit despite significant increases in hair mass. A nearly full jar of marbles that contains 100 marbles will appear similar when 10 more marbles are added. The same jar that has only 10 marbles will still look nearly empty when 10 marbles are added to make 20 marbles. Good quality PRP does increase hair density and prolongs the lifespan of your hair. However, the patient should make individual decisions regarding cost and benefit.
We often encourage patients to consider pharmacologic options because the cost is less, and the benefits can be significant. Again, patients should weigh the risk of side effects against benefits. Pharmaceuticals are not for all individuals.
I have written multiple published papers on PRP and regenerative medicine in hair loss. Unfortunately, it does not seem many physicians read them, or they just don’t care. I will continue to search for improved methods to produce the best regenerative outcomes for all patients and continue to educate physicians, who are interested in better outcomes. Good quality PRP improves hair density. Good quality PRP may not give you a full head of hair does prolong the life of hair. Hair loss is a progressive process that gets worse every year. We can improve coverage naturally in appearance very well through surgical solutions. It is very important for patients to understand the limitations of their donor areas. Eventually, the donor area will be depleted as hair loss progresses over time. Therefore, intervention with cell-based therapy or pharmaceuticals is so important. Patients must help us help them.