Hair Restoration for Generation X

One of the most common and pressing aesthetic needs for the age range that Generation X (Gen X) occupies is hair restoration. To learn about that demand and the latest options available, we spoke with Modern Aesthetics Editorial Board member Suneel Chilukuri, MD, FAAD, FACMS.

DO YOU NOTICE DIFFERENCES IN GENERATION X’S EXPECTATIONS AND DESIRES FOR HAIR RESTORATION TREATMENTS COMPARED WITH BABY BOOMERS?

I do. The biggest difference is that baby boomers typically feel a tremendous amount of guilt spending on themselves. With Gen Xers, often their kids are finally grown and they’re willing to finally think about themselves. Additionally, baby boomers ask fewer questions; while they are always learning, they trust their physician and are generally more reluctant to question a clinician about anything. Gen Xers usually have already undergone treatments and already utilize more tools to address their concerns; they often look like they are in their 30s instead of their 40s or 50s. They are always curious and asking, “What else is there and what else can/should we be doing?”

As a result, this generation is changing the market with its curiosity about biohacking and regenerative medicine. Everything we have been able to do with neuromodulators, hyaluronic acids, and energy-based devices led us to this revolution of learning how to both prevent and “naturally” correct some of these situations. That is how we have gotten into platelet-rich plasma (PRP), platelet-rich fibrin matrix (PRFM), platelet-derived growth factors (PDGF), exosomes, stem cells, etc. In addition, what’s old is becoming new again. We are using fat to create the micronutrients and nano-nutrients that are needed for facial improvement as well as hair growth.

WHAT ARE THE MOST POPULAR HAIR TREATMENTS THAT YOU’RE DOING?

Up until about 2 years ago, we were trialing many new treatments and it was exciting, but I was not able to consistently provide results. We were doing PRP, which graduated to PRFM, and we would get a good success rate—between 85% and 89%. I’m a scientist; I wanted to understand why that 11% to 15% was not successful. How do we weed them out so they don’t waste money or effort and they’re not disappointed?

We performed a retrospective study of 10,000 PRP and PRFM treatments in our clinic and, surprisingly, learned that the unsuccessful outcomes were not age-related. Numerous people had theorized that hair growth failure was due to patient maturity or even gender, but that was not the case. By working in combination with a hematology lab to analyze the platelets and platelet function, we discovered a couple of common factors. If a patient consumed alcohol within 3 days of their blood being drawn for PRP or PRFM treatment, some platelets were nonfunctional or less functional. Additionally, ingestion of a nonsteroidal anti-inflammatory drug (NSAID) within 3 to 3.5 weeks led to decreased platelet activity and platelet function. Those were the common denominators. Also, there was no difference in male vs female platelets on the blood smear. So, failure was not related to age or gender, which I thought was very interesting.

HOW ELSE HAVE HAIR TREATMENTS EVOLVED IN RECENT YEARS?

We were initially injecting micro and nano fat to the scalp, utilizing some of the most incredible nutrients. The challenge in a clinical setting is it’s a 2-step procedure to harvest the fat—which requires skill, concentrating the fat and then injecting it. Fewer clinicians or patients are willing to dedicate time and energy to this method. 

Arriving on the scene since that time were exosomes, first identified in 1983 and named in 1987. Exosomes are simply communication factors. I describe their function similary to Google. If you looked up “Sarah Connor” in the White Pages many years ago, you found 7 pages of Sarah Connors (that’s why the Terminator was unsuccessful). Exosomes are like Google: You say, “Sarah Connor, Houston, Texas,” and you give a 4-block radius, and you will find only 5 or 6 Sarah Connors. The same thing happens when you use an exosome. These communication factors recruit a more efficient response to skin injury—some are anti-inflammatory, some are biostimulatory. We are studying the various types of exosomes right now. Exosomes utilized for tissue injury allow a more efficient response in all phases of wound healing—hemostasis, inflammation, proliferation, and remodeling. While we had good outcomes in the past with microneedling alone, or microneedling with PRP injections, the use of off-the-shelf exosomes post procedure allows decreased edema, erythema, and pain, while allowing greater collagen production and hair stimulation. For hair, we don’t need to go deep; I typically utilize 0.5 mm or 1 mm using the SkinPen (Crown Aesthetics). I do 2 passes because I do not want it to bleed; if it bleeds, then anything applied topically will be pushed right out. I then introduce a topical lipolyzed human adipose-derived exosome (BENEV) and re-apply every 30 minutes for 6 to 8 hours. 

We are currently studying topical exosomes from INVO Aesthetics, which uses what they call BioBlend Techology™. They are claiming more than 3 trillion exosomes in a pre-mixed topical solution applied at the time of microneedling treatment. In addition, we add a pulse red light LED that does not heat the scalp or the hair while effectively decreasing inflammation and enhancing greater blood flow for micronutrient delivery. 

Our challenge now is identifying the ideal combination to provide the greatest efficacy. While some clinicians are using lasers, microneedling is very cost efficient for most practices, allowing access to a greater number of patients. The best part is we are very consistently providing hair growth. As a self-identified science geek, I am in the middle of multiple hair growth studies with my team.

HAVE ANY OTHER FACTORS LED TO INCREASED DEMAND FOR HAIR TREATMENTS AMONG GEN X?

The popularity of GLP-1 drugs has had a significant impact. When comparing patients on GLP-1s vs those who have never been exposed, there is approximately a 62% greater incidence of hair loss in those using these receptor agonists. Remember that any weight loss tends to lead to hair loss. With the unregulated use of GLPs, especially with rapid weight loss and suboptimal diets, we will continue to see greater and greater need for hair restoration and prevention of hair loss. 

Other unfortunate aggravators are COVID-19 and other systemic illnesses that lead to telogen effluvium and exacerbate alopecia arreata.

ARE GEN XERS DEMANDING MORE OF THOSE ADVANCED TREATMENTS THAN TRADITIONAL TREATMENTS SUCH AS MINOXIDIL?

In my opinion, Gen Xers consume more social media than boomers. As a result, this population often comes in having performed research and they want to understand if they would be good candidates. The most successful outcomes that we are seeing utilize a combination of in-office procedures with take-home care. There are a few supplements available that have differing degrees of clinical evidence and concerning possible side effects; I know there are many more in our pipeline. 

As for minoxidil, we know it works well as a topical but even better as an oral therapy. The question is whether it is best to start at 2.5 mg or 5 mg and whether gender makes a difference. Traditionally, we would use the higher dose to treat men. A recent prospective, double-blinded study showed that 2.5 mg was as effective in men as the 5-mg dose. Unfortunately, a small subset of patients are affected by fluid retention and pericarditis; while uncommon, how do we determine whom that will affect? 

Of course, there’s finasteride, which may be more useful in keeping current hair vs promoting new hair growth.  

WITH ALL of THESE OPTIONS AVAILABLE, IS THERE A FEELING THAT GEN X EXPECTS TO NEVER HAVE TO GO BALD?

Yes, 100%. The only option that we had when we were growing up was to wait for enough balding and then get a hair transplant. Now, it’s a conversation that I have with almost every woman in her late 30s or early 40s; let’s identify any signs of hair loss and then address the etiologies early. Women who are perimenopausal and menopausal did not know that there is actually something that we can be doing for age-/hormonal-related hair loss or genetic androgenic alopecia, but we are now educating people. Those who are watching social media channels are fed more content on hair loss solutions as they start spending time on those videos. 

What may have started this push was the pandemic; a lot of people who had COVID-19 or even had a COVID vaccine had hair loss in addition to their other symptoms. When meeting with their clinician, they were so distressed they would ask for solutions or referrals. We just need to continue educating primary care clinicians so they let their patients know that there are so many successful options now. As part of my physical examination for every single person visiting our practice, whether they’re getting a neuromodulator, HA filler, a biostimulatory agent, or a device treatment, I now examine their scalp and hair density. My only concern, because I’m an academician and a science nerd, is with theoreticals; the fact that an ingredient should help does not mean it is bioavailable. Is it actually getting inside the body? Is it being absorbed properly? How do we show that it’s actually activating the end organ—the hair follicle? I embrace research and always quote Ted Lasso: “Be curious, not judgmental.”