Latest / The Science of Skin / Hair Loss Treatments: Dr. Nicole Rogers on What Actually Works

Transcript

Hair Loss Treatments: Dr. Nicole Rogers on What Actually Works · The Science of Skin

• 0:08
  SPEAKER_00: All right, I'm Dr.
• 0:11
  SPEAKER_00: I don't know.
• 0:13
  SPEAKER_00: This episode of the Science of Skid Podcast.
• 0:16
  SPEAKER_00: I have a very good friend and colleague in studio with me today, Dr.
• 0:21
  SPEAKER_00: Nicole Rogers.
• 0:22
  SPEAKER_00: And the subject we're going to talk about, I think it's so timely, Nicole, because we're seeing so much on social media about the different ways to treat hair loss.
• 0:31
  SPEAKER_00: And for those of you who don't know Nicole, anybody in the hair loss space knows her, but if you're not in that area, let me read her bio to you so you understand a little bit about her background.
• 0:42
  SPEAKER_00: She is a board-certified dermatologist.
• 0:44
  SPEAKER_00: She trained at Tulane, which is where I met Nicole.
• 0:47
  SPEAKER_00: She's also fellowship trained in hair transplant surgery.
• 0:50
  SPEAKER_00: Her practice is called the hair restoration of cells.
• 0:54
  SPEAKER_00: I mean called hair restoration of the south.
• 0:57
  SPEAKER_00: And then it's located in the Metro New Orleans area.
• 1:00
  SPEAKER_00: It's dedicated to both medical and surgical treatment of hair loss.
• 1:04
  SPEAKER_00: Before that, I was lucky enough to have Nicole in my practice, where she practiced general and cosmetic dermatology.
• 1:11
  SPEAKER_00: She was also doing transplants.
• 1:12
  SPEAKER_00: And quite frankly, Nicole, you got so successful that you had to open your own practice to accommodate the patient flow and the number of transplants you were doing, and you're so good at it.
• 1:23
  SPEAKER_00: So congratulations, you've been so wildly successful in your own practice.
• 1:28
  SPEAKER_00: Also, you've co-edited two books on hair transplant surgery, which I did not know.
• 1:33
  SPEAKER_00: I know you've published numerous peer-reviewed articles, and you are a regular on the lecture circuit around the world, quite frankly, on the topic of hair loss.
• 1:42
  SPEAKER_00: In 2023, she was awarded the Golden Follicle Award, and I'm so proud of you for this, Nicole.
• 1:49
  SPEAKER_00: This is given yearly by the International Society of Hair Restoration Surgery, and one physician gets it who has made an outstanding and significant clinical and educational contributions in the field of hair restoration surgery.
• 2:03
  SPEAKER_00: So, Nicole, welcome.
• 2:05
  SPEAKER_00: And I'm so, like I said, proud of all your accomplishments.
• 2:08
  SPEAKER_00: So amazing.
• 2:09
  SPEAKER_01: Oh, well, thank you.
• 2:11
  SPEAKER_01: And, you know, I kudos to you for mentoring me so much over the years.
• 2:16
  SPEAKER_01: I feel so grateful to have spent eight wonderful years working with you at Old Medtery Durham.
• 2:22
  SPEAKER_00: We had so much fun.
• 2:23
  SPEAKER_01: So much fun.
• 2:25
  SPEAKER_01: Taught me so much about patient interaction.
• 2:28
  SPEAKER_01: I'll never forget, you know, one of my first patients.
• 2:32
  SPEAKER_01: I came out of the room and it was a rash I've never seen before.
• 2:35
  SPEAKER_01: And it was so challenging.
• 2:36
  SPEAKER_01: And I had my nurses setting me up for a biopsy and blood work, maybe multiple biopsies.
• 2:42
  SPEAKER_01: And you followed me in the room and you said, that's poison ivy.
• 2:49
  SPEAKER_01: And I love that story.
• 2:51
  SPEAKER_01: So grateful because I learned so much from you and such practical wisdom.
• 2:57
  SPEAKER_00: Well, you know, when you're in the academic setting, you see a lot of unusual rashes, but the common things are hard when you first go into private practice because they're common things.
• 3:08
  SPEAKER_00: You know, you're seeing all the details, right?
• 3:10
  SPEAKER_00: So I remember well when I joined Nia, I was new.
• 3:14
  SPEAKER_00: So we have to mentor each other through the easy stuff.
• 3:22
  SPEAKER_01: Oh my gosh.
• 3:23
  SPEAKER_00: Ratches, viral rashes, all the stuff that needs bread and butter when you're in private practice.
• 3:30
  SPEAKER_00: Let's start, and there's so much we could talk about, and this is such a timely subject, Nicole, because I mean, is social media not just flooded with people talking about hair loss?
• 3:41
  SPEAKER_00: It's unbelievable.
• 3:43
  SPEAKER_00: And the dermatologists in particular are really hitting it.
• 3:46
  SPEAKER_00: There's a lot of new things getting ready to come into the marketplace, but let's kind of start with some of the trendy stuff that's on social media.
• 3:54
  SPEAKER_00: Everybody wants to talk about nutraceuticals, pumpkin seed oil, rosemary oil.
• 3:59
  SPEAKER_00: I mean, do any of these in your mind play a role or should they be part of a treatment for a patient who's suffering with hair loss?
• 4:07
  SPEAKER_01: Yeah, you know, I think it all depends on where the patient is in their journey.
• 4:12
  SPEAKER_01: You know, if they have really advanced, you know, early stage male, female pattern hair loss, you know, and they present to our office and they've already got see-through scalp, you know, and they're shedding, you know, you you want to do a comprehensive workup to make sure you're not missing anything.
• 4:30
  SPEAKER_01: You know, you want to check for certain things like vitamin D and you know, low iron, low zinc, you know, check their thyroid.
• 4:37
  SPEAKER_01: But you want to be prepared to move pretty aggressively to traditional medical therapies for those patients.
• 4:44
  SPEAKER_01: And I think, you know, unfortunately, it takes a while for people to get the correct diagnosis, especially women.
• 4:51
  SPEAKER_01: And sometimes they are okay starting with things that are say over-the-counter for early stages, and especially if they're not sure if it's actually a genetic presentation, say, of female patterned hair loss, maybe it's just a little early shedding, maybe it's due to you know, recent childbirth or some kind of a recent viral illness, or you know, nowadays everybody's getting on these GLP drugs, they're losing all kinds of weight and they're presenting with hair loss that way, you know, so you can use things um in a temporary fashion, but if they if they have really early onset aggressive, you know, male-female pattern hair loss, I'm usually going to try and move them to actual prescription medical therapy as soon as they're willing.
• 5:35
  SPEAKER_00: Right.
• 5:36
  SPEAKER_00: And I love the way you put it in their hair loss journey because it is such a journey uh for the patients who suffer with hair loss.
• 5:44
  SPEAKER_00: Um, let's talk a little bit about some of the new things that are coming, like the long-acting oral formulation of or of minoxidil.
• 5:52
  SPEAKER_01: Yeah.
• 5:53
  SPEAKER_00: I know everybody's anticipating that.
• 5:56
  SPEAKER_01: Yeah, so this is very exciting.
• 5:58
  SPEAKER_01: Um, a company named Veridermix has been developing um an extended release version.
• 6:05
  SPEAKER_01: You know, oral monoxidil was first approved under the trade name Lonatin back in 1979, and that's when we actually realized it grew hair, and that's when Johnson Johnson pivoted and they developed the topical version called Rogane.
• 6:18
  SPEAKER_01: Um, but you know, we've been using it off label for the last probably five or ten years now, and you know, been seeing very nice results.
• 6:26
  SPEAKER_01: Patients are really happy, they don't have to necessarily put stuff on their head.
• 6:30
  SPEAKER_01: Um but but the problem with the current version is it is a pro-drug, which means that it does have to get converted by monoxidal, there's a certain enzyme, um, and it converts it into monoxidyl sulfate, which is the active form.
• 6:45
  SPEAKER_01: And so what happens is you really only get about a four-hour window of efficacy from that medicine.
• 6:52
  SPEAKER_01: Um, and so what Virodermix has realized is that if they can increase the longevity of that drug in the system, that they can actually give people even more benefit from that oral monoxidal molecule.
• 7:05
  SPEAKER_01: And so they're they figured out a way to engineer this molecule so it'll be a 4.5 milligram uh twice daily dosing in women and an 8.5 milligram twice-daily dosing in men.
• 7:17
  SPEAKER_01: Um, so you know, they're currently what in phase three clinical trials.
• 7:21
  SPEAKER_01: So that's probably gonna be the next FDA-approved medication um that is available to us as dermatologists, and it's very exciting.
• 7:30
  SPEAKER_00: It is exciting.
• 7:31
  SPEAKER_00: I wonder looking at head-to-heads, how it will stack up, you know, will that longer bioactivity make a huge difference?
• 7:40
  SPEAKER_00: It's gonna be super interesting.
• 7:42
  SPEAKER_01: Yeah, well, Chris, you know, Dr.
• 7:43
  SPEAKER_01: Crystal Agu um at Johns Hopkins was presenting some, you know, of their uh data, and it's very exciting because basically what they're seeing at two months in terms of regrowth is comparable to what we've seen at more like six or eight months with traditional oral monoxidyl or phenasteride, even.
• 8:03
  SPEAKER_00: That's great news.
• 8:05
  SPEAKER_00: Um, talk a little bit about phenasteride and do tasteride.
• 8:09
  SPEAKER_00: I know you use them both.
• 8:10
  SPEAKER_00: We know they're five alpha reductase inhibitors with little different nuances.
• 8:15
  SPEAKER_00: So kind of tell us how do you use those and when do you turn to those?
• 8:20
  SPEAKER_01: Mm-hmm.
• 8:21
  SPEAKER_01: So, you know, in my pre-menopausal females, you know, many of them often will suffer from acne, dandruff, um, oily skin, oily scalp.
• 8:32
  SPEAKER_01: And so sporonalactone can be a great choice for your pre-menopausal females because it also gives them all those side benefits.
• 8:40
  SPEAKER_01: And, you know, if they're suffering from unwanted facial hair, it can help with that, um, unwanted body hair.
• 8:46
  SPEAKER_01: So you get a lot of side benefits with sporonalctone in the pre-menopausal patient population, and it's less scary in terms of, you know, uh risk of uh birth defects.
• 8:58
  SPEAKER_01: Um, but once we have the luxury of women having gone either gone through menopause or maybe they had a hysterectomy, or you know, maybe they had a vasectomy, their husband had a vasectomy, um, then we have the luxury of saying, okay, you know, we can move you to finastride.
• 9:18
  SPEAKER_01: And I usually start with the five milligram dose.
• 9:21
  SPEAKER_01: You know, the one milligram is how it's traditionally FDA approved in men.
• 9:25
  SPEAKER_01: Um, but the problem is that when Vera Price did that uh first clinical trial using the one milligram dose in women, it just didn't work that well.
• 9:35
  SPEAKER_01: And that combined with the risk of birth defects, that's when Merck pulled the plug on the clinical trials.
• 9:41
  SPEAKER_01: Um, but subsequently we've been using it, you know, off label at higher doses of 2.5 and 5 milligrams, and finasteride works wonderfully.
• 9:49
  SPEAKER_01: You know, um, I have so many women who, you know, they love it.
• 9:53
  SPEAKER_01: I can't get I can't get them off of it, you know, because it's so safe, it's so well tolerated, you know, they can take it with or without food any time of day.
• 10:02
  SPEAKER_01: You know, there's no real lab monitoring required as long as they have a healthy liver, you know, it does get metabolized by the liver.
• 10:08
  SPEAKER_01: There's no drug interaction.
• 10:10
  SPEAKER_00: That's fantastic.
• 10:11
  SPEAKER_00: So there's really no reason to get them off.
• 10:14
  SPEAKER_01: Right, exactly.
• 10:15
  SPEAKER_01: And, you know, we've been somewhat cautious, um, you know, because there was some question about could finasteride increase estrogen levels.
• 10:24
  SPEAKER_01: Um, and so, you know, women who maybe get diagnosed with an estrogen-sensitive breast cancer, you know, we might have a conversation with their oncologist about whether it's safe to keep them on it.
• 10:35
  SPEAKER_01: Um, but there was a recent um publication in our JAD showing that even that doesn't really seem to be too much of a worry because it really doesn't seem to affect estrogen levels that much in patients after all.
• 10:49
  SPEAKER_00: Interesting.
• 10:50
  SPEAKER_00: I didn't see that article, but that's valuable information.
• 10:54
  SPEAKER_00: What about in men, finasteride and doasteride?
• 10:57
  SPEAKER_00: Is there still lots of concern about this post-phenesteride syndrome that we heard so much about?
• 11:04
  SPEAKER_01: You know, um that there is still so much stigma, you know, when when men look online, and I can't even tell you, you know, how many young men they come into my practice and they're just like, oh, nope, I don't want to take finasteride, you know, I've heard what can happen.
• 11:20
  SPEAKER_01: And, you know, usually um, you know, that the they're they're a little more open to it after I give them some coaching and I give them some more information.
• 11:31
  SPEAKER_01: Yeah, I mean, I think the the main thing for us as dermatologists to reassure our patients is just that phenasteride has a very short half-life.
• 11:40
  SPEAKER_01: And so if they do have any kind of problem, they just stop it and it's out of their system in less than a week.
• 11:47
  SPEAKER_01: Um, and if they're nervous about developing possible side effects, I'll usually just tell men, you know, just take the one milligram, maybe just start off three days a week and you know, see how you tolerate that.
• 11:59
  SPEAKER_01: And if they're fine with it, then they can, you know, maybe slowly, you know, ramp up.
• 12:04
  SPEAKER_01: Um but you know, there's a it just it doesn't make sense, you know, from a pharmacologic perspective, this whole post anasterite syndrome, you know, the idea that it could be in your drug in your system forever and that it could, you know, cause this permanent change in mood, this permanent depression, you know, I I just I don't think any any hair specialist or hair transplant surgeon can really, you know, wrap their mind around that and and you know, tell their patient, oh yes, this could definitely happen.
• 12:35
  SPEAKER_00: Yeah.
• 12:36
  SPEAKER_00: Interesting because it's certainly out there circulating that that is the case or that could be the case.
• 12:43
  SPEAKER_00: So pharmacologically, there's a disconnect there.
• 12:46
  SPEAKER_01: And I think a lot of it um overlaps with Accutane.
• 12:51
  SPEAKER_01: You know, there's we deal with so much misinformation amongst our Accutane patients, you know, they've heard terrible stories, and you know, and it it is true.
• 13:00
  SPEAKER_01: I think that um it was the the father of a man who committed suicide after taking finesteride, and then there was a senator whose son committed suicide, and so you know, basic basically both of these men went on a war path to make sure that the drugs again.
• 13:16
  SPEAKER_01: Right.
• 13:17
  SPEAKER_00: We fought that for a long time.
• 13:18
  SPEAKER_00: What about topical use of finesteride and detasteride as an alternative in those patients who are concerned?
• 13:25
  SPEAKER_01: It's a great option.
• 13:26
  SPEAKER_01: And um the absorption actually seems to be comparable, the effects seem to be comparable.
• 13:31
  SPEAKER_01: Um, there really don't seem to be any reports of sexual side effects or mood changes.
• 13:37
  SPEAKER_01: So I think for you know, men who are just looking to avoid any chance of side effects whatsoever, I think it's totally reasonable.
• 13:45
  SPEAKER_01: You know, they can get it online.
• 13:47
  SPEAKER_01: So many of them are getting it just from these online prescribing companies.
• 13:51
  SPEAKER_01: But, you know, we as dermatologists, we can we could just prescribe, you know, say a 0.25% finasteride solution um through a local pharmacy.
• 14:01
  SPEAKER_01: And then that way our patients compounding pharmacies.
• 14:04
  SPEAKER_01: Right.
• 14:05
  SPEAKER_01: They can just, you know, go to somebody who they trust and um get it made up locally.
• 14:12
  SPEAKER_01: Um, I've I have some really um incredible results of you know, gentlemen who have used the topical finasteride monoxidal combination consistently.
• 14:21
  SPEAKER_01: I have one gentleman who he completely re-regrew his hair over a two-year period.
• 14:26
  SPEAKER_01: Wow.
• 14:27
  SPEAKER_01: That's impressive.
• 14:28
  SPEAKER_01: And he was just very consistent with it.
• 14:30
  SPEAKER_01: He was very dedicated.
• 14:32
  SPEAKER_01: Um, and you know, I think that's half the battle with these topical formulations.
• 14:37
  SPEAKER_00: Right.
• 14:37
  SPEAKER_00: It's hard to comply with something topically.
• 14:40
  SPEAKER_00: I mean, there's no doubt.
• 14:41
  SPEAKER_00: It's it's definitely a challenge.
• 14:43
  SPEAKER_00: Talk about uh red light.
• 14:47
  SPEAKER_00: I see so many people on social media with these red light caps on.
• 14:51
  SPEAKER_00: And I remember you and I talking about this so long ago when the data was just starting to come out.
• 14:57
  SPEAKER_00: So, you know, how how are these purported to grow hair?
• 15:02
  SPEAKER_01: Mm-hmm.
• 15:03
  SPEAKER_01: So the idea is that the red light, usually around that 650 to 700 nanometer um wavelength, penetrates the mitochondria and it upregulates the production of ATP or energy for your hair follicles.
• 15:20
  SPEAKER_01: And um, you know, there's a decent body of um, you know, research that is had has been published in the medical literature.
• 15:28
  SPEAKER_01: I think Michael Hamblin, who is a researcher at Harvard, he's at their um Wellman Um lab for photomedicine.
• 15:36
  SPEAKER_01: He's really done a lot of the, you know, very good basic science publications in this area.
• 15:42
  SPEAKER_01: Um, you know, Dr.
• 15:43
  SPEAKER_01: Mark Avram, who I did my fellowship with, he and I used to joke that it seemed like the marketing was the ahead of the science, right?
• 15:50
  SPEAKER_01: You know, because there were just so many devices.
• 15:53
  SPEAKER_01: Um, and I, you know, I I think the more of these publications that come out, the more we realize, okay, this technology is definitely here to stay.
• 16:03
  SPEAKER_01: But I think what we have to do is manage our patients' expectations with what they can achieve using low-level light therapy.
• 16:10
  SPEAKER_01: You know, would that would that be my first and only monotherapy for somebody with advanced, you know, male or female pattern hair loss, you know, starting out in their teens or their 20s?
• 16:22
  SPEAKER_00: Probably not.
• 16:23
  SPEAKER_00: Probably not.
• 16:24
  SPEAKER_01: You know, but can we add it for maybe somebody who's been on, you know, multiple medications, say, you know, for five or ten years and they feel like, oh, you know, I'm kind of plateauing.
• 16:35
  SPEAKER_01: What kind of what else can I add to the mix?
• 16:37
  SPEAKER_01: I think, I think low-level light therapy is a great option.
• 16:40
  SPEAKER_01: And the other thing that's nice about it is that it's safe.
• 16:44
  SPEAKER_01: You know, it's the one thing that I can offer my my pregnant female patient, you know, and I can confidently reassure them, yes, this will be, you know, no harm to your baby, it's gonna be a great option, you know, and and that's something that you can use throughout your pregnancy and beyond if you like it.
• 17:02
  SPEAKER_00: Right.
• 17:02
  SPEAKER_00: Yeah, that is an advantage, no doubt about it.
• 17:06
  SPEAKER_00: How does the consumer who's gonna buy one know what to buy?
• 17:09
  SPEAKER_00: I mean, is there any way that they can know which one might be more effective than another?
• 17:18
  SPEAKER_01: I think it can be very challenging.
• 17:21
  SPEAKER_01: Um, you know, one of the things that I have been sort of looking at is warranties, you know, with these devices, because at the end of the day, it is a gadget and it is subject to a expensive, aren't they?
• 17:35
  SPEAKER_01: And they're they're they can be pricey.
• 17:37
  SPEAKER_01: Yeah.
• 17:37
  SPEAKER_01: I mean, you can spend probably anywhere from$300 to$300,000 or$4,000, you know, on these devices.
• 17:46
  SPEAKER_01: So, you know, it's nice if you find a company.
• 17:49
  SPEAKER_01: I wouldn't buy it from like a fly by night company, you know.
• 17:52
  SPEAKER_01: I also don't know if I would recommend, you know, getting a super cheap used one somewhere.
• 17:59
  SPEAKER_01: Although, you know, if you're not planning on using it that long, you could always do that as like a starter option.
• 18:04
  SPEAKER_01: Um, but you know, probably no harm, but it may not help.
• 18:09
  SPEAKER_01: Yeah, exactly.
• 18:10
  SPEAKER_01: And but like like I said, look at the warranty, look at how long the company has been in business, you know, and and you know, if you don't like it, can you return it?
• 18:20
  SPEAKER_01: You know, because these are all things to to consider.
• 18:24
  SPEAKER_00: Yeah, it's a lot.
• 18:25
  SPEAKER_00: I mean, we can we have to talk for a second about PRP because that has really, I think, also changed the treatment of hair loss.
• 18:34
  SPEAKER_00: So tell us, you know, sort of maybe what's new and you know, where are you using it most?
• 18:41
  SPEAKER_01: Mm-hmm.
• 18:42
  SPEAKER_01: So, you know, I think one of the things that people love talking about is stem cells, right?
• 18:47
  SPEAKER_01: Yes.
• 18:48
  SPEAKER_01: You know, like they're just so sexy and everybody thinks it's like the greatest thing ever.
• 18:53
  SPEAKER_01: Well, you know, where PRP, I think, is gonna continue to add value to us in the hair regrowth space is that they're a safe autologous form of stem cells, right?
• 19:05
  SPEAKER_01: You know, we know that it's coming from that person, that person alone, it's staying in their body.
• 19:10
  SPEAKER_01: You know, we don't have to worry about it getting sourced from, you know, some kind of a blood bank in a foreign country where they may or may not test for different diseases.
• 19:21
  SPEAKER_01: And, you know, even if they do test for diseases, what about the diseases we don't even know about yet?
• 19:27
  SPEAKER_01: You know, like what happened to those poor hemophiliacs back in the 1980s, right?
• 19:32
  SPEAKER_01: Um, so you know, I I think PRP is like low-level light therapy.
• 19:37
  SPEAKER_01: I think I think we can expect modest results from it.
• 19:41
  SPEAKER_01: You know, I don't usually promise the moon to my patients when we're incorporating PRP.
• 19:47
  SPEAKER_01: Um, but where it can be helpful is, you know, if you have somebody uh even who has maybe like chronic telogen of luthium, you you can incorporate that.
• 19:56
  SPEAKER_01: And sometimes that will help arrest, you know, whatever shedding they might be having.
• 20:02
  SPEAKER_01: Um, you know, in terms of the data, they've they've actually done several meta-analyses looking at different techniques, which protocols seem to be the best, you know, and I think most of us still use what was published by Amelia Hausauer um several years ago, you know, basically recommending three monthly treatments followed by maintenance treatments every three to six months thereafter.
• 20:26
  SPEAKER_01: Um and the other thing that um Dr.
• 20:29
  SPEAKER_01: Adeitya Gupta from Canada um found in his meta-analysis is that probably acting activating the platelets is a good idea.
• 20:38
  SPEAKER_01: So if you can add either things like calcium glucanate or calcium chloride, you know, that's in one of the commercially available PRP kits, um, you know, that will probably help release those growth factors a little bit quicker, exactly.
• 20:52
  SPEAKER_01: So you get a little bit more assurance that the platelets are gonna do their job.
• 20:57
  SPEAKER_00: So again, it sounds like it's a part of a comprehensive treatment plan, more than likely.
• 21:04
  SPEAKER_01: Yeah, you know, um, we sometimes will inherit patients who have already done a whole bunch of PRPs in another clinic, you know, and and you know, I always feel I feel bad for them when I say, well, what about menoxida or what about phenasteride?
• 21:19
  SPEAKER_01: And they may or may not even have been told about these treatment options, you know.
• 21:24
  SPEAKER_01: So I think I think what we have to realize um, you know, as dermatologists is just that, you know, we have to always kind of go in a stepwise ladder and just you know, go by the things that have the most data to support their youth, you know, and not just the things that necessarily um, you know, might increase your bottom line.
• 21:43
  SPEAKER_00: Yeah, exactly.
• 21:45
  SPEAKER_00: Interesting because I know a lot of people are doing PRP now.
• 21:49
  SPEAKER_00: You know, it's really spelled out and lots of people are using it and and doing it in their clinics.
• 21:55
  SPEAKER_00: You know, we can't talk about PRP without probably talking about exosomes.
• 22:00
  SPEAKER_01: the the the other it girl when it comes to hair loss and and everything skin care and skin aging for that matter but where does the do the experts I should say in hair loss where are they putting exosomes are they doing them I know they're not FDA approved for injection at this point so how are you all using those in practice well you know the FDA has really put the kibosh on you know using them injecting them right um into the scalps of patients with uh thinning hair I I think there's a lot of um promise you know and it's certainly interesting seeing what the industry is developing in terms of you know are we get getting them from humans are we getting them from plants are we getting them from red deer you know like they're they seem to be sourcing them from all these different places you know I just think safety is the main thing with these exosomes and um you know I I just I want to I I I really think that we need more studies we need more clinical trials that's that's the bottom line.
• 23:11
  SPEAKER_00: Yeah which which exosomes is the is the best and how how do you use them?
• 23:16
  SPEAKER_00: I mean we have these same debates in the aesthetic arena you know using them periprocedurally and it it's it is a positive yeah oh yeah they're expensive I love listening to the point counterpoint lectures which we hear a lot of in at aesthetic meetings where you have somebody speak for them who's real enthusiast and then the other side is always a safety discussion you know because you just honestly never really know.
• 23:44
  SPEAKER_01: Yeah yeah and it like in in our patient population you know we were we were injecting exosomes for a brief while before the FDA you know intervened but the cost was so high you know it was almost a little embarrassing talking to patients about how much these cost and how little data there was for them.
• 24:05
  SPEAKER_01: Has the cost gone down Nicole because if if you're gonna spend that kind of money on them yeah you better have data to prove well you might as well get a hair transplant.
• 24:14
  SPEAKER_01: Well good point right yes you know and it can be you know in the thousands what patients are being asked to pay for these exosomes.
• 24:23
  SPEAKER_00: Yeah that's incredible I didn't realize they were that expensive and that price has not come down over the years now because it's been a while we've had exos in the market for a good time amount of time.
• 24:34
  SPEAKER_01: Yeah like I said I I'm I'm sort of holding off I'm I'm kind of waiting I'm watching and waiting before I jump into that arena.
• 24:43
  SPEAKER_00: I think some transplant surgeons are doing them like through with microneedling and things like that, aren't they?
• 24:49
  SPEAKER_01: They are um you know I I just like I said if I if I could see some really continue to see really good results from you know colleagues that I really trust and you know believe then I would I would I would probably be more jumping into it myself.
• 25:07
  SPEAKER_00: Yeah it's never bad never bad to sit back and wait till the data catches up with the hype in my opinion especially with something like that with potential safety issues.
• 25:17
  SPEAKER_00: There's there's some new molecules that I ran across and I don't even know where but I read a lot and one of them is PP405 which is also in clinical trials.
• 25:27
  SPEAKER_00: Tell us a little bit about that because it sounds super interesting and we talked about stem cells and this is like a whole new category of therapies for hair loss.
• 25:38
  SPEAKER_01: Yeah yeah so you know and and this is another molecule that's kind of been all over the news but I have to admit I think some of the other molecules like the extended release of oral monoxidol are going to come to market first.
• 25:52
  SPEAKER_00: Right.
• 25:52
  SPEAKER_01: Yeah this is a ways away right so so basically um and this is my understanding of the story there was a a researcher named Bill Lowry who was at um he's at UCLA and he was using this prototype molecule called UK5099 and what it does is it basically um is an inhibitor of mitochondrial pyruvate carrier okay so what this molecule does is it carries pyruvate into the mitochondria so what he figured out is that if you block that carrying of the mitochondria uh of the pyruvate then the pyruvate builds up and it gets converted into lactate which activates lactate dehydrogenase and what they found is that lactate dehydrogenase is actually um what activates the stem cell the the the dormant stem cell uh hair follicles and so you know they s they kind of I guess switch gears and they found this other molecule which was similar but different from the one that was just being used for lab research and um they started using it in mice and they found that it was able to you know upregulate things like WNT beta catenin uh AMPK and um modulate mTOR and in in doing so basically waking up these hair follicle stem cells and increasing things like hair shaft production and antigen prolongation, right?
• 27:31
  SPEAKER_01: Because that's what it's all about.
• 27:32
  SPEAKER_01: If we can you know the antigen phase.
• 27:36
  SPEAKER_01: Yeah I use this analogy with my patients all the time right I say you know as hard as you may be working on you know your job, taking care of your family, taking care of your kids, it's like your follicles are coming to work late and they're leaving early and and the whole time they're there, they got their feet up on the desk, they're scrolling their phone, they're filing their nails, they're smoking cigarettes of them.
• 27:59
  SPEAKER_01: Okay.
• 28:00
  SPEAKER_01: So yeah so I mean that's what we have to tell our follicles they have to get back to work.
• 28:05
  SPEAKER_01: You know we're basically telling them they got to show up on time they got to work a full day they got to be productive you know and so when patients start incorporating these different you know hair treatments they're basically telling their hair follicles who's a boss wake up wake up and get moving and getting them back to work.
• 28:23
  SPEAKER_00: Yeah it's so interesting to be able to like wake up a dormant hair follicle by stimulating the stem cells.
• 28:29
  SPEAKER_00: I just thought that was so fascinating.
• 28:31
  SPEAKER_01: Yeah well it's also interesting a bit I was going to say it's interesting because it's different from the traditional like lowering DHT levels and increasing blood supply.
• 28:41
  SPEAKER_00: It's like a unique mechanism of action yeah it's gonna be like it's its own category which is what I think is is maybe why it's getting a lot of hype but it's very cool.
• 28:50
  SPEAKER_00: In the last few minutes we have talk a little bit about maybe some of the innovations in hair transplant surgery.
• 28:58
  SPEAKER_00: I know you're so on top of that and I know things change quickly in the surgical specialty of of hair restoration.
• 29:07
  SPEAKER_01: Yeah I mean you know what's really been amazing is seeing how much the industry has shifted from traditional linear linear what we called FUT harvesting to individual folliculate unit excision or FUE harvesting.
• 29:24
  SPEAKER_01: And it really can be very nice for especially men if they tend to wear their hair short in the back you know the idea that they don't have to worry about getting a linear scar is huge.
• 29:35
  SPEAKER_01: You know that means they can wear their hair much shorter the other thing that's interesting is that it allows us to relatively cherry pick when we're going in and removing those um groupings we can actually go after more of the larger two and three hair and four hair groupings.
• 29:51
  SPEAKER_01: Now the trade-off the trade-off is that it it can thin out that donor area faster right um and so we always have to do it in a very artful way you know that makes sure that we're balancing you know where we take it from and making sure we know we don't totally deplete that donor area.
• 30:10
  SPEAKER_00: That's so interesting.
• 30:12
  SPEAKER_01: But it's yeah it's I mean I I think that's been interesting like I'm glad that we still offer strip harvesting because you know this is still the the the chosen method of harvest for almost 99% of our female patients you know they really prefer to not have to shave the back of their head you know that's that's that's just a no go for most women you know I can't blame them.
• 30:37
  SPEAKER_01: And and there are I have colleagues who are doing what we call no shave FUE which probably is also you know the next sort of frontier but it's very challenging and it's very tedious.
• 30:49
  SPEAKER_01: It's gotta be so not no shave?
• 30:52
  SPEAKER_01: Yeah wow that makes a difference you either have to pre-cut the hairs right pre-cut the hairs or or you have to kind of use special you know harvesting equipment and you know I if if I have patients who really want to do that I'll usually send them to you know some of my colleagues in uh Brazil or Guatemala who you know have become kind of thing yeah yeah interesting well having seen having been on the receiving end and seen a lot of your before and afters I understand the artistry that it is and you are an artist when you do it.
• 31:25
  SPEAKER_00: It is a it is a labor of love.
• 31:27
  SPEAKER_00: It is a lengthy procedure it's a lot it's a lot for the surgeon to go you know to do and to make it look the way you do.
• 31:36
  SPEAKER_01: And again it's it's a journey in and of itself because it may be multiple procedures that really ultimately gets that patient where they want to be right well we're look we're lucky we're lucky because we have such nice patients you know and and usually I find like people have pretty reasonable expectations and you know they're usually pretty motivated to also do some kind of medical therapy you know to to help re to help prevent ongoing thinning and then also to enhance the growth of the transplants.
• 32:09
  SPEAKER_00: That's great.
• 32:10
  SPEAKER_00: Well listen thank you so very much for this such an informative discussion and I learned a lot as I always do.
• 32:17
  SPEAKER_00: For those of you who are listening I'm sure you're gonna enjoy this episode uh if you like this podcast we'd be so grateful if you'd give us a review and subscribe we're getting bigger numbers as time goes on and we're super excited about that and we actually have a nice international reach so that's been a lot of fun interacting with our colleagues around the world.
• 32:37
  SPEAKER_00: So thank you so much for listening.
• 32:39
  SPEAKER_00: Thank you Dr.
• 32:40
  SPEAKER_00: Rogers for joining me I thoroughly enjoyed it you and I need a glass of wine sooner rather than later right we have a lot to get job thanks so much everybody