Postpartum Hair Clues

Understanding the difference between postpartum telogen effluvium and more serious hair loss conditions is essential for aesthetic practitioners to offer timely, targeted, and effective treatment, says Dr Sravya Tipirneni.

Postpartum hair loss is a common but often distressing concern among new mothers. For practitioners, distinguishing between temporary telogen effluvium and more persistent or pathological causes is key to offering appropriate treatment. As aesthetic interventions grow more sophisticated, so do options for accelerating recovery and restoring hair health. In this comprehensive clinical overview, Dr Sravya Tipirneni, Consultant Dermatologist, Cosmetologist & Trichologist at Manipal Hospitals, Bengaluru, outlines a structured diagnostic approach, compares emerging regenerative therapies like PRP, polynucleotides, and exosomes, and offers insights into tailoring treatment strategies — including laser and combination therapies — for optimal postpartum hair restoration.

The approach

Differentiating between temporary postpartum telogen effluvium and more serious hair loss conditions is crucial for appropriate management. Aesthetic medicine practitioners can employ several strategies.

Detailed patient history: A thorough history is paramount.

This includes:

• Timeline of hair loss: Postpartum telogen effluvium typically begins two to four months after delivery and resolves within 6-12 months. Earlier onset, prolonged duration (beyond a year), or cyclical patterns might suggest other conditions.

• Pattern of hair loss: Telogen effluvium is characterised by diffuse thinning all over the scalp. Localised patches, widening part lines (beyond typical postpartum changes), or recession at the temples or crown could indicate androgenetic alopecia (female pattern hair loss) or alopecia areata.

• Hair shedding characteristics: Ask about the amount of shedding, the presence of short, tapered hairs (vellus hairs, suggesting miniaturisation in androgenetic alopecia), and any changes in hair texture or scalp health.

• Medical history: Inquire about pre-existing hair loss conditions, family history of hair loss, thyroid disorders, iron deficiency, autoimmune diseases, recent illnesses, medications, and stressful life events (beyond childbirth).

• Obstetric history: Details about the pregnancy, delivery, and breastfeeding status are important.

Physical Examination:

• Scalp examination: Assess for inflammation, scaling, redness, or signs of scarring.

• Hair pull test: Gently pull small sections of hair (around 60 strands) in different areas of the scalp. More than 6 telogen hairs (club-shaped root) pulled in each section suggests active shedding. While positive in telogen effluvium, it can also be positive in other active hair loss conditions.

• Hair density assessment: Visually assess hair density across the scalp.

• Hair diameter variation: Look for significant differences in hair strand thickness, which can be a sign of miniaturisation seen in androgenetic alopecia.

Trichoscopy: This non-invasive technique uses a handheld dermatoscope to visualise the scalp and hair shafts at high magnification. It can help identify:

• Increased telogen hairs in telogen effluvium.

• Anisocytosis (variation in hair shaft diameter) and perifollicular signs characteristic of androgenetic alopecia.

• Yellow dots, black dots, and exclamation mark hairs seen in alopecia areata.

• Signs of inflammation or scarring.

Blood tests: While not always necessary for typical postpartum telogen effluvium, blood tests can help rule out underlying medical conditions:

• Complete Blood Count (CBC) with Ferritin: To assess for iron deficiency anemia.

• Thyroid Function Tests (TSH, Free T4): To screen for thyroid disorders.

• Vitamin D levels: Low levels can sometimes be associated with hair loss.

• Other tests: Depending on the clinical suspicion, tests for autoimmune markers (ANA), zinc levels, or other nutritional deficiencies may be considered.

• Scalp biopsy: In cases of diagnostic uncertainty, persistent localised hair loss, or signs of scarring, a scalp biopsy performed by a dermatologist can provide definitive histopathological information.

When to suspect more serious conditions:

• Hair loss that starts before two months postpartum or persists beyond 12 months.

• Distinct patterns of hair loss (e.g., recession, widening part, localised bald patches).

• Significant changes in hair texture (e.g., becoming very fine and brittle).

• Scalp inflammation, pain, itching, or scaling.

• Family history of significant hair loss at a young age.

• Presence of other systemic symptoms.

Effective treatments

While postpartum telogen effluvium typically resolves spontaneously, aesthetic medicine treatments can help accelerate regrowth, improve hair density and quality, and address persistent shedding or underlying contributing factors.

Platelet-Rich Plasma (PRP) therapy:

• Mechanism: PRP involves concentrating platelets from the patient’s own blood. These platelets are rich in growth factors (e.g., VEGF, PDGF, EGF, TGF-β) that, when injected into the scalp, stimulate hair follicle stem cells, promote angiogenesis (new blood vessel formation), prolong the anagen (growth) phase of the hair cycle, and reduce inflammation.

• Biological level: PRP delivers a concentrated cocktail of signalling molecules that directly interact with the hair follicle microenvironment, promoting cell proliferation, differentiation, and survival, ultimately leading to hair regrowth and increased hair thickness.

Polynucleotides (PNs):

• Mechanism: PNs are long chains of deoxyribonucleotides derived from natural sources like salmon DNA. When injected into the scalp, they provide the building blocks for DNA and RNA synthesis, stimulate fibroblast activity, promote collagen and elastin production, improve scalp microcirculation, and possess anti-inflammatory and antioxidant properties.

• Biological level: PNs create a favourable environment for hair follicle regeneration by providing essential nucleic acids, enhancing tissue repair, improving nutrient delivery to the follicles, and protecting them from oxidative stress.

Exosome therapy:

• Mechanism: Exosomes are nano-sized extracellular vesicles secreted by various cell types (e.g., mesenchymal stem cells). They contain a cargo of proteins, lipids, mRNA, and miRNA that can be delivered to target cells, influencing their behaviour. Exosomes used in hair restoration are typically derived from stem cells. They are rich in growth factors and signalling molecules that can stimulate hair follicle stem cells, promote angiogenesis, and modulate inflammation.

• Biological level: Exosomes act as intercellular communicators, delivering specific signals to hair follicle cells to promote proliferation, differentiation into hair shaft-producing cells, and extension of the anagen phase. They offer a cell-free approach to regenerative medicine.

Low-Level Laser Therapy (LLLT) / Red Light therapy:

• Mechanism: LLLT devices emit low-intensity laser or LED light at specific wavelengths (typically in the red or near-infrared spectrum). When applied to the scalp, this light energy is absorbed by the mitochondria in hair follicle cells, stimulating cellular metabolism, increasing ATP production, improving blood flow to the scalp, and reducing inflammation.

• Biological level: LLLT energises hair follicle cells, promoting their activity and potentially shifting follicles from the telogen to the anagen phase. Improved blood flow ensures better nutrient and oxygen delivery, supporting hair growth.

Comparing hair growth therapies

Direct head-to-head comparative studies between PRP, polynucleotides, and exosomes for postpartum hair loss are still limited. However, based on current evidence and understanding of their mechanisms.

Efficacy:

• PRP: Has a relatively strong evidence base for hair restoration, showing improvements in hair density, thickness, and reduction in shedding in various types of hair loss, including telogen effluvium and early androgenetic alopecia. Its autologous nature is a key advantage.

• Polynucleotides: Emerging evidence suggests promising results in improving hair density and quality, likely through scalp revitalisation and support of hair follicle health. They may be particularly beneficial for improving scalp health and microcirculation.

• Exosomes: While showing significant potential in preclinical studies and early clinical applications, the long-term efficacy and optimal protocols for exosome therapy in hair restoration is still being investigated. Standardisation of exosome products and treatment protocols is crucial.

Patient factors determining the best choice:

• Severity and duration of hair loss: For more pronounced or persistent postpartum hair loss, PRP with its established efficacy might be considered as a first-line option. Polynucleotides could be a good alternative or adjunctive therapy, especially if scalp health is a concern. Exosomes might be considered in cases where a more potent regenerative stimulus is desired, or when autologous treatments are not preferred.

• Underlying contributing factors: If there are signs of scalp inflammation or poor microcirculation, polynucleotides might be particularly beneficial. PRP’s growth factors can also address inflammatory components.

• Scalp health: Polynucleotides excel at improving scalp hydration, elasticity, and overall health, which can indirectly support hair growth.

• Patient preferences and tolerance: PRP involves blood draw and injections, which some patients may find less appealing. Polynucleotides and exosomes are also typically administered via injection. LLLT is a non-invasive option that can be used at home.

• Cost: The cost of each treatment varies. PRP typically involves a series of in-office treatments. Polynucleotide and exosome therapies can also be costly depending on the source and preparation. LLLT devices require an initial investment.

• Availability and practitioner experience: The availability of specific treatments and the experience of the practitioner are important considerations.

• Allergies and sensitivities: While PRP is autologous and generally well-tolerated, potential allergic reactions to carrier solutions or preservatives in polynucleotide or exosome products should be considered.

PRP has the most robust clinical evidence currently. Polynucleotides show great promise for scalp and hair follicle health. Exosomes are an exciting area of research with significant potential but require further long-term data. The best choice depends on a comprehensive assessment of the individual patient and their specific needs and preferences.

Laser and energy-based devices

Laser therapy, specifically Low-Level Laser Therapy (LLLT), plays a valuable role in treating postpartum hair loss.

• Mechanism of action in postpartum hair loss: LLLT stimulates hair follicle cells, improves blood flow, and reduces inflammation. In the context of postpartum telogen effluvium, this can help shorten the telogen (shedding) phase, accelerate the transition to the anagen (growth) phase, and increase hair density and thickness over time.

• Evidence and efficacy: Several studies have demonstrated the efficacy of LLLT in promoting hair regrowth in various types of hair loss, including telogen effluvium and androgenetic alopecia. While specific studies focusing solely on postpartum telogen effluvium might be fewer, the underlying mechanisms suggest it can be beneficial.

• Types of LLLT devices: LLLT devices are available in various forms, including in-office laser devices and at home devices. In-office devices are often more powerful and administered by professionals, and at-home devices such as laser combs, caps, and headbands, offer convenience but typically have lower power output.

• Advantages of LLLT: Non-invasive and painless; relatively safe with minimal side-effects; can be used as a standalone treatment or in combination with other therapies; and at-home devices offer convenience for ongoing maintenance.

• Limitations of LLLT: Results may take time to become noticeable (typically several months of consistent use). Efficacy can vary depending on the device, treatment parameters, and individual response. And compliance with regular at-home use is crucial for optimal results.

While LLLT is the most established energy-based therapy for hair loss, other devices like microneedling with radiofrequency (RF) are also being explored. Microneedling creates microinjuries in the scalp, stimulating the release of growth factors and potentially enhancing the penetration of topical treatments. RF energy can add a thermal component that further stimulates collagen production and improves circulation. However, their specific role and evidence base for postpartum hair loss are still evolving.

Combination therapies

Combining therapies can often lead to synergistic effects and improved outcomes for postpartum hair loss. Here are some potential and commonly used combinations:

PRP with LLLT: This is a popular and often effective combination.

• Rationale: PRP provides growth factors directly to the hair follicles, stimulating regeneration. LLLT enhances cellular metabolism, improves blood flow, and can potentially amplify the effects of the growth factors in PRP.

• Evidence: Some studies suggest that combining PRP with LLLT can lead to better and faster hair regrowth compared to either treatment alone.

• Practical application: PRP injections are typically performed in-office, and patients can use at-home LLLT devices between PRP sessions.

PRP with microneedling:

• Rationale: Microneedling creates microchannels in the scalp, which can enhance the penetration and absorption of PRP growth factors. The micro-injuries themselves also stimulate collagen production and the release of growth factors.

• Evidence: Studies have shown that combining PRP with microneedling can be more effective than microneedling alone for hair restoration.

• Practical application: PRP can be applied topically to the scalp immediately after microneedling, or injected as a separate session.

Polynucleotides with LLLT:

• Rationale: Polynucleotides improve the scalp environment and provide building blocks for hair follicle regeneration. LLLT can further stimulate these follicles and enhance microcirculation, potentially optimising the benefits of polynucleotides.

• Evidence: While specific studies on this combination for postpartum hair loss may be limited, the complementary mechanisms suggest potential benefits.

PRP with polynucleotides:

• Rationale: PRP provides a direct boost of growth factors, while polynucleotides work to improve the overall health and regenerative capacity of the scalp. This combination could address both the immediate stimulation of hair follicles and the long-term support of a healthy scalp environment.

• Evidence: This is an area of growing interest, and anecdotal evidence and mechanistic understanding suggest potential synergy.

Exosomes with LLLT:

• Rationale: Exosomes deliver potent regenerative signals to hair follicle cells. LLLT can potentially enhance the uptake and activity of these signals by improving cellular metabolism and blood flow.

• Evidence: Research on this specific combination is still emerging, but the complementary mechanisms are promising.

Considerations for combination therapies:

• Individual patient needs: The best combination depends on the specific characteristics of the patient’s hair loss, scalp health, and treatment goals.

• Mechanism of action: Combining therapies with different but complementary mechanisms of action is generally more effective.

• Treatment sequencing and timing: The order and spacing of different treatments may influence outcomes.

• Cost and convenience: Combining therapies can increase the overall cost and may require more frequent visits or at-home device usage.

• Practitioner expertise: It is crucial to choose a practitioner experienced in using combination therapies for hair loss.

Combining therapies like PRP with LLLT or microneedling, or exploring combinations with polynucleotides and exosomes, can be a valuable strategy to enhance the effectiveness of postpartum hair loss treatments. The optimal combination should be tailored to the individual patient and guided by clinical assessment and emerging evidence.

Contraindications in postpartum women

While many aesthetic treatments for postpartum hair loss are generally considered safe, certain contraindications and precautions exist, especially for breastfeeding women:

General contraindications (applicable to postpartum and breastfeeding women):

• Active scalp infections or inflammation: Treatments should be postponed until the infection or inflammation resolves.

• Bleeding disorders or use of anticoagulants: PRP and injectable treatments may carry a higher risk of bruising or bleeding.

• Certain autoimmune diseases: Some autoimmune conditions may be contraindications for PRP or other regenerative therapies.

• Cancer: Active cancer treatment is generally a contraindication for most elective aesthetic procedures.

• Pregnancy: Most aesthetic treatments are contraindicated during pregnancy.

Specific considerations for breastfeeding women:

• PRP therapy: Generally considered safe as it uses the patient’s own blood. However, the local anesthetic used during the procedure could theoretically enter breast milk in very small amounts. While the risk is considered low, some practitioners may advise pumping and discarding milk for a short period after the procedure as a precautionary measure.

• Polynucleotides: The safety profile of polynucleotides in breastfeeding women is not as well-established. While they are derived from natural sources, it is prudent to exercise caution due to limited data on potential transfer into breast milk and effects on the infant. Many practitioners may advise against their use during breastfeeding.

• Exosome therapy: Similar to polynucleotides, the safety of exosomes in breastfeeding women is not fully understood. Due to the potential for systemic effects, even with topical or local administration, caution is advised, and many practitioners may recommend avoiding this treatment during breastfeeding.

• LLLT: Generally considered safe for breastfeeding women as it is a non-invasive, light-based therapy with no known systemic absorption or transfer into breast milk.

• Microneedling: While the procedure itself is minimally invasive, there is a theoretical risk of local anesthetic absorption and potential entry into breast milk. Additionally, any topical agents applied after microneedling should be carefully considered for breastfeeding safety.

• Topical medications (e.g., minoxidil): Systemic absorption is minimal with topical application, but it is classified as potentially hazardous for breastfeeding.

Recommendations for practitioners:

• Thorough consultation: A detailed medical history, including breastfeeding status, is crucial.

• Weighing risks and benefits: Carefully consider the potential risks and benefits of each treatment in the context of breastfeeding.

• Informed consent: Discuss potential risks and uncertainties with the patient and obtain informed consent.

• Prioritise safety: Opt for treatments with established safety profiles during breastfeeding whenever possible.