Aesth Plast Surg

https://doi.org/10.1007/s00266-024-04332-3

ORIGINAL ARTICLES FACIAL SKELETON

Effectiveness of Exosome Treatment in Androgenetic Alopecia:

Outcomes of a Prospective Study
Mert Ersan1 • Emre Ozer1 • Ozlem Akin2 • Pakize Neslihan Tasli3 •

Fikrettin Sahin3

Received: 18 April 2024 / Accepted: 9 August 2024

Ó The Author(s) 2024

Abstract tracking analysis (NTA), hair densities were calculated via

Objective Harnessing the regenerative capabilities of stem digital imaging analysis, and patient satisfaction was
cell-derived exosomes holds great promise for developing questioned with a modified survey.
novel hair growth therapies, offering hope for individuals Results NTA results showed a characteristic distribution of
experiencing hair loss or alopecia. This aimed to elucidate peaks for exosomes 139.7 ± 2.3 nm in diameter. A sta-
the effect of ‘‘foreskin-derived mesenchymal stromal cells tistically significant increase in hair density was observed
derived exosome’’ injection into the scalp on hair density in in the 4th and 12th weeks after treatment (p \ 0.05).
patients with androgenetic alopecia and the contribution of Patient-reported satisfaction revealed a statistically signif-
this treatment on patient satisfaction. icant difference in the answers given in the 12th week
Method This prospective study included 30 male patients, compared to the 4th week (p \ 0.05). No side effects or
aged between 22 and 65, with hair type III-VI according to complications were observed after exosome injection.
the Norwood-Hamilton scale. Characterization of the stem Conclusion Foreskin-derived mesenchymal stromal cells
cell exosomes was performed with the nanoparticle derived exosome injection increased hair density, with
sustained patient satisfaction throughout the study. The
exosome application resulted in no side effects.
& Mert Ersan Level of Evidence IV This journal requires that authors
[email protected]
assign a level of evidence to each article. For a full
Emre Ozer description of these Evidence-Based Medicine ratings,
[email protected]
please refer to the Table of Contents or the online
Ozlem Akin Instructions to Authors www.springer.com/00266.
[email protected]
Pakize Neslihan Tasli Keywords Androgenetic alopecia
Exosome

[email protected]
Extracellular vesicles
Hair density
Hair loss

Fikrettin Sahin Mesenchymal stromal cells
[email protected]
1
Plastic, Reconstructive and Aesthetic Surgery Department,
Kozyatagi Hospital, Faculty of Medicine, Yeditepe Introduction
University, Icerenkoy Mahallesi, Hastahane Sokak, 34752
Atasehir, Istanbul, Turkey
Androgenic alopecia (AGA) occurs through different
2
Dermatology Department, Kozyatagi Hospital, Faculty of mechanisms in people with genetic predisposition; its fre-
Medicine, Yeditepe University, Icerenkoy Mahallesi,
quency and severity increase with age have different
Hastahane Sokak, 34752 Atasehir, Istanbul, Turkey
3
characteristic hair loss patterns in men and women. Since
Genetics and Bioengineering Department, Faculty of
the pathogenesis, clinical features, and treatment manage-
Engineering and Architecture, Yeditepe University,
Kayisdagi, Inonu Mahallesi, Kayisdagi Caddesi, 34755 ment of androgenetic alopecia may differ, evaluating it as
Atasehir, Istanbul, Turkey male-type and female-type androgenetic alopecia is more

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accurate. In men, hair in the frontal, vertex, and sometimes Research into the therapeutic potential of stem cell-
temporal areas of the scalp is lost, while the frontal hairline derived exosomes for hair regeneration is rapidly advanc-
is usually preserved, and hair loss is observed in women’s ing, with studies highlighting their involvement in various
frontal and vertex areas [1]. The prevalence of androge- cellular processes crucial for hair growth. Harnessing the
netic alopecia is estimated to vary between 23 and 87%. regenerative capabilities of stem cell-derived exosomes
Although the possibility of polygenetic inheritance cannot holds great promise for developing novel hair growth
be excluded, it is thought to show an autosomal dominant therapies, offering hope for individuals experiencing hair
transmission with variable penetrance [2]. loss or alopecia [7].
Androgenic alopecia treatment aims to stop follicular Within the scope of this research, we aimed to elucidate
miniaturization and improve hair density. Before starting the effect of ‘‘foreskin-derived mesenchymal stromal cells
treatment, patients should be informed about the treat- derived exosome’’ injection into the scalp on hair density in
ments’ possible effects, side effects, and costs. The patients with androgenetic alopecia and the contribution of
patient’s expectations from the treatments should be care- this treatment on patient satisfaction.
fully questioned, and it should be shared with the patient
that even if there is no new hair growth, even the cessation
of hair loss will be considered a good response to the Materials and Methods
treatment [3].
Minoxidil is the most used drug in local treatment. This prospective study included 30 male patients, aged
Antiandrogens and 5-a reductase inhibitors belong to the between 22 and 65, with hair type III–VI according to the
class of androgen-dependent treatments. Among the Norwood-Hamilton scale. They agreed not to change their
antiandrogens, cyproterone acetate (CPA), spironolactone hairstyle and would not undergo any hair care or treatment
(SP), and flutamide are used only in female patients due to during the study. All procedures followed were under the
their potential side effects in male patients. CPA suppresses ethical standards of the responsible committee on human
the production of gonadotropins by inhibiting the release of experimentation (institutional and national) and with the
gonadotropin-releasing hormone. It also blocks androgen Helsinki Declaration of 1975, as revised in 2008. Our study
receptors. CPA, which is often included in oral contra- was conducted under strict ethical guidelines and received
ceptives in combination with androgen and treated with institutional ethical approval under protocol number 1809.
estradiol, is especially preferred in female patients with The exosomes used in this study were produced in aseptic
hyperandrogenism. The basic surgical method is auto conditions under GMP regulations by Yeditepe University
transplantation, where hair follicles in the occipital region Gene and Cell Therapy Excellence Center (YUCTEC), a
are transplanted to the frontal, temporal, parietal and vertex GMP-compliant laboratory licensed by the Ministry of
regions [1, 4]. Health, Turkish Medicines and Medical Devices Agency.
Extracellular vesicles are lipid-bound structures secreted All participants provided informed consent. Exosome iso-
by various cell types. They play a crucial role in intercel- lation, preparation, and injection were performed under
lular communication by transporting various molecules sterile conditions, and participants were closely monitored
between cells, such as proteins, nucleic acids, and other for any adverse effects.
bioactive molecules. Recent research suggests that these Patients using finasteride, dutasteride, steroids,
extracellular vesicles, particularly stem cell-derived exo- vasodilators, anticonvulsants, beta-receptor blockers,
somes, possess remarkable regenerative properties, bronchodilators, diuretics, spironolactone, cimetidine, dia-
demonstrating a potential for stimulating hair follicle zoxide, cyclosporine, ketoconazole; patients with a history
regeneration and promoting hair growth [5]. of surgery for hair loss, such as hair transplantation or scalp
Exosomes contain growth factors, cytokines, and reduction; patients with a history of topical steroids or hair
microRNAs that can modulate signalling pathways growth solutions for hair within the last year; those with
involved in hair follicle development and regeneration. uncontrolled blood pressure and blood sugar levels in the
Moreover, stem cell-derived exosomes can interact with last six months, infectious skin diseases or psychiatric
target cells by binding to specific membrane receptors, disorders, a history of treatment of hyperthyroidism or
initiating signalling cascades, and promoting hair follicle hypothyroidism, aspartate aminotransferase (AST) or ala-
proliferation and differentiation. Furthermore, the transfer nine aminotransferase (ALT) serum levels [ 80 mg/dL or
of membrane proteins from exosomes to recipient cells creatinine (Cr) level [ 1.5 mg/dL; and patients who were
through membrane fusion facilitates the integration of actively pregnant, breastfeeding, or planning to become
exosomal contents into the cellular machinery of target pregnant within the next six months were excluded from
cells, leading to enhanced hair follicle function and growth the study.
[6].

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Cell Culture Conditions points in the frame range. Video recordings were con-
ducted at the 16th camera level with 30-sec intervals
Foreskin-derived mesenchymal stem cells (MSCs) were between captures. After each capture, the sample was
utilized and sourced from the Extracellular Vesicle and introduced into the flow cell to rinse the previous portion.
Exosome Research Laboratory (EVER Lab) at Yeditepe A total of 10 captures were acquired for each sample—
University. The mesenchymal stem cells used in the article subsequent analysis involved employing suitable threshold
were human foreskin stem cells which were collected from settings. The video capture and analysis processes were
the newborn prepuce tissue in Yeditepe University/Turkey executed utilizing NTA software version 3.4.
Biotechnology Laboratories as performed by Somuncu
et al. [8]. Cells were maintained in Dulbecco’s modified Surface Antigen Measurement
Eagle’s medium (DMEM, #41966-029, Invitrogen, Gibco,
UK), supplemented with either 10% foetal bovine serum Exosomal surface antigens were assessed using flow
(FBS, #10500-064, Invitrogen, Gibco, UK) and 1% peni- cytometry. Initially, approximately 109 nanoparticles
cillin/streptomycin/amphotericin (PSA, Invitrogen, Gibco, (*5 lg) of exosomes were bound to 5 lL of alde-
UK) or without FBS. The culture of MSC cells followed hyde/sulphate latex beads (ThermoFisher, A37304), each
the manufacturer’s instructions, utilizing a complete media with a concentration of 4% w/v and a size of 4 lm. This
composed of Basal Medium (#PT-4927) supplemented mixture was then incubated for 15 min on a shaker at room
with the appropriate additives (SingleQuot Kit, #PT-4514). temperature. After the incubation period, Exo-Bead sus-
Cells were maintained at 37 °C in a humidified atmosphere pension was divided into four tubes for antibody incuba-
containing 5% CO2. tion. Conjugated antibodies targeting common exosome
markers, including CD9 (Biolegend, 124808), CD63
Exosome Isolation (Biolegend, 143904), and CD81 (Biolegend, 349506,
USA), were added to each sample at a dilution of 1:1000
The identification of exosomes was performed in our lab- and allowed to incubate overnight. Finally, exosome
oratory, as in the study by Sagrac et al. [9]. The cell culture analysis was performed via flow cytometry using a Becton
media is collected from a combination of FBS and antibi- Dickinson (BD) FACSCalibur Flow Cytometry System
otic-free stem cell culture. An ATPS-exosome isolation (Becton Dickinson, San Jose, CA, USA).
solution is prepared by blending polyethylene glycol (PEG)
and dextran (DEX) at a 7.7:3.3 (w/w) ratio with distilled Evaluation of AGA
water. Centrifugation was performed at 10.000 g for
10 min to remove larger contaminants from 20 mL of plant Before the exosome injections of 30 male patients with
lysate. The supernatant is mixed with the ATPS-exosome androgenetic alopecia, frontal and vertex regions where
isolation solution at a 1:1 volume ratio. Phase separation is hair loss occurred on the scalp were imaged with a digital
induced by centrifuging the mixture at 1.000 g for 10 camera (Canon Eos 5D Mark II, Canon Inc. Tokyo, Japan).
minutes. Two rounds of removing 80% of the upper PEG- To ensure measurements from the same point during con-
rich phase and substituting it with the upper phase of a trols, some topographic points were determined. For 2
washing solution are performed. The washing solution, points in the frontal region, the points within 5 cm of the
produced by mixing the exosome isolation solution with hairline at the left and right mid-pupil lines were consid-
distilled water at a 1:1 volume ratio and centrifuging at ered, and for the one point at the vertex, 2 cm medial to the
1.000 g for 10 min, is utilized. Following the second wash, hair whorl was taken as the basis. An area of 1 cm2 from
exosomes are extracted from the phase comprising 10% of each of the mentioned areas was selected, and 9 40
the total solution. The collected exosomes are now devoid magnification images of those areas were taken with digital
of cellular debris and can be subjected to subsequent dermatoscopy (MoleMax HD, Derma Medical Systems,
analyses or experiments. Austria). These dermatoscopic images recorded hair den-
sities (hair count/cm2) with Trichoscan (TrichoLab GmbH,
NTA Analysis Germany). The average values of 3 regions (2 frontal and 1
vertex points) were taken. After the imaging, the applica-
Stem cell exosome concentration measurement and deter- tion was performed: A total of 3 mL of exosomes (2 mL to
mination of exosome size and density distribution were the frontal and 1 mL to the vertex region) was injected
conducted using Nanosight NS300 (Malvern Panalytical, using the napage technique (1010 extracellular vesicles in
England) equipped with a 488-nm laser. Exosomes were 1 mL). Patients were observed for possible side effects for
appropriately diluted to match the recommended concen- 1 h after the procedure. Patients were instructed not to
tration range of the instrument, spanning from 20 to 200 wash their hair and avoid heavy activities for 1 day after

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the injection. The patients were called for control at the 4th of exosomes can be seen in Video 1. The isolated stem cell
and 12th weeks after the injection. During these sessions, exosome particle number was 1.59 1010 ± 108 nanoparti-
photographs of the same areas were taken with the same cle/mL. The surface antigens CD9, CD63, and CD81,
digital camera, from the same distance and under the same assessed using flow cytometry, are shown (Fig. 1d–f),
light and flash (1/200 s; f/6, 3; ISO 160). During the con- respectively.
trols, the same topographic points were found (2 frontal
and 1 vertex point), and these areas were imaged with Digital Image Analysis and Hair Density
digital dermatoscopy under 9 40 magnification. Hair Improvement
densities were recorded using Trichoscan analyses, and the
averages of the 3 treated areas were taken. Two independent observers evaluated the macroscopic
Additionally, at the 4- and 12-week check-ups, a hair photographs. We observed significant improvements in
growth survey, as defined by Barber et al. [10] , was both the macroscopic view (Figs. 2, 3, 4) and the der-
modified and administered to the patients. In this modified matoscopic images (Fig. 5).
survey, patients were asked two questions. Question one According to the patients’ digital dermatoscopy images
was, ‘‘Has your hair loss decreased?’’ while the second and Trichoscan analyses, the distribution of hair density at
question was, ‘‘Have you noticed new hair growing?’’ the 4th week after treatment compared to before treatment,
Participants answered both questions: ‘‘1-I strongly agree, at the 12th week after treatment compared to before
2-I agree, 3-I am undecided, 4-I disagree, 5-I strongly treatment, and the 4th and 12th weeks after treatment are
disagree’’. denoted in Table 1. A statistically significant increase was
observed in the 4th and 12th weeks after treatment com-
Statistical Analysis pared to pre-treatment (p \ 0.05). The mean hair density
increased from 149.7 ± 13.7 hairs/cm2 at pre-treatment to
All statistical analyses were performed using SPSS (Sta- 153.6 ± 16.8 hairs/cm2 at the 4th week (p = 0.043) and
tistical Package for Social Sciences) version 29.0 software further to 157 ± 18.3 hairs/cm2 at the 12th week
(IBM SPSS Inc., Armonk, NY, USA). Descriptive statistics (p = 0.002).
were presented to measure the clinical characteristics of the
results. These were mean, median, standard deviation (SD), Survey Results and Patient Satisfaction
minimum, and maximum for continuous variables, and
frequency and percentage for categorical variables. A two- The distribution of the answers to the question ‘‘Has your
tailed Kolmogorov–Smirnov test was applied to examine hair loss decreased?’’ given in the 12th week according to
whether the continuous quantitative variables follow a the answers given in the 4th week is elaborated in Table 2.
Gaussian distribution. The Wilcoxon signed rank test or There was a statistically significant difference in the
paired sample T test was used to compare two dependent answers given in the 12th week compared to the 4th week
groups. The ‘‘p’’ value of \ 0.05 was accepted for statis- (p \ 0.05). According to the answers given by the patients
tical significance. in the 4th week, a positive change was observed in the
12th week. The distribution of the answers to the question
‘‘Have you noticed new hair growing?’’ given in the
Results 12th week according to the answers given in the 4th week
is elaborated in Table 3. A statistically significant differ-
A total of 30 male adults with alopecia areata were enrolled ence was seen in the answers given in the 12th week
in this prospective research. The average age of the par- compared to the 4th week (p \ 0.05). According to the
ticipants was 34.65 years (range 22–65 years). All patients patients’ answers in the 4th week, a positive change was
completed the study and the follow-up period with no observed in all but five patients in the 12th week.
dropouts. No side effects or complications were observed
immediately after exosome injection or during follow-up.
Discussion
Exosome Identification
Exosomes can be obtained from all body fluids and play an
NTA results showed a characteristic distribution of peaks important role in many biological functions, such as
for exosomes 139.7 ± 2.3 nm in diameter (Fig. 1a). Exo- intercellular communication, signal transmission, genetic
some sizes were measured between 30 and 200 nm material transfer, and regulation of the immune response.
(Fig. 1a–c). Exosomes have a homogeneous structure with Understanding that exosomes have such functions has
a round-shaped morphology (Fig. 1b, c). Brownian motion revealed different areas of nanovesicle use. The first of

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Fig. 1 Characterization of stem cell exosome. a Size and concen- image of C-Exo particles. c Intensity and size distribution. d Surface
tration measurements of stem cell exosome with NS300 NTA system antigen CD9. e Surface antigen CD63. f Surface antigen CD81
with 15 different reads for 30 sec. each reads. b Brownian motion

these is diagnosis due to their content and role in the study stated that exosomes stimulated hair follicle prolif-
pathogenesis of different diseases [11]. Another one is due eration, accelerated the transition from the telogen to the
to the immune regulatory properties of exosomes, which anagen phase, and protected hair follicle cells against
even lead to cancer treatment. In addition to all these roles, reactive oxygen species. The authors injected exosomes
exosomes play important roles in immune responses and into the scalp, similar to platelet-rich plasma (PRP), and
ensure immune homeostasis. Studies have shown that treatments can be adjusted to the degree of hair loss.
exosomes of different cell origins have suppressive and The spheroid form of exosomes derived from dermal
activating effects on immune cells, which can have mul- papilla triggered the transition from the telogen phase to
tiple effects (pleiotropic). The pleiotropic effects of exo- the anagen phase better compared to minoxidil treatment
somes, depending on the state of the cells from which they [16]. Dermal papilla-derived exosomes provide many
originate, enable the emergence of different biomedical benefits to overall hair growth. The presence of ‘‘miRNA’’
applications of these natural nanovesicles [12]. ensures the proliferation/differentiation of stem cells and
MSC exosomes are also promising in hair restoration as the formation of longer hair shafts. Other source cells
they contain potent cytokines and growth factors that studied for hair growth include mesenchymal stem cells
promote hair growth. Early studies have shown that MK and keratinocytes. Yang et al. [17] stated that the micro-
exosomes induce the proliferation/migration of human needle-based transdermal drug delivery approach showed
dermal papilla cells and secretion of VEGF and IGF-1 increased effectiveness compared to subcutaneous exo-
in vitro [13]. Rajendran et al. (2017) injected dermal some injections and topical UK5099 application. Hair
papilla cell-derived exosomes in mice. They showed that it follicle-derived MSCs have also been shown to reduce
accelerated the onset of the anagen phase of the hair fol- inflammation and decrease hair loss in vitro in mice with
licle, delayed the catagen phase, and stimulated the AA, an autoimmune type of hair loss [18].
expression of beta-catenin and ‘‘sonic-hedgehog’’ growth Festa et al. [19] indicated that the number of adipocyte
factors [14]. Kwack et al. [15] reported that exosome precursor cells changed with the hair cycle. The cell
treatment increased average hair density and thickness. The number peaked in the skin during follicular stem cell

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Fig. 2 The frontal area of the patient who received a single dose of Fig. 3 A close-up view of the right frontal area of the patient taken
exosome injection, respectively (from top to bottom), pre-treatment, from the right oblique angle, who received a single dose of exosome
four weeks after treatment, and 12 weeks after treatment. The average injection, respectively (from top to bottom) pre-treatment, 4 weeks
hair density (hair count/cm2) from two designated frontal points was after treatment, and 12 weeks after treatment. The hair density (hair
128, 155, and 162, respectively count/cm2) taken from a designated frontal point on the right side was
151, 164, and 170, respectively
activation (anagen) and decreased during the catagen
phase. They also reported that mature adipocytes and ADSC-CM intradermal injection showed that ADSC-CM
preadipocytes have been defined as skin niche cells that application promoted hair density and thickness in these
regulate hair follicle stem cell activity. ASCs facilitate the patients without adverse reactions [21].
production and secretion of growth factors such as vascular Clinical studies on MSC-derived exosomes have shown
endothelial growth factor (VEGF), transforming growth promising safety profiles, with no significant adverse
factor (TGF-b), hepatocyte growth factor (HGF), platelet- effects, such as anaphylaxis, reported in several trials. For
derived growth factor (PDGF), placental growth factor example, MSC-derived exosomes in various clinical set-
(PlGF), and basic fibroblast growth factor (bFGF) [20]. tings have demonstrated safety without inducing significant
Intradermal injections of adipose-derived stem cell condi- adverse effects, including immune reactions or anaphylaxis
tioned media (ADSC-CM) have also been investigated [22–24]. These findings support the safety of exosome
previously. A retrospective cohort of 27 individuals with therapy, although continuous monitoring and preparedness
female-pattern hair loss (FPHL) treated with a single for managing potential side effects are essential. Although
no side effects or complications were observed

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Fig. 4 The vertex area of the patient who received a single dose of Fig. 5 The dermatoscopic image of the left frontal area of the patient
exosome injection, respectively (from top to bottom) pre-treatment, (different patient from those in the macroscopic images) who received
four weeks after treatment, and 12 weeks after treatment. The average a single dose of exosome injection, respectively (from top to bottom)
hair density (hair count/cm2) taken from designated vertex points was pre-treatment, four weeks after treatment and 12 weeks after treat-
121, 128, and 133, respectively ment. The hair density (hair count/cm2) taken from a designated
vertex point was 139, 172, and 175, respectively
immediately after the exosome injection or during follow-
up, we took several precautionary measures to ensure and respond to anaphylactic reactions promptly. In the
patient safety. Before the procedure, we carefully checked event of an anaphylactic reaction, our protocol includes
each patient for potential allergies or risk factors related to immediately administering intramuscular epinephrine,
exosomes. This included a thorough medical history, providing supplemental oxygen, administering antihis-
focusing on any known allergies, previous allergic reac- tamines and corticosteroids, and arranging for emergency
tions to medications or treatments, and family history of medical transport if necessary.
allergies. Patients were observed for 1 hour post-procedure Stevens et al. [25] evaluated the efficacy of stromal
to monitor for any immediate adverse reactions, including vascular fraction (SVF) injections in combination with
anaphylaxis. Our clinic has emergency medical supplies platelet-rich plasma (PRP) in the upper scalp of AGA
and medications to manage anaphylaxis, such as epi- patients. In their study, hair density significantly increased
nephrine auto-injectors, antihistamines, corticosteroids, after 6 weeks from an average baseline value of
and oxygen. Our staff members are trained to recognize 157–177 hairs/cm2 (p = 0.013). At 12 weeks, the hair
density increased to 185 hairs/cm2 (p \ 0.001). Regarding

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Table 1 Distribution of hair

Hair density (hair count/cm2) Mean ± SD? Median (min–max) p value
density (hair count/cm2) results
of the patients before treatment, Pre-treatment 149.7±13.7 149.5 (121-187) *0.043
4th week and 12th week after
treatment 4. week 153.6±16.8 154.5 (118-194)
Pre-treatment 149.7±13.7 149.5 (121-187) **0.002
12. week 157±18.3 156 (119-202)
4. week 153.6±16.8 154.5 (118-194) **0.002
12. week 157±18.3 156 (119-202)
* p \ 0.05; ** p \ 0.01
?
SD standard deviation

Table 2 The distribution of patients’ responses regarding the ‘‘decrease in hair loss’’ at the 4th and 12th weeks after treatment
Has your hair loss decreased in the 12th week? p value
I agree I don’t agree Undecided Disagree Strongly disagree

Has your hair loss decreased in the 4th week? n (%) ***\0.001
I agree 2 (50) 2 (50) 0 (0) 0 (0) 0 (0)
I’m undecided 3 (27.3) 4 (36.4) 3 (27.3) 0 (0) 1 (9.1)
I disagree 4 (44.4) 3 (33.3) 2 (22.2) 0 (0) 0 (0)
I strongly disagree 3 (50) 2 (33.3) 0 (0) 1 (16.7) 0 (0)
*** p \ 0.001

Table 3 The distribution of patients’ responses regarding the ‘‘new hair growth’’ at the 4th and 12th weeks after treatment
Have you noticed new hair growing in the 12th week? n (%) p value
Strongly agree Agree Undecided Disagree

Have you noticed new hair growing in the 4th week? n (%) *0.035
Strongly agree 11 (73.3) 4 (26.7) 0 (0) 0 (0)
Agree 2 (14.3) 8 (57.1) 4 (28.6) 0 (0)
Undecided 0 (0) 0 (0) 0 (0) 1 (100)
* p \ 0.05

their research outcomes, they admitted that a single treat- adequate treatment safety [20]. Our study observed a sta-
ment of platelet-rich stroma injected in the scalp of patients tistically significant increase in hair density at the 4th and
with AGA significantly increased hair density within 12th weeks post-treatment with exosome injections in
6–12 weeks [25]. Tak et al. [20] conducted a randomized digital dermatoscopy images and Trichoscan analyses. The
controlled trial on 38 AGA patients (29/38 males) who mean hair density increased from 149.7 ± 13.7 hairs/cm2
self-applied the ADSC constituent extract topical solution at pre-treatment to 153.6 ± 16.8 hairs/cm2 at the 4th week
twice daily over the scalp with fingers and analyzed hair (p = 0.043) and further to 157 ± 18.3 hairs/cm2 at the
count and thickness at 16 weeks. In the study, the hair 12th week (p = 0.002). Comparing these results, it is evi-
density, 139.7 ± 2.3 hairs/cm2, increased to dent that the exosome injections in our study demonstrated
153.6 ± 16.8 hairs/cm2 at week 16 (p \ 0.05). They comparable efficacy to the PRP and SVF injections used in
declared that applying adipose-derived stem cell con- the study by Stevens et al. (2018) and the adipose-derived
stituent extracts topical solution enhanced hair regrowth by stem cell constituent extract topical solution used by Tak
increasing hair density and thickness while maintaining et al. [20, 25]. These studies reported significant increases

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in hair density over their respective timeframes, aligning Open Access This article is licensed under a Creative Commons
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optimize treatment protocols.
Apart from previous literature, patient satisfaction could
be attributed as the strength of this research. Patients References
reported decreased hair loss and improved growth in the
4th and 12th weeks after exosome injection. 1. Rudnicka L, Arenbergerova M, Grimalt R et al (2024) European
We believe our study has some limitations. The first is expert consensus statement on the systemic treatment of alopecia
the absence of a control group. This study could pave the areata. J Eur Acad Dermatol Venereol 38(4):687–694. https://doi.
org/10.1111/jdv.19768
way for a larger patient population study, including a 2. Ntshingila S, Oputu O, Arowolo AT, Khumalo NP (2023)
control group created with saline injections. Another lim- Androgenetic alopecia: an update. JAAD Int 13:150–158. https://
itation of the study is that it does not evaluate the effects of doi.org/10.1016/j.jdin.2023.07.005
repeated exosome injections. We believe our study will 3. Goldberg LJ (2023) Alopecia—new building blocks. J Am Acad
Dermatol 89(2S):S1–S2. https://doi.org/10.1016/j.jaad.2023.05.
shed light on further research investigating the effects of 048
repeated exosome injections at certain intervals. 4. Mateos-Haro M, Novoa-Candia M, Vanegas GS et al (2023)
Treatments for alopecia areata: a network meta-analysis.
Cochrane Database Syst Rev 10(10):CD013719. https://doi.org/
10.1002/14651858.CD013719.pub2
Conclusion 5. Stefanis AJ (2023) Adipose tissue in the treatment of androgenic
alopecia. Tuková tkáň v léčbě androgennı́ alopecie. Cas Lek Cesk
Foreskin-derived mesenchymal stromal cells derived exo- 162(1):9–12
some injection increased hair density in the first and third 6. Donovan J (2024) Androgenetic alopecia: what works? Cutis
113(1):7–9. https://doi.org/10.12788/cutis.0924
months after application. The patient satisfaction was 7. Devjani S, Ezemma O, Kelley KJ, Stratton E, Senna M (2023)
sustained throughout the study. Last but not least, the Androgenetic alopecia: therapy update. Drugs 83(8):701–715.
exosome application resulted in no side effects or with- https://doi.org/10.1007/s40265-023-01880-x
drawals. There is a need for larger population studies where 8. Somuncu ÖS, Taşlı PN, Şişli HB, Somuncu S, Şahin F (2015)
Characterization and differentiation of stem cells isolated from
exosome injections are compared with different hair loss human newborn foreskin tissue. Appl Biochem Biotechnol
treatment methods, and the efficacy of repeated exosome 177(5):1040–1054. https://doi.org/10.1007/s12010-015-1795-8
injections is also evaluated. 9. Sağraç D, Aydın S, Kırbaş OK, Öztürkoğlu D, Şahin F (2024)
Extracellular vesicles derived from human foreskin cells (hFS-
Supplementary Information The online version contains Exo) accelerate cell migration and angiogenesis through MAPK
supplementary material available at https://doi.org/10.1007/s00266- pathway: an in vitro study. Mol Biol Rep 51(1):471. https://doi.
024-04332-3. org/10.1007/s11033-024-09378-9
10. Barber BL, Kaufman KD, Kozloff RC, Girman CH, Guess HA
Acknowledgements The authors declare that they have no conflict of (1998) A hair growth questionnaire for use in the evaluation of
interest, and none of the authors have a financial or material interest in therapeutic effects in men. J Dermatol Treat 9(3):181–186
any of the drugs, products and devices mentioned in the study. 11. Théry C, Witwer KW, Aikawa E et al (2018) Minimal infor-
mation for studies of extracellular vesicles 2018 (MISEV2018): a
Declarations position statement of the international society for extracellular
vesicles and update of the MISEV2014 guidelines. J Extracell
Conflict of interest The authors declare that they have no conflict of Vesicles 7(1):1535750. https://doi.org/10.1080/20013078.2018.
interest. 1535750
12. Kırbaş OK, Bozkurt BT, Asutay AB et al (2019) Optimized
Ethical Approval All procedures followed were in accordance with isolation of extracellular vesicles from various organic sources
the ethical standards of the responsible committee on human exper- using aqueous two-phase system. Sci Rep 9(1):19159. https://doi.
imentation (institutional and national) and with the Helsinki Decla- org/10.1038/s41598-019-55477-0
ration of 1975, as revised in 2008. Ethics committee approval has 13. Cunha E, Rocha K, Ying W, Olefsky JM (2024) Exosome-me-
been granted from our institution with protocol number 1809, and diated impact on systemic metabolism. Annu Rev Physiol
informed consent has been obtained from all participants. 86:225–253. https://doi.org/10.1146/annurev-physiol-042222-
024535

123
 Aesth Plast Surg

14. Rajendran RL, Gangadaran P, Bak SS et al (2017) Extracellular alopecia. Stem Cells Transl Med 9(8):839–849. https://doi.org/
vesicles derived from MSCs activates dermal papilla cell in vitro 10.1002/sctm.19-0410
and promotes hair follicle conversion from telogen to anagen in 21. Shin H, Ryu HH, Kwon O, Park BS, Jo SJ (2015) Clinical use of
mice. Sci Rep 7(1):15560. https://doi.org/10.1038/s41598-017- conditioned media of adipose tissue-derived stem cells in female
15505-3 pattern hair loss: a retrospective case series study. Int J Dermatol
15. Kwack MH, Seo CH, Gangadaran P et al (2019) Exosomes 54(6):730–735. https://doi.org/10.1111/ijd.12650
derived from human dermal papilla cells promote hair growth in 22. Rezaie J, Feghhi M, Etemadi T (2022) A review on exosomes
cultured human hair follicles and augment the hair-inductive application in clinical trials: perspective, questions, and chal-
capacity of cultured dermal papilla spheres. Exp Dermatol lenges. Cell Commun Signal 20(1):145. https://doi.org/10.1186/
28(7):854–857. https://doi.org/10.1111/exd.13927 s12964-022-00959-4
16. Wang G, Wang Z, Zhang J et al (2023) Treatment of androge- 23. Lotfy A, AboQuella NM, Wang H (2023) Mesenchymal stromal/
netic alopecia by exosomes secreted from hair papilla cells and stem cell (MSC)-derived exosomes in clinical trials. Stem Cell
the intervention effect of LTF. J Cosmet Dermatol Res Ther 14(1):66. https://doi.org/10.1186/s13287-023-03287-7
22(11):2996–3007. https://doi.org/10.1111/jocd.15890 24. Shi H, Yang Z, Cui J, Tao H, Ma R, Zhao Y (2024) Mesenchymal
17. Yang G, Chen Q, Wen D et al (2019) A therapeutic microneedle stem cell-derived exosomes: a promising alternative in the ther-
patch made from hair-derived keratin for promoting hair apy of preeclampsia. Stem Cell Res Ther 15(1):30. https://doi.
regrowth. ACS Nano 13(4):4354–4360. https://doi.org/10.1021/ org/10.1186/s13287-024-03652-0
acsnano.8b09573 25. Stevens HP, Donners S, de Bruijn J (2018) Introducing platelet-
18. Deng W, Zhang Y, Wang W et al (2021) Hair follicle-derived rich stroma: platelet-rich plasma (PRP) and stromal vascular
mesenchymal stem cells decrease alopecia areata mouse hair loss fraction (SVF) combined for the treatment of androgenetic
and reduce inflammation around the hair follicle. Stem Cell Res alopecia. Aesthet Surg J 38(8):811–822. https://doi.org/10.1093/
Ther 12(1):548. https://doi.org/10.1186/s13287-021-02614-0 asj/sjy029
19. Festa E, Fretz J, Berry R et al (2011) Adipocyte lineage cells
contribute to the skin stem cell niche to drive hair cycling. Cell Publisher’s Note Springer Nature remains neutral with regard to
146(5):761–771. https://doi.org/10.1016/j.cell.2011.07.019 jurisdictional claims in published maps and institutional affiliations.
20. Tak YJ, Lee SY, Cho AR, Kim YS (2020) A randomized, double-
blind, vehicle-controlled clinical study of hair regeneration using
adipose-derived stem cell constituent extract in androgenetic

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