Self-Assessments of Standardized Scalp Massages for Androgenic Alopecia: Survey Results

Between May 2014 and September 2015, SAGASs searching online for AGA therapies beyond FDA-approved AGA management drugs navigated to PerfectHairHealth.com and purchased literature and a demonstration video detailing massages as a potential AGA therapy. The materials encouraged two 20-min scalp massages daily, a commitment to massaging for at least 10 months, and a recommendation to record hair changes by taking monthly photographs at comparable lightings, angles, and distances with similar hair styles, lengths, and wetness. SAGASs were offered email support for massage-related questions and to foster adherence. From 2014 to 2016, some massage-adhering SAGASs submitted photographs showing positive hair changes, then participated in qualitative email and video interviews to describe their techniques and adherence. In October 2016, the literature and demonstration video were updated to standardize the massages based on the techniques of therapy-responding SAGASs (Materials S1, Materials S2).

In December 2017, 1899 SAGASs who had purchased the updated literature and demonstration video between October 2016 and October 2017 were contacted once through email to participate in an online survey. Entries were limited to one response per computer to prevent repeat submissions. One hundred eighteen (6.2%) contactees had also viewed the original literature and demonstration video—potentiating the evaluation of long-term (> 1 year) massage adherence. For a flowchart detailing participant collection, see the supplementary material (Fig. S1).

Participants reported age, gender, region of hair loss (i.e., frontal/temporal, vertex, diffuse), AGA gradient, and confirmed if they had read the literature, watched the demonstration video, and attempted the SSMs. SSM participants then estimated their minutes daily and months of SSM adherence, as well as their diet and concomitant use of AGA-related topicals, supplements, drugs, and SBTs (Materials S3). Self-perceived hair changes were reported using a five-point scale (i.e., −2 to +2; 0 = hair loss stabilization)—amended from a seven-point self-assessment scale used in AGA microneedling studies [10].

The SSMs specified twice-daily, 20-min, hand-generated scalp massages spaced 12 h apart. SSM sessions were segmented into one of three rotational scalp regions (frontal/temporal, vertex, sides/back) and divided between hand presses, stretches, and pinches. SSM sessions were as follows: 3 min of warm-up (cyclical presses at 5–10 lb of downward force per hand across the entire scalp), followed by 17 min of region-specific tissue manipulation:

The updated literature and demonstration video recommended a commitment to SSMs of at least 10 months. The materials also emphasized the importance of acute inflammation generation (as evidenced by mild erythema by the end of an SSM session) and tissue stretching—to mimic potential mechanistic overlap from SBTs and mechanotherapies previously shown to have therapeutic effects on human scalp hair (Materials S1, Materials S2).

Since SSM participation and hair changes were self-assessed, we sought to quantify potential bias in reporting. Analyses for bias exploration can be found in the supplementary material (Materials S4).

Prior to analyses, email addresses and open-ended commentary were removed to prevent the sharing of personally identifiable information. All nonnumeric variables were recoded into numeric values. Analyses were conducted in SPSS v24 using linear multiple regression techniques. All procedures performed in studies involving human participants were in accordance with IntegReview IRB, who granted an exemption from Institutional Review Board oversight in accordance with 45 CFR 46.101(b), and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.

Of the 1899 survey contactees, 360 (19.0%) responded, 340 (17.9%) completed the survey, and 327 (17.2%) reported attempting at least one SSM. Of the 327 SSM participants, 296 (90.5%) identified as male, 29 (8.9%) identified as female, and 106 (32.4%) reported SSM adherence ≥ 10 months. In total, 319 (97.6%) SSM participants reported all estimations for SSM adherence, self-perceived hair changes, and at least one hair loss type/region. For purposes of consistency across analyses, figures (unless otherwise noted) present data of these 319 participants.

Daily SSM efforts spanned from 0–10 to 41+ min. Median daily massage time was 11–20 min, with a frequency distribution of 0–10 (25.8%), 11–20 (23.8%), 21–30 (17.6%), 31–40 (22.9%), and 41+ (10.3%) min daily. SSM participation ranged from 0 to 37+ months with an average adherence of 7.4 ± 6.6 months. Total SSM effort (minutes daily × months) ranged from 0 to 647.5 h, with median and mean effort of 50.0 and 85.6 h, respectively. SSM participants reporting 0–10 min daily averaged a total SSM effort of 14.3 h, whereas those reporting 41+ min daily averaged 182.7 h—demonstrating that, on average, greater daily massage time resulted in greater total SSM effort (Fig. 1).

Of the 319 SSM participants, 119 (37.3%) reported hair loss stabilization (0) and 101 (31.7%) reported slight or significant hair regrowth (+1 or +2). SSM participants reported a mean self-perceived hair change of 0.03, indicating that independent of total SSM effort, the average participant perceived hair loss stabilization (Fig. S4).

Increasing total SSM effort was associated with increased self-perceived hair change (Fig. 2). On average, self-perceived hair changes beyond stabilization were achieved after 36.3 h (± 13 h, 85% confidence interval) of SSM effort. Interpretation of the trendline beyond 200 h requires caution since the data distribution is positively skewed, with SSM efforts in the bottom 10% spanning 0–5 h and the top 10% spanning 210–647 h. Accordingly, a fairer representation of the data is achieved by binning total SSM efforts by 10% increments, with bin size selected to have equal numbers of participants (n = ~ 32). The top 20% of total SSM effort participants (≥ 152 h) reported self-perceived hair changes of 0.36 and the bottom 20% (< 12.5 h) reported −0.52, with positive results achieved and maintained at total SSM efforts in the top 50% (≥ 50 h) (Fig. S5).

We sought to determine if the minutes daily by which participants reached a total SSM effort influenced self-perceived hair changes. Participants were binned into total SSM effort groups of low (25–45 h), medium (85–120 h), and high (180–250 h), then segmented by minutes daily to evaluate mean hair changes and SSM efficiencies (i.e., hair change/total SSM hours per participant) (Fig. S4). Low-effort participants reporting 0–10, 11–20, and 21–30 min daily achieved similar total SSM efforts of 32.5 (n = 13), 38.0 (n = 22), and 30.7 h (n = 11), but hair changes of −0.21, 0.00, and 0.545, respectively. From 0–10 to 21–30 min daily, SSM efficiencies in the low-effort group increased from −0.006 to 0.018 units/h, respectively. Results were consistent for medium- and high-effort groups. From 11–20 to 31–40 min daily, medium-effort participants reported hair changes of 0.20 (n = 15; effort = 105 h) and 0.30 (n = 30; effort = 111 h), respectively. For high-effort participants, increases in hair changes and SSM efficiencies were observed from 30–41 (n = 18; hair change = 0.11; efficiency = 0.0005 units/hour) to 41+ min daily (n = 11; hair change = 0.64; efficiency = 0.003 units/h)—indicating that, on average, hair changes improved with more minutes daily of massaging across effort groups.

However, since total SSM effort is a function of minutes daily × months, binning participants by effort creates significant variance in the average months of adherence at minutes daily endpoints. For instance, while the low-effort group completed 25–45 h of massaging, its participants reporting 0–10 min daily achieved an average of 13.5 months of effort, compared with 2.5 months for those reporting 41+ min daily. Accordingly, we considered ways to standardize months of adherence in our analysis. On average, SSM participants reported 7.4 months of effort and hair loss stabilization or greater after 4.5 months (Fig. S5). As such, we selected participants with minimum adherence of ≥ 6 months, segmented by minutes daily, then evaluated mean hair changes and the percent reporting hair loss stabilization or greater (0, +1, or +2). As daily efforts increased from 0–10 to 41+ min, hair changes and the percent reporting ≥ 0 hair changes rose 0.37 points and 15.4%, respectively, but at the expense of a 6.14-fold increase in average total SSM effort (i.e., an additional 212.8 h). This indicates consistent results across analytical approaches, but also that incremental hair changes from higher minutes daily of effort came alongside substantially greater time investments.

Due to the small sample size of female SSM participants (n = 29), hair loss region and gradient analyses were restricted to males. To determine an association between Norwood gradients and self-perceived hair changes, we grouped male participants by reported gradients of early stage (Norwood 01–02), mid-stage (03–03 vertex), late stage (04–05), and end-stage (06–07). When controlling for total SSM effort, self-perceived hair changes did not vary across stage gradients (Table 1).

As AGA gradients progress, hair loss regions overlap. Accordingly, 55.7% of male SSM participants reported more than one hair loss region. Reported frequencies of frontal/temporal, vertex, and diffuse hair loss were 235 (81.3%), 134 (46.4%), and 117 (40.5%), respectively (Fig. S6). Total SSM effort distributions were relatively consistent across participants regardless of their reported hair loss regions, with mean total SSM efforts of 81.2, 106.2, and 92.2 h for frontal/temporal, vertex, and diffuse thinning, respectively (Fig. 3). However, self-perceived hair changes varied depending on the regions a participant reported, with lower hair changes for those with diffuse thinning (−0.11) relative to frontal/temporal (0.03) or vertex thinning (0.08). When considering participants in the top 50% of total SSM effort (≥ 50 h), mean self-perceived hair changes for frontal/temporal, vertex, and diffuse thinning participants were 0.24, 0.19, and 0.00, respectively. Notably, for participants in the top 20% of total SSM effort (≥ 152 h), this increased to 0.48, 0.47, and 0.12, respectively—indicating positive self-perceived hair changes for participants reporting any hair loss region with continued effort (Fig. 3).

Finally, we investigated if secondary parameters were associated with self-perceived hair changes in addition to SSM participation: diet; use of minoxidil, finasteride, microneedling, supplements, and topicals; as well as age and gender. All predictors were examined independently while controlling for total SSM effort.

To investigate the association between diet and self-perceived hair change, the standard American diet was used as the reference category against two additional categories to represent plant-based (vegetarian or vegan) and paleo (low-carbohydrate paleo, moderate-carbohydrate paleo, or modified paleo) diets. There was a marginal effect for plant-based diets versus a standard American diet, and no effect for a paleo diet. There were no significant associations between self-perceived hair changes and minoxidil, finasteride, microneedling, supplement, or topical use alongside SSM adherence. Neither age nor gender was associated with self-perceived hair change (Table 1).