Female Alopecia: Guide to Successful Management

By Ralph M. Trüeb

Few dermatologic problems carry as many emotional overtones as hair loss in women, which is by far the most common hair problem encountered in daily clinical practice. Fortunately, a specific diagnosis can usually be established through the application of appropriate examinations and tests, and treatment suited to the diagnosis is likely to control the problem. This comprehensively illustrated monograph provides both specialists and primary care physicians with the practical know-how required for successful management of hair loss in female patients of all ages. The book opens by critically examining various myths about hair loss. The different examination techniques are then described, and the various forms of hair loss and their treatment are discussed in detail. Approaches to follow-up are outlined, and the management of patient expectations is carefully considered. The potential role of hair care and cosmetics is also explored in some depth.                                                                                                                

• Language: English
• Publisher: Springer
• Release date: Feb 26, 2013
• ISBN: 9783642355035

Book preview

Ralph M. TrüebFemale Alopecia2013Guide to Successful Management10.1007/978-3-642-35503-5_1

© Springer-Verlag Berlin Heidelberg 2013

1. Introduction

Ralph M. Trüeb¹ 

(1)

Center for Dermatology and Hair Diseases, Wallisellen, Switzerland

Abstract

By definition, a myth is either a traditional sacred story, typically revolving around the activities of gods and heroes, which purports to explain a natural phenomenon or cultural practice, or a fiction or half-truth, especially one that forms part of an ideology. With reference to the myths relating to the condition of our hair, a distinction can be made between the historical myths, the popular or layman’s myths, and the physician’s myths. At the end of the book, we will turn to the religious myth.

Insanity: Doing the same thing over and over again and expecting different results.

Albert Einstein (1879–1955)

By definition, a myth is either a traditional sacred story, typically revolving around the activities of gods and heroes, which purports to explain a natural phenomenon or cultural practice, or a fiction or half-truth, especially one that forms part of an ideology. With reference to the myths relating to the condition of our hair, a distinction can be made between the historical myths, the popular or layman’s myths, and the physician’s myths. At the end of the book, we will turn to the religious myth.

1.1 Historical Myths: Experiments on Hair Loss Cures

As early as can be traced in history, written documents testify endeavors shown by humanity to please by means of the hair. The literature on hair is almost as vast as the myths, legends, and superstitions that flourished around it. From the 4,000-year-old medical papyri of the ancient Egyptians, throughout Greek and Roman civilization down to modern times, human hair growth and color have been the object of superstition and mystery as well as cosmetic and medical interest.

For prevention or treatment of hair loss, countless herbal solutions, oils, lotions, magic pills, and even spiritual invocations have been advanced with questionable result. With the advance of medical technologies, ultraviolet light-emitting lamps, electrical scalp stimulators, and ­vacuum-cap machines have all been alleged to help stimulate the follicles to grow hair.

What is remarkable about the history of hair loss cures is that despite the more recent genuine advances in effective medical treatments, hair cosmetics, and surgical procedures, phony hair loss solutions continue to be marketed today with an amazing success. Despite their outrageous claims, most lack scientifically measurable efficacy in preventing hair loss or promoting hair growth. But people are so concerned about their hair loss; they want to believe some miracle cure or some charismatic healer will help them.

In ancient Egypt treatment of the scalp obtained much attention.

One of the oldest medical specialties, according to Herodotus (490/480–424 BC), was the Egyptian physician of the head (ιητροì κεφαλης) who specialized in affections of the scalp.

Among the earliest forms of hair cosmetic procedures were hair setting by the use of beeswax, letting it dry exposing the head to the sun, until it hardened, and hair coloring with henna (Lawsonia inermis) and indigo (Indigofera tinctoria). Ancient Egyptians used to wash their hair regularly with a mix of water and citric juices. They used almond oil as a conditioner after washing the head. The hair results smooth and brilliant. Rosemary oil and castor oil were used to strengthen the hair. Finally, elaborately arranged hair or an ornamental wig was part of the toilet of a woman hoping to engage in love. Hair, whether natural or artificial, was intended to invoke male recognition of feminine appeal and desirability.

Besides the numerous prescriptions for beautification of the scalp, the Papyrus Ebers, Smith, and Hearst embody an abundant Dreckapotheke of remedies for prevention or treatment of alopecia. Most of these were accompanied by ­elaborate exorcisms. The Papyrus Ebers, discovered in Luxor, Egypt, probably includes medical information drawn from the earlier described compendium of medical knowledge which was collected yet another 2,000 years earlier. It is the oldest complete medical text ever found, and it includes a written prescription for treating baldness: a mixture of iron oxide, red lead, onions, alabaster, honey, and fat from a variety of animals including snakes, crocodiles, hippopotamuses, and lions. The mixture was to be swallowed, after first reciting magical invocations to the sun god.

In ancient Greece, Hippocrates (460–370 BC), whom we consider the father of Western medicine, tried many medical solutions for his own progressive hair loss. One of his medical formulas was a mixture of opium, horseradish, pigeon droppings, beetroot, and various spices that were applied to the head. Nevertheless, Hippocrates himself eventually lost his hair to the extent that today we still refer to androgenetic hair loss as Hippocratic baldness. In his collection of observations called the Aphorisms of Hippocrates, he noted that Persian army eunuchs guarding the king’s harem never experienced hair loss. He noticed that virile hot-blooded men went bald, but since eunuchs were castrated, they lacked hot blood and therefore retained their hair. On the same line, Greek philosopher Aristotle (384–322 BC) noted that women do not go bald, because their nature is akin to eunuchs and children. Aristotle himself recommended goat’s urine to cure baldness.

In ancient Rome, abundant hair symbolized power. This presented a problem for Julius Caesar himself, since his hairline was gradually receding. First, he began growing it long in the back and combing it straightforward over his bald spot. Soon he took to wearing a laurel wreath around his head to hide his hair loss. The trademark wreath soon became a symbol of power. Caesar’s protégée and consort, Egyptian Queen Cleopatra (69–30 BC), concocted a mixture of ground horse teeth and deer marrow to help out Julius Caesar’s receding hairline. She did this to save her beloved from being ridiculed since his name Caesar means head of hair in Latin.

Roman women originally dressed their hair with great simplicity. One of the simplest styles of wearing the hair was allowing it to fall down in tresses behind and only confining it by a band encircling the head. Another popular but simple hairstyle was platting the hair and then fastening it behind with a large pin. During the reign of Emperor Augustus (63 BC–14 AD), a variety of different and elaborate hairstyles came into fashion, and eventually, during the Flavian Dynasty (69–96 AD), hairstyles were raised to a great height by rows of false curls. In addition, wigs and hair pieces were used to create an illusion of abundant locks. When Julius Caesar (100–44 BC) triumphantly returned to Rome from the Gallic wars bringing with him captive blond-haired female Gauls, there was much enthusiasm for their blond hair among the brunette women of Rome. Though the aristocratic Roman ladies scorned the captives as pictae (painted women), indeed, they came to fashion wigs from their hair. Later they took to bleaching their hair with pomades composed of beech ashes and the tallow from natural goat fat.

Byzantium represents the natural continuation of the Greco–Roman civilization from the time Constantine the Great (272–337) transferred the capital of the Roman Empire to Constantinople in 324, until 1453, when it fell to the Ottomans. Byzantium was not only a religious state of holy men; it had a bustling social life with the Byzantine ladies paying special attention to their appearance. A typical example is that of Empress Zoe Porphyrogenita ­(978–1050). Although she was 50 when she first married, despite her age, she married twice more. With typical Byzantine ingenuity, she had many rooms in her chambers converted into laboratories for the preparation of secret ointments for beautification. The vanity and desire for beauty of the Byzantine ladies was given the attention of the Byzantine physicians, the majority of whom had acquired their knowledge of earlier medical texts of Hippocratic, Hellenistic, and Roman times in Alexandria, enriching this material with personal experience. The Byzantine physicians dealt especially with the specialty of dermatology and paid special attention also to the topic of cosmetics, including the condition and color of the hair.

Oribasius of Pergamum (325–403) recommended for the treatment of continual falling of hair preparations containing maidenhair (πολ⌡τριχον in Greek, which means many haired), ladanum, wine, and oil of myrtle. Alexander of Tralles (525–605) believed that the causes of hair loss were numerous, including lack of supply of nutritious substances and dense or few pores, and suggested baths and a special dietetic regime, prohibiting salt, heavy food, and excess of wine or of sex. For the increase of hair growth, Paul of Aegina (625–690) suggested an inunction prepared from dried stomach of hare, leaves from the top of myrtle, bramble, maidenhair, and acacia, all finely chopped and sieved, with the addition of fat from bears and seals, and preserved in a lead container.

While the Byzantine doctors still followed the pagan aesthetic concept of the beauty of the body, early Christian activists, such as Tertullian (150–230), Clement of Alexandria (150–215), and Cyprian (200–258), put forward Christian grooming rules for women, bringing cosmetics of the hair and the wearing of wigs into disrepute:

This [male] sex of ours acknowledges to itself deceptive trickeries of form peculiarly its own. I am referring to things such as... arranging the hair, and disguising its hoariness by dyes. (Tertullian)

It is enough for women to protect their locks, and bind up their hair simply along the neck with a plain hair-pin, nourishing chaste locks with simple care to true beauty. (Clement of Alexandria)

A woman should not be adorned in a worldly ­fashion.. . . Let your women be such as adorn themselves with shamefacedness and modesty, not with twisted hair, nor with gold, nor with pearls, or precious garments. (Cyprian)

Whatever is born is the work of God. So whatever is plastered on, is the devil’s work.... How unworthy of the Christian name it is to wear a fictitious face — you on whom simplicity in every form is enjoined! You, to whom lying with the tongue is not lawful, are lying in appearance. (Tertullian)

Ultimately, Clement of Alexandria declared that when a wig wearer was blessed, the blessing would remain on the wig and not go to the wearer. For Clement and his fellow church fathers, the beauty of a woman comes from within and is the free flower of health.

During the early medieval era, women usually had long hair, extended to knee length, with two long braids at the sides of the head, or tied in a chignon. The hair was arranged to reveal the complete foreheads; often the hair was shaved around the hairline to give an appearance of a higher line. The forehead was at that time considered a very important feature of the face, while women’s hair itself was considered an erotic feature. Consequently, married woman had to cover it with veils, and women’s hair was legally considered as a property of the husband.

In the twelfth century, the medical school at Salerno, Italy, had become the most prominent school of medicine in Europe of the Middle Ages, teaching the knowledge of old medical treatises of Latin, Greek, Arab, and Hebrew origin. An extraordinary woman at that time with the honor of holding a chair in the medical faculty was Trotula di Ruggiero (eleventh–twelfth century), who very soon gained great celebrity in Europe, having until today legendary connotations. Trotula is ascribed a number of important written medical treatises, especially dedicated to women, including a treatise on cosmetics (De Ornatu Mulierum or Recipes for Cosmetics). De Ornatu Mulierum gives a great importance to physical beauty as a sign of body health and harmony with the universe. Its cosmetic methods are based in the use of herbal species, with the school of Salerno disposing of a garden with 300 medicinal species, and in the use of animal fats. Among the recipes, one for encouraging hair growth instructs to:

Take barley bread with the crust, grind it with salt and bear fat. But first burn the barley bread. With this mixture anoint the place and the hair will grow. In order to make the hair thick, take agrimonies and elm bark, root of vervain, root of willow, southernwood, burnt and pulverized linseed, and root of reed. Cook all these things with goat milk or water, and wash the area.

Trotula’s work has been completely translated to English in 2001 (A Medieval Compendium of Women’s Medicine. Edited and translated by Monica H. Green. Philadelphia: University of Pennsylvania, 2001). Today there is a dispute about the single authorship of Trotula, since many historians think that the treatises actually are independent works grouped under her illustrious name.

As the Renaissance (fifteenth and sixteenth century) was a time of intellectual turmoil, it also led to a change in women’s hairstyles, in some way reflecting a transition to more independence of thought. Women started to expose their hair. They preferred taller hairstyles, adorned with headbands or jewels or gem stones.

Three prominent exponents of the Renaissance woman with strong political, religious, and personal attitudes were Queen Elizabeth I of England (1558–103), Mary Stuart, Queen of Scots (1542–1587), and Catherine de Medici (1519–1589), queen consort of France from 1547 to 1559. Queen Elizabeth I made popular among women in England a reddish-gold hair color hairstyle, which was her natural hair color, and tall hair dresses with a very exposed forehead, while her cousin Mary Stuart wore her hair arranged over a heart-shaped wire frame. The fashions of Catherine de Medici were considered among the most fashionable in Europe and were the main trendsetters of courts at the time. Catherine introduced into France the Italian gusto for aesthetic chemistry and, with the aid of her royal sons, prepared salves and pomades. It is to her that yolk of egg probably owes its long-standing reputation for enhancing hair growth. In her laboratory, Catherine also used camphor, terebinth, powdered pearls, distilled honey, and lilies. Legend maintains that she also concocted hair lotions on the basis of arsenic and even more deadly products to eliminate her rivals. The care of hair, during the Renaissance came in for serious study and ­produced a voluminous literature. One of the most famous doctor–alchemists of his time, Theophrastus Bombastus of Hohenheim, called Paracelsus (1493–1541), invested a considerable amount of his energy in searching for the elixir of life. When Diane de Poitiers (1499–1566), the favorite of French King Henry II (1519–1559), was disturbed seeing her hair falling out upon reaching the age of 50, Paracelsus allegedly brought her in secret a phial containing a dark red liquid made from the blood of a woman in childbirth, the blood of a murdered newborn baby, and viper’s wine (spirits in which the snakes had been drowned) to restore her hair.

In early seventeenth century, a symposium was held at the Accademia dei Fisiocratici in Siena on De capelli e peli (On hair and skin). With reference to ancient Roman superstition that snake poison, released occasionally into the air, was detrimental to the hair and the authority of the medical scriptures of Galen, the physicians unanimously agreed that miasmi pestiferi, the old equivalent to today’s air pollution, was the cause of hair problems. Evidence of fears of this kind can be traced until today: Institutes and apothecaries offer hair analyses in relation to the environment and offer supplementation treatments for detoxification.

The first genuine scientific studies on hair began when Antonie van Leeuwenhoek (1632–1723) first observed the hair shaft under the microscope, and Marcello Malpighi (1628–1694) described the anatomy of the hair follicle in his treatise De pili. And yet, nothing was understood of the biology of hair growth. In search of information before engaging in the development of a new hair growth promoting agent, makers of cosmetics turned to the medical faculty and received only very vague indications. When questioned, the doctors remained evasive. The hair, despised, thus abated to malpractices of the risky kind. The more the care and arrangement of an eighteenth century Frenchwoman’s hair gained attention, the more charlatans appeared at the courts of Europe whose exploits grew constantly more outrageous, such as the infamous Josefo Francopolli and Giuseppe Balsamo (Cagliostro). The charlatan chemists of this age were just as ineffectual but definitely more dangerous than their ­physician colleagues. One could quote throughout Europe thousands of secret treaties. With certain lotions in which toxic ingredients played a part, accidents must have occurred not infrequently, since the French chemist Antoine Laurent de Lavoisier (1743–1794) urged for some control which unfortunately never was realized. France held the monopoly for miraculous elixirs. It exported to America its Eau de Ninon de L’enclos, named after a beautiful courtesan whom had preserved her hair to the age of 85. French doctor August Caron, who published in 1806 an Encyclopedia of Beauty (Toilette des dames ou Encyclopédie de la beauté) warned the women of fashion of his time against the potential toxicity of products of mysterious origin, after a wretched woman had been driven to madness after using a tonic called Eau de Chine. The products remained just as dubious, akin to alchemy with its tendencies to quackery and toxicological risks, while in the Romantic era their names had grown more sentimental…

1.2 Age-Old Myths: Popular or Layman’s Myths

Exactly as the fixation on treating hair loss is not a new phenomenon, age-old myths regarding hair growth and shedding continue to exist up to this day. In the effort to find ways to prevent hair loss or to promote hair growth, many people have fallen victim to these myths. In dealing with women with the fear or complaint of hair loss, it is important to weed out these myths from the facts.

Among the most commonly encountered layman’s myths are:

Popular or Layman’s Myths

Myth # 1: Wearing Hats Causes Hair Loss

Fact: Unless a headdress is worn tight enough to cause long-standing pressure to the scalp or traction to the hair, such as a nurse’s cap, wearing a hat does not cause hair to fall. In the contrary, coverage of the scalp may contribute positively by blocking UV radiation from the sun to cause damage to the scalp and hair. The perception of hair loss in association with the wearing of hats or helmets derives from the fact that male pattern baldness typically starts at an age in which young men become active in the military or in professions with headgears. It represents nothing more than a temporal coincidence.

Myth # 2: Frequent Washing and Blow Drying Can Lead to Hair Loss

Fact: Neither washing nor blow drying affects the condition of the hair follicle and therefore has no impact on hair growth. Nevertheless, overaggressive shampooing, toweling, and excessive heat from blow dryers may cause physical damage to the hair shaft resulting in brittle hair. Frequently, patients claim of hair loss in association with the use of a particular shampoo, typically an antidandruff shampoo. This observation is easily explained either through the more intense scrubbing of the head with a special care shampoo causing more telogen hairs to be shed or the shedding of telogen hairs trapped in scales, once these are effectively removed from the scalp. A study did not show any effect of dimethicone- or non-dimethicone-containing shampoos on daily hair loss rates.

Myth # 3: Hairstyling Products and Dyes Cause Hair Loss

Fact: There is both truth and fiction when it comes to hairstyling and hair loss. With the instances cited below, it is rather the particular hairstyle than the styling product, such as hair sprays, perm solutions, or ­coloring, that may result in hair loss. Again, anything causing long-standing traction to the hair, such as tight ponytails, cornrows, or chignons will lead to focal hair loss, particularly in women prone to androgenetic alopecia. In addition, some hair grooming practices peculiar to the African population, such as hair straightening, may lead to a central centrifugal type of scarring alopecia, originally described as hot comb alopecia. Finally, acute telogen effluvium may be induced by allergic contact dermatitis to hair dyes, particularly to paraphenylenediamine. In these cases, patch testing will reveal the culprit.

Myth # 4: Brushing Your Hair Can Make It Stronger and More Resistant to Hair Loss

Fact: The suggestion that brushing the hair 100 times will stimulate hair growth is a fantasy. This myth stems from the idea that hair loss is due to poor circulation and that brushing or massaging would improve blood flow. The truth is, bald or not, there’s no major difference in scalp circulation. In fact, brushing the hair too much, especially in a wet condition, will cause damage to the superficial condition of the hair shaft. Some extremely hair conscious women are capable of fierce fits of hair brushing, so-called telogen mania, which represents possibly a peculiar form of obsessive–compulsive disorder.

Myth # 5: Cutting Your Hair Will Make It Grow Back Thicker

Fact: The growing hair is thicker at its base than at the tip; therefore, cutting hair makes it appear thicker at first. During its normal life span, the hair shaft is constantly exposed to physical and chemical trauma from the environment, resulting in weathering of the hair. Getting frequent cuts might be a good way to keep existing hair looking strong and healthy by removing damaged and split ends but does not affect the hair growth rate or original thickness of hair.

Myth # 6: Hair Loss Can’t Be Stopped or Helped

Fact: This last of popular myths is probably the most misunderstood about hair loss. In the past, this was true, and the history of treatments for hair loss is one of charlatanry and quackery. In a survey of 508 men, when topical minoxidil and oral finasteride were available for treatment of androgenetic alopecia, we found that 27 % of balding men denied the use of hair growth promoting agents because they did not believe in their efficacy. Today, with the advances in science and technology and our understanding of hair growth and disorders, effective treatments have become available for the prevention of hair loss and recovery of hair both in men and women, in the young, and old. Hair loss medications, hair transplantation, and hair pieces are all means to help hair loss sufferers restore hair or improve the appearance of hair.

1.3 Physician’s Myths: Don’t Believe Everything You Hear on Hair

While the popular or layman’s myths are usually easy to dismiss, the physician’s myths root deeper in the conception of primary care physicians. Adding to the patient’s concern about hair loss may be prior frustrating experiences with physicians, who tend to trivialize complaints of hair loss or even to dismiss them completely. This attitude on the part of physicians may result from lack of knowledge or from misconceptions regarding hair loss in women. Prerequisite for delivering appropriate patient care is an understanding of the pathologic dynamics of hair loss and the multitude of cause relationships. It is the aim of the next chapters to systematically refute the following most prevalent among physician’s myths standing in the way to successful management of female alopecia:

Physician’s Myths

Myth # 1: The Majority of Women Complaining of Hair Loss Are Suffering of Imaginary Hair Loss

Fact: The majority of women complaining of hair loss are right. With the appropriate methods for early diagnosis of hair loss, a diagnosis can usually be made and the appropriate therapy can be initiated. Only a minority of women complaining of hair loss suffer of imaginary hair loss or psychogenic pseudoeffluvium. In these cases, we are dealing with hypochondriac disease and body dysmorphic disorder. More frequently we are dealing with adjustment disorders to a true hair loss disorder. Probably the best way to alleviate the emotional distress caused by a hair disorder is to eliminate the hair disease that is causing the problem.

Myth # 2: Losing 100 Strands of Hair per Day Is Normal

Fact: The number of hair loss per day is dependent on the amount of hairs on the scalp and on a number of internal and external factors. The hair follicle is subject to constant turnover in the course of perpetual cycles through phases of proliferation, involution, and resting, with regeneration in the successive hair cycle. Cyclic hair growth activity occurs in a random mosaic pattern, so that on average, the amount of new scalp hair formation matches the amount that is shed, thereby maintaining a consistent covering. Each follicle possesses its own individual control mechanism over the evolution and triggering of the successive phases of the hair growing cycle, though systemic factors, such as the hormonal system, cytokines, and growth factors, as well as external factors linked to the environment, toxins, deficiencies of nutrients, vitamins, and energy, have influence. In androgenetic alopecia, hair loss results from a progressive shortening of the proliferation phase of the hair cycle without synchronization, so that significant hair loss can result with a relatively small number of hairs shed per day, while seasonal effects may result in partial synchronization phenomena with temporary increase of hair shedding.

Myth # 3: The Most Frequent Single Cause of Hair Loss in Women Is Iron Deficiency

Fact: Iron deficiency represents the most common nutritional deficiency with the highest prevalence in adolescent girls and women of childbearing age. Several studies have evaluated the relationship between iron deficiency and hair loss. The various observational studies that evaluated the association between decreased ferritin levels and hair loss have resulted in opposing conclusions. A critical appraisal of available data points to the fact that iron deficiency is probably overestimated as a single cause of hair loss in women.

Myth # 4: The First-Line Treatment for Androgenetic Alopecia in Women Are Antiandrogens

Fact: Since androgenetic alopecia is considered a genetically determined, androgen-induced, age-dependent progressive loss of hair, antiandrogens have been the first line of treatment for androgenetic alopecia in women. The observation that female pattern hair loss may develop in the absence of circulating androgens and that female pattern hair loss does not respond to antiandrogen or finasteride treatment, unless there is an hyperandrogenic state, points to the fact that other, androgen-­independent pathomechanisms underlie androgenetic alopecia in women and that therefore antiandrogen treatment has so far been overestimated.

Myth # 5: Nutritional Supplements Have No Significant Effect on Hair Growth

Fact: Pharmacy aisles and Internet drugstores are full of vitamins promising full, thick, luscious hair for prices that range from suspiciously cheap to dishearteningly exorbitant. Unless the hair is falling out due to a vitamin deficiency, there’s only so much that vitamins can do to increase the size of individual hairs. This is because hair thickness is largely genetic. Nevertheless, there are external factors that influence hair health to a great degree, and vitamins can boost hair that’s suffering from these problems. There is growing evidence for the modes of action and efficacy of nutritional supplements on the basis of l-cystine and B vitamins for promoting hair growth.

Myth # 6: Aging of Hair and Androgenetic Alopecia Are Basically the Same

Fact: Aging of hair is characterized by a reduction in the duration of hair growth and diameter of hair shafts and a prolongation of the interval separating the loss of a