Review Article Skin Appendage Disord 2019;5:72–89 Received: April 22, 2018 DOI: 10.1159/000492035 Accepted: July 10, 2018 Published online: August 21, 2018 Complementary and Alternative Treatments for Alopecia: A Comprehensive Review Anna-Marie Hosking Margit Juhasz Natasha Atanaskova Mesinkovska Department of Dermatology, University of California, Irvine, Irvine, CA, USA Keywords Introduction Alopecia · Complementary and alternative medicine · Efficacy According to the National Center for Complementary and Integrative Health (NCCIH), a branch of the Nation- al Institutes of Health (NIH; Bethesda, MD, USA), more Abstract than 30% of adults and 12% of children utilize treatments The treatment of alopecia is limited by a lack of therapies developed “outside of mainstream Western, or conven- that induce and sustain disease remission. Given the nega- tional, medicine,” with a total USD 30.2 billion out-of- tive psychosocial impact of hair loss, patients that do not pocket dollars spent annually [1]. In the treatment of alo- see significant hair restoration with conventional therapies pecia, there is an unmet need for therapies providing sat- often turn to complementary and alternative medicine isfying, long-term results. Patients often turn to (CAM). Although there are a variety of CAM treatment op- complementary and alternative medicine (CAM) in an tions on the market for alopecia, only a few are backed by attempt to find safe, natural, and efficacious therapies to multiple randomized controlled trials. Further, these mo- restore hair. Although CAMs boast hair-growing poten- dalities are not regulated by the Food and Drug Administra- tial, patients may be disappointed with results as there is tion and there is a lack of standardization of bioactive in- a lack of standardization of bioactive ingredients and lim- gredients in over-the-counter vitamins, herbs, and supple- ited scientific evidence. ments. In this article, we provide a comprehensive review of Multiple factors contribute to hair loss, including ge- the efficacy, safety, and tolerability of CAM, including natu- netics, hormones, environmental exposure, medications, ral products and mind and body practices, in the treatment and nutrition. Treatment of hair loss requires a multi- of hair loss. Overall, there is a need for additional studies modal approach and the use of CAM may provide added investigating CAM for alopecia with more robust clinical de- benefits. Vitamins and trace minerals are vital to the hair sign and standardized, quantitative outcomes. follicle cycle and maintain homeostasis as enzyme cofac- © 2018 S. Karger AG, Basel tors, hormones, antioxidants, and immunomodulators. © 2018 S. Karger AG, Basel Anna-Marie Hosking, BS Department of Dermatology, University of California, Irvine 118 Med Surge I, Irvine, CA 92697 (USA) E-Mail [email protected] E-Mail ahosking @ uci.edu www.karger.com/sad Botanical products regulate inflammation, minimize oxi- containing amino acids, and hair is brittle [4]. In homo- dative stress, and control hormone levels (i.e., dihydrotes- cystinuria, patients have thin and hypopigmented hair tosterone). Beyond supplementation, mind and body [5]. Many nutraceuticals contain cysteine rather than cys- practices, including acupuncture and massage, help to re- tine, in particular N-acetyl-L-cysteine (NAC), as it is bet- duce physiologic and emotional stress, which may con- ter absorbed than any other cysteine product [6–8]. tribute to hair loss. Oral L-cystine (70 mg) in combination with retinol was evaluated for the treatment of diffuse alopecia, with in- Complementary and Alternative Medicine creases seen in both hair density and anagen rate [9]. Oral Complementary medicine refers to practices used L-cystine (unknown dose) was also studied in combina- concomitantly with conventional therapies, while alter- tion with histidine, copper, and zinc taken 4 times daily, native medicine is used in place of these therapies. The resulting in a significant mean change in total hair count NCCIH divides CAM approaches into three main catego- after 50 weeks (29 vs. 11% for placebo) in 24 patients with ries: (1) natural products; (2) mind and body practices; AGA [10]. Millet seed containing amino acids, silicic and (3) other (i.e., homeopathy) [1]. CAM provides the acid, several B vitamins, and dietary minerals including option to choose promising, low-risk, adjuvant and alter- manganese in combination with L-cystine (2 mg), and native therapies. Herein, we provide a comprehensive re- calcium pantothenate (Priorin®; Bayer Inc., Mississauga, view of CAM treatment options for alopecia, with most ON, Canada) taken twice daily for 6 months showed a evidence in androgenetic alopecia (AGA) and alopecia significantly increased anagen rate in 40 female patients areata (AA). Table 1 provides an in-depth summary of [11]. Supplementation with L-cystine (20 mg), medicinal these investigations. yeast, pantothenic acid, thiamine, keratin, and para-ami- nobenzoic acid (Pantogar®; Merz Pharmaceuticals GmbH, Raleigh, NC, USA) in 30 women with telogen ef- Natural Products fluvium (TE) resulted in significant improvement and normalization of the mean anagen hair rate after 6 months Natural products encompass a variety of subgroups in- compared with placebo [12]. cluding vitamins and minerals, herbs/botanicals, and Lysine is an essential amino acid found in meat and probiotics, all of which are globally marketed as dietary eggs, and is thought to play a role in the absorption of supplements and do not require Food and Drug Admin- iron. In patients with chronic TE, supplementation with istration (FDA) approval. The 2012 National Health In- L-lysine (1.5 g), iron (72 mg), vitamin B12, vitamin C, bio- terview Survey reports natural products to be the most tin, and selenium (Florisene®; Lambers Healthcare Ltd, popular CAM approach for dermatologic conditions, Kent, UK) resulted in a significant 39% reduction in hair used by 17.7% of Americans [2, 3]. Data is available for shedding after 6 months, as well as a significant increase the use of amino acids, caffeine, capsaicin, curcumin, gar- in serum ferritin levels in women who had previously lic gel, marine proteins, melatonin, onion juice, procy- failed with iron supplementation alone [13]. anidin, pumpkin seed oil, rosemary oil, saw palmetto, vi- Methionine is another essential amino acid that is vital tamin B7 (biotin), vitamin D, vitamin E, and zinc to treat for both keratin and procollagen synthesis. Studies have hair loss. suggested a role for L-methionine in slowing the onset of grey hair in an in vitro model by counteracting hydrogen Amino Acids peroxide-mediated oxidative stress and blunting of me- A variety of amino acids have been studied for the thionine sulfoxide repair. Currently, there are no in vivo treatment of hair loss. Most notably, cystine and lysine studies in human subjects demonstrating a benefit for the have been evaluated in humans. Other amino acids, in- treatment of hair loss [14]. cluding methionine and arginine, are often included in Arginine is a nonessential amino acid that is protective hair nutraceuticals, but have not yet been evaluated in against the negative effects of hydrogen peroxide on hair clinical studies. proteins and hair surface lipids secondary to oxidative Cysteine plays a central role in hair health; it forms di- coloring or bleaching [15]. However, there are no studies mers that are oxidized to produce cystine, creating disul- that support arginine supplementation for the treatment fide bridges that provide strength and rigidity between of hair loss. Overall, the data regarding the use of amino keratin strands. In disorders with decreased cysteine, acids to treat hair loss is limited. All of the trials reviewed such as trichothiodystrophy, there is a deficiency of sulfur here combined amino acids with various other supple- Complementary and Alternative Skin Appendage Disord 2019;5:72–89 73 Treatments for Alopecia DOI: 10.1159/000492035 74 Table 1. Summary of clinical investigations on complementary and alternative treatments for alopecia Authors Disease Intervention Control treatment Patients, Quality Study design Efficacy Safety n ratinga Natural Products Hertel et al. Diffuse Oral L-cystine (70 mg), retinol, sss NA 36 2 Cohort study Reduction of the telogen rate by 8.3%, increase of the anagen rate by No AEs [9] 1989 alopecia and gelatin 11%, and increase of the hair density by 6.9% Hertel et al. Diffuse Oral L-cystine (70 mg), retinol, Placebo tablet 47 1 Double-blind RCT Decrease in telogen rate by 13.5 vs. no change with placebo; No AEs [9] 1989 alopecia and gelatin 8% improvement in anagen rate vs. 7.8% decrease with placebo Morganti et al. AGA Oral L-cystine, L-methionine, copper, Soy oil, starch placebo 24 2 Cohort study Significant mean change in total hair count after 50 weeks, 29 vs. 11% for No AEs [10] 1998 zinc, soy oil, gelatin 4 times daily tablet placebo (p < 0.005) Gehring et al. AGA Oral millet seed extract, Placebo tablet 40 2 Cohort study Increased anagen rate (p = 0.0225) No AEs [11] 2000 L-cystine (2 mg) and calcium pantothenate twice daily (Priorin®) Lengg et al. TE L-cystine, medicinal yeast, pantothenic Placebo capsule (lactose, 30 1 Double-blind RCT Significant improvement and normalization of the mean anagen hair GI symptoms (n = 4), weight [12] 2007 acid, thiamine, keratin, para- microcrystalline cellulose rate after 6 months (p = 0.008) compared with placebo gain (n = 4), transient elevation aminobenzoic acid (Pantogar®) and magnesium stearate) in pancreatic enzymes (n = 1) Rushton et al. TE L-lysine (1.5 g), iron, vitamin B12, NA 22 2 Cohort study Significant reduction in hair shedding (39%, p < 0.001) No AEs [13] 2002 vitamin C, biotin, selenium Sisto et al. AGA Caffeine shampoo Placebo shampoo 66 1 Double-blind RCT Greater improvement in intensity of hair loss, speed of progression of No AEs [18], 2012 hair loss, and number of hairs shed while combing in treatment group; 84.8% in treatment group vs. 36.4% placebo group reported treatment satisfaction at 6 months Bussoletti et al.