To Fut It Baldly: Treatment of Loss Is a Losing Proposition

.,, - ,. r.-. -.. l-.l .4anlm4 Numtrer 5u >eDtemoer z I, 1% I

For centuries, people have searched and lost strength. But noticeable for remedies for , The ancient hair loss can begin by age 20 or earlier.1 Egyptians prescribed a concoction that Interestingly, in our search of the litera- consisted of the fats of the lion, hippo- ture on baldness, we found no studies of potamus, crocodile, and snake. Other the average person’s attitudes toward folk remedies handed down through the balding. Some literature does cover the centuries include elm bark; watercress; psychological problems that have been onions and honey; quinine; and crushed said to cause baldness. ~ 11 There are bees, wasps, and horse leeches with salt. also psychoanalytical studies that ex- In the 1930s, some shops in the amine hair as a sexual symbol. 12,13 It US were equipped with vacuum ma- seems odd that social scientists have not chines that were applied to the scalp. Its taken a closer look at how people, bald users believed this would stimulate the or not, feel about baldness. scalp and promote hair growth, 1 Baldness seems to have some hidden The search for solutions to baldness or unconscious meaning for human be- has not stopped. Each year Americans ings. The biblical story of Samson and pay about S3 million to a mail-order De!ilah perhaps epitomizes the negative baldneswemedy industry. For their attitudes. On the other hand, there is a money they get lotions, vitamins, oils, positive side to baldness. It is said to perfumes, and other products of no connote dignity and intelligence. There proven value. The US Food and Drug is even a compliment buried in the med- Administration is trying to take these ical term for baldness. Alopecia comes products off the market.z from the Greek word for fox. Baldness There is, of course, no sure for is called alopecia because foxes are sub baldness. In fact, there are several dif- ject to bald patches. But the fox is also ferent types of baldness. It can be an animal renowned in folklore for its caused by , disease, and, cunning. 1 perhaps, by emotional stress. In some To understand why people lose their cases, it can be reversed. However, all hair, it’s helpful to understand how hair of us are genetically programmed to grows. Humans are relatively unhairy lose some scalp haii throughout Me. mammals, but liie all mammals, they Some of us lose more than others, Ge- have two types of hair. Venus are netics is the reason behind the vast ma- so fine and fair that they are barely visi- jority of cases of baldness,s and there is ble to the naked eye. They grow all over no known adequate way to stop or the skin, except on the soles and palms. reverse genetic hair loss. The coarser, longer hairs you can see It is not even certain why people seem are called terminal hairs. After , to want a cure for baldness, Common they too occur ahnost everywhere on baldness is not in itself unhealthful. the body. The reason scalp and men’s Some people may regard it as a sign of grow to a greater length than

247 other is not fulIy understood. uncle lost a beautiful crop of red hair We do know it is a product of our evolu- after a bout with scarlet fever. ) Sudden tionary heritage. 14 baldness may also be related to diet. A Hairs are structures made up mostly shortage of the vitamin ,lo or too of dead cefls that contain large amounts much or too little vitamin A,zl may of a fibrous protein called keratin. They make one’s hair fall out. Also, people grow from hair follicles, which are tubes who suddenly and severely limit their that begin in the dermis and end in caloric intake have suffered hair loss. 22 openings on the skin surface. A smaU Emotional stress or mental disorders mass of ceUs at the bottom of the follicle have been reported as possible causes. 2J produces the hair. Follicles periodically Many such cases of alopecia can be stop growing hair, become dormant, reversed when the cause is corrected. and then start growing hair again. The One t~e of sudden hair loss, alopecia newly grown hair pushes the old one areata, is an au toimmune disease, in out. 15 Each follicle has its own cycle. which the body’s immune system at- For scalp hairs, the growth stage lasts tacks parts of the body itse~ in this from three to five years; the dormant case, hair follicles are attacked. Other stage, about three months. lb autoimmune diseases include Normal scalphair loss can be acceler- erythematosus, which is characterized ated to produce baldness. There are by -like symptoms and a redden- several ways that this can happen. Some ing of the skin, and vitiligo, which is people literaUy pulf out patches of their manifested by smooth white spots on hair. When it’s done inadvertently, it’s the skin. AIopecia areata sometimes oc- usuafly the result of braiding one’s hair curs with some other autoimmune dis- too tightly too often, or putting hair eases.zd under too much tension with curlers. It Dermatologist Rudolf Happle, Uni- can also be caused by excessive brush- versity of Munster, Federal Republic of ing, or brushing or combing wet, tan- Germany, has shown that in some cases gled hair. The hair loss this causes is the can be treated with result of damage to the . chemicals that cause an aflergic reaction Repeated damage to follicles may even- on the scalp. In a 1977 study, he showed tually destroy them so that hair won’t that a chemical called dinitrochloroben- grow. Baldness that occurs in this way is zene (DNCB) helped regrow hair on the called , [y scalps of 33 of 43 patients. zs Since then, Essentially the same type of damage DNCB has been shown to be mutagenic. occurs in a disorder called trichotilb So Happle is studying another aUergy- mania, which is the irrational behavior of inducer, dibutylester pulling out one’s hair. It’s been reported (SADBE). ThK chemical helped regrow to occur among children or adults expe- hair on 37 of 53 alopecia areata suf - riencing stressful events, such as a par- ferers.zb Happle theorizes that induced ent’s death or a financiaf dmter. In time allergy might generate certain lymphm it may disappea~ sometimes psychiatric cytes that inhibit the reaction against counseling helps.a,g But as with traction hair follicles.z7 I should emphasize that alopecia, bald spots may persist this treatment is good only for alopecia throughout Me. 17 areata, and doesn’t always work. In some types of reversible or treat- patients who undergo theme able baldness, scalp hair falls out sud- therapy may experience hair loss as one denly. TMs kmd of bafdness is some- of many disturbing side effects. Though times called . 18There this side effect seems trivial in com- are many causes. Toxins and fever from parison to the disease, it can be em~ bacterial infections can cause hair tionaliy distressing, since hair can be loss. 19 (I vividly remember the time my lost in a day or two. This hair loss could

248 be more serious than it seems, because a nism.Jz.s3 Anti- treatment may patient’s attitude may be important in help slow the process. treating cancer. Fortunately, hair loss Since androgenetic alopecia can’t be can be prevented in some cancer pa- cured, many people look for ways to tients receiving the drug . cover it up. There are several ways to do The solution is to chill the scalp while this. All of them have advantages and the drug is being administered. Ap- disadvantages. parently the coldness causes vasocon- Hair transplants have been known to striction: thus, smalfer amounts of the work relatively weff for about 25 years, drug reach the scalp. The chill also since the technique was pioneered by reduces cellular absorption of the drug. New York City dermatologist Norman A study by Judith C. Dean and col- Orentreich.~ Orentreich’s method is leagues, University of Arizona Cancer simply to remove several groups of ten Center, showed that 20 of 33 patients to 15 follicles from the back of the head receiving this treatment suffered less and transplant them to a bald area of hair Ioss.m the same scalp. The transplanted folli- The chill treatment is similar to an cles grow hair as before in their new earlier one, cafled a scalp tourniquet. locations. This method is usuafly safe if Patients’ scalp circulation is decreased done by a qualified physician. The areas by an inflatable rubber ring while cer- from which follicles are removed won’t tain cancer drugs are adminktered. grow hair again, but hair from the ad- This, too, diminishes the blood flow to joining follicles camouflages the loss. the scalp and may decrease hair loss. z~ Transplants have their drawbacks, The most common form of baldness is though. It’s not always possible to cover androgenetic alopecia, which is also an entire balding scalp by this method, caIled male pattern baldness. It is a simply because there may not be dominant hereditary trait in both sexes. enough transplantable hair foflicles on It’s also linked to hormones. Our hair one’s scalp to go around. But one need follicles seem to be genetically predeter- not have all of one’s hair back to mined to be sensitive to , or achieve a satisfactory look. Also, it male hormones. This inherited sensitivi- takes several weeks to complete the ty to androgens causes hair loss.~ procedure and nine months before the In 1942, Yale University anatomist hair is completely regrown. A hair James B. Hamilton reported evidence transplant operation can cost from $750 for the androgen liik from a study of to S1O,OOO.35 104 men who had been castrated. Near- A variation on this procedure is to ly all of these men had a full head of graft whole skin flaps of haii follicles hair. Yet when they were injected with from the back of the head to the bald male hormones, those with a hereditary spots. This method was developed by tendency toward baldness began to lose Argentine surgeon Jos& Jun,~ and its their hair.sl Thus, those who associate usefulness was confirmed by plastic hair loss with lack of obvi- surgeon Sheldon S. Kabaker, University ously have it aff wrong. The only sure of California, San Francisco.37 way to prevent androgenetic alopecia in Hair transplants should not be con- men is castration (or large doses of fused with a dangerous treatment called female hormones). synthetic hair implant. In thk method, Women can suffer from androgenetic strands of nylon or other synthetic alopecia, too. In women, it is usually materials are surgically implanted in the characterized by sparseness or diffuse patient’s scalp. The medical literature thinning of the hair. Hair loss is not on this treatment is uniformly negative. usually as severe as it is in men, but it is A recent study of 20 implant patients caused by the same hormonal mecha- documented the ugly side effects of this

249 tecfilque.~ Usuafly the fibers were and those he didn’t like, he covered pulled out during brushing or up.” Also available, for S2.50, is a brush ing. Some broke off, leaving the knot for bald heads (no bristles). Capps, who embedded in the scalp. These knotted signs hls letters “Bald John, ” is simply fibers caused painful infections, swell- trying, through silliness, to make people ings, , and scarring. All aware that too much concern over one’s patients lost their implanted fibers in hair, or lack of hair, is sillier still.qs less than ten weeks. Nine of them lost Undoubtedly, however, many people some natural hair as a result of the in- still wish there was a chemical cure for fections, Other researchers have report- male pattern baldness. Unfortunately, ed similar dismal results .gq-’$lWith good there is no such thing as yet. It’s always reason, the FDA is considering a ban on possible, though, that basic research on this operation.g the biology of hair growth may turn up a Hairpieces and are a safe and solution. simple means of disguising baldness and The specialty of hair growth is not a they are less expensive than transplants. large or active enough field to have prm Good ones made of human hair cost duced a research front that can be iden- $500 and up. One advantage to hair- tified with ISVBIOMED ‘“ . However, pieces and wigs is that they require no William Montagna, director, Oregon surgery. But they can make the wearer Regional Primate Research Center, tells hot and uncomfortable, especially since us that scientists are interested in learn- they are often held to the scalp with ing how hair grows.’t4 In a telephone adhesive tape.as The body loses a lot of conversation, he mentioned some lead- heat through the scalp.4’2 ing researchers in this field. They in- Hair weaving also involves using a clude Jean D. Wilson,4s University of hairpiece to cover the scalp. The dif- Texas, and colleagues, who are studying ference is that the hairpiece is braided androgen metabolism and hair, and securely to the weare~s remaining Vera H. Pnce,g~ University of Califor- natural hair. As with plain hairf-ieces, nia, San Francisco, who has examined this cover-up method can be both un- metabolism in hair follicles. convincing and uncomfortable. Also, Montagna’s work includes studies of the fit must be periodically readjusted baldness in stumptailed monkeys.* I because the growth of one’s natural hair should emphasize that such work is loosens the hairpiece from the scalp. A basic research on the biology of growth, too-tight weave, of course, can cause not applied research aimed at finding a traction alopecia.ss chemical treatment for androgenetic The simplest “cure” for baldness is baldness. simply to accept it. Some bald men have However, a recently-begun study of a even gone beyond mellow, philosophi- drug called minoxidif could conceivably cal acceptance of baldness. A seven- lead to a baldness treatment. Minoxidif year-old organization called the Bald is a vasodilator used for treating cases of Headed Men of America (BHMA), 901 severe that have resisted Arendell Street, Morehead City, North other drugs. As a side effect, Carolina 28557, claims a membership of induces , or excessive hair 9,500 (three are women). The founder, growth, in many patients. One recent a printer named John T. Capps III, case was reported by Anthony R. Zap urges members to take a militant sense pacosta, Bryn Mawr Hospital, Penn- of pride in baldness. The pride is laced sylvania.47 He said that a 38-year-old with a liberal dose of humor, evidenced man, bald since 20, regrew his dark- by the paraphernalia BHMA sells. It in- brown scalp hair after treatment with cludes buttons and stickers with slogans minoxidil. like ‘iRub a bald head tonight,” and The drawback to minoxidtis hair- “God only made a few perfect heads, growing properties is that its effects are

250 unpredictable. In a case reported by false hopes, because there’s little J.L. Burton and A. Marshall, Royal In- evidence at this point. firmary, Bristol, England, a bald man Of course, anyone who does develop given minoxidil for hypertension had in- a baldness treatment stands to reap creased hair growth on his face, body, huge profits. One hopes more basic ears, and —but not on KIS research will lead to a better under- scalp. @ Zappacosta’s patient afso ex- standing of alf causes of hair loss. perienced increased growth of the hair Understandably, alopecia does not get on his face and body. Side effects like the highest priority at the National Insti- this sometimes make severe hyperten- tutes of Health. However, a better sive reluctant to take minoxidil. understanding of how the body grows The reason minoxidil grows hair is hair is a valid goal. It is possible that, unknown. And another of its side ef- given the genetic basis for much scalp fects is a possible decrease in blood baldness and body-hair growth, genetic pressure. But a major pharmaceutical engineering may one day provide a solu- company is studying it in search of a tion to androgenetic alopecia. Male pat- baldness treatment. In April 1981, For- tern baldness, like the common cold, is turre magazine reported that Upjohn a relatively trivial problem that won’t go Co., Kalamazoo, Michigan, has funded away. But the hope always remains that several researchers to study minoxidil in science may one day uncover a solution. male pattern baIdness and alopecia areata. Upjohn markets the drug under ● ☛☛☛☛ the trade name Loniten. The research- ers include Howard Bad en, Harvard Medical School, and Orentreich.’+g For- My thanks to Thomas Marcinko, tune reporter Lee Smith says the results Jenny L. Stark, and Edward M. wilf not be available until April 1982 or Sweeney for their help in the prepam- later. Upjohn does not want to raise tion of this essay. em>,56

REFERENCES

1. Rattner H. Ordinary baldness. Arch. Dermatoi. Syphilol. 44:201-13, 1941. 2. FDA propows to ban ‘’ for baldness. Chem, Week 127(2):20, 19 November 1980. 3. Bare facts about baldness. Changing Time, 35(4):65-6, ApriJ 1981. 4. MoxItxgn,e W. Human skii. Encyclopedia Britannica. Chicago, IL: H.H. Benton, 1974. Vol. 16. p. 838-44. 5. Gramtharg S L Alopecia smata. Arch. Dewnatol, 72:454-7, 1955. 6. Cohen I H & Lkhtenberg I D. Alopecia areata. Arch. Gen, Fkychiat. 17:&3& 14, 1%7, 7. Mehhmu R D & Grfeaemer R D. Alopecia sreata in tbe very young, Amer. J, Psychiat. 12S:60>14, 1%8. 8. Tobeck C & Rajkumar S. The emotional dk.turbance underlying alopxia amata, and trichotiliomania. ChiM Psyc)tiaf. Hum, Develop. 10(2): 114-7, Winter 1979. 9. Ottens A J. Multifaceted treatmemt of compulshe hair puffing. ~ ffehav. Ther. E.rp. Psychiat. 12(1):77-80, March 1981. 10. Rowen R. Hypnotic age regression in the treatment of a self-destructive habit: . Amer. J, Clin. Hypn, 23(3) :19S-7, Januaq 1981. 11. GeJskf T J. The adjunctive use of hypnosis in the treatment of trichotiflomania: a case report. Amer. J. C/in. Hypn. 23(3): 198-201. January 1981. 12. Batg C. The unconscious significance of hair. Im. J, Psychoanal. 17:73-S8, 1936. 13. Ambwxem J J. Rapunzel: the symbofkn of the cutting of hair. J. Amer. Psychoanal. Assn. 28:69-88, 1980. 14. Mmuo D D & Dsrfey CR. Hair, [Fitzpatrick T B, Eisen A Z, Wofff K, Freedberg I M & Austen F K, eds. ) in geneml medicine. New York: McGraw-HW, 1979. p. 395-418. 15. Ptukus H. Embryology of haii. (Montagna W & Ellis R A, eds. ) The biology of hair gro wfh, New York: Academic Press, 1958. p, 1-32, 16. Van ScotI E L Keratinization and hair growth. Annu, Rev. Med. 19:337-50, 1968. 17. Fxrbar E M & Ahal E A. Dermatology, 10. Mweffsneous dermatoscs, Scientific Amen’can Medicine, New York: Scientific American, 1981. Vol. 1. No, 2. p, x-l-x-11,

251 18. $Mec V H. Management of hair problems, lnf. J. Dermatol, 19:95-103, 1979. 19. Alopecia. (Berkow R J, cd. ) Merck manual of diagnosis and thetnpy. Rahway, NJ: Merck & Co., 1977. p, 15S?+1, 20. ChnAas B M, HmMerg G, Grwmr A, Prdfkt R, Bmsfett K & Taftz L S. Biotin-responsive alopecia aud developmental regression. bncet 2:118-20, 1979. 21. Prfce V H. Disorders of the hair in chifdren. Pediat. Clin, N. Am.r. 25:305-2Q, 1978. 22. Goette D K & IMum R B. Alopecia in cmah dieters. J, Amer. Med. Assn. 235:2622-3, 1975, 23. R%% S A & Wlnkefmamr R K. Afopecia areata. Arch. Dermat.!, 88:29@?, 1%3, 24. CtxxdEfc W 1, HaU R. Steve!mam C J & Wefgfrtmmn D. Alopecia areata, th~oid disease and . flrif. J. Dernmfol. 81:87’7-81, 1969. 25. E&apple R & Echterrmcbt K. fnduction of hair growth in alopecia areata with D. N,C.B. Lancet 2:1002-3, 1977. 26. Hap-@e R, Kafvemrn K J, Biidmm U, EchternacfsbHap@c K, Gogg&msm W & Summer K H. Contact alfergy an a therapeutic tnol for alopecia areata: application of squanc acid dibutylester, Derma/olog/ca 161:289-97, 1980. 27. Happ!e R. Antigenic compctitiosr as a therapeutic concept for alopecia areata. Arch. Derrrtatol, Res. 267: 1C9-14, 1980. 28, D-J C, Safmen S E & Grfffitfr K S. Prevention of doxorub!cin-induced hair loss with scalp hypnthernda. N. .&ng[. J. Med. 301:1427-9, 1979. 29. MaxwcE M B. Scalp tourniquets for -induced alopecia. Amer. J. Num. 80:9@3-3, 1980. 30. Orerr&ek!r N. Medical treatment of baldnexs. Ann. Plast. SUT. 1:1l&8, 1978. 31. Ikmfltori I B. Male hormone stimulation is prerequkite and an incitant in common baldnesa. Amer. J. Armt. 71:451-W, 1942. 32. Lwlwfg E. Classifkation of the types of androgenetic alopecia (common baldness) occurring in the female sex. Bn’t J, Derma to/. 97:247-54, 1977. 33, price V H. Testosterone metabolism in the skin. Arch. Derrnato{ 111:1496-.502, 1975. 34. Orcrmrckh N. : tbe punch graft technique, Surg. C/in. N. Amer. 5f:511-31, 1971. 35. U~er W P, Alternatives in hair replacement, CufM 19:6238, 1977. 36. Jrrrf 1. Use of par’ieteoccipital flaps in the surgical treatment of baldnexs. PhMt. Recorwtr. Surg. 55:456-60, 1975. 37. Kabr&r S S. Jusi flap procedure for the treatment of baldness. Arch. Oto/.ryngo/. 105:509-14, 1979. 38. Hmke C W & Bergfehf W F. Fiber implantation for pattern baldnexx. J. Amer. Med. Assn. 241; 146-8, 1979. 39, Lapriw M 1. Complications of implantation of synthetic fibers into scalps for “hair” replacement. J. Dermafol, $urg. Once/. 5:201-4, 1979. 40. Kokm S R, Treafment of pattern baldness with fiber implantation. Arch. Dermmro). 116:21, 1980. 41. .%hwcrtz R S & Dormfmirr T F. Dangers of synthetic fiber implantation for male pattern baldness. Cutis 25:491-2, 1980. 42. Shanks B. Hypothermia, Sierra 66(4): 18-21, July-August 1981. 43, CJ.?mmosra L. John T. Capps IJI. He’s still the no, 1 ‘skinhead.’ New$-Time$ (Morehead Cit y-Beaufort, NC) 16 March 1981, p, 69. 44, Montagna W. Telephone communication. 20 July 1981, 45, W flmrr I D & Grfffkr 1 E, The use and misuse of androgens, Metabolism 29:1278-95, 1980, 46. Takaahfrw 1 & Montagna W. Studies of common baldness of the stump-taikd macaque (Ma coca speciosa ). 6. The effect of testosterone on common baldness, Arch. Dermotol, 103:527-34, 1971. 47. Zappacrrsta A R. Reversal of baldness in patient receiving minoxid:l for hypertension. N. Engl. J. Med. 203:1480-1, 1980. 48. Burton I L & MamhaU A, Hypertrichosis due 10 minoxidif, Brtt J. Dennafo(. 10I:593-5, 1979. 49. SmJth L. Hati-raising happenings at Upjohn, Fortune ll)3(7):b7-9, 6 April 1981,

252