Hair disorders broadly include alopecia, hirsutism, and hair shaft disorders. Alopecia is the loss or thinning of hair and includes both scarring (hair follicles are destroyed) and non-scarring (potentially reversible) types. Male-pattern baldness (androgenic alopecia) is the most prominent type of hair disorder and affects, to varying degrees, 50% of males over 50 years of age. Hirsutism is male-pattern hair growth in women. It may or may not include virilization and affects up to 8% of adult women. Hair shaft disorders are usually hereditary hair shaft abnormalities. Systemic disease and poor prognosis often accompany these latter disorders.

Alopecia—non-scarring:

• Cutaneous disorders (e.g., alopecia areata, tinea capitis, and others)
• Drugs (e.g., warfarin, vitamin A, isotretinoin, chemotherapy, and others)
• Systemic disease (e.g., lupus, secondary syphilis, thyroiditis, and others)
• Autoimmunity
• Iron deficiency
• Fatty acid deficiency
• Severe stress—major surgery, anorexia
• Scalp radiation
• Pregnancy
• Self induced hair loss (plucking), psychiatric disturbance—trichotillomania
• Adrenal compromise

Alopecia—scarring:

• Cutaneous disorders (e.g., lupus, lichen planus, neoplasms, and others)
• Systemic disease
• Microbial infections

Hirsutism:

• Drugs that would not otherwise promote virilization
• Adrenal or ovarian tumors
• Excessive adrenal or ovarian hormone production
• Polycystic ovarian disease
• Congenital adrenal hyperplasia
• Idiopathic—with apparent normal adrenal function, ovaries, and menses

Hair shaft disorders:

• Over-processed hair (coloring, permanent waves, excessive heating)
• Specific shaft disorders—associated with certain systemic conditions

Alopecia:

• Male
• Genetic predisposition
• Pregnancy
• Age
• Physical or emotional stress
• Poor diet

Hirsutism:

• Genetic predisposition
• Anovulation

Hair shaft disorders:

• Genetic predisposition
• Damaging grooming practices

Alopecia—non-scarring:

• Diffuse shedding of normal hair—typically in male-pattern baldness
• Triangular recession of scalp line
• Broken hairs
• Smooth scalp
• Inflammation
• Fibrosis
• Circular areas of hair loss
• Possible loss of lashes, eyebrows, pubic hair

Alopecia—scarring:

• Circumscribed areas
• Inflammation at periphery, follicle loss toward center of lesions
• Violet-colored macules
• Scaling

Hirsutism:

• Male-pattern hair growth in women
• Irregular menses, anovulation
• Acne
• Virilization—deepening of voice, balding, clitorimegaly

Hair shaft disorders:

• Broom-like fracture ends (trichorrhexis nodosa)
• Brittle, coarse, light-colored, spangled hair; grooved shaft twisted on its axis; cutaneous and systemic abnormalities (pili torti, Menkes' kinky hair, Björnstad's syndrome)
• Dry, brittle, fragile, beaded hair; cutaneous and systemic abnormalities (monilethrix)
• Sparse, short, brittle hair; shaft is flattened or folded with nodules, longitudinal grooving; may be accompanied by receding chin, protruding ears, raspy voice, and other cutaneous and systemic abnormalities if trichothiodystrophy
• Bands of light and dark hair that is not fragile (pili annulati)
• Tight, curly hair; cutaneous and ocular abnormalities (woolly hair disease)

Determine the type of hair disorder through history, physical examination, and possibly laboratory and microscopic analysis, and treat accordingly.

Alopecia:

• Differentiate scarring from nonscarring and shedding from thinning.
• Identify systemic illness, course of progression of thinning, environmental insults.

Hirsutism:

• Pelvic examination for ovarian tumors and clitorimegaly
• History of anovulation—polycystic ovarian disease

Hair shaft disorders:

• Microscopic examination—distinguishes type
• Identify systemic illness or environmental insults

Alopecia:

• Scalp biopsy with immunofluorescence and microscopic examination—identify microbials, distinguish type
• CBC (immunologic disorders), hormonal evaluation, thyroid function tests, and others—determines any underlying disorder

Hirsutism:

• Serum and urinary androgens
• Urinary cortisol screening—Cushing's disease
• Elevated LH/FSH ratio—polycystic ovarian disease
• ACTH stimulation test—adrenal hyperplasia

Hair shaft disorders:

• Test for systemic disorder (e.g., low serum copper—Menkes' disease)
• Scanning electron microscopy—distinguishes specific shaft disorder

Alopecia:

• Large numbers of anagen (growing) hairs entering the telogen (dying) phase
• Possibly elevated dehydroepiandrosterone levels
• Pustules with Staphylococccus aureus
• Trichophyton tonsurans—with tinea
• Postinflammatory hyperpigmentation—with lichen planus
• Lymphocytic infiltrate around hair bulbs

Hirsutism:

• Increased levels of androgens
• Dihydrotestosterone—increases facial hair and decreases scalp hair

Hair shaft disorders:

• Distinctive shaft appearance for each disorder

Imaging:

• Hirsutism—laparoscopy or MRI diagnosis of possible adrenal or ovarian tumors

Alopecia:

• Wood's light—fluorescent glow with fungal infections
• Pluck test—ease of hair shaft removal differentiates between normal and excessive hair loss

• Treat underlying cause
• Hair regrowth drugs or steroids as indicated
• Teach healthy grooming practices, correct damaging practices
• Cosmetic therapies, such as surgical placement of follicle-supporting plugs or folds

Alopecia

• Topical 2% minoxidil (Rogaine)—encourages hair regrowth, may prevent further loss; six months of use for optimal benefit; must be used indefinitely thereafter; local irritation and other side effects possible
• Tretinion (Retin-A)—decreases thick scalp layer and increases minoxidil penetration
• Topical fluorinated steroids (Synalar HP)—bid for at least three months; no systemic but some local side effects
• Finasteride (Propecia)—may be effective for hair regrowth (1 mg/day) but teratogenic (feminizes a male fetus)
• Triamcinolone coticosteroid injections, 3 mg/mL
• Psoralen with ultraviolet A (PUVA) therapy—20 to 40 sessions; nausea possible
• Anthralin 0.5% or 1.0% creme—for alopecia areata; six months of use for optimal benefit; local side effects
• Griseofulvin—for tinea; 5 mg/kg/d for children, 250 to 375 mg/d for adults for six to eight weeks; side effects may include headache; best to use with selenium sulfide shampoo

Hirsutism

• Glucocorticoids—suppress ACTH and androgen secretion
• Oral contraceptives
• Dexamethasone—0.125 to 0.250 mg at bedtime for at least six months
• Spironolactone—inhibits androgen production; 75 to 200 mg/d for at least six months

Hair shaft disorders

• Minoxidil—possibly for monilethrix
• Copper-histidine injections—for Menkes' disease; 50 to 150 mg/kg/d for life

Hirsutism—tumor removal if due to adrenal or ovarian tumor

Nutritional supplements may be helpful in optimizing hair health. In addition, nutrients and herbs can be used to address the underlying cause of hair loss.

• Avoid sugar, caffeine, and refined foods. Include foods high in B vitamins and minerals, such as whole grains, dark leafy greens, and sea vegetables. Maintain adequate intake of protein, especially during times of stress or illness.
• B-complex vitamins, especially B₅ (100 mg/day), biotin (300 mcg/day), PABA (30 to 100 mg tid), and inositol (250 to 1,000 mg/day), are essential for normal hair growth.
• Minerals, especially calcium (1,000 mg/day), magnesium (400 mg/day), selenium (100 to 200 mcg/day), manganese (10 mg/day), and zinc (20 to 30 mg/day) are necessary for hair health.
• Vitamin C (500 to 1,000 mg tid), vitamin E (400 IU/day), and vitamin A (10,000 IU/day) or beta carotene (25,000 IU/day) are needed for skin health.
• Omega-3 fatty acids (EPA, DHA, flaxseed oil, fish oil) or omega-6 fatty acids (borage or evening primrose oil), 1 tbs. or equivalent bid to tid

Herbs may be used as dried extracts (pills, capsules, or tablets), teas, or tinctures (alcohol extraction, unless otherwise noted). Dose is 1 heaping tsp. herb/cup water steeped for 10 minutes (roots need 20 minutes). Herbs that support circulation facilitate the transport of nutrients to the scalp. Combine the following herbs in equal parts and use as a tea (2 to 3 cups/day) or tincture (20 to 30 drops bid to tid).

Alopecia and hair shaft disorders:

• Ginkgo leaf (Ginkgo biloba), rosemary (Rosemarinus officinalis), and prickly ash bark (Xanthoxylum clava-herculis), horsetail (Equisetum arvense), yarrow (Achillea millefolium), and elderberry (Sambucus nigra).
• With concurrent infection, add coneflower (Echinacea purpurea) with goldenseal (Hydrastis canadensis) for bacterial infections or oregano (Origanum vulgare) for fungal infections.
• With associated stress, substitute oatstraw (Avena sativa) for elderberry.

Hirsutism:

• Saw palmetto (Serenoa repens) 200 mg bid to tid to reduce androgen uptake

Topical applications of essential oils may be beneficial in cutaneous infections and for stimulating new hair growth. Use three to four drops each of chamomile (Matricaria recutita), rosemary, and sage (Salvia officinalis) in 1 tbs. vegetable oil (i.e., flax, borage, or olive). Massage gently into affected area one to two times daily.

An experienced homeopath would consider the individual's constitution. Some of the most common acute remedies are listed below. Acute dose is three to five pellets of 12X to 30C every one to four hours until symptoms resolve.

• Ignatia for hair loss or excessive hair growth following a grief
• Pulsatilla for excessive hair growth, especially with hormonal imbalance
• Sepia for hirsutism, especially with skin conditions and hormonal changes

May be beneficial in addressing underlying cause.

May aid in enhancing circulation and relieving the effects of stress.

• As underlying condition necessitates
• Monitor drug side effects and liver toxicity

• Complications can be caused by underlying conditions or by the treatment.
• Poor self-image may result with hair loss.

Alopecia:

• Androgenic alopecia, untreated or unsuccessfully treated, will result in a continuous loss of hair, but at an unpredictable rate.
• Alopecia due to injury or underlying condition is dependent on the circumstances.

Hirsutism:

• Ongoing drug treatment slows hair growth—reversal unlikely
• Surgical treatment of possible tumor may show high rates of success

Hair shaft disorders:

• Spontaneous improvements—at puberty, pregnancy, or with oral contraceptives
• Menkes' disease presents with other complications
• No effective treatment exists for some disorders

Delay any drug treatment until after pregnancy. Hirsutism may be related to underlying conditions that may lead to infertility. Diffuse but primarily frontotemporal hair loss can occur one to four months after childbirth; recovery occurs in less than one year.

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