Various treatments used in complementary and alternative medicine.
In recent years, people have begun to give further emphasis to the external beauty, especially for their hair. Except drugs with proven effectiveness, complementary and alternative treatment options that have not yet been clarified of their effectiveness and side effect profiles have been used for centuries. Many plants or their extracts are widely used to prevent hair loss and treat alopecia (e.g., androgenetic alopecia, alopecia areata, or traction alopecia) worldwide, especially in Far Eastern countries. The mechanisms of action of these plants are still unknown. Although there are little randomized-controlled studies investigating the effectiveness in the treatment of hair loss, reported results have demonstrated that complementary and alternative medicine will become much more popular in the near future.
- hair loss
The social and sexual communication roles of hair as well as its protective function have absolutely undeniable for both sexes for many years [1, 2]. Although the loss of hair is not a life-threatening condition, the loss of hair at an early age or sudden onset hair loss may cause serious psychological distress, thus it may directly affect the quality of life negatively [1, 3]. For this reason, patients with suffering from hair loss should be considered finically in order to distinguish ordinary hair shedding from pathologic hair loss. A loss of 100 or less hair falling per day should not be considered as pathological hair loss. But in case of hair loss more than 100 per day, a pathological condition should be mentioned .
Hair loss is a common dermatological problem that has been estimated to affect between 0.2 and 2% of the world’s population. There are several factors leading to hair loss including major physical-emotional stress, chemotherapy, genetic predisposition, dihydrotestosterone (DHT), excessive sebum, cardiovascular diseases, smoking, and endogenous substances . The common hair diseases that dermatologists are often faced in daily practice are androgenetic alopecia (AGA), alopecia areata (AA), telogen effluvium, anagen effluvium, and traumatic alopecia such as trichotillomania and traction alopecia . AGA, known as male pattern hair loss in men and as female pattern hair loss in women, is the most common form of hair loss in adults [1, 4, 5]. Approximately 60% of males between the ages 30 and 50 years and 17% of women under 50 years of age suffer from AGA . The role of DHT which is reduced from testosterone by enzyme 5α-reductase is clearly known in the mechanism of AGA . In early stage, the process begins with shortening of the anagen phase and continuous miniaturization of sensitive follicles . During this process, terminal hairs are replaced by vellus hairs which are shorter, finer and nonpigmented in the frontal and vertex regions of the scalp [3, 4]. Year after year, permanent baldness occurs at the site of miniaturized hair . AA is a common, chronic inflammatory disease that is characterized by non-scarring alopecic patches on the scalp. It affects approximately 2% of the United States (US) population [7, 8]. Although the mechanism of AA is exactly unknown, it is thought that a necessary secondary event or cofactor such as febrile illness, pregnancy, or a major life crisis in addition to genetic predisposition [8, 9]. Even though AA may regress spontaneously, the disease may remain stable or even may spread to the entire scalp (known as alopecia totalis) or body (known as alopecia universalis). Telogen effluvium is a disease that occurs as a result of passing of a portion of hair from anagen phase to telogen phase. It is characterized by diffuse hair shedding. While trichotillomania is an impulse control disorder, traction alopecia is association with patients’ hairstyle. These two diseases that occur after recurrent and chronic trauma are frequently seen in females than males. Both of them can result with permanent scarring .
In recent years, complementary and alternative medicine (CAM) is becoming increasingly popular all over the world. In fact, CAM is still the only option to cure and treat some diseases in some regions of Africa, Asia, and South America . Alternative medicine refers to the use of CAM in place of conventional medicine, while complementary medicine refers to the use of CAM along with conventional medicine . According to The National Center for Complementary and Alternative Medicine (NCCAM) in the United States, CAM is defined as ‘a group of diverse medical and health-care system, practices, and products that are not presently considered to be a part of conventional medicine’ . In some countries like Korea, oriental medicine has been officially approved and has gained support from legal system using the licensing system . The number of visits to alternative care practitioners increased by about 1.5 times in 7 years (from 427 billion in 1990 to 629 billion in 1997) in the United States . The National Health Interview Survey estimated that in 2007 alone, 38% of adults in the United States used CAM .
CAM is separated by NNCAM into four categories: alternative medical systems, biologically based therapies, manipulative and body-based therapies, and mind-body therapies. The details of these therapies are shown in Table 1 . In a survey study conducted in the United Kingdom (UK) in 2010, the most popular CAM therapies were reported as acupuncture, hypnotherapy, and chiropractic, while the least preferred CAM were noted as aromatherapy, reflexology, and medical herbalism . The annual expenditure on CAM is about $30 billion in the United States and £1.6 billion in the UK [18, 19].
|Nonvitamin nonmineral natural products|
Similarly, using of CAM is quite often among patients suffering from dermatologic disorders such as acne, atopic dermatitis, psoriasis, dermatophytes, actinic keratosis, vitiligo, hair loss, cosmetic indications, melanoma, and lupus erythematosus [20–27]. A survey data from UK indicated that 35–69% of patients who have various skin diseases have used CAM in their lifetime . The prevalence of CAM use by dermatology patients were 25.7 and 41% in Singapore  and Taiwan , respectively, while it ranges from 33.5  to 43.7% in Turkey . As the most frequently complementary medicines used by patients to treat their dermatological diseases have been reported as homeopathy, herbalism, diets, and food supplements in the UK [19, 27], the most used types of CAM have been recorded as herbal remedies, special diet, and megavitamin in Taiwan . In one study, positive feedbacks from patients using CAM, especially herbal therapies, were noteworthy for both skin-related and non-skin-related conditions. Approximately 85% of patients with skin-related conditions, many of those with chronic diseases such as acne and eczema, noted improvement with CAM use . To treat hair loss, the first two groups shown in Table 1 are more preferred than the others.
Ideal treatment of hair loss should include the drugs that have both 5α-reductase inhibition effect and hair growth promoter substances, together. The most used conventional treatments are topical minoxidil, finasteride, dutasteride, combination of cyproterone acetate and estrogen, spironolactone, flutamide, topical progesterone, cimetidine, zinc sulfate, topical niacin, topical aminexil, topical ketoconazole, and cyclosporine-A . In particular, minoxidil and finasteride are widely used for treating hair loss. But adverse effects of all of these agents have limited to their usage [1, 2]. Hence, patients suffer from hair loss have begun to turn to alternative therapies, even though there is little scientific evidence to prove their effectiveness.
2. Complementary and alternative medicines for hair loss
2.1. Herbal drugs
Herbal medicine is extremely popular since ancient times in Ayurveda, Siddha, Chinese, and Unani systems of medicine [3, 33]. Many plants and/or their extracts have been used to prevent hair loss and treat alopecia. These plants and their properties are summarized in Table 2.
|Botanical name||Family||Possible mechanisms of action|
|Inhibition of 5α-reductase enzyme|
|Increasing the circulation of the scalp|
|Inhibition of 5α-reductase enzyme|
|Inducing early telogen-to-anagen conversion|
|Proliferation of dermal papilla cells, expression of FGF-7, up-regulating Shh and β-catenin expression|
|Stimulating expression of IGF-1|
|Inhibition of 5α-reductase enzyme|
|Inhibition of 5α-reductase enzyme, decreasing DHT uptake by hair follicle, decreasing the binding of DHT to androgenetic receptors|
|Expression of VEGF, antiapoptotic activity|
|Anagen phase induction, reducing level of TGF-β1|
|Inhibition of 5α-reductase enzyme|
|Inhibition of 5α-reductase enzyme|
|Inhibition of 5α-reductase enzyme|
|Inhibition of 5α-reductase enzyme, vasodilator and antiandrogen effects|
|Inhibiting nuclear translocation of the androgen receptor, enhance proliferation of human dermal papilla cells|
|Inhibition of 5α-reductase enzyme|
|Inhibition of 5α-reductase enzyme|
|Inhibition of 5α-reductase enzyme|
|Inhibition the neurotrophin (NT)-4 activation|
|Inhibition of 5α-reductase enzyme|
|Inhibition of 5α-reductase enzyme|
2.1.1. Thuja orientalis
2.1.2. Citrullus colocynthis
2.1.3. Rosmarinus officinalis
2.1.4. Green tea
Green tea (
2.1.5. Asiasari radix
2.1.6. Allium cepa L
Onion juice (
2.1.7. Polygonum multiflorum
2.1.8. Allium tuberosum Rottler ex Spreng
2.1.9. Pumpkin seed oil
Pumpkin seed oil (PSO, family
2.1.10. Serenoa repens
2.1.12. Eclipta alba (L.) Hassk
2.1.13. Zizyphus jujuba
2.1.14. Allium sativum
2.1.15. Avicennia marina
2.1.16. Phyllanthus niruri
2.1.17. Rice bran
It has been believed that rice bran extract, which is produced by milled rice (
2.1.18. Sophora flavescens Aiton
2.1.19. Laminaria japonica
2.1.20. Chrysanthemum zawadskii var. latilobum
2.1.21. Scutellaria baicalensis
2.1.22. Cuscuta reflexa Roxb
2.1.23. Ishige sinicola
2.1.24. Grateloupia elliptica
2.1.25. Puerariae flos
2.1.26. Curcuma aeruginosa
2.1.27. Hura crepitans
2.1.28. Tobacco leaves
Tobacco leaves (family
2.1.29. Tectona grandis Linn
2.1.30. Boehmeria nipononivea
Acupuncture is an ancient holistic system of Chinese medicine and has been practiced there so many years. China had the cultural and traditional exchange with its neighbors, and therefore, it spread to all over the world in time. Today, it is one of the most frequently used forms of complementary medicine .
Acupuncture aims to bring a complete cure, not only managing the outstanding symptom but to heal the whole body. Even though various acupuncture techniques are available, the fundamental techniques are needling, moxibustion, cupping, suction, and acupressure. Over the centuries, acupuncture has been used to treat a wide variety of diseases including skin disorders such as acne, alopecia, eczema and dermatitis, pruritus, pityriasis, psoriasis, rosacea, systemic lupus, urticaria, herpes zoster, chicken pox, impetigo, leprosy, and vitiligo. The exact mechanism of action of acupuncture treatment in skin disorders is not clear but investigations revealed that acupuncture stimulation effects on three key points: the hypothalamus-pituitary-adrenal axis, the autonomic nervous system, and brain-derived neurotrophic factor. There may be an increase on serum levels of cortisol by the effect of acupuncture. It has also been demonstrated by functional MRI that manual needle acupuncture distinctively activates the hypothalamus-limbic system .
Degranulation of mast cells significantly increases in autoimmune diseases such as AA and chronic inflammation. A mouse model for AA study has shown that severe mast cell degranulation and accumulation around the anagen hair follicle cause a self-attack of the hair follicle cells by migration of the inflammatory cells. This attack induces the hair matrix cell phase to the telogen phase that results with hair loss. Acupuncture treatment reduces T1-cell attacks on hair bulb and activates blood circulation by warming the local collaterals; therefore, it may help to reduce hair loss. The same mouse study indicated that electro-acupuncture reduces mast cell degranulation in the dermis. It is reported that may be the cause of the pathological changes causing AA but reliable evidence is not yet available [117, 118].
Even though acupuncture treatment in dermatological diseases is safe and inexpensive, improperly performed acupuncture can cause potentially serious adverse effects such as vasovagal events, local infections, damage to internal organs, pneumothorax, spinal cord injury, and hepatitis B infection .
The hypnotic phenomenon has been used over thousands of years, and it is a form of trance induction. Recently, the use of hypnotic therapy in somatic medicine has been supported by the British Medical Association in 1955 and the American Medical Association in 1958. A hypnotic trance can be described as an altered state of consciousness with “inward focus.” It can be differed from other states of consciousness by electroencephalography (EEG) and imaging modalities. A hypnotic state can be induced by a therapist or an individual can induce hypnotic trace in himself or herself (self-hypnosis) [119, 120].
Hypnosis has been used for several indications such as induction of anesthesia or to heal irritable bowel syndrome and psychosomatic diseases as well as a variety of skin disorders including AA and trichotillomania. Nowadays, medical hypnosis is performed by physicians whom have received appropriate training in many countries all over the world. For some selected skin disorders, with proper training and selection of appropriate patients, medical hypnosis can relieve symptoms and in some cases can cure the illness [119, 120].
Hypnosis is a cost-effective and nontoxic therapy and can be used in dermatological treatment especially in patients with psychosomatic component [119, 120]. In a preliminary study, hypnotic sessions including relaxing suggestions and symptoms-oriented suggestions were held as a complementary or the only treatment once every 3 weeks in patients with severe AA, alopecia totalis, or alopecia universalis. Twelve of 21 patients showed significant improvement after 4–13 (mean 5.5) sessions of hypnosis, while treatment success could not be achieved in 9 patients. But also, minimal relapses were observed in all patients responded well . In another prospective cohort study, it has been suggested that hypnosis had no significant contribution on hair regrowth in patients with refractory AA .
Despite confusing conclusions have been reported about the efficacy in the treatment of AA, hypnosis seems to be salubrious in the treatment of both children and adolescents with trichotillomania. Cohen et al. reported that complete resolution of their complaints was seen in two children after 7–8 weeks and in one child after 16 weeks. Even if just a recurrence was observed in one patient during follow-up, the patient completely recovered again with hypnotic retreatment .
3. Side effects
The side effects reported after CAM is often minimal. Contact dermatitis was reported with onion juice in patients with AA, thus patients should be informed about skin irritation on the skin surface in contact with the onion juice (Figure 1) .
In recent years, although the increasingly widespread use of CAM, scientific data are still not enough. The observed results with herbal medicine are promising in the treatment of hair loss, especially AGA and AA. According to acceptable results, hypnosis may be an effective and safe alternative option in patients with hair loss, especially AA and trichotillomania. Even so, there is need for more scientific data proving its effectiveness and reliability.
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