ALOPECIA

Synonyms.—Baldness; Calvities; Fr., Alopécie; Ger., Alopecie; Kahlheit; Haar-
schwund.

Definition.—Alopecia is a general term applied to loss of hair,
which may vary in extent from slight thinning to complete baldness.

The so-called varieties are essentially based upon etiology, and are
known as alopecia congenita, alopecia senilis, alopecia præmatura,
and alopecia areata. This last is an entirely distinct affection, presenting
a special symptomatology of its own, and differs in many particulars, and
is, therefore, considered elsewhere under a separate heading.

Alopecia Congenita (Alopecia Adnata).⁵—Congenital alopecia is a rare
condition in which the hair loss may be patchy, or the general hair growth
may simply be scanty, incompletely grown, or downy in character. In
exceptional instances the hair has been entirely wanting, and in such cases
it is usual to find also defective development of other structures, such

¹ E. Wilson, Lectures on Dermatology, London, 1878.

² Leonard, The Hair, etc., Detroit, 1880.

³ McCall Anderson, Diseases of the Skin, p. 77.

⁴ Kaposi, Diseases of the Skin, p. 487.

⁵ A recent paper by Kingsbury, “Alopecia Congenita,” Jour. Cutan. Dis., 1906, p.
418, reporting 3 cases in a family with hereditary tendency gives a résumé of many of the
recorded cases, with bibliography.

988                       DISEASES OF THE APPENDAGES

as the teeth and nails, the latter more rarely.¹ Schede² recorded 2 cases,
brother and sister, in whom the hair was completely lacking on scalp and
elsewhere, and remained permanently so; they were otherwise healthy,
as were likewise the parents and their other two children, and with normal
hair growth. As Michelson³ states, however, in some of the congenital
cases there is not a permanent arrest of hair growth, but merely delayed,
the scalp after a year or so often becoming covered with downy growth,
which sooner or later may develop into hair of normal thickness; he refers
briefly to an instance under his own observation, and also one observed
by Luce. More frequent, probably, are those examples in which the
alopecia is only partial, and, according to Michelson, who briefly describes
2 cases, in such instances growth is never to be anticipated. Audry⁴
had under observation a case in which the alopecia followed the cranial
sutures.

The fact that not infrequently the condition is observed in brothers
and sisters, an example of which has already been referred to, furnishes
the only known etiologic cause—heredity. Hutchinson’s⁵ observation
of congenital alopecia of the scalp in a boy aged three and one-half
years, whose mother had been bald since the age of six, primarily be­
ginning as patchy areas, is also a suggestive instance. As illustrating
this fact and other features of this malady, the cases—mother and two
daughters—observed by Abraham⁶ may be referred to: the mother had
complete absence of hair from eyebrows, eyelids, arms, legs, and body,
but had a scanty supply on the scalp, pubes, and in the axillæ; at birth
she had a little down on the head, but this soon disappeared, and she
remained absolutely hairless until the age of eighteen was reached, at
which time it began to appear gradually on the scalp, axillæ, and pubes.
Her two children—girls—aged respectively five years and fifteen months,
were both practically hairless; the older child was born with a little down
on scalp, which fell out when she was about three months old, and since
then the alopecia had remained nearly complete; the younger child was
born with but little real black hair, which fell off at about the same age,
and she had remained completely without hair.

The pathologic anatomy has been studied by Schede, Jones, and
Aitkens, but inasmuch as the cases vary considerably, little has been
learned. Schede found, in his older patient, that the sebaceous glands
opened directly on the skin, and that there were no hair-follicles, but
in the deeper layers of the corium he found rudiments of such appear-

¹ Thurnam reported (London Med. Chir. Soc’y Trans., 1848, p. 71) 2 cases—cousins
—who had but little lanugo hair on scalp or general surface, and who had but four teeth;
he also quotes additional cases; Danz, quoted by Michelson (Zienissen’s Handbook),
saw 2 adults who had never had either hair or teeth. See also literature references un­
der Diseases of the Nails.

² Schede, Archiv für klin. Chirurg., 1872, vol. xiv, p. 158 (with histologic illustra­
tions); Kingsbury, “Alopecia Congenita,” Jour. Cutan. Dis., 1906, p. 419 (3 cases in a
family, with illustration of cases and histologic cut; review and bibliography); Hyde,
“Congenital Alopecia as an Expression of Atavism,” Jour. Cutan. Dis., 1909, p. 1
(several illustrations, review, and bibliography).

³ Michelson, loc. cit., p. 409.

⁴ Audry, Annales, 1893, p. 899 (with cuts).

⁵ Hutchinson, London Med.-Chir. Soc’y Trans., 1886, p. 473 (case demonstration).

⁶ Abraham, Brit. Jour. Derm., 1895, p. 162 (case demonstrations).

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989

ing as short, straight, or slightly convoluted tubules, without percept­
ible internal cavity, their whole structure corresponding to the external
root-sheath. Jones and Aitkens, quoted by Michelson, found the epi-
derm atrophic, the cutis replaced by “cord-like areolar tissue, with inter­
spersed fat-cells and accumulations, between which were altered follicles,
and here and there indications of papillæ."

Alopecia Senilis.—Senile alopecia, as its name implies, is that so fre­
quently seen in men developing in advancing years, being rather uncom­
mon in women. It is usually preceded by graying of the hair. It may
consist of a general thinning, or more cpmmonly of a general thinning
with complete baldness of the vertex. Pincus states that if the latter its
starting-point is almost always at the very summit or central point of the
vertex, and then advances anteriorly, and later also laterally and pos­
teriorly. From this it gradually, and, as a rule, slowly, extends, and in
some instances involves a large part of the entire region, generally leaving
a fringe of variable width, except anteriorly, where the baldness is, as a
rule, complete. The loss of the stiff hair is usually followed by the ap­
pearance of down, but this, for the most part at least, soon disappears, and
with the atrophic thinning and partial or complete disappearance of vis­
ible follicular openings the shiny, billiard-ball smoothness more or less
characteristic of the condition results. It is commonly believed, or
often alleged, that a certain amount of thinning of the hair also is to be
noted on other parts of the body, and this would seem to find support
in the investigations by Pincus and Neumann, which indicate that the
hair-loss is simply the result of cutaneous atrophic changes concomitant
with old age; but this is by no means always the fact, for while some­
times observed, in most instances, on the contrary, advancing years, ac­
cording to my own observations, which agree with the views of Michelson
and Unna,¹ show a tendency to increased hairiness on other parts—at
least on the general body surface. As Unna rightly states, this tendency
to increased general hairy growth is observed in women as well as in men.
The anatomic structure of the skin in senile alopecia has been studied
chiefly by Pincus, Neumann, Michelson, and Unna. As to be expected,
atrophic changes are found, and considerable thinning of the cutis proper,
and also of the hypoderm; in fact, in its essential features Pincus found the
changes more rapid, but similar to those observed in alopecia seborrhoica
(alopecia pityrodes), an opinion which Unna shares, the latter diverging
somewhat from Pincus, believing that there are no differences further
than the simple difference of age, and inclining to the opinion that in
reality the condition is only a relatively delayed alopecia due to long­
standing seborrheic catarrh. According to Michelson, the atrophic
changes are preceded by alterations in the blood-vessels, the cutaneous
arteries being narrowed by a fibrous endarteritis, and with a resulting
destructive atrophy or destruction of the capillary network. Not much
change is noted in the glandular structures; and Unna found a thick­
ening of the panniculus, at the expense of the thinned cutis.

Alopecia Præmatura.—Premature alopecia is conveniently divided
etiologically into two varieties—idiopathic and symptomatic. Idio-
¹ Unna, Histopathology, p. 1062.

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DISEASES OF THE APPENDAGES

pathic premature alopecia may be briefly described as an alopecia, for
the most part similar to senile alopecia, and occurring without recogniz­
able cause beyond hereditary influence. At first it is noted that there
is a good deal of daily loss, and as this continues thinning is noticed, and
also that the new-growing hairs are less vigorous. While, like alopecia
senilis, it often begins at the vertex, it frequently takes its start anteriorly,
usually at the temple, and gradually extending backward in elliptic shape,
encroaching on sides and the middle of the scalp, so that, when well
advanced, the whole anterior portion excepting a small ridge toward
the ears and a tongue-like projection in the middle is completely bald.
Not infrequently it thins both centrally and in the forehead region, and
in occasional instances almost the entire scalp may be denuded of hair.
As in other forms or varieties, slight or moderate downy growth takes
the place of the normal hair, but this, with the exception of a scarcely
perceptible tuft here and there, also often disappears. In some instances
a seborrhea is added, or goes hand in hand with the hair fall, although such
cases usually belong to the symptomatic type, the alopecia being due to
the seborrhea. Alopecia præmatura idiopathica presents itself, as a rule,
between the ages of twenty and thirty-five, and chiefly in men, occa­
sional cases only being observed in women. It is, as already stated,
without recognizable cause except heredity. Family influence is almost
always noted, and this is observed, too, in the very form the baldness
takes, its starting-point, extent, etc, being often a counterpart of a father,
grandfather, or near male relative. Various causes have been assigned,
such as wearing hats, especially a stiff hat, which binds the temporal
arteries, and, I believe, with Jamieson and others, that this must be con­
sidered one of the contributing factors. In consequence also of keeping
the scalp sealed against the light and air, contrary to nature’s intentions,
growth is impaired, the vascular supply in the skin about the roots is
thus indirectly lessened, and the hair suffers from want of nutritive ma­
terial.¹ It is known, too, that premature idiopathic baldness is much
more common among mental workers, especially of the professional class,
who are a great part of the time indoors. As corroborative of its greater
prevalence among the intellectual and educated classes, Eaton² found
in Boston, in church and opera-goers, that from 40 to 50 per cent, of the
men were bald, whereas in the audiences of cheap museums and prize-
fights the average was less than half this percentage. It is in the intel­
lectual and brain-working class, too, according to my experience, that the
occasional cases of this variety of hair loss or moderate alopecia is noted
in women. Ellinger³ is inclined to the view, in which opinion Jackson⁴
apparently concurs, that the habit of daily sousing the scalp with water
is a possible contributing factor, inasmuch as he found this to be the cus-

¹ Harding, “Exposure to the Sun as an Etiological Factor in Alopecia,” Jour.
Cutan. Dis., March, 1911, p. 167, is of the opinion, from repeated observations, that
the mode in vogue with youth of the present day of going hatless is becoming a factor
in hair loss.

² Eaton, The Popular Science Monthly, Oct., 1886.

³ Ellinger, Virchow’s Archiv, 1879, vol. lxxvii, p. 549.

⁴ Jackson, “Baldness: What Can We Do For It?” New York Med. Record, April 7,
1887.

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991

tom of 85 per cent, of his patients. Various other causes are often named,
but, after all, in these cases the strongest factor is heredity. Pincus¹
ascribes this variety of baldness to the fact that in certain families there
is a distinct tendency to sclerosis of the connective tissue underlying the
aponeurosis of the occipitofrontalis muscle, in this way gradually atrophic
changes in the hair-papillæ ensue, and probably also compression and
restriction of the vascular supply as well; in fact in occasional instances
of decided general scalp hair thinning or more or less baldness the skin is
somewhat hide­bound, moderately sclerodermic with variable atrophy.²
Symptomatic premature alopecia, in contradistinction to the idio-
pathic variety, has a recognizable cause, and this may be widely dif­
ferent in the various cases. The hair loss takes place either gradually
or rapidly, and may be temporary or permanent. The final condition
may be such as already described, or it simply consists of more or less
general thinning. After fevers or other severe acute systemic diseases,
rapid hair-shedding (defluvium capillorum) is, as well known, not in­
frequently observed, but rarely progresses to baldness. In the active
stage of syphilis, several months or so following the contraction of
the disease, there is usually hair loss of the character of thinning out,
rather than the production of distinct alopecia; it is commonly limited
to the scalp, but it is also sometimes observed on other parts as well.
The hair loss occurring after these various systemic conditions is rarely
permanent, both after fevers and other acute constitutional diseases,
as well as after syphilis, a regrowth, with some exceptions, generally
taking place unless there is a family tendency to baldness, in which event
it is more likely to be permanent. The most common cause of symp­
tomatic premature alopecia, however, is seborrhea or the allied condition,
dermatitis seborrhoica (alopecia pityrodes, alopecia furfuracea). Elliot’s³
analysis of 344 cases gave 316 in which he attributed the hair fall to sebor-
rheic disease. Jackson⁴ found this the exciting cause in about 75 per cent,
of his patients, and C. J. White⁵ in 79 per cent. No one can question
the important etiologic bearing of this seborrheic affection, but in many
instances doubtless it has the aid of a hereditary predisposition. There
is usually a general thinning of the scalp hair, usually more marked over
the vertex and at the temporal regions; this may continue slowly, with­
out producing perceptible baldness for some time, but sooner or later,
in most cases, the usual goal is reached. If seborrheic affections are to be
considered communicable, then, as the factor in most cases of baldness,
this latter practically becomes so likewise. In fact, in recent years, the
hint has been made now and then that baldness, irrespective of the sebor-
rheic factor, is possibly contagious—a conclusion that needs much to
support it before it can gain full acceptance. Sabouraud maintains that

¹ Pincus, Berlin, klin. Wochenschr., 1883, p. 645.

² Sutton, Jour. Cutan. Dis., 1912, p. 471, describes 3 cases of this character in women
and suggests the name “alopecia indurata atrophica.”

³ Elliot, “A Further Study of Alopecia Prematura, and its Most Frequent Cause,
Eczema Seborrhoicum,” New York Med. Jour., 1895, vol. lxii, p. 525.

⁴Jackson, ‘Loss of Hair: A Clinical Study Founded on Three Hundred Private
Cases,” Trans. Amer. Derm. Assoc. for 1900, p. 50.

⁶ C. J. White, “Alopecia and Seborrhœa,” Jour. Amer. Med. Assoc, Sept. 24, 1910,
p. 1074.

992                       DISEASES OF THE APPENDAGES

the essential factor in practically all cases of baldness is his microbacillus
of seborrhea. Other diseases of the scalp which are followed by loss of
hair, usually circumscribed or partial in character, are chronic and per­
sistent eczema, psoriasis, erysipelas, folliculitis decalvans, lupus eryth-
ematosus, ringworm, favus, and late atrophic or ulcerative syphilo-
dermata. Eczema and psoriasis are rarely attended by any pronounced
hair loss, and only, as a rule, after long continuance; and after their cure
the hair usually regrows; that following erysipelas is seldom permanent.
In ringworm the hair loss is temporary; in favus, in which destruction
and atrophy of the follicles frequently result, the loss is never entirely
made up. The destructive syphilodermata, lupus erythematosus, and
folliculitis decalvans bring about follicular destruction, and naturally the
effect is lasting. Other diseases, usually of rare occurrence, such as
morphea, leprosy, etc, may also be followed by permanent hair loss in
the areas involved.

Prognosis.—The prognosis has been touched upon in speaking
of the individual varieties. Exceptional cases of congenital alopecia
finally present permanent growth, although most are hopeless. There
is, moreover, no hope in senile alopecia, and but little in pure uncompli-
cated and apparently causeless cases of idiopathic premature alopecia,
especially if the hereditary tendency is pronounced. Much can be done
in the symptomatic forms, and if the element of heredity is lacking, a
regrowth is not unusual, certainly worth trying for; indeed, all cases of
hair falling or lost hair, except those in which distinct atrophic changes
are evident, as shown by a thinning and stretched-looking and bound-
down condition of the skin and a partial or complete obliteration of the
follicular openings, are worth an effort, if not to cure, certainly toward
the prevention of further loss. An opinion as to regrowth should, how­
ever, in all cases be given with a good deal of reserve. The hair thinning
following the acute systemic diseases and active syphilis will usually
look after itself, although much more rapidly and more certainly under
treatment. The custom of shaving the scalp after fevers is absolutely
unnecessary, barbarous, and without common sense to support it. Re­
peated shaving, at intervals of a few days, and for one or two months,
might possibly stimulate growth, but a single operation does nothing
except to disfigure and grieve the victim and enrich the wig-makers.
Another custom may also be mentioned here, and that is the practice
of singeing, alleged “to seal up the hair and prevent the outflow of the
hair strength or nutrition”; this is not only a wholly useless measure,
solely benefiting the tonsorial establishments, but it has no scientific
basis, and is damaging to the hair for an inch or more up beyond the ends
to which the heat is applied. It needs only to be mentioned, therefore,
to be condemned.

Treatment.—In the treatment of hair loss, both the state of the
patient’s general health and the scalp must be considered. There are
really no specifics as to constitutional remedies, although it has seemed
to me that in some instances arsenic, fluidextract of jaborandi, or pilo-
carpin, and sulphur in small doses—2 or 3 grains (o.13 5-0.2) three times
daily—have an influence. Of the general tonics, when indicated, arsenic,

ALOPECIA

993

strychnin, iron, and cod-liver oil and the hypophosphites need only be
mentioned. The external treatment is the essential part of the manage­
ment. In cases in which seborrhea or dermatitis seborrhoica is the cause
or is present, treatment (q. v.) is to be directed against that alone, and
when this is removed, the usual applications for uncomplicated cases of
hair loss can be resorted to to stimulate new growth. Various applica­
tions are in favor for this purpose, often failing, however, in accomplish­
ing the end. Most of the remedies used in seborrhea and seborrheic
dermatitis are also often valuable, as hair tonics, especially the resorcin
lotions, one containing 15 to 30 grains (1.-2.) to the ounce (32.) of water,
of 1 part of alcohol and 3 of water, or alcohol alone; if the former, then
with 2 or 3 minims (o.135-0.2) of glycerin; if alcohol, the same quantity
of castor oil to the ounce (32.). Carbolic acid can also be often added
to advantage, in the proportion of 5 to 10 grains (0.33-0.65) to the ounce
32.). A caution is necessary as to resorcin; it should not be used ex­
cept cautiously, scantily, and for a short time, in those of white or gray
hair, as this drug undergoes change of color, and often gives the hair in
such cases a dingy or dirty yellowish tinge. If used carefully and to the
scalp only, keeping it off of the hair, this does not result so readily.
Indeed, in all instances remedies are to be employed sparingly, as most
of them are dark colored and stain. Both Elliot and C. J. White speak
well of:

R. Hydrarg. chlorid. corros.,                               gr. i-ij (0.066-0.12);

Euresol,                                                          3j (4.);

Spts. formicarum,                                          f3ij—iv (8.-16.)

01. ricini,                                                        Mxxx-xc (2.-6.);

Spts. vini rect.,                                  q.s. ad f3iv (120.).

Another compound lotion often valuable is: R. Resorcin., 3j (4.);
quininæ (alkaloid), gr. xv (1.); ol. ricini, Mx-xxx (0.65-2.); alcohol, ad
f3iv (128.). In those of very light or gray hair the resorcin can be
omitted. An excellent stimulating tonic, long in general use, is one con­
taining 2 to 4 drams (8.-16.) of tincture of cantharides, 4 to 8 drams
(16.-32.) of tincture of capsicum, 20 to 60 minims (1.35-4.) of castor
oil, and alcohol to make 4 ounces; or the oil and alcohol can be replaced
by bay-rum.

Ointments frequently do better than lotions, and one that seems
to be of aid is that composed of: R. Ac salicylici, gr. x-xxx (0.65-2.);
ß-naphthol, gr. xx-lx (1.35-4.); sulphur, præcip., 3j-ij (4.-8.); vaselin,
q. s. ad 3j (32.). Another containing coal-tar, a tarry preparation which
is free from penetrating and tenacious odor, is: R. Liq. carbonis deterg.,
3j-ij (4.-8.); lanolin, 3iij (12.); vaselin, ad 3j (32.). The ordinary tars
are more valuable, but their odor limits their use: Oil of cade, 1 or 2
drams (4.-8.), 2 drams (8.) of lanolin, and vaselin to make an ounce (32.),
is one of the best; occasionally, in warm weather, a small proportion of
paraffin, to stiffen it, may be needed. Or this oil can be used with 2 or
3 parts of olive oil, liquid vaselin, or alcohol, and in this form is sometimes
preferred. Heitzmann¹ commended the crude oleum rusci, made up
with vaselin and paraffin, or vaselin and lanolin, in 10 to 20 per cent.
¹ Heitzmann, Trans. Amer. Derm. Assoc, 1885, p. 32.
63

994

DISEASES OF THE APPENDAGES

strength; this is valuable, but the odor finds many objectors. An oint­
ment containing pilocarpin, 5 to 10 grains (0.35-0.65) to the ounce (32.)
of vaselin, can also be used. Lassar,¹ thoroughly believing in the para­
sitic character of the alopecias, advises, more especially for alopecia
furfuracea, the following: first washing the scalp with tar soap, rinsing,
drying, and applying a lotion consisting of 3 grains (0.2) of corrosive sub­
limate and 2 ounces (64.) of alcohol, and 5 drams (20.) each of glycerin
and cologne spirits; the scalp is then dried, and an alcoholic solution of
naphthol, 0.5 to 1 per cent, strength, is applied; and, finally, a 1.5 per
cent, carbolized oil. This is to be done at first daily. It is a method
to which, however efficacious, the average hurried American would
object. Cottle² advises: R. Ac. acetici, 3ij (8.); pulv. boracis, gr. xxx
(2.); glycerin., 3iss (6.); spts. vini, 3ij (8.); aq. rosæ, 3iv (128.); and also
R. Liq. ammon. acetat., 3j (32.); ammon. carbonat., gr. xv (1.); glycerin.,
3iss (6.); aq. sambuci, ad 3iv (128.) Jackson, while not placing much
weight upon medicinal applications, speaks well of an ointment of cold
cream as the base, with 10 per cent, of precipitated sulphur, and 3 to 5
per cent, of salicylic acid; also of one containing 1 dram (4.) of extract
of jaborandi to the ounce (32.); and one suggested by Bronson, of 20
grains (1.35) of ammoniated mercury and 40 grains (2.65) of calomel to
the ounce (32.) of vaselin. Davis has used freely in alopecias and sebor-
rheic conditions and extols highly a “stearoglycerid ointment’’ as an
ointment base—made up of 2 ounces (64.) of stearic acid, 18 drams of
glycerin (72.), 30 grains (2.) of potassium carbonate, 12 grains (0.7)
of sodium borate, and 34 drams (136.) of water; incorporating most
frequently sulphur and beta-naphthol. Boric acid and salicylic acid are
incompatible with it, but the effect of the latter, if desired, can be
obtained by incorporating sodium salicylate, 20 to 40 grains (1.3-2.6)
to the ounce (32.) The advantages over the ordinary bases are that
“it is not greasy, is soluble in water and therefore easily washed off”
(Davis).

The application selected should be made for the first few weeks
once daily, later three or four times weekly. Shampooing is necessary
from time to time, once every one to two or three weeks, depending in
great part upon the care with which the applications have been made—if
used freely and carelessly, a certain amount of soiling of the hair the
sooner results. For shampooing the most satisfactory soap is one of boric
acid or the tincture of green soap, with 10 to 20 grains (0.65-1.35) of
resorcin to the ounce (32.).

There are certain other measures to be advised in these cases which
are really often more beneficial than the remedial applications. The
scalp should be kept well aired, exposed to light and air as much as pos­
sible. Massage should be practised once or twice daily, and this is best
done by grasping the scalp with one or both hands laterally as well
as anteroposteriorly, and with some pressure loosening the tissues from
the underlying parts and trying to raise it into folds. It can also be gone
over with one hand, pinching it up with the extended finger-ends, and pro-

¹ Lassar, Monatshefte, 1882, p. 131.

² Cottle, The Hair in Health and Disease, London.

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995

ducing some vascular flux and a sense of warmth. Simply rubbing the
scalp is of very little use, and as done with the amount of friction put on
by the average barber even the good hair can be rubbed out. This
procedure—massage—which Jackson considers the only one remedy
worth the name for stimulating the growth of hair, is one that should
not be neglected, and should be an essential part of the treatment
except in cases where there is seborrhea or irritation; if the latter are
present, they should at first receive attention, after which massage can
be instituted. Another measure of therapeutic importance is the use of
electricity. Two or three times weekly or more frequently the scalp
can be gone over for five to ten minutes with a metallic brush or comb
attached to a faradic battery, using as strong a current as can be com­
fortably borne; this often produces considerable temporary hyperemia
and stimulation. In addition to this the static current is also of value,
and, employed with the crown a few inches above the scalp for five
minutes, several times weekly, it has seemed to me to be of value in some
cases.

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