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Am J Clin Dermatol 2010; 11 (1): 1-10

1175-0561/10/0001-0001/$49.95/0

REVIEW ARTICLE

2010 Adis Data Information BV. All rights reserved.

Complementary and Alternative Medicine

in Alopecia Areata
Frank J.H.M. van den Biggelaar,1,2 Joost Smolders3 and Jacobus F.A. Jansen2,3,4
1
2
3
4

Alopecia Areata Patient Organization, Utrecht, The Netherlands

Department of Radiology, Maastricht University Medical Center, Maastricht, The Netherlands
School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
Department of Medical Physics and Radiology, Memorial Sloan-Kettering Cancer Center, New York, New York, USA

Contents
Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
2.1 Whole Medical Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

AUTHOR PROOF

2.2 Mind-Body Medicine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

2.3 Biologically Based Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
2.4 Manipulative and Body-Based Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
2.5 Energy Healing Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
2.6 Animal and In Vitro Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
3. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
3.1 Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
4. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Abstract

Alopecia areata is an unpredictable hair-loss condition. As there is no cure for alopecia areata and no
effective conventional therapy, a substantial number of alopecia areata patients resort to complementary
and alternative medical remedies and therapies (CAM). This review on the application of CAM in alopecia
areata addresses two pertinent aspects. First, it provides a current overview of the published medical literature on CAM used in alopecia areata, and alopecia areata-related studies. Second, it presents a thorough
assessment of the considerations and limitations of the use of CAM for the treatment of alopecia areata.
A systematic MEDLINE search yielded 13 studies of the clinical use of CAM in the management of
alopecia areata, all belonging to one of the five main categories of CAM. Methodological quality was
analyzed using objective assessment scores (Wilson and Lawrence scores). Unfortunately, no study was of
sufficient internal validity to provide robust evidence of the benefit of CAM. This might be attributable to
several specific disease characteristics of alopecia areata, which require an especially solid trial design to
properly assess the therapeutic effects of CAM. The review concludes with some recommendations for
improving the quality of trials incorporating CAM in the treatment of alopecia areata.

Alopecia areata is an unpredictable, usually patchy, nonscarring, autoimmune, inflammatory hair-loss condition.[1] It is
a relatively common condition, with a reported incidence of
0.15% of the population,[2] and it accounts for approximately

2% of new patients attending dermatology outpatient centers in

the UK and the US.[3,4] The severity and pattern of hair loss can
vary substantially between individuals, for example, from
small, hardly visible spots that often regenerate spontaneously,

van den Biggelaar et al.

AUTHOR PROOF

to long-term forms of complete hair loss. Extensive hair loss is

experienced by about 30% of people with alopecia areata.[2] The
condition can affect the entire scalp (alopecia totalis) or can
even cause loss of all body and scalp hair (alopecia universalis).[4] The majority of people with alopecia areata experience only the occasional bald area, which spontaneously
resolves within a year, but most will experience a relapse at
some stage in their life. Factors associated with a less favorable
prognosis are a family history of alopecia areata, childhood
onset, severe hair loss, and a history of atopic diseases or autoimmune conditions, particularly thyroid disease.[3] Although
the exact pathogenesis of alopecia areata is unknown, an autoimmune basis is assumed.[5] A combination of a genetic susceptibility and as yet largely undefined environmental factors is
believed to trigger alopecia areata development. These environmental factors include physical stress, trauma, or a major
life crisis,[3] but often a specific trigger cannot be identified.[2]
There is no cure for alopecia areata and no effective conventional therapy to induce hair regrowth and sustain remission.[2] Conventional treatment options most often used, albeit
with a disappointing success rate, are glucocorticoids and
minoxidil.[6] Alopecia areata is associated with significant
psychosocial problems, such as reduced self-esteem, and may
negatively affect quality of life.[7] As the psychologically debilitating nature of alopecia areata and the possibility of longterm hair loss are rather unpleasant for many alopecia areata
patients, a substantial number of them resort to complementary
and alternative medical remedies and therapies (CAM).[8] This
interest in CAM can be clearly noted through the numerous
threads on alternative therapy on the message boards for
patients with hair problems,[9] blogs reporting on CAM,[10]
and the patients questions on CAM for medical specialists
associated with the National Alopecia Areata Foundation.[11]
On the whole, a dramatic increase in the use of CAM by
the public has been reported in recent years.[12] Consumers
find CAM attractive as they perceive many modalities to be
based on what they regard to be a more holistic approach,
which allows patients to feel they are more actively participating in their own healthcare. In addition, there is the belief
that natural therapies will be safer and more effective than
synthetic pharmaceuticals. On the other hand, healthcare
professionals often dismiss CAM, based on what they believe
to be a lack of sufficient scientific evidence to support their
effectiveness, and attribute their perceived efficacy, by patients, to the high placebo response rates associated with
many of the disorders for which CAM are most commonly
employed. However, since alternative medicine is becoming
increasingly popular with the public worldwide, it is also
2010 Adis Data Information BV. All rights reserved.

starting to receive more attention in systematic studies and

experimental research.
CAM is defined by the National Center for Complementary
and Alternative Medicine (NCCAM) of the National Institute
of Health (Bethesda, MD, USA) as medical practices that are
not currently considered to be a part of conventional medicine.[13] Complementary medicines or medical practices are
taken or used in conjunction with conventional medicines,
whereas alternative medicines or medical practices are taken or
used in place of conventional medicines or practices. CAM are
usually divided into five main categories: (i) whole medical
systems; (ii) mind-body medicine; (iii) biologically based practices; (iv) manipulative and body-based practices; and (v) energy healing therapies.[13]
Individual physicians are currently confronted with questions from patients regarding all these therapies. Therefore, it
would be beneficial to have a comprehensive review that covers
the evidence for the efficacy of different CAM that have been
published so far. Numerous reports on CAM and their effects
on hair growth in the form of case reports, patient series, animal
studies, and in vitro cellular studies have been published.
However, the number of CAM that have been submitted to
scientific study in the form of randomized controlled trials
(RCTs) in alopecia areata populations is rather limited.
This review on the application of CAM in alopecia areata
addresses two pertinent aspects of CAM and its application to
alopecia areata. First, it provides a current overview of the
literature on all CAM used in alopecia areata, and alopecia
areata-related studies (animal or in vitro). Second, it presents a
thorough assessment of the considerations and limitations of
CAM and their application to alopecia areata.

1. Methods
A systematic MEDLINE search was performed to identify
alternative medications and their potential clinical uses from
human, animal, and in vitro studies. Review articles were also
searched for additional references. No restrictions were placed
on the search by type of publication, publication date, or
country. The search was restricted to publications in English,
French, and German.
All papers evaluating CAM in the management of patients
categorized as having alopecia areata, irrespective of the criteria for diagnosis, were included. Multiple component therapies were excluded. Any patient-related outcome measure was
deemed eligible for inclusion. All study designs were included in
an attempt to capture all the available data.
Am J Clin Dermatol 2010; 11 (1)

AUTHOR PROOF

Alternative Medicine in Alopecia Areata

A scoring system was used to assess the internal validity for

non-randomized trials.[14] Uncontrolled studies are recognized
to be methodologically weaker than RCTs. We assessed the
quality of the uncontrolled trials by extracting data according
to a four-point scoring system (Wilson score) that took into
account the availability of before and after data (one point),
assessment of confounders (one point), and dropouts (two
points). The quality of trials to a randomized standard was
assessed by a three-point scoring system defined by the Canadian
Task Force on the Periodic Health Examination[15] as implemented by Lawrence and Mickalide[16] (Lawrence score).
This score ranks grades of evidence as: (I) evidence obtained
from at least one properly conducted RCT; (II-1) evidence from
well designed, controlled trials without randomization; (II-2)
evidence from well designed cohort (prospective or retrospective) or case-controlled studies, preferably from more than
one center or research group; (II-3) evidence obtained from
comparisons between times or places with or without intervention; and (III) opinions of respected authorities, based on
clinical experience, descriptive studies, or reports of expert
committees. Data extraction aimed to establish the study size,
patient demographics, details of interventions, outcome measures, duration of follow-up, and results. Final searches of the
literature were undertaken in January 2008.
2. Results
A systematic MEDLINE search yielded 13 studies of the
clinical use of CAM in the management of alopecia areata, all
belonging to one of the five main categories of CAM. The
studies are summarized in table I. The quality and validity of
the studies are expressed as the Wilson and the Lawrence
scores.
2.1 Whole Medical Systems

Whole medical systems is the NCCAM classification for

those forms of alternative medicine that are built upon a
complete system of theory and practice. Of these approaches,
homeopathy has been applied by Itamura.[17] Homeopathy is a
form of alternative medicine in which a dilution of a certain
substance (pathogenic or non-pathogenic) to a non-detectable
low concentration is claimed to have a therapeutic effect on
consumers.[31] In a case report, Itamura[17] describes the treatment of a 20-year-old woman, who had alopecia universalis for
7 years, with the homeopathic medicine Mercurius. The patient
was treated for 3 months, and effectiveness of the treatment was
evaluated using the patients own assessment of overall im 2010 Adis Data Information BV. All rights reserved.

pression. According to the patient, the homeopathic treatment

yielded a significant improvement.

2.2 Mind-Body Medicine

Mind-body interventions are alternative therapies that cover

a variety of techniques designed to enhance the minds capacity
to affect bodily function and symptoms.[13]
Two studies have evaluated the effect of hypnotherapy for the
treatment of alopecia areata.[18,19] In hypnotherapy, the subject
is brought into a trance-like state (hypnosis) of inner absorption, concentration, and focused attention that is induced by a
therapist, whose suggestions are readily accepted by the subject.[19]
Harrison and Stepanek[18] treated patients with extensive alopecia areata using hypnotherapy. They included 12 patients in
the study, of whom five completed the protocol. During this
therapy, techniques were used such as direct and indirect suggestions, and ego strengthening. Afterwards, the patients who
completed the protocol reported a feeling of general well-being.
However, cosmetic hair growth was seen in only one patient.
Recently, Willemsen et al.[19] used hypnosis to treat 28 alopecia
areata patients who were refractory to previous conventional
treatments. Hypnotherapy was either applied in an alternative or complementary fashion. Of the 28 patients included, 21
patients completed the treatment and seven withdrew because
of lack of motivation. The 21 patients who completed the study
were comprised of nine with alopecia totalis or alopecia universalis and 12 with extensive alopecia areata, with a disease
course varying from 6 weeks to 4 years. After treatment, all patients who completed the protocol had a significantly lower score
for anxiety and depression. Significant hair growth was found in
12 patients after three to eight sessions, with total hair regrowth in
nine patients. Of these responders, three used no additional
conventional therapies, whereas eight used conventional therapy
including corticosteroids and immunotherapy. In five patients, a
significant relapse occurred when treatment ended.
Psychotherapy and administration of immunosuppressants
(2 months of monotherapy with prednisolone 510 mg/day,
followed by 45 months of combination therapy with cyclosporine [ciclosporin] 2.5 mg/kg) was used by Teshima et al.[20]
for the treatment of alopecia areata. Eleven patients with refractory alopecia universalis were included in this study: six
patients received psychotherapy and immunotherapy, whereas
five patients received only immunotherapy. Psychotherapy included relaxation and image therapy and was conducted for
30 minutes once a week for a 2-month period. Hair regrowth
and stress relief were observed in five of six patients treated with
Am J Clin Dermatol 2010; 11 (1)

110 y

6 wk to 4 y

NR

ALT

Hypnotherapy/COMP + NR

Hypnotherapy/ALT

hair growth

Well-being,

Hair growth

Well-being

Outcomes

Trial

Follow-up

2 mo

5y

3 mo

3 mo

NR

4 mo to 4 y

NR

NR

duration period

regrowth in 12/21,

Better well-being;

Slight improvement

improvement

Significant

Results

2010 Adis Data Information BV. All rights reserved.

study (130;
56 M, 74 F)

Germany

Comparative

Case report

et al.,[26] 1969,

IV

III

Hofer

2005,

study (66)

Comparative

(40; 22 M, 18 F)

db, rct

(1 F)

Xie,

III

III

(62; 40 M, 22 F)

China

[25]

1976, Switzerland

Much,[24]

Iran

et al.,[23] 2007,

Hajheydari

2002, Iraq

III

sb, pc study

Al-Obaidi,[22]

Sharquie and

rct
(84)

II

(11; 6 M, 5 F)

Patient series

1998, UK

Hay et al.,[21]

Japan

et al.,[20] 1991,

669

11

NR

25 16

350

39 15

NR

1.5 y

NR

<1 mo

Recent

0 to >9 y

massage/COMP

Segmental

TCM concoction/ALT

corticosteroids

Oral

NR

Well-being,

Hair growth

hair growth
35 wk

3 mo

NR

NR

growth time

Clear reduction in

Improvement

pts)

acid vs 47% of control

treated with vitamin A

Improvement (hair

improvement

Significant

pts)

juice vs 13% of control

treated with onion

regrowth in 87% of pts

improvement (hair

Significant

21% in control group)

group improved vs

pts in active treatment

(n = 36)

8 wk

NR

Significant
improvement (54% of

(n = 30)

3 mo

3 mo

NR

7 mo

regrowth in 70% of pts

Hair growth

Hair growth

8 wk

7 mo

corticosteroids

Topical

(n = 20)

Placebo gel

Hair growth

Hair growth

immunotherapy)

psychotherapy plus

(5/6 pts receiving

(tretinoin)/ALT

Vitamin A acid

(n = 20)

Garlic gel/COMP

(n = 45)

Water (n = 17)

(n = 41)

Onion juice/COMP

Carrier oils

(n = 43)

(n = 5)

Immunotherapy Hair growth

Aromatherapy/ALT

(n = 6)

Psychotherapy/COMP

Full regrowth

928

1568

>5 y

NR

treatment

or COMP

Homeopathy/ALT

Control

Intervention/ALT

Teshima

(21; 5 M, 16 F)

Patient series

1964

7y

areata

alopecia

Duration of

with relapse in 5 pts

II

II

(12; 4 M, 8 F)

Patient series

20

(y)

Age

Belgium

et al.,[19] 2006,

Willemsen

1991, UK

Stepanek,[18]

II

(1 F)

Japan

Harrison and

Case report

Itamura,[17] 2007, I

Design (no. of
pts; sex)

CAMa

location

Study, year,

Table I. Complementary and alternative medical remedies and therapies (CAM) in alopecia areata

AUTHOR PROOF

Wilson Lawrence

II-2

III

II-2

II-1

III

III

III

III

Continued next page

scoreb scorec

4
van den Biggelaar et al.

Am J Clin Dermatol 2010; 11 (1)

ALT = alternative therapy; COMP = complementary therapy; db = double-blind; F = female; M = male; NR = not reported; pc = placebo-controlled; pts = patients; rct = randomized controlled
trial; sb = single-blind; TCM = traditional Chinese medicine; TMS = transcranial magnetic stimulation.

Lawrence score: (I) evidence obtained from at least one properly conducted rct; (II-1) evidence from well designed controlled trials without randomization; (II-2) evidence from well
designed cohort (prospective or retrospective) or case-controlled studies; (II-3) evidence obtained from comparisons between times or places with or without intervention; (III) opinions of
respected authorities based on clinical experience, descriptive studies, or reports of expert committees.[16]
c

Greece

2002, 2004,

b Wilson score: before and after data available (one point); assessment of confounders (one point); dropouts recorded (one point); follow-up of the dropouts (one point).[14]

14 mo
Hair growth
Regular

2010 Adis Data Information BV. All rights reserved.

a CAM categories: (I) whole medical system; (II) mind-body intervention; (III) biologically based practice; (IV) manipulative and body-based practices; (V) energy healing therapies.

III
improvement
(6; 5F, 1 M)
et al.,[29,30]

Anninos

China

Case reports

623

18 y

TMS/ALT (n = 3)

therapy (n = 3)

2y

Significant

0
Complete regrowth

in 8 pts

1y
NR
Hair growth
NR
Acupuncture/ALT
Case reports (9) 55 (mean) 3 mo
Ge,[28] 1990,

IV

III

III
1
Full regrowth
14 mo
149 d
Patch size
NR
and reward/ALT

Massage, relaxation
5y

(1 M)
1994, US

Case report

areata

treatment
or COMP

Putt et al.,[27]

16

Follow-up
Control
Intervention/ALT

alopecia

Duration of
Age

(y)
pts; sex)

Design (no. of
Study, year,

Table I. Contd

CAMa
location

AUTHOR PROOF

Outcomes

Trial

duration period

Results

Wilson Lawrence

scoreb scorec

Alternative Medicine in Alopecia Areata

psychotherapy, whereas hair regrowth was observed in one

of five patients treated with immunosuppressants alone. The
authors suggested that alleviating stress facilitates recovery of
immunologic competence.
Aromatherapy is the use of essential oils from plants to
support and balance the mind, body, and spirit. Alopecia areata
was treated with 7 months of aromatherapy by Hay et al.[21,32]
A mixture of thyme, rosemary, lavender, and cedarwood essential oils in jojoba and grape seed carrier oils massaged into
patients scalps significantly improved the alopecia areata when
compared with the carrier oils alone (improvement in 54% and
21% of patients, respectively). The efficacy of the treatment was
evaluated at initial assessment and 3 and 7 months after treatment by dermatologists visual scoring of photographs and
a computerized analysis of traced areas of alopecia. The
distribution of several prognostic factors in the cohorts was
described, but the distribution between the treatment arms of
disease duration and the extent and severity of the alopecia
areata were not mentioned.
2.3 Biologically Based Practices

Biologically based practices in CAM use substances found in

nature, such as herbs, foods, and vitamins that are not part of
conventional medicine.[13] Several researchers have used biologic compounds to treat alopecia areata patients. Sharquie and
Al-Obaidi[22] investigated the effectiveness of topical crude
onion juice in the treatment of patchy alopecia areata in comparison with tap water. Sixty-two patients were enrolled in
a single-blind, placebo-controlled clinical study of 8 weeks
duration. Forty-five patients underwent the onion juice treatment, and 17 patients underwent the control treatment with tap
water. All patients had recently developed alopecia areata, and
severe cases (alopecia universalis and alopecia totalis) were
excluded. Hair regrowth was observed in 87% of patients
treated with onion juice, whereas only 13% of the control group
displayed hair regrowth.
An Iranian research group investigated the effectiveness of
topical garlic gel as complementary medicine in the treatment
of alopecia areata.[23] A group of 40 patients with alopecia
areata received topical application of corticosteroid twice daily.
Patients had up to three hairless patches, and a disease duration
of <1 month. Using a randomized, double-blind, controlled
design, the patients were divided into two groups: a group of 20
patients treated with garlic gel, and a control group of 20 patients receiving a placebo treatment for 3 months. Effectiveness
was assessed by a dermatologist, blinded to the treatment
status. A beneficial effect of garlic gel on the therapeutic efficacy
Am J Clin Dermatol 2010; 11 (1)

van den Biggelaar et al.

AUTHOR PROOF

of topical corticosteroid therapy in patients with alopecia

areata was observed.
The treatment of alopecia areata with vitamin A acid
(tretinoin 0.05% gel) was described by Much.[24] In this study,
30 patients with alopecia areata were treated with vitamin A
acid and 36 patients were treated with a topical corticosteroid
or hyperemia-producing gel. Patients with patches on the
head, excluding patients with alopecia totalis, were treated for
12 weeks. The efficacy of the treatment was evaluated by a
dermatologist 8 weeks after termination of therapy, who indicated a successful treatment when hair was fully regrown, or
when an obvious improvement of the clinical status by >50%
had occurred. Hair regrowth was observed in 70% of patients
treated with vitamin A acid, whereas only 47% of the control
group displayed hair regrowth.
Xie[25] described a case report of an 11-year-old girl with a
1.5-year history of alopecia areata, who was treated with a
traditional Chinese medicine concoction. The concoction,
mostly consisting of roots of various origins, was taken orally
and applied to the scalp. After treatment for 3 months, hair regrowth occurred and an improvement in well-being was observed.
2.4 Manipulative and Body-Based Practices

This form of alternative therapy is based upon manipulation

and/or movement of one or more parts of the human body.[13]
In the literature, massage for the treatment of alopecia areata
has been described by two research groups.
Hofer et al.[26] described an investigation of the efficacy of
segmental massage for the treatment of alopecia areata. A total
of 130 patients were divided into four groups: (I) local treatment with propyl niacin (pyridine-3-carboxylate; a nicotinic
acid propylester, also used as a hyperemia-inducing substance);
(II) local treatment with propyl niacin and segmental massage;
(III) local treatment with propyl niacin and oral prednisone
30 mg/day; and (IV) local treatment with propyl niacin, oral
prednisone 30 mg/day, and segmental massage. Groups I and II
included milder forms of alopecia areata, whereas III and IV
included more severe forms of alopecia areata. Patients with
alopecia areata totalis were excluded. Efficacy of treatment was
evaluated by measuring the time to grow hairs with a length of
0.51.0 cm in all areas. A total of 1224 segmental massages
were applied by an experienced physiotherapist. Segmental
massage significantly reduced the time for hair regrowth by
34% compared with propyl niacin therapy alone, and 75%
compared with propyl niacin and prednisone therapy.
In a case report described by Putt et al.,[27] three treatment
techniques (hair massage, relaxation procedures, and monetary
2010 Adis Data Information BV. All rights reserved.

reward) were applied to a 16-year-old male patient with a 5-year

history of alopecia areata. During the 7-month treatment period,
disease went into remission and hair loss was reduced. During the
last 4 months of the study, new hair growth was observed.
2.5 Energy Healing Therapies

In energy healing therapies, energy is applied during treatment. Two types of energy exist: (i) veritable, which can be
measured; and (ii) putative, which has yet to be measured.[13]
Transcranial magnetic stimulation (TMS) is a form of veritable energy therapy. Neurons in the brain are believed to be
excited by weak electric currents induced in the tissue by rapidly
changing magnetic fields.[29] TMS was recently applied by
Anninos et al.[29,30] for the treatment of alopecia areata. In
total, three patients with alopecia areata (duration 18 years)
were treated with TMS, with a therapeutic protocol consisting
of a low-intensity external magnetic field (five sessions per
week). All patients displayed an improvement in hair regrowth
during the treatment period.
Another form of energy healing therapy is acupuncture. This
putative form of energy therapy is a technique of inserting and
manipulating needles into points on the body with the aim of
restoring health and well-being. Ge[28] described nine patients
with alopecia areata who were treated with acupuncture. Full
hair regrowth was reported in eight patients, and marked improvement in one patient.
2.6 Animal and In Vitro Studies

A vast amount of literature exists where CAM have been

applied to promote hair growth in non-human subjects. The
examined populations vary from shaved mice,[33-37] Wistar albino rats,[38] and cats[39] to human hair follicles.[37,40] One case
report describes the successful application of acupuncture to a
cat with alopecia due to extensive licking.[39] Most of these
therapies belong to CAM category III biologically based
practices. Root[34,36] and plant worm[35] extracts are especially
popular, in addition to polyphenolic compounds present in
green tea.[33,40] Often, these compounds are traditionally acclaimed for their hair growth-promoting potential. However,
the clinical relevance of these studies is limited. The evidence
that a certain natural compound is beneficial with respect to
hair growth on shaved mice has little relevance for patients with
alopecia areata. The in vitro application of certain compounds
on cultures of human dermal papilla cells might be more relevant,[37,40] although the cells used usually originate from men
with alopecia androgenetica, a condition where other cellular
and molecular mechanisms are involved.[41]
Am J Clin Dermatol 2010; 11 (1)

AUTHOR PROOF

Alternative Medicine in Alopecia Areata

Another approach for understanding, implementing, and

refining new therapies for alopecia areata is the use of rodent
models. Two established rodent models for alopecia areata are
the C3H/HeJ mouse[42] and the DEBR (Dundee Experimental
Bald Rat).[43] These models display a patchy alopecia that is
clinically and histopathologically similar to human alopecia
areata.
C3H/HeJ mice display a diffuse non-scarring alopecia with
clinical and pathologic features similar to alopecia areata.[42]
On the dorsal skin, the alopecia develops in circular areas with
disease involvement restricted to anagen follicles.
The DEBR arose as a spontaneous mutation at the University of Dundee, Scotland.[43] These animals grow a normal
first coat of hair but then become progressively hairless. Histology of the skin confirms the persistence of hair follicles in a
pattern similar to that observed in human alopecia areata. Thus
far, mostly traditional topical sensitizers such as diphencyprone
have been applied on these rodent models, yielding convincing
hair growth on the treated portions of the animals.[44] In future
CAM studies, it might be interesting to apply the therapy to one
of the established rodent models for alopecia areata, instead of
shaven mice or rats.
3. Discussion
All of the published trials identified by this comprehensive
systematic review provided evidence to suggest that CAM are
effective in the management of alopecia areata, with the main
measured effects being substantial hair regrowth and improved
well-being. This is remarkable, as of the 13 studies identified,
approximately one negative result would be expected by chance
alone. These unanimous positive results hint at a publication
bias.[45]
However, despite all the positive results, unfortunately no
study was of sufficient internal validity to provide robust evidence of the benefit of CAM in alopecia areata. Even the RCTs
(of Hay et al.[21] and Hajhydari et al.[23]) and controlled studies
(Sharquie and Al-Obaidi,[22] Much,[24] and Hofer et al.[26]) included in this review did not satisfy objective quality requirements. This might be attributable to several specific disease
characteristics of alopecia areata, which require an especially
solid trial design to assess the therapeutic effects of CAM
properly. In this regard, the development of alopecia areata and
its evolution over time is relevant. Madani and Shapiro[3] stated
that: the only predictable thing about the progress of the
alopecia areata is that it is unpredictable. An evaluation of 230
patients by Walker and Rothman[46] showed that the duration
of the initial attack was <6 months in 33% and <1 year in 50% of
2010 Adis Data Information BV. All rights reserved.

patients. This indicates that results from studies that include

patients who have had alopecia areata for <1 year should be
interpreted with caution. Furthermore, Walker and Rothman[46]
reported that relapse occurred in 86% of the patients. Vestey
and Savin[47] included 50 patients with extensive alopecia areata
(>40% hair loss). Twenty-four percent of these patients experienced spontaneous complete or nearly complete regrowth
in a follow-up period of 33.5 years. Tosti et al.[48] followed
191 patients who had mild and severe alopecia areata for <2 years
at the first consultation for a mean of 17.7 years. In patients
with mild alopecia areata, about 50% were free of disease after
long-term follow-up. These studies show that regrowth can
occur at any time, which makes it very difficult to draw conclusions when only a few patients are included in a trial and
when no solid randomization has been applied.
Furthermore, alopecia areata is a disease of great heterogeneity in which the severity and extent can vary from a
few patches to alopecia universalis. A trial should either contain enough patients to assess the effect of treatment in
each specific subgroup, or be confined to an individual group.
There are several factors that affect the disease course, including family history and the presence of other autoimmune diseases. Treatment and placebo arms should therefore be well
matched and these factors should be taken into account in
appropriate statistical methods to correct for the multiple
comparisons.
There are also some CAM-specific pitfalls that should be
taken into account when assessing therapeutic effects. The lay
literature and the Internet continue to maintain the perception
that natural therapies and products such as herbs tend to be
safer than conventional medicines. Modern medical practice
relies heavily on the use of highly purified pharmaceutical
compounds whose purity, efficacy, and toxicity can be easily
assessed. In contrast, for many CAM, such as herbal medicines,
there are different manufacturing standards and criteria of
purity, and these herbs contain mixtures of natural compounds
that have not undergone detailed analyses and whose mechanism of action is not known.[49] Therefore, safety and adverse
effects are important issues when considering CAM strategies.[31] Translating traditional CAM practices into acceptable
evidence-based Western therapies can be challenging.[50] For
example, the medicinal role of herb extracts may lie in the
synergistic interaction of the many constituents. When such a
complex mixture is fractioned, the active ingredients are separated and efficacy may be lost. Similarly, therapies such as
acupuncture, hypnotherapy, and aromatherapy require well
trained therapists, whose professional training has unfortunately not been standardized.
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van den Biggelaar et al.

AUTHOR PROOF

3.1 Recommendations

It is essential that, in a similar fashion as for conventional

therapies, alternative therapies are evaluated using rigorously
conducted scientific tests of efficacy based on accepted rules
of evidence. The lack of properly designed and conducted
RCTs is a major deficiency. The current evidence is inadequate
for development of practice guidelines for alternative therapies, largely because of a lack of relevant outcomes data from
high-quality clinical trials. We recommend adhering to the
CONSORT statement,[51] which is intended to improve the
reporting of RCTs, enabling readers to understand the design,
method, analysis, and interpretation of a trial, and to assess the
validity of its results. It emphasizes that this can only be
achieved through complete transparency from authors.
However, some supporters of alternative medicine might
argue that many alternative therapies can not be subjected to
the standard scientific method and, thus, instead must rely on
anecdotes, beliefs, theories, testimonials, and opinions to support effectiveness and justify continued use. Regardless of the
origin or type of therapy, the theoretical underpinnings of its
mechanism of action, or the practitioner who delivers it, the
critical questions are the same.[52] For virtually all medical
therapies and interventions, whether conventional or alternative, determination of effectiveness and recommendations
for clinical application should be based on the strength of the
scientific evidence using explicit criteria for grading the quality
of evidence.
Additionally, alternative medicine comprises a large and
heterogeneous group of treatments, many of which are procedures that are not readily testable under blinded conditions and
for which the choice of appropriate control conditions is by no
means straightforward. Sometimes, it is nearly impossible to
conduct studies under conditions in which both the patients and
practitioners are blinded.[53] Training and competency are a
prerequisite to providing the treatments, and experienced
practitioners will know which treatment is hypothesized to be
active. Unlike pharmacotherapy studies in which the active
medication and the pill placebo can be made to be identical in
appearance, procedures are observably different to all of the
participants in the study. For example, acupuncture RCTs may
need to be conducted unblinded, with multiple checks on bias.[53]
Nevertheless, a proper, well considered design will yield
more scientific evidence than studies of inferior quality. In cases
where it is hard to use therapeutic procedures under fully
blinded conditions, it should always be possible to rely on objective assessment of (successful) treatment. Studies will hugely
benefit when the assessment of hair regrowth is performed
2010 Adis Data Information BV. All rights reserved.

using objective criteria. In this regard, the objective four-point

scale as described by Hull and Norris[54] is highly recommended. Hay et al.[21] also describe an additional standardized
professional photographic assessment performed by two independent observers and a computerized patch size analyzer
using transparent films. In addition to hair regrowth, the
patients well-being is a valuable outcome measure to incorporate in an alopecia areata trial. After all, if the patients wellbeing improves, even without any hair regrowth, the end result
can still be positive. For this outcome, a questionnaire such as
the Symptom Check List (SCL)-90,[55] which assesses eight
different psychological symptoms, can be advantageous.
Unfortunately, the studies presented in this review do not
satisfy objective quality requirements and should therefore be
interpreted with caution. Further investigation of these therapies under accurate experimental conditions would better estimate their true clinical benefit. Indeed, the lower cost, ample
accessibility, and potential clinical improvement with these
newer unconventional remedies is encouraging for continued
research. However, it remains to be seen which, if any, provide a
more advantageous therapeutic ratio than standard agents.
4. Conclusions
The recourse of alopecia areata patients to CAM is widespread, and therefore doctors must be familiar with this practice.
Furthermore, it would be beneficial if physicians attempted to
understand their patients confidence in these therapies despite
a lack of scientific basis. It is important to realize that not all
CAM are identical, and that some, such as hypnotherapy or
forms of herbal therapy, may well find a place in the complete
armamentarium of a physician caring for alopecia areata patients. Nevertheless, more research in the form of controlled
studies is needed. These studies should not only assess hair
regrowth in an objective manner, but also look at the patients
well-being. The lack of truly randomized, placebo-controlled
trials of high quality for CAM is rather disappointing.
Acknowledgments
No sources of funding were used to assist in the preparation of this
review. The authors have no conflicts of interest that are directly relevant
to the content of this review.

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AUTHOR PROOF

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Correspondence: Dr Jacobus F.A. Jansen, PhD, Department of Medical Physics

and Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue,
New York, NY 10021, USA.
Email: jansenjfa@gmail.com

2010 Adis Data Information BV. All rights reserved.

Am J Clin Dermatol 2010; 11 (1)