Hair in Homo sapiens, who are also known as the naked apes, may sound like an oxymoron, but whatever little is left in them is of profound importance. Although hair no longer is a primary factor in temperature regulation and that we may be totally devoid of hair in the next centuries as a result of natural selection, its role in sexual identification remains undiminished at present. It comes as no surprise then, that there has been an explosion of hair care and management products in the last two decades and a renewed interest in physiology, pathology and management of hair.
Hair has always been of utmost fascination to the human race. Mythology all over the world has amusing tales associated with the hair.
In the Jewish bible, the secret of Samson's heroic strength was attributed to the length of his hair. Among the Hebrews, baldness was considered not only a defect, but also a curse.
Venus of Brassempouy, one of the earliest known realistic representations of a human face, is a fragmentary ivory figurine from the Upper Paleolithic (circa 23,000 BCE) found in Brassempouy, France. The checkerboard-like pattern on the head has been interpreted as a wig, a hood, or simply a representation of hair (Fig. 1.1). Combs are amongst the most ancient objects that archaeologists have found in their excavations.
The Native Americans believed that longer hair implied presence of more thoughts. For them, the hair has profound significance, for they believe that thoughts originating in the head emerge along with the hair.
Similarly, a peek into Chinese culture reveals the importance attributed into the arrangement of hair all through its history. The form of use of hair had a strong symbolic meaning, as haircuts or hairstyles always marked social or civil status, religion or profession. Not sporting any form of hair arrangement was considered by them as a sign of disease or depression.
Closer home, kesh is the most important of all the precepts of Sikhism. It is the practice of never cutting the hair as a symbol of respect for the perfection of God's creation.
These anecdotes are a few examples that illustrate humankind's obsession with hair.
As much as a lush mane on the scalp and abundant facial hair in men is universally desirable, presence of hair over other body parts in women is despised in several cultures worldwide. Distress caused by loss of hair over scalp is in the same league as that caused by the growth of hair over undesired sites. Thus the presence, as well as the absence of hair can be a cause of grave concern depending on the affected person's gender, race, age, and ethnicity.
Naturally, the study of hair and its disorders is a subject of keen interest across the globe.
The Birth of Trichology
Trichology is the name given to the study and practice concerned with the hair and scalp. It owes its origin to the ancient Greek word “thrix”, which means hair. In the modern era, the seeds of trichology were first sown around 1860 in a London barbershop by an academic named Professor Wheeler. However, it came to be officially known as trichology only in 1902, the year that also saw the formation of the first official professional association for trichologists–The Institute of Trichologists.
Fig. 1.1: Venus of Brassempouy, a fragmentary ivory figurine from the Upper Paleolithic era. The checkerboard-like pattern on the head has been interpreted as a representation of hair.
Over the next few decades, the branch started gaining momentum and the first trichology course was developed in 1974 at the University of Southern California under the tutelage of David Salinger, an office bearer of the Institute of Trichologists and also the newly formed International Association of Trichologists (IAT). The International Society for Hair Restoration Surgery was founded in 1993, while The Hair Research Society of India and Association of Hair Restoration Surgeons of India came into being in 2005 and 2008, respectively.
HAS HAIR LOSS AND BALDNESS BEEN INCREASING?
There is a general impression amongst trichologists that there is a steady increase in the number of patients with hair loss, patterned hair loss in particular. This opinion is ably supported by the findings of an Australian survey, in which 98.6% of men and 64.4% of women had reported bitemporal hair loss.1 Increasing awareness, availability of treatment modalities and easy access to care have perhaps contributed to the hike in the number of patients. Another reason for the rise could be androgenetic alopecia's (AGA) link to metabolic syndrome, a condition whose incidence has been increasing over the last few decades. Several studies have pointed towards association of AGA, early onset type in particular, with metabolic syndrome.2–8 A corollary to this is trichologists’ observation of a shift in the age group of the patients, present day patients being far younger than their predecessors.
Being a naked ape, what remains of hair has proved increasingly important to the Homo sapiens–be it the lack or excess of it. There is an important link between hair and identity.9
People with severe hair loss are more likely to experience psychological distress.10 The experience of alopecia is psychologically damaging, causes intense emotional suffering, and leads to personal, social, and work-related problems.11 About 40% of women with alopecia have had marital problems as a consequence, and about 63% claim to have had career-related problems.12
At the same time, a high number of women seek effective treatment for hirsutism as it is viewed as a presumptive loss of feminity in many cultures. An Indian study estimated the prevalence of hirsutism to be 10% in women of child-bearing age group.13
A study on the psychological impact of hirsutism in women showed that a considerable amount of time was spent on the management of facial hair (mean—104 min/week). Two-thirds (67%) in the study population reported continually checking in mirrors, 76% reported checking by touch and 40% felt uncomfortable in social situations. High levels of emotional distress and psychological morbidity were detected; 30% had levels of depression above the clinical cut off point, while 75% reported clinical levels of anxiety; 29% reported both. Although overall quality of life was good, scores were low in social and relationship domains–reflecting the impact of unwanted facial hair.14,15
Another study found that the quality of life improved dramatically with Laser hair removal. The number of days spent removing hair reverted to baseline at 12–30 months post laser hair removal, and a significant decline was seen in the emotional burden on quality of life over time (p = 0.04).16
Several papers have documented the impact of loss or excess of hair on the psyche. Many of these patients may also be suffering from body dysmorphophobia, which needs to be identified and addressed at the earliest.17,18
DERMATOLOGIST—IS HE THE TRUE TRICHOLOGIST?
This question has arisen as many other specialists, alternative medicine doctors and non-doctors are advertising themselves as trichologists. Nearly 30% of hair transplant surgeries are performed by such doctors.
Hair is one of the three main subjects of study in dermatology, skin and nails being the other two subjects in the triad. Learning about the structure and function of hair is an integral part of dermatology syllabus. Following adequate training during postgraduation, a young dermatologist is quite capable of diagnosing most disorders affecting the hair and the scalp.
Management of hair disorders requires the clinical acumen of a physician as well as the dexterity of a surgeon's hands. A dermatologist, who inherits both these qualities by virtue of the postgraduate training, can master techniques of hair surgeries on completion of advanced training. The term “dermato-trichologist” may soon be the norm to address a dermatologist trained in and practicing ethical trichology.19
However, what has been observed over the years has been the rise of nondermatologist as a trichologist. Doctors from other specialties, alternative medicine specialists and even non-doctors are practicing as trichologists, the reasons for which are not hard to seek.
RISE OF TRICHOLOGY
The practice consensus released by the International Society of Hair Restoration Surgery (ISHRS) in 2017 had quite a few astounding findings:
- It estimates that approximately 635,189 hair restoration procedures were performed worldwide in 2016, a whopping 60% surge as compared to 2014 (397,048 procedures performed).
- Asia, the largest contributor with 195,284 surgeries, saw a surge of 36% in comparison with the contribution in 2014.
- Extrapolated worldwide total number of hair restoration patients (surgical and medical) in the past year was 1,838,946, a massive increase of 74% when compared with the total number of 1,055,480 in 2014.20
According to the recently released 2014 American Society for Dermatologic Surgery (ASDS) Survey on Dermatologic Procedures, about 633,000 laser hair removal procedures were performed by its members in 2014—a 27% increase from 2013 and a 51% climb from 2012.21
This raising demand for trichology is not met fully by dermatologists because of several reasons:
- The number of dermatologists is simply not enough to cope up with the workload.
- Dermatologists are busy with dermatology, treating disorders affecting the skin such as skin cancer, psoriasis, eczema, leprosy, etc.
- Dermatologists, even if they treat hair, do not have the time needed to handle hair cases.
- Hair patients often have special requirements—they need detailed counseling, including psychological counseling, which are difficult to perform in a busy skin clinic.
- Medical management options for hair disorders are limited with very few drugs and hence not challenging enough.
- Surgical treatment is time consuming and has a steep learning curve.
This has led to the situation where nondermatologists have assumed the role of trichologists.
CHALLENGES FACED BY DERMATOTRICHOLOGIST
Successful management of hair disorders requires a two-pronged approach; expert handling of the technical aspect and empathetic dealing of psychological aspect.
On the technical front, factors that ensure a favorable outcome are—an accurate diagnosis, an in-depth understanding of the underlying pathophysiology, practice of evidence-based medicine, and standardized global photographic assessment and computer-assisted image analysis during every follow-up visit. While arriving at a diagnosis, the dermato-trichologist must explore the possibility of a multitude of factors underlying the hair disorder, and if found, a multitargeted treatment approach must be considered. Evidence-based medicine can be practiced effectively by integrating individual clinical experience with the best and latest available external evidence.22
It is a matter of some concern that despite extensive research, no new drugs have emerged for management of hair growth. All the drugs currently available are a result of serendipity. While so much is spent on research for the dead part of the hair, so little has been achieved for the living part of the hair. This has resulted in the industry advocating products with poor evidence and little scientific basis as standard treatment; for example, peptides, plant products, botanicals, mesotherapy, etc.
With respect to the psychological aspect, successful outcome depends largely on the dermato-trichologist's communication skills. Acknowledging the patient's concern and perception of hair loss forms the first step in establishing a rapport with the patient. After gaining the patient's trust, the dermato-trichologist must explore to assess the extent of patient's expectation from the treatment. The patient should then be educated about the biology of hair cycle and counseled about the need for patience while waiting for cosmetic recovery.23–25
Patients are perceived difficult when they exhibit unrealistic demands with respect to the treatment outcome, and refuse to heed to the doctor's advice. Most often, these patients would have had a disillusioning experience with another physician in the past. However, a few of the difficult patients may have an underlying psychosomatic disorder, which has to be identified at the earliest. Ability to communicate well and an intent to understand and care for the patient will go a long way while handling a patient perceived to be difficult.26
Trueb RM has laid out the following recommendations for improvement of patient compliance:
- Recommending treatments only in circumstances where they are required
- Restricting the number of medications to a minimum, for example, prescribing a single compound comprising of a combination of several active ingredients
- Improving the compliance by opting for preparations that need fewer doses during the day
- Selecting a treatment modality that has lesser incidences of side effects or long-term risks
- Discussing in detail about the possible adverse effects and methods to cope with them
- Informing the patient about the importance of continuing medication irrespective of mild side effects
- Ensuring regular follow-up and reassuring the patient about safety of the drug and benefits of continuing treatment
- Forging a bond strong enough to allow a patient to confide the reason when unable to take a particular drug, allowing the doctor to suggest a more acceptable alternative.22
While hair and its disorders are a normal fixture in the syllabi for residency and postgraduation courses, there is no doubt that not enough attention is paid to the teaching of this subject due to the crowded curriculum. While students learn about conditions like alopecia areata, hair shaft disorders and cicatricial alopecia, not enough time is spent on AGA, trichoscopy and drugs for AGA. Particularly, counseling skills, which are of paramount importance to a dermato-trichologist, are seldom imparted. The syllabus, therefore, needs to be revised thoroughly to encompass the topics discussed in Box 1.1.
HAIR TRANSPLANTATION SURGERY
Hair restoration surgery has had a checkered history, with many fits and starts; several discoveries have been made only to be forgotten, and to be retrieved and reused later. However, it can now be said that surgery has reached a stage of maturity and has produced consistent results. Surgical techniques have outstripped the advances in medicine, and it is no wonder that hair transplantation is now the most commonly performed cosmetic surgery. Surgeries are simpler, side effects commendably minimal and results are far more consistent than ever before. Several exciting advances such as robotics have seen light of the day. There is now a strong logic behind the methods of hair transplantation. Scientific advances in the field of instrumentation for extraction, holding solution, and cellular therapies have enhanced the consistency and efficacy of results. Greater amount of donor hairs can be harvested from beard and body, making it possible to treat even Stage 7 patients satisfactorily.
The procedures are now less invasive, with lesser down time. However, this has also resulted in the entry of technicians and doctors with poor techniques and training; and there is a fear that due to nonadherence to basic principles and standards of care, the technique may go into disrepute as it had happened in the 1960s. More seems to be merry as the number of grafts have consistently gone up, with surgeries extending over 3–4 days performed frequently. Poor standards of care have meant that unthinkable can occur, as in the case of the tragic death of a medical student in Chennai. There is a strong need to define standards of care.
Who Should Perform Hair Transplantation?
This has been a question that has been discussed often in recent times. The authors agree with the opinion of Association of Hair Restoration Surgeons that dermatologists and plastic surgeons are the natural and automatic choice as hair transplant surgeons. However, dermatologists need training in surgery and plastic surgeons in trichology. There have been claims that ear-nose-throat (ENT) surgeons can perform the surgery too, as ENT surgeons perform head surgery also.
On the contrary, ISHRS permits all Bachelor of Medicine, Bachelor of Surgery (MBBS) doctors as members and leaves it to regulatory authorities in respective countries to regulate the physicians. While there is debate on this issue, there can be no doubt that dentists, alternate medicine physicians, and technicians should not perform this surgery.
Role of Technicians
Alarmingly, in the recent times, technicians are often employed by clinics to perform the surgery, often in the absence of a surgeon. With increasing mechanization and automation, this is likely to increase. However, this needs to be deplored strongly and role of technicians should be limited to assisting the surgeon and performing dissection of hair follicles.
QUACKERY IN TRICHOLOGY
The total market size for hair restoration surgery has increased by 64% since 2014, with an average number of 188 hair restoration surgical procedures being performed by an ISHRS member in 2016.20 Therefore, it is but natural that this field attracts young men and women from various specialties, the same way a flower attracts bees. The entry of nondermatologists is further fueled by the fact that many a times, obtaining an appointment with a dermatologist can be a time-consuming affair.
The International Association of Trichologists, which confers certification course in trichology, has only one eligibility criteria for accepting students—18 years and above. The association defines a trichologist as—“A trichologist helps people who have problems with their hair or scalp. The client may complain of sudden excessive hair loss from all over the scalp, a bald patch which has suddenly appeared, or itching and excessive scaling of the scalp. These are the sorts of problems a trichologist sees.” However, a disorder of hair is rarely that straightforward, the manifestation may just be the tip of an iceberg of underlying systemic illness. The pathogenesis of excessive hair growth or hair loss is most often a complex amalgamation of a multitude of factors. To manage such cases, interdisciplinary bonding with other specialties such as endocrinology, immunology, obstetrics and gynecology, psychiatry, and surgery is essential.19 These issues can be efficiently dealt with by a dermatotrichologist. On several occasions, the underlying disorders are not diagnosed by the quacks and the patients present to the dermato-trichologist at a much advanced stage of systemic issues.
Stringent laws have to be put forth to prevent the misuse of gullible patients at the hands of quacks masquerading as trichologists.
Role of Associations
Associations need to play a strong role in creating awareness, educating doctors and the public, imparting training, and influencing governmental organizations to ensure ethical practice. A case in example is the ISHRS, which through its website and social media activity, has played a major role in shaping public opinion about trichology. Indian Association of Dermatologists, Venereologists and Leprologists has laid down standard guidelines of care for hair transplantation and has also taken up with Medical Council and National Board of Examinations for starting fellowships in trichology.27
FUTURE OF TRICHOLOGY
It is a matter of concern that while millions of dollars are spent on products such as oils, shampoos, conditioners that target the shaft which is a dead portion of the hair, very little has been achieved so far for the living part of the hair. Drugs available currently for hair growth such as minoxidil and finasteride have been serendipitous discoveries and not products of designed research. And of these, compliance with minoxidil is poor, while there is profound apprehension about the side effects of finasteride. This is one of the main reasons why patients have often been unhappy with the treatment and sought help of alternative medicine healers.
Another factor to reckon with is the role of blatant advertisements by nondermatologists practicing trichology. Hyped advertisements with misleading content promising unrealistic results can be found in almost every city and town of India. Advertisements about platelet-rich plasma, stem cells, and follicular extraction are often confusing and misleading, and leave the patients in a quandary and doubt as to who is genuine and who is not.
The social media's habit of glorifying physical perfection has also played an increasing role in creating the demand for trichology services and has fueled its growth.
SUMMARY: WHAT IS IN STORE? HOW WILL TRICHOLOGY EVOLVE?
There is no doubt that the field and the time is ripe for major advances in the field. Much is needed in the field of:
- Elucidation of immune privilege disorders such as alopecia areata and possible biologicals for such diseases
- Cicatricial alopecia, and possible drugs for management to treat the fibroplasia
- Drugs to convert vellus hair to terminal hair
- Advances in instrumentation for follicular unit extraction and body hair transplantation
- More selective antiandrogens with less concern about impotence
- Stem cell treatment and cloning, which have remained in the realm of experimental treatment for long.
- Gan DC, Sinclair RD. Prevalence of male and female pattern hair loss in Maryborough. J Investig Dermatol Symp Proc. 2005;10(3):184–9.
- DeMuro-Mercon C, Rhodes T, Girman CJ, et al. Male-pattern hair loss in Norwegian men: A community-based study. Dermatology. 2000;200(3):219–22.
- Norwood OT. Male pattern baldness: Classification and incidence. South Med J. 1975;68(11):1359–65.
- Severi G, Sinclair R, Hopper JL, et al. Androgenetic alopecia in men aged 40-69 years: Prevalence and risk factors. Br J Dermatol. 2003;149(6):1207–13.
- Bakry OA, Moneim Shoeib MA, El Shafiee MK, et al. Androgenetic alopecia, metabolic syndrome, and insulin resistance: Is there any association? A case-control study. Indian Dermatol Online J. 2014;5(3):276–81.
- González-González JG, Mancillas-Adame LG, Fernández-Reyes M, et al. Androgenetic alopecia and insulin resistance in young men. Clin Endocrinol (Oxf). 2009;71(4):494–9.
- Mumcuoglu C, Ekmekci TR, Ucak S. The investigation of insulin resistance and metabolic syndrome in male patients with early-onset androgenetic alopecia. Eur J Dermatol. 2011;21(1):79–82.
- Cannarella R, Condorelli RA, Mongioì LM, et al. Does a male polycystic ovarian syndrome equivalent exist? J Endocrinol Invest. 2017.
- Weitz R. Rapunzel's Daughters: What Women's Hair Tells Us About Women's Lives New York: Farrar, Straus and Giroux; 2004.
- Hunt N, McHale S. Clinical review: the psychological impact of alopecia. Br Med J. 2005;331:951–3.
- Hunt N, McHale S. Reported experiences of persons with alopecia areata. J Loss Trauma. 2005;10:33–50.
- Hunt N, McHale S. Understanding Alopecia. London: Sheldon; 2004.
- Azziz R, Carmina E, Sawaya ME. Idiopathic hirsutism. Endocr Rev. 2000;21(4):347–62.
- Lipton MG, Sherr L, Elford J, et al. Women living with facial hair: the psychological and behavioral burden. J Psychosom Res. 2006;61(2):161–8.
- Keegan A, Liao LM, Boyle M. ‘Hirsutism’: a psychological analysis. J Health Psychol. 2003;8(3):327–45.
- Roche A, Sedgwick PM, Harland CC. Laser treatment for female facial hirsutism: are quality-of-life benefits sustainable? Clin Exp Dermatol. 2016;41(3):248–52.
- Cash TF. The psychological effects of androgenetic alopecia in men. J Am Acad Dermatol. 1992;26(6):926–31.
- Kranz D. Young men's coping with androgenetic alopecia: acceptance counts when hair gets thinner. Body Image. 2011;8(4):343–8.
- Yesudian P. Hail the Dermato-Trichologist! Int J Trichology. 2014;6(3):85.
- ASDS 2014 Survey on Dermatologic Procedures. Rolling Meadows, IL: American Society for Dermatologic Surgery; 2014.
- Trüeb RM. The difficult hair loss patient: A particular challenge. Int J Trichol. 2013;5(3):110–4.
- Eckert J. Diffuse hair loss and psychiatric disturbance. Acta Derm Venereol. 1975;55:147–9.
- Cash TF, Price VH, Savin RC. Psychological effects of androgenetic alopecia on women: Comparisons with balding men and with female control subjects. J Am Acad Dermatol. 1993;29:568–75.
- Maffei C, Fossati A, Rinaldi F, et al. Personality disorders and psychopathologic symptoms in patients with androgenetic alopecia. Arch Dermatol. 1994;130:868–72.
- Teutsch C. Patient-doctor communication. Med Clin North Am. 2003;87:1115–45.
- Patwardhan N, Mysore V. Hair transplantation: Standard guidelines of care. Indian J Dermatol Venereol Leprol. 2008;74, Suppl S1:46–53.