TREATMENT OF ALOPECIA
WITH CHINESE HERBS

by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Alopecia may arise from numerous causes, including stress reactions, hypothyroidism, exposure of the hair follicles to topically-applied chemicals, therapies used for cancer, and genetic male-pattern balding. The disorder is often classified by its specific manifestation, such as patchy balding (alopecia areata), total loss of head hair (alopecia totalis), or total loss of body hair (alopecia universalis). Alopecia areata and alopecia totalis frequently affect women, and the disorder may persist for several months to about a year, sometimes longer.

Generally, alopecia is interpreted by Chinese doctors as the result of a deficiency syndrome, specifically involving blood deficiency, with generation of internal wind or invasion of external wind that affects the head; the situation is sometimes complicated by blood stasis and/or blood heat. The belief that there is an influence of wind in the etiology of the hair loss is reflected in the Chinese name for the disease, which is youfeng, literally oil-wind. The reference to oil, which can also mean glossy, is an expression characterizing the smooth, shiny scalp appearance where the hair has been lost. The Chinese name has led to some humorous translations; in the package insert for Alopecia Areata Pills, the primary indication is for "grease hair dropping."

The underlying pathological processes cause the hair follicles to be undernourished. Blood deficiency can arise from poor diet, excessive use of drugs, the aging process, stress reaction (worry, anxiety, depression, which impairs spleen function and thereby reduces nurturing of blood), and debilitating diseases. Sudden hair loss, like other sudden health changes, is interpreted as a consequence of "wind;" in this case it is invading the channels that traverse the scalp.

A typical description of the cause of alopecia is presented in Practical Traditional Chinese Dermatology (1):

The hairs are the extension of blood, and the normal growth and development of long, pliable, and tough hairs depends on the sufficient supply of nourishment from ying and blood. If the supply of nutrients is reduced, the wind may be produced in the body to cause loss of hairs. Nervousness, depression, and mental instability may cause production of internal heat, and the excessive heat in the blood may produce wind and cause loss of hairs due to reduced nutrition supply, and such patients may show clinical manifestation of wind syndrome due to blood heat. In patients with chronic diseases and exhaustion of essence and blood, the deficiency of blood may also produce wind to cause loss of hairs, and such patients may show the clinical manifestation of wind syndrome due to deficiency of blood. In patients with their diseases wrongly treated or refractory to any treatment, the fresh blood can not be produced to nourish the hairs because of the stagnation of blood and obstruction of meridians, and such patients may show clinical manifestations of wind syndrome owing to blood stagnation.

According to the English-Chinese Encyclopedia of Practical Traditional Chinese Medicine (2),

Alopecia is mostly caused by deficiency of liver and kidney with subsequent failure of [blood to go up and nourish] the hair. The hair pores are open when the hair is poorly nourished, and wind invades the pores on the occasion. Therefore, deficient blood with wind [invasion] leads to hair loss. However, stagnation of liver qi and impaired qi mechanism will also result in hair loss because of the malnutrition of hair due to stagnation of qi and stasis of blood.

The same encyclopedia has an elaboration of the etiology of alopecia in the volume of dermatology (16):

This disease is often caused by deficiency of blood, which fails to cooperate with qi in nourishing the skin. The striae of skin and muscles in turn become loose, and the opening of the sweat glands is loose, hence, pathogenic wind intrudes from outside, causing blood-dryness and malnutrition of the hair. Besides, the mood of depression, stagnation of liver qi, and overwork may impair the heart qi and cause stagnation of qi and blood stasis so that qi and blood cannot nourish the hair, hence the occurrence of the disease; deficiency of the liver qi and kidney qi may also cause this disease, because the liver stores the blood whose state can be manifested by the hair, while the kidneys produce bone marrow which is also responsible for the growth of hair.

RECOMMENDED PRESCRIPTIONS

In Practical Traditional Chinese Dermatology, three basic formulas are recommended:

A slightly different presentation of patterns and formulas is offered in the book Manual of Dermatology in Chinese Medicine (3)

Again, the English-Chinese Encyclopedia of Practical Traditional Chinese Medicine offers yet another group of formulas, the first three for "blood-deficiency and wind-dryness" and the latter two for "activating blood flow to remove blood stasis:"

In this last group, Qibao Meiran Dan is the same as the Pill for Deficiency of Yin and Blood mentioned above. This Chinese name of this formula is translated in Formulas and Strategies (17) as "Seven-Treasure Special Pill for Beautiful Whiskers." The prescription is attributed to a master herbalist of the Ming Dynasty, Shao Yingjie, but it was recorded by Wang An, in his book Yifang Jijie during the early Qing Dynasty (1682 A.D.). By that time, the formula had become quite popular.

One can see that in virtually all formulations (the exception being the last two presented above), tonification therapy is important, but there are distinctly different groups of ingredients that are relied upon for different syndromes and by different authorities. Ginseng Nutritive Combination (Renshen Yang Rong Tang), similar to the decoction for qi and blood deficiency related above, is a well-known traditional prescription given for general weakness and nutritional deficiency; that formula has been recommended by Japanese doctors for treating alopecia (4).

While there are no individual herbs that stand out as being essential to the treatment of alopecia, there is obvious reliance on the ingredients of Siwu Tang (Tang-kuei Four Combination, comprised of tang-kuei, peony, cnidium, and rehmannia), as well as herbs that are characteristically recommended for preventing graying of hair (a condition also thought to be due to blood deficiency syndrome), notably ho-shou-wu, ligustrum, morus fruit, and biota leaf. Although mentioned only once among the ingredients for the above formulas, eclipta is also used for preventing greying of hair and is included in some of the formulas used in clinical trials, as described below. For blood stasis, red peony, cnidium, persica, and carthamus are the most frequently used. Wind-dispelling herbs are broadly selected from the range of available items, with dictamnus, chiang-huo, morus leaf, schizonepeta, vitex, typhonium, and green onion (congbai; Chinese chive) mentioned in the above formulas. Some herbs that have black color (the color of Chinese hair) are used: black sesame seeds, black soy beans (soja), and psoralea are examples. Cuscuta is mainly used for tonifying the kidney, a principle of therapy not much relied upon other than through inclusion of cooked rehmannia as part of the blood nourishing strategy.

An examination of the herb formulas reveals very few ingredients in each formula for dispelling wind (sometimes none) and no ingredients specific to calming internal wind other than the single mention each of gastrodia and hematite (this may have been included mainly as a blood nourishing agent). The emphasis on wind in the etiology of alopecia as described in modern texts appears to be more of an academic nod to the ancient name of the disease than to a persisting belief that wind is an important factor in the disease. As with the formulas recommended above, those prescriptions subjected to clinical trials rarely include wind-dispelling or wind-settling ingredients.

CLINICAL EVALUATIONS OF INTERNAL THERAPIES

Alopecia areata, the condition that is the subject of the clinical evaluations, can spontaneously resolve. Therefore, it is difficult to know the effectiveness of treatment in the absence of a carefully controlled study. The reports in the medical literature generally involve uncontrolled studies, which means that one can not separate out cases of improvements due to herb therapy from spontaneous remission. According to the reported results (summarized briefly below), with a treatment time of 1-3 months duration (though sometimes longer), the majority of cases treated are resolved or, at least, improved. An examination of formula ingredients reveals that tonic therapies, especially herbs that nourish the blood, are relied upon.

Shengfa Wan (literally, pill to generate hair), is a modification of Qibao Meiran Dan, made by adding Erzhi Wan (a formula comprised of just ligustrum plus eclipta). According to Formulas and Strategies:

This formula [Erzhi Wan] is widely used in China, both by itself and as an additive to other formulas when the liver and kidney yin need to be tonified. It is considered safe and relatively mild. It is often compared to Liuwei Dihuang Wan [Rehmannia Six Formula]....Erzhi Wan is considered by some to be superior in treating premature graying or loss of hair.

The complete formula, containing ho-shou-wu, ligustrum, eclipta, lycium, cuscuta, tang-kuei, achyranthes, psoralea, and hoelen, was made as large honey pills, 10 grams each, and administered three times daily (5). The pills, which provided about 20 grams of herbs in powder form and 10 grams of honey as binder, were administered before meals, unless digestive disturbance occurred, in which case the pill was given after meals instead. Treatment time was 1-3 months. It was stated that of 21 cases treated, 2 cases were cured, 8 markedly improved, and 3 significantly improved (with 8 cases not improved).

A similar formula, Shengfa Yin, a decoction comprised of ho-shou-wu, rehmannia, tang-kuei, schizandra, morus fruit, biota seed, ligustrum, and eclipta, was reported to cure 30 of 36 persons affected by alopecia areata, with 4 others improved (6). The obviously better results, compared to the report on Shengfa Wan, may have been due to use of a higher dosage form of administration and longer therapy (duration not specified in the report).

According to another report, all of 50 cases of alopecia areata treated could be cured within 9 weeks with daily ingestion of a decoction of ho-shou-wu, black sesame, soja, astragalus, gelatin, atractylodes, longan, and jujube, taken along with cystine (100 mg, three times daily), and topically applying concentrated decoction of morus bark (7). Specifically, 6 cases were resolved after three weeks, another 32 cases after 6 weeks, and the remaining 12 by 9 weeks. Cystine is important to protein structure and was given to promote good hair formation; it is an oxidized form of the common amino acid cysteine. The high rate of success might have been due to the combination of using a decoction plus applying a topical preparation; the role of cystine is questionable, and it is not included in the other trials.

In a large-scale study (8), the internal treatment for alopecia, Tuofa Zaisheng San, included ligustrum, ho-shou-wu, rehmannia, biota twig, salvia, schizandra, peony, tang-kuei, carthamus, cnidium, and chiang-huo, was given along with topical application of the drug minoxidil. According to the report, treatment time was 2-12 months, with 117 of 146 cases cured, and 11 cases improved. A follow-up after one year showed that there was relapse in only 10 cases. This formula is very similar to the patent remedy called Alopecia Areata Pills (Trichogen), which was developed during the 1970's and has been marketed worldwide since the 1980's. According to the package labeling, the formula is:

The herbs are extracted, formed into small pills (250 mg each), and recommended to be taken 6 pills each time, three times daily (daily dose of the extract is 4.5 grams), for a course of treatment of 600 pills (if taken continuously, 6 bottles of the product, over a period of 33 days). Since the body weight of the Chinese, at the time this package insert was written, was quite a bit lower than most Westerners, the dosage should probably be increased by as much as 50%. The package insert proclaims "satisfactory results" were attained with over 1,000 trial cases and that:

After treatment for a period of time, light color, newly grown, soft hair gradually becomes darker and black. But in a few occasions the patients have recurrence of baldness. In order to reduce the recurrence, one or two [additional] courses of treatment is necessary to ensure efficacy.

Alopecia that occurs in the elderly is responsive to treatment, according to one report (9). A double-blind placebo-controlled study of an anti-aging mixture named Huolisu, including astragalus, salvia, and ho-shou-wu, was conducted with 507 subjects, 287 receiving the herbs. The power of the placebo and the rate of spontaneous remission was here demonstrated, with nearly 35% of the control group showing some improvements in both subjective and objective measures. However, the herb treatment group had nearly 77% of patients showing improvements, including a reduction in alopecia during a 3 month trial.

TOPICAL TREATMENTS

Alopecia often occurs in individuals who are relatively healthy; they may suffer from substantial emotional stress and poor nutrition, but the most evident symptom-or the symptom of greatest immediate concern to them-is the alopecia. In such cases, topical treatments are deemed especially appropriate, because of the localization of the symptom. Also, since the hair follicles are just below the skin surface, topical treatment is deemed a means of rectifying the problem even if an internal therapy is also needed to improve the function of the internal organs, nourish the blood, and overcome disorders such as blood stasis.

There are three major approaches to topical treatment with herbs:

1. Use strong circulatory stimulants, such as hot pepper or ginger, to try and restore the scalp circulation.
2. Use blood-vitalizing herbs, such as those used in internal therapies, to promote microcirculation.
3. Employ herbs with a reputation for benefiting the hair, such as ho-shou-wu, morus fruit, or ligustrum.

The diversity of recommended topical treatments, which includes some that are not easy to explain by the usual interpretations of herb actions, makes it difficult to select one that would be workable, and most Westerners are not well disposed to making these unusual preparations and using them regularly, so only brief mention will be made here. In Practical Traditional Chinese Dermatology, three topical treatments are described:

• A mixture of dictamnus, biota leaf, ginger, crataegus, and angelica is made as a tincture and applied once or twice a day.
• Fresh slices of ginger are rubbed onto the bald area to produce a hot feeling, three times daily.
• Powder of chuanwu (a type of aconite) is mixed with vinegar or ginger juice and applied once a day to the bald area.

In Manual of Dermatology in Chinese Medicine, these topicals are mentioned:

• A mixture of biota leaf, zanthoxylum, and pinellia is made as a decoction and mixed with fresh ginger root juice, and applied to the affected area twice daily.
• A mixture of artemisia, chrysanthemum, mentha, siler, kao-pen, vitex, schizonepeta, and musk; make a decoction (musk is added separately) and wash the head with it; let it set in the head for 5 minutes, and repeat; then rinse with warm water.
• Cordyceps tincture is applied to the affected area 3-5 times daily.
• Brassica is powdered, mixed with oil to form an ointment, and applied to the affected area once daily.

In the English-Chinese Encyclopedia of Practical Traditional Chinese Medicine, vol. 16: Dermatology, these are suggested:

• Psoralea tincture (Bugu Zhiding), applied three times daily.
• Fresh ginger roots slice: rub the affected part rapidly.

According to the book Oriental Materia Medica (10), the herb swertia is "80% effective in treating all cases of hair loss." Research in Japan has shown that an extract of swertia (a relative of gentiana that is used frequently in the treatment of hepatitis) dramatically enhances the circulation to the skin when applied topically. This herb has been extracted in an essential oil base (geraniol) in the hair tonic product Gentax that is produced and widely used in Japan and is now available in the U.S. (via Kenshin Trading Company, in Torrance, California). The crude herb swertia is rarely exported from the Orient, so is difficult to obtain other than in this prepared form.

A popular Chinese "hair growth" tincture-Lily Brand Hair Tonic-is made with extract of capsicum (and other undisclosed ingredients); this is similar to the home remedy made by the Chinese with red chilies soaked in wine. The action of capsicum, like that of ginger and zanthoxylum, is to promote local circulation via "counterirritant" action (spicy components cause the vessels to dilate).

The largest clinical evaluation of a topical treatment for alopecia involved over 8,300 patients (11). The liquid, known as "101 Hair Regenerating Alcohol" (which has been made available in Chinese shops in the U.S.) contains ginger, ginseng, astragalus, tang-kuei, cnidium, persica, carthamus, salvia, and some undisclosed ingredients. The liquid was applied 2-3 times per day, for 2-3 months. It was claimed in the report that the "cure" rates for alopecia areata, alopecia totalis, and alopecia universalis were 91.7%, 83.4%, and 62.1% respectively. Less than 6% of those treated in each category failed to respond to the treatment.

In another large-scale clinical evaluation, 822 patients suffering from alopecia areata or alopecia totalis were treated with the topical formula, Suxiao Ketuling Shengfa Jing (12). The ingredients, extracted in alcohol, include capsicum, eclipta, ho-shou-wu, biota twig, drynaria, ginseng, carthamus, and cnidium. According to the report, 630 patients were cured and others had partial regrowth of hair; only 48 patients (less than 6%) showed no response.

Yet another topical treatment that was evaluated is Jumei Renshen Shengfalu (13). The liquid extract of biota twig, drynaria, ginseng leaf, and melia was applied topically for 88 cases of alopecia areata resulting in improvement in 71 of those cases, and 74 cases of alopecia seborrheica, with improvement in 52 cases. A control group was treated with a "Western" style topical liquid containing salicylic acid, resorcinol, glycerin, and carbolic acid. The effective rate for that treatment was only 48%. Both the herb and drug liquids were applied twice daily for 2-3 months.

HAIR LOSS ASSOCIATED WITH CHEMOTHERAPY

Chemotherapy for cancer and certain other drug treatments may cause alopecia, which is difficult to prevent while the drug is being used. In books about treating side effects of cancer therapy (e.g., Cancer Treatment with Fu Zheng Pei Ben Principle (14) and Treatment of Toxic Side Effects Resulting from Radiation and Chemotherapy (15)) there is no mention of alopecia. Nonetheless, ITM received reports of some cases of patients undergoing chemotherapy that did not result in hair loss or resulted in less hair loss than was expected (these cases were unexplained by Western doctors in the U.S.); the patients were using Chinese herb tonic formulas to help prevent leukopenia. One of the proposed mechanisms involved in overcoming leukopenia is promoting microcirculation in the bone marrow; the herbs that accomplish this, such as millettia, hu-chang, and salvia (see: Millettia (Jixueteng)) may also promote microcirculation in the skin and, thereby, help alleviate alopecia. So, there is some preliminary and circumstantial evidence, as well as theoretical basis, to expect that this type of alopecia might be prevented by early intervention with Chinese herbs. When the drug therapy or radiation is stopped, the combination of tonic herbs and topical application of circulation-promoting agents may help to more quickly restore hair growth in those who begin the herb treatment after hair loss has already occurred.

REFERENCES

1. Li Lin, Practical Traditional Chinese Dermatology, 1995 Hai Feng Publishing Company, Hong Kong.
2. Xu Xiangcai (Chief ed.), The English-Chinese Encyclopedia of Practical Traditional Chinese Medicine, vol. 6: Therapeutics of Acupuncture and Moxibustion, 1990 Higher Education Press, Beijing.
3. Shen De-Hui, Wu Xiu-Fen, and Nissi Wang, Manual of Dermatology in Chinese Medicine, 1995 Eastland Press, Seattle, WA.
4. Otsuka K, et al., Natural Healing with Chinese Herbs, 1982 Oriental Healing Arts Institute, Long Beach, CA.
5. Jiang Haiyan, Treatment of 21 cases of alopecia with Shengfa Wan, Sichuan Journal of Traditional Chinese Medicine 1987; 5(4): 47-48.
6. Lan Ke and Chen Huiren, Treatment of 36 cases of alopecia areata with Shengfa Yin, Hubei Journal of Traditional Chinese Medicine 1988; 6: 19.
7. Tang Bingguang, Treatment of alopecia areata mainly with Chinese herbs, Hunan Journal of Traditional Chinese Medicine 1987; 3(3): 55, 61.
8. Lu Jingbin, Treatment of 146 cases of hair loss with Tuofa Zaisheng San and Shengfa Shui, Journal of Integrated Traditional and Western Medicine 1987; 7(7): 438-439.
9. Du Xin, et al., Antiaging effect of Huolisu-A controlled, double-blind study of 507 subjects of middle and old age, Chinese Journal of Integrated Traditional and Western Medicine 1986; 6(5): 271-274.
10. Hong-Yen Hsu, et al., Oriental Materia Medica: A Concise Guide, 1986 Oriental Healing Arts Institute, Long Beach, CA.
11. Zhao Zhangguang, Treatment of 8324 cases of alopecia with 101 Hair Regenerating Alcohol, Journal of Traditional Chinese Medicine 1988; 29(9): 693-694.
12. Zhang Zhongxing, Treatment of 822 patients with alopecia areata with Suxiao Ketuling Shengfajing, Hubei Journal of Traditional Chinese Medicine 1991; 13(6): 9-10.
13. Xiang Xirui and Xue Changhua, Treatment of alopecia with Jumei Renshen Shengfalu, Chinese Journal of Integrated Traditional and Western Medicine 1989; 9(1): 39.
14. Pan Mingji, Cancer Treatment with Fu Zheng Pei Ben Principle, 1992 Fujian Science and Technology Publishing House, Fujian.
15. Cheung CS, Kaw UA, and Harrison H (compilers), Treatment of Toxic Side Effects Resulting from Radiation and Chemotherapy by Traditional Chinese Medicine, 1980 Traditional Chinese Medical Publisher, San Francisco, CA.
16. Xu Xiangcai (Chief ed.), The English-Chinese Encyclopedia of Practical Traditional Chinese Medicine, vol. 16: Dermatology, 1990 Higher Education Press, Beijing.
17. Bensky D and Barolet R, Chinese Herbal Medicine: Formulas and Strategies, 1990 rev. ed., Eastland Press, Seattle, WA.

    June 1999