A Global Perspective on a Strictly Medical Discipline
Ralph Michel Trüeb , Sergio Vañó-Galván , Daisy Kopera , Vicky ML Jolliffe , Demetrios Ioannides, Maria Fernanda Reis Gavazzoni Dias , Melanie Macpherson, Javier Ruíz Ávila, Aida Gadzhigoroeva, Julya Ovcharenko, Won-Soo Lee, Sundaram Murugusundram, Sotaro Kurata, Mimi Chang, Chuchai Tanglertsampan
History
“The medical practice is divided among them (the Egyptians) as follows: each physician is for one kind of sickness, and no more, and all places are crowded with physicians: for there are physicians for the eyes, physicians for the head, physicians for the teeth, physicians for the stomach, and for internal disease.”
Herodotus, Histories 2,84
Few dermatologic problems carry as much emotional overtones as the complaint of hair loss, and the best way of alleviating the distress related to hair loss is to treat it effectively. In fact, one of the oldest medical professions documented in Greek historian and traveler Herodotus’ “Histories” is the Egyptian physician who specialized on diseases of the head. Herodotus (484–425 BC) was the first historian known to have broken from the Homeric tradition to treat historical subjects as a method of investigation by collecting his materials systematically and critically and arranging them into a historiographic narrative. Thereby, Herodotus provides us with much information about the nature of the world and the status of science during his lifetime [1].
The most remote representations of hair loss that can be traced back around 30′000 years to wall engravings in a prehistorical cave are somewhat reminiscent of today’s categorization of pattern hair loss, and the story is still ongoing in our modern society [2]. The first written document on the importance of making a distinction between inflammatory alopecia (tzaraat, Hebrew תערצ, breaking out on the head) from common baldness dates back to the Old Testament. The term tzaraat describes disfigurative conditions of the skin, hair of the beard and head. All variations are mainly referred to in chapters 13–14 of Leviticus (written ca. 538–332 BC) [3].
And yet, from the 4′000-year-old medical papyri of the ancient Egyptians down to modern times, human hair growth and color have been the object of superstition and mystery, besides arousing cosmetic and medical interest [4]. For the prevention or treatment of hair loss, countless herbal solutions, oils, lotions, magic pills, and even spiritual invocations have been advocated. What is remarkable about the history of hair loss cures is that despite the more recent genuine advances in effective medical treatments, hair cosmetics, and surgical procedures, phony hair loss solutions continue to be marketed today with an amazing success. Despite their outrageous claims, most lack scientifically measurable efficacy in preventing hair loss or promoting hair growth. As much today as in biblical times, people are so desperately concerned about their hair loss that they want to believe some miracle cure or some charismatic healer will help them.
The first genuine scientific studies on hair probably began when the English natural philosopher and polymath Robert Hooke (1635–1703) studied the hair shaft under the microscope [5] and the Italian biologist and physician Marcello Malphighi (1628–1694) described the anatomy of the hair follicle in his treatise “De pilis observationes” [6]. However, the biology of hair growth was not understood at this time. In search of information before engaging in the development of a new hair growth-promoting agent, makers of cosmetics turned to the medical faculty and received only very vague indications. When questioned, doctors remained evasive, and the hair was thus abated to malpractices of all sorts. The charlatan chemists of this age were as ineffectual but significantly more risky than their physician colleagues. With certain lotions in which toxic ingredients playing a role, accidents must have occurred frequently, and the French chemist Antoine Laurent de Lavoisier (1743–1794) urged for regulatory control of ingredients, which was never realized. France held the monopoly for miraculous elixirs and exported to America its “Eau de Ninon de L’enclos,” named after a beautiful courtesan whom had preserved her hair to the age of 85 years [7]. The French physician Auguste Caron, who published an “Encyclopedia of Beauty” [8] in 1806, warned the women of fashion of his time against the potential toxicity of products of mysterious origin, as a wretched woman had been driven to madness after using a tonic called “Eau de Chine.” The products remained just as dubious, whilst acquiring sentimental names as befitting the Romantic period. With the advance of medical technologies, ultraviolet light-emitting lamps, electrical scalp stimulators, and vacuum-cap machines have joined the repertory of treatments alleged to help stimulating the follicles to grow hair.
Probably the first sound scientific attempt toward hair restoration was the demonstration that it was possible to transplant hair from a hair-bearing to a non-hair bearing area in 1822 by the German medical student Johann Dieffenbach (1792–1847) [9]. However, it was not until 1939 that the era of hair transplantation began in earnest with the efforts of the Japanese physician Shoji Okuda (1886–1962) and later the New York dermatologist Norman Orentreich. Today, we hardly know anything about the medical background of Shoji Okuda, and his seminal work on hair transplantation remained virtually unknown outside Japan because of the outbreak of World War II. Moreover, the papers were written using old kanji (Japanese pictographs) and are consequently unintelligible even to modern Japanese medical readers. It was only in 2004 that the “Okuda Papers” were translated into English by Yoshihiro Imagawa, a retired gynecologist trained in the USA [10]. Okuda developed a circular scalpel for the purpose of transplanting hair into areas of alopecia [11]. In 1959, Norman Orentreich established the pivotal theory of donor dominance of the hair transplant. The basis of the theory was that plugs of hair follicles taken from the occipital scalp would continue growing when moved to the balding frontal scalp because those hair follicles were genetically programmed to do so. The concept became the foundation for the entire ensuing field of hair restoration surgery, and for the following decades, dedicated surgeons all over the globe have worked on refining the method with today close to natural results [12].
The authors have no ethical conflicts to disclose.
