A gyNl-s*: 
ON f, 
ALOPECIA AREATA 
AND ITS 
TREATMENT 
BY 
L. DUNCAN BULKLEY, A.M., M.D. 
NEW YORK 
Reprinted from The Medical Record, March 2, 1889 
NEW YORK 
TROW’S PRINTING AND BOOKBINDING CO. 
201-213 East Twelfth Street 
1889 A Clinical Study on Alopecia Areata, 
and its Treatment.' 
By L. DUNCAN BULKLEY, A.M., M.D., 
NEW YORK. 
Reprinted from The Medical Record, March 2, 1889. 
Although not a dangerous affection, and one ordinarily 
thought of mainly in connection with cosmetic effect, 
alopecia areata may, and often does, cause an amount of 
annoyance and distress which is as hard to be borne as 
actual pain. While in some instances it may be but a 
transient affair, and may consist of but one or more 
small, perfectly bald spots, which are readily concealed by 
hair of ordinary length, in other instances it may prove 
most intractable, lasting years, involving large and con- 
spicuous areas, and even removing every hair from the 
body, including eyebrows and lashes; in its fullest de- 
velopment it causes a very considerable disfigurement, 
and even in moderately severe cases the baldness is so 
striking that it becomes a veritable cross to the sufferer, 
from the attention it attracts and from the uncertainty as 
to the nature and cause of the affection. 
It may be well, therefore, for us to give a little con- 
sideration to this complaint as it appears clinically among 
us, and to indicate the treatment most successful in 
remedying the disease. 
I shall not attempt at all to enter into a discussion of 
the nature or causation of alopecia areata, which has been 
so ably presented by Robinson3 in his article before the 
1 Read before the New York State Medical Society, February 7, 
1889. 
a Robinson : Transactions of the Ninth International Congress, 
Washington, 1887, vol. iv., p. 2-ji. 2 
Ninth International Congress in 1887. The subject is a 
great one, about which much has l)een written in ad- 
vocacy of its neurotic origin on the one hand, and of its 
parasitic nature on the other. A further discussion of 
the matter here would be fruitless, and foreign to the 
purpose of the paper, which is simply to present personal 
clinical experience in the disease, with an analysis of the 
cases which have been under my observation and care. 
Alopecia areata is presented for treatment much less 
frequently than I had supposed, previous to making my 
inquiries into the statistics of cases of skin disease which 
have been under my care. In my first analysis of one 
thousand cases of skin disease,1 I find but four instances 
of alopecia, and of these only one was recorded as alopecia 
areata, one of alopecia partialis, and the other two had 
no special designation. In my next series of cases ana 
lyzed 8 not a single instance of the complaint was recorded 
among 617 cases of skin disease; and in my third analysis 1 
only one patient with alopecia areata was seen among 
774 cases of skin disease. In a subsequent study and 
rej>ort on 8,000 cases of skin disease in private and pub- 
lic practice,4 there were 46 cases of alopecia areata; of 
these, 32 occurred among 2,583 cases in private practice, 
1.24 per cent., and but 14 cases were seen in public 
practice among 5,417 cases, or only 0.25 per cent, of all 
skin cases. 
On examining carefully later records I now find data 
relative to 119 cases of alopecia areata, occurring among 
12,725 cases of skin disease, seen in private practice, at 
the New York Hospital, and at the Skin and Cancer 
Hospital. I have excluded all of the earlier records of 
skin cases seen in other institutions, localise the original 
data are not accessible at present. 
The proportion of cases of alojiecia areata to the whole 
number of patients is here seen to lie 0.94, or not quite 
1 American Practitioner, May, 1875. 
* Ibid., April and May, 1876. 
* New York Medical Journal, April and June, 1877. 
4 Archives of Dermatology, vol. viii., No. 4, 1882. 3 
one per cent. But when we come to examine the rec- 
ords of cases seen in private practice as compared with 
those seen in public institutions, the difference will be 
found very striking. Thus, among these 119 cases, 
only 32 were observed in public practice among 
7,086 cases, it forming there but 0.45 per cent., whereas 
in private practice there were 87 instances among 
5,639 cases of general skin disease, or something over 1.54 
per cent. The reason for the larger percentage of cases 
occurring among the public cases now analyzed than 
among those previously referred to, is found partly in the 
fact that in the hospitals last mentioned the grade of 
patients is higher than in many other public institutions, 
approaching more nearly to the class treated in private 
practice. 
It will be seen that in these statistics the proportion of 
cases of alopecia areata was more than three times greater 
in private than in public practice, namely* 1.54 per 
cent, to 0.45 per cent. This difference in relative fre- 
quency cannot be wholly attributed to the greater atten- 
tion which would be paid to the complaint among the 
former class of patients, for the appearances presented by 
the bald, smooth, white patches are so striking that they 
cannot escape attention, and my experience has been 
that the plainer classes are often quite as solicitous about 
the disease, when present, as are the rich. I believe alo- 
pecia areata to be relatively much less frequent among 
the poor than among the rich, which is, in a certain 
measure, an argument against its supposed parasitic 
origin, and in favor of its neurotic nature. 
In the large statistics gathered by the members of the 
American Dermatological Association, almost entirely 
or very largely from public practice, the disease forms 
only about 0.64 per cent., corresponding more to that 
observed by me in public practice. It seems, however, 
to be somewhat more frequent in other countries, as Me • 
Call Anderson 1 gives nearly two per cent, among his cases, 
•McCall Anderson: A Treatise on Diseases of the Skin, p. 44. 
London, 1887. 4 
and Crocker1 says that his statistics yield about the 
same proportion of cases. 
Referring now to the 119 personal cases already men- 
tioned, we will find many points of considerable interest 
in them, as the histories of almost all of them have been 
preserved. 'The following table presents the ages of the 
patients when applying for treatment: 
Table I.—Ages of One Hundred and Nineteen Patients 
with Alopeeia Areata. 
Age. 
Males 
1*'EMA1.ES. 
Grand 
total. 
Private 
practice. 
Public 
practice. 
Total. 
Private 
practice. 
Public 
practice. 
Total. 
5 years and under . 
1 
1 
1 
1 
2 
5 to 10 years 
I 
I 
4 
3 
7 
8 
to to 15 years 
6 
6 
5 
1 
6 
12 
>5 to 20 years. 
3 
1 
« 
3 
4 
7 
11 
20 to 25 years 
7 
7 
>4 
4 
I 
5 
•9 
25 to 30 years....... 
12 
5 
>7 
X 
I 
2 
>9 
30 to 35 years 
IO 
2 
12 
3 
2 
5 
>7 
35 to 40 years 
12 
1 
•3 
4 
I 
5 
18 
40 to 45 years 
2 
2 
4 
2 
2 
(, 
45 to 50 years 
1 
X 
I 
50 to 55 years 
.1 
3 
3 
X 
I 
4 
S5 to 60 years.... 
60 to 65 years 
I 
I 
I 
Unknown 
1 
I 
X 
Total 
59 
*9 
78 
28 
»3 
41 
119 
It will lie noted here that the number of the males is 
almost double that of the females, seventy-eight to forty- 
one. 
'Hie ages of the patients will lie found to vary greatly, 
from early childhood to over sixty years of age, but the 
disease is found to be relatively rare in either extreme of 
life. The youngest patient was a little girl of four and a 
half years, now under treatment, who had had the 
disease since a few months of age. The oldest patient was 
a gentleman of sixty-one, who had been affected several 
times; the first attack occurred thirty-nine years pre- 
viously, the second twenty years previously, and the third 
attack began six months before his visit. 
1 Crocker. Diseases of the Skin, p. 609. London, 1888. 5 
Taking the years in decades, it will be found that there 
were comparatively few cases during the first ten years of 
life, but ten patients in all; this number is relatively small, 
considering the large number of individuals living at that 
age. It is a little curious also that of these ten cases, 
eight were in females, whereas in the total statistics the 
males were so largely in excess; in the next decade the 
females were again in excess, by three. I think that the 
reason for the larger proportion of females during these 
earlier periods of life can only be explained by the greater 
delicacy of their nervous organism at this time, taken in 
connection with the nervous theory of the disease in ques- 
tion. 
The third decade, that between twenty and thirty years 
of age, presents by far the largest share of all the cases of 
alopecia areata, namely thirty-eight, or almost one-third of 
the entire number analyzed. And here is seen another strik- 
ing fact in regard to sex, namely, that during this decade 
the proportion between the sexes is exactly reversed from 
that which was observed in the first decade of life; namely, 
that the males are in very great excess, instead of the 
females. Thus, we find here thirty-one males to but seven 
females ; namely, more than four to one ; exactly the re- 
verse of that seen in the first decade, when there were 
four females to one male. If any supposition or deduc- 
tion can be drawn from so small a number of cases, is it 
not that during this busy period in men’s lives, when the 
cares of life begin to press, it is most likely that a nervous 
affection of this nature should develop? 
In the fourth decade, that from thirty to forty years of 
age, we find still a large proportion of the cases, namely, 
thirty-five, more than in the first two decades together. 
Here the males are two and a half times the number of 
the females, namely, twenty-five to ten, the figures still 
supporting the nervous theory of the affection. In the 
later periods of life the disease is seen to be very much 
less frequent—indeed, it is rarely met with after fifty years 
of age. We find, then, that no less then seventy-three 
patients, or over sixty-one per cent, of the cases, occurred 6 
between the ages of twenty and forty. A negative argu- 
ment against the alleged parasitic nature of the complaint 
is found in this fact, as it is well known that vegetable 
parasitic diseases belong largely to early youth, and are 
comparatively infrequent in adult life. 
In the preceding table the ages of the patients were 
given at the time when they first presented themselves for 
treatment; this, however, does not exactly represent the 
age at which the disease appears, for in some of the pa 
tients it had existed for a considerable time l)efore apply- 
ing for relief. The following table, (II.) gives the alleged 
ages at which the disease developed in those patients in 
regard to whom a record is found of the fact, namely, in 
ninety-seven cases. 
Fable II.--Age at which Alopecia Areata Commenced in 
Ninety seven Cases. 
Age. 
Walks. 
1 
p 
Females. 
Grand 
total. 
Private 
practice. 
Public 
practice 
Total. 
’rivate , Public 
racticc. practice. 
Total. 
5 years and under ... 
2 
I 
3 
2 
2 
5 
5 to to years 
3 
3 
4 
4 
8 
1 1 
to to 15 years 
8 
8 
5 
I 
6 
«4 
15 to 20 years 
4 
2 
6 
2 
2 
4 
IO 
20 to 25 years 
8 
2 
IO 
4 
O 
4 
*4 
25 to 30 years 
‘3 
I 
M 
I 
1 
15 
30 to 35 years .. 
4 
2 
6 
3 
I 
4 
IO 
35 to 40 years 
7 
7 
5 
5 
12 
40 to 45 years 
O 
I 
1 
I 
* 
2 
45 to 50 years 
I 
i 
I 
to 55 years 
3 
3 
.3 
'iota! 
53 
9 
62 
27 
8 
97 
In looking at this table we see that the figures still cor 
roborate the deductions drawn from the preceding table. 
Thus, of the ninety seven cases in which the age of the pa 
tient at the commencement of the disease was recorded, 
in no less than twenty-nine patients, or thirty per cent., it 
l>egan between the ages of twenty and thirty years, and of 
these twenty-nine patients, twenty-four were males and five 
were females. 
Table III. exhibits the duration of the complaint t>efore 7 
the patient came under treatment. It would be very in- 
teresting to give also a table of the entire duration of the 
disease, but, unfortunately, so many of the cases pass 
from notice, especially in public practice, before a per- 
fect cure is obtained, and so many patients are seen in 
consultation, or but a single time, that it is very difficult 
to secure accurate statistics on this point. From this 
table, however, we learn that the affection is by no means 
a brief or transitory affair, but that the baldness, which 
may begin with a single insignificant spot, may increase 
and remain, often resisting all treatment even for many 
years. 
Table III.—Duration of Alopecia Areata in Ninety-three 
Patients. 
Males. 
Females. 
Grand 
total. 
Duration. Private 
practice. 
Public 
practice. 
.Total. 
i rrivate Public ... . 
practice, practice. 0 
i month and under .. | i 
I 
S 3 8 
9 
i to 2 months 2 
I 
3 
4 .. 4 
7 
2 to 3 months ; 7 
7 
7 
3 to 4 months 1 
I 
2 
2 
4 to 5 months 2 
2 
I . . I 
3 
5 to 6 months 5 
5 
2 . . 2 
7 
6 months to 1 year ... 8 
1 
9 
3 2 5 
14 
1 to 2 years 5 
I 
6 
2 2 
8 
2 to 3 years 3 
I 
4 
21 3 
7 
3 to 4 years 3 
2 
5 
4 .. 4 
9 
4 to s years j 3 
3 
3 •• 3 
6 
5 to 10 years 6 
6 
.. | .. 
6 
10 to 15 years 1 
I 
2 
2 
15 to 20 years 2 
2 
2 
20 to 25 years 2 
2 
a 
25 to 30 years 1 
1 
t 
30 to 35 years 
35 to 40 years 1 
1 
1 
Total 53 
8 
61 
| 26 j 6 32 
93 
Of the cases here analyzed, namely, ninety-three, where 
the duration was recorded, thirty-five, or nearly half, had 
lasted six months before coming under treatment; in 
fourteen others the disease had existed between six months 
and a year; in eight it had lasted between one and two 
years; in seven between two and three years; and in 
nine between three and four years, and so on ; while some 8 
cases are recorded as of twenty, twenty five, and even 
thirty years’ duration. 
Alopecia areata, however, will occasionally be seen to 
be quite self-limited, or rather to get well spontaneously 
without medical aid. In a number of instances among 
these cases there is record of former attacks, where the 
bald spots have become perfectly covered without treat 
ment, in a varying space of time from a few weeks to 
some months; the disease has then again developed, 
perhaps, after an interval of months or years, persisting 
then, in spite of treatment, for some considerable time. 
In other patients, suffering from quite different skin affec- 
tions, we also occasionally get the history of one or more 
attacks of alopecia areata which have recovered sponta 
neously, and not returned up to the date of observation. 
But in my exj>erience this spontaneous recovery is rela 
tivelv rare, and in the larger share of instances it is not 
permanent. 
The longest period during which 1 have observed a 
case is in connection with that of a young gentleman now 
nearly thirty-nine years of age, whom I first saw something 
over twelve years ago. The disease had l)egun in him 
at two years of age, when the hair l)egan to come out in 
spots, until within a year or two he had lost all the hair 
and eyebrows. He wore a wig until fifteen or sixteen 
years of age, there being almost no attempt at hair re pro 
duction, when, after spending a little time at Richfield 
Springs, the hair reappeared over almost the entire scalp, 
and he l>egan to grow beard and whiskers, which at nine 
teen years of age were full and natural. Affairs remained 
in this condition until he was twenty six years of age, when 
alopecia areata appeared in the beard, and soon new spots 
developed, until, when seen nine months later, al>out one- 
fourth of the hairy surface of the face and scalp was l>e 
reft of hair. In spite of pretty diligent treatment the 
trouble remained, and increased until he became almost 
entirely bald on the scalp and face, including the eye- 
brows and lashes, and he lost the hair also from the body 
and limbs, including axillae and pubes. From this relapse 9 
lie has never recovered, for, although the hair regrows to 
a slight degree here and there, he is still obliged to wear 
a wig, and there is almost no reproduction of the hair on 
the face. He, however, after the first few months, has 
never been very diligent in treatment, and has always been 
burdened with a rather vexatious business, and has also 
had considerable depressing nervous influences in his 
family relations. 
Among the cases here analyzed there occur thirteen 
cases—six males and seven females—in whom the disease 
was almost universal. Several of these recovered en- 
tirely ; in one instance, a man acquired syphilis shortly 
after the hair had completely regrown from the alopecia 
areata, and within a few months the hair again fell, this 
time from the syphilis, in a very characteristic manner, 
quite different from that before presented, and again it 
regrew perfectly under anti-syphilitic treatment. 
The limits of this paper do not permit of a further 
analysis of the cases, nor of the presentation of individual 
cases, many of which present points of very great interest, 
and I will pass to a brief consideration of the therapeu- 
tical aspect of the subject. 
Successful treatment must ever depend upon a correct 
knowledge of the clinical history and nature of the dis- 
ease, and a few words may be added in regard to this 
latter, without attempting, however, to enter the subject 
at all exhaustively. 
From what has preceded it is readily seen that I be- 
lieve in the nervous origin and nature of alopecia areata. 
I may say that I have examined a large number of the 
hairs taken from patients with this affection, as also 
scales scraped from the surface, and have always failed 
to detect any parasitic elements; and I may add that in 
no single instance has the disease been presented to me 
in a manner to show contagion, as occurs constantly in 
favus and ringworm, and no two of my cases occurred in 
the same family. 
Time does not permit of the mention, or even of analy- 
sis, of the various researches on alopecia areata, and 10 
opinions concerning the disease. I may state, however, 
that Robinson, in the article referred to, shows pretty 
conclusively the untenability of the parasitic theory of the 
disease ; but he also argues, though less forcibly, against 
its nervous origin. Robinson claims to have found the 
real cause of alopecia areata in micrococci, having “ their 
seat specially in the lymph-vessels; that they give rise to 
inflammatory changes in the corium, and frequent coagu- 
lation of fibrine in the lymph and blood-vessels.” He 
lielieves that “the interference to the growth of the hair 
would seem to depend, partly at least, upon the thick 
ened blood vessel walls, and, in recent cases, also upon 
the presence of coagula in the arteries and lymph-vessels, 
interfering with the nutrition-supply. If an artery should 
be closed, the hair could fall out very suddenly in an area 
of considerable size, namely, the area supplied by that 
vessel; or a considerable extent of lymph-vessels could 
be clogged, and the same result could follow.” 
The theory is a plausible one, and if these observations 
as to the existence of micrococci deep in the corium are 
confirmed by others, it may possibly be found that they 
have some pathogenetic relations as to the ultimate causa 
tion of the disease. But, on the other hand, even if 
these foreign bodies were found to be present, it by no 
means follows that they are a primal cause of the disease 
in question. It is not claimed that they are acquired by 
infection from other cases, and the question arises as to 
whether they are not accidental, or a result rather than a 
cause of the disease under consideration. A theoretical 
argument has little worth in matters such as this, and at 
any rate we must wait further researches on the subject. 
But even if these micrococci are an element of causa- 
tion, the same arguments hold here as in other diseases, 
such as pneumonia, where they are detected, namely, that 
some condition of system or of the tissues is necessary in 
order that such microties may find a footing and effect a 
development. 
This brings us, therefore, to what I believe to lie the true 
elements to be considered in alopecia areata, namely, the 11 
constitutional, and especially the neurotic, aspects of the 
cases. In proportion as I have regarded these in prac- 
tice, so far have I had success in removing the alopecia 
areata, both at the time and permanently ; whereas purely 
local treatment has never, in my hands, yielded thoroughly 
satisfactory results. 
I need not dwell long upon the actual methods and 
details of treatment, for they are such as will readily 
suggest themselves when a correct knowledge of the 
true nature of the complaint is obtained and borne in 
mind. 
Patients with alopecia areata should be put in the best 
possible condition hygienically ; for, although they gener- 
ally seem to be in good health, careful investigation will 
often show some departure from the normal condition 
which has more or less bearing upon the disease. Thought 
must be especially directed toward nerve nourishment, 
and all my cases of late years which have done the best 
have been treated on this plan. The fats and phosphates 
should be increased in the dietary, and I always encourage 
largely the use of fresh butter, cream, fat of meats, etc. 
Milk is also of great service, if well borne ; but, as I have 
fully explained elsewhere, this does not agree well with 
adults when taken in connection with other food. I di 
rect it therefore to be taken absolutely alone, in the inter- 
vals between meals, say one hour before each meal, and 
at bedtime, provided this is three or four hours after the 
evening meal. The idea is, that as milk contains all the 
elements of nutrition, and is the substance from which the 
hair was originally grown, it will best aid in its later repro- 
duction and nutrition. 
The phosphates are best found in whole wheat, and I 
encourage the use of whole wheat bread, also crushed 
wheat with cream, and any other preparation in which 
the phosphates abound; fish I believe to be beneficial in 
these cases, and I urge its use once daily. 
'I'he medicinal treatment is based on the same principle, 
and my best results have been obtained under the free 
and continued administration of strychnia with phosphoric 12 
acid. Arsenic is of moderate value, and should l>e given 
in alternation with the former. Cod-liver oil is also valu- 
able, especially in patients who cannot or will not take the 
fats in their dietary; and some of the emulsions, with a 
large proportion of phosphates, serve the double purpose 
above indicated. 
Locally, the whole treatment is summed up in the single 
idea of stimulation of the diseased patches. While para- 
siticides are not actually called for by any local parasite 
present, experience has shown that many of the remedies 
used for this purpose are also of benefit in alopecia areata. 
Bichloride of mercury, in a strength to moderately excite 
the skin, is frequently the best application; but my pref- 
erence is for veratria in ointment, of a strength of five to 
ten or more grains to the ounce. Croton-oil, strong 
carbolic applications, aeetum cantharidis, capsicum, and 
other stimulating applications may also be used with ad 
vantage. 
In conclusion, however, I am j>ositive that the l>est re 
suits in the management of this often troublesome affection 
will be reached when it is looked upon, not as a local 
affair, but as a manifestation of a constitutional derange 
ment, having its basis in lowered vitality of the nervous 
system. 
4 Kast Thirty-skvknth Stkikt.