SOME SUCCESSFUL METHODS OF TREATING ALOPECIA 
AND ALOPECIA AREATA. 
By A. H. OHM ANN-DU vIESNIL, 
Professor of Derm tology and Syphilology in the St Louis College of 
Physicians and Surgeons. 
Reprinted from the July, i8q2, number of the New Orleans Medical and Surgical fournal. 
Alopecia and alopecia areata are diseases of the s-calp 
which have always interested dermatologists, and the problems 
connected with these conditions have acquired a new impetus,, 
of late years, by reason of the extensive studies which have 
been directed toward them. The questions which have been 
considered mostly are the etiology and the treatment of these 
conditions. These questions are interdependent to a great 
degree, and for that reason it may not be regarded as inoppor- 
tune to devote a few words to the consideration of the etiology 
of these diseases before devoting the major portion of this 
paper to the subject matter pure. As the etiology and consid- 
eration of the causes leading to the diseases, of whose suc- 
cessful treatment I propose speaking, have a considerable in- 
fluence upon the adoption of successful therapeutic measures, 
I will give a brief resume of these questions, more especially 
as they have been the topics of many long and unsatisfactory 
discussions, and are still regarded as being in a great measure 
sub judice. 2 
In regard to the etiology, there exists some difference of 
opinion, and the advocates of the different theories advanced 
may be roughly divided into three groups, viz.: Those con- 
tending that all cases of these diseases are of parasitic origin; 
those who contend that the origin of these troubles is of a 
neurotic character, and those who are inclined to favor the 
one or the other, according to the particular indications pre- 
sented in each individual case. The upholders of the para- 
sitic theory have made a strong case, apparently, but their 
arguments possess certain inherent defects which are of such 
a nature as to considerably invalidate their claims. The 
evidence is far from convincing in a large number of instances, 
and we have added to this the suppression of the negative 
cases of such experiments as do not tend to support the view 
which is advanced. The fact that strong antiseptics, locally 
applied, will tend to promote a growth of hair, is no proof 
that the result is due to the destruction of parasites or of micro- 
organisms of a pathogenic character. The further fact that 
these applications must be of considerable strength seems to 
invalidate the position still more. For it can be justly argued 
that the growth is due not to the parasitical properties of the 
remedy, but rather to its stimulating qualities. Again, we 
have had exhibited to us cultivations of organisms obtained 
from such cases. Unfortunately for the cause advocated, 
these cultivations have but too often proved to consist simply 
of saprophytes, and the same could be obtained from organ- 
isms found on perfectly healthy scalps. Such evidence falls 
very short of proof, and this is the result found in a large 
number of cases which present themselves for treatment and 
who are affected with the troubles under consideration. I do 
not intend to deal exhaustively with these defects in the matter 
of proving the opinion advanced, but merely desire to point 
out some possible sources of error to which investigators have 
become blinded by their enthusiasm. 
Those who contend that alopecia and alopecia areata have 
a constant neurotic basis have a certain amount of objections to 
contend with which they have not yet successfully .overcome. 
They h ave very plainly demonstrated that the parasites are not 
the cause, in a certain number of instances, They have also 3 
proven, experimentally, that lesions to certain nerves are fol- 
lowed by alopecia. But, in some cases, all the neurotic phe- 
nomena discoverable and undiscoverable have been treated 
with no beneficial results, even when aided by external stimu- 
lating measures. No results could be obtained until strong 
parasiticides were employed ; and, while claiming merely 
stimulating properties for these agents, the obvious conclusion 
could not but force itself upon an impartial observer that the 
disease was, in fact, of parasitic origin. I do not desire to di- 
late further on this point, but will pass on to that class of ob- 
servers whose conclusions appear to me to be not only more 
rational, but correct, and in consonance with clinical and 
pathological observation, besides being confirmed by the 
therapeutic results obtained. 
I refer to those whose contention it is that alopecia and 
alopecia areata may be due to either parasitic or to nervous 
trouble, or to both combined. The negative results obtained 
by the rigid adherents to either of the first two theories have 
found that in cases of failure a resort to the other method or 
the adoption of both has resulted in success. Those who per- 
sisted in one plan have been mortified by observing that failure 
followed their best efforts. Some clinical considerations are 
not dealt with in a manner which the importance of the subject 
demands. For there are certain objective symptoms which 
can be observed in some cases which will serve to distinguish 
between an alopecia of neurotic and one of parasitic origin. 
Of course when I refer to alopecia, in this paper, I do not de- 
sire to include the senile form, nor that in which the follicles 
of the hair have been- destroyed, atrophied, or lost beyond re- 
demption; but rather to presenile alopecia, defluvium capil- 
lorum and alopecia areata. In the last affection, we find the 
neurotic and parasitic types rather plainly differentiated by 
their respective histories and objective characteristics. In the 
parasitic form a history of infection may or may not be made 
out. The disease may be traced to the barber's brush, the in- 
fection from caps, hats, etc., worn by other individuals suffer- 
ing from the same trouble; or nothing definite may be learned 
in this respect. Itching, of a more or less marked character, 
will be present. The history of the attack will show that the 4 
falling out of the hair was gradual and peripheal. On inspec- 
tion, the involved area does not present a growth surface. It 
is roughened to a certain degree and the hairs at its border are 
lacking in lustre, as well as easily broken upon attempting 
extraction. 
Those portions of the scalp most often scratched are in- 
volved and include the temporal and occipital portions of the 
scalp, with occasionally the vertex. Auto-inoculation can be 
clearly made out in many cases and the entire evolution of the 
trouble traced upon the scalp of the individual. Scrapings from 
an affected area, if carefully rubbed into the skin of a dog, will 
produce an analogous condition, thus verifying in a satisfactory 
manner the positive character of the cause of the alopecia. It 
must always be remembered, however, that these conditions 
all apply to cases which have not been tampered with. In the 
neurotic variety of alopecia areata, which, in my experience, 
occurs more frequently than the parasitic, we may or may not 
have a history of neuralgia, traumatism, or nervous or mental 
shock. The subjective sensations, if any exist, are not suf- 
ficiently well marked to attract much attention. The history 
of the onset is generally that it has been sudden, one or sev- 
eral areas becoming suddenly denuded of hair. These may 
be roundish or ovalish, or of irregular contour. The sizes of 
these areas also vary considerably, and while progressive to a 
certain extent we have a stationary period establishing itself and 
an effort at spontaneous recovery. Objectively the denuded 
spots have a white, almost glistening, appearance, the compar- 
ison to ivory being a very apt one. A peculiarity which is 
present in this disease is that it is not limited to the scalp alone, 
but may attack, as it often does, the eyebrows, axillae, breast 
and pudenda. 
The few symptoms enumerated are sufficiently well marked 
to distinguish the conditions from one of parasitic origin. But 
we are sometimes called upon to treat cases of alopecia areata 
in which both a parasitic and neurotic cause is at work. In 
these the mixed effect due to the different causes may fre- 
quently be observed quite readily, whereas, in others, the 
problem presents such conflictions as to require fine discrimi- 
native powers as well as close observation and examination. 5 
It is hardly necessary to allude, to any considerable de- 
gree, to the other forms of alopecia which I have mentioned. 
The same general conditions and appearances will hold as in 
alopecia areata mutatis mutandis. Concomitant phenomena 
are always found in connection with each individual case of 
such a nature as to lead to tolerably accurate conclusion in re- 
gard to its etiology. This being done, the rational method to 
pursue readily suggests itself, and the success of the thera- 
peutic measure employed will wholly depend upon a proper 
selection of the remedies and the method of their application. 
Having made these few preliminary remarks, I now desire 
to speak of some of the successful methods which I have em- 
ployedin the treatment of some cases of alopecia and alopecia 
areata. I have briefly alluded to the etiology of these affec- 
tions in order to avoid useless repetition later on, and will 
premise by saying that I desire to speak of methods without 
entering into a detailed recital of cases, as those of the same 
type would be similar to one another, and, on that account, 
possibly wearisome to the reader. I will further state that I 
only proposed speaking of alopecia areata and of presenile 
areata, these being by far the greatest number of cases of 
falling out of the hair which I have had occasion to treat, and, 
for that reason, the successful treatment of such possesses 
more value than it would in cases less frequently observed and 
subjected to therapeutic measures. 
The cases of presenile alopecia which I have had occasion 
to treat (exclusive of such as were of syphilitic origin) occurred 
in males, and the majority of these were light blondes. In all 
cases the hair was fine and silky, and the scalp rather pale. In 
some seborrhea existed, and the amount of secretion varied 
from very small amount to quite a considerable quantity. In 
all these there was a history of more or less itching, and of a 
gradual loss of hair, chiefly at the angles of the forehead and 
the vertex. Combing the hair showed that this loss was con- 
siderable, although a considerable portion consisted of bed- 
hairs, so that the actual loss was by no means equal to the ap- 
parent. All were individuals who were otherwise in apparent 
health, and whose functions in general seemed to be in perfect 
condition with the exception of one, possibly. The nervous 6 
system lacked that stability and repose which should exist in 
the normal individual, and which is so essential to proper assim- 
ilation. While this condition was not so apparent in all those 
who did not exhibit the grosser phenomena of nervous disturb- 
ances, they did exhibit psychical phenomena which plainly 
pointed to this state of affairs. Irritability upon slight provo- 
cation, anxiety concerning trivial affairs, depression of spirits 
out of proportion to the exciting cause, and similar perturba- 
tions showed themselves as evidence of the neurotic condition 
present in the individual. A prominent feature was the hope- 
lessness of the patient as far as regarded any ultimate result in 
the treatment of his case. 
It will be readily seen that such cases are not very prom- 
ising, yet a little moral suasion has quite an effect in improving 
such a condition, and success is not the impossibility which it 
might appear at first blush. The general treatment I have 
adopted has been various in different cases, but has been 
directed to the amelioration of the nervous system. In some 
cases I have ordered the following pill thrice daily: 
J£. Strychniae Sulphatgr. 
Ferri Redact!gr. j. 
Quiniae Bisulphatgr. j. 
M. Ft. Caps. No. j. 
or, if starvation of the nerves seemed to be present, the com- 
pound syrup of hypophosphites (Fellows) was ordered taken 
in drachm doses four times daily, with a milligramme gr.) 
of strychnia sulphate with each dose. In some cases I have 
found it advantageous to supplement this treatment with mu- 
riate of pilocarpine taken at bedtime, a powder containing 
| to | of a grain of the remedy being taken in water. The ef- 
fects of this internal medication was not a matter of coincidence, 
for, by its alternate withdrawal and resumption, most notable dif- 
ferences could be observed. These differences were so marked 
as to attract the attention of the patients and lead them to the con- 
clusion that the internal medication was of a most beneficial 
character in the improvement of the local condition. Such re- 
sults occurred not only in one case, but in several, and, al- 
though failure might follow the same course in some future 
cases, the success which has been accomplished is sufficiently 
encouraging to justify a continuance of the method until a bet- 
ter one could be suggested that will stand as a rigid test. 7 
Alopecia areata presents difficulties, occasionally, of such 
a nature as to almost make us despair of any successful 
issue. 
I have been extremely fortunate in securing good results 
and can only attribute them to the energetic means which 
have been used. 
Before entering into the consideration of the treatment, I 
desire to premise that I have always been careful to distin- 
guish between the parasitic and the neurotic varieties of the 
affection. Having done this, the treatment was adapted to 
the condition present, and, whilst one method might fail, the 
general principle was always kept in mind in the application 
of the treatment. 
In the parasitic form of alopecia areata I have used two 
parasiticidal mixtures. One, the weaker, for the purpose of 
applying to the entire scalp and thus preventing new infection 
and a further spread of the trouble ; the other, the stronger, 
to apply directly to the implicated areas for the purpose of de- 
stroying the parasite, and thus putting an end to the disease. 
Both preparations were ordered applied twice daily; and, as all 
the cases I observed occurred in males, I had the hair clipped 
close to the scalp, thus facilitating a thorough application of 
the remedy. For the weaker application I first used a 1-750 
bichloride of mercury solution, afterward using a 3 per cent, 
creolin solution. Both acted well, and the only advantage in 
the latter is the smaller danger of toxic infection from its use. 
This wash is to be applied to the entire hairy scalp, the affected 
areas being attended to after the first operation had been gone 
through with. For the affected areas I ordered the applica- 
tion of sapo viridis, and this to remain about five minutes. 
Then a mild scrubbing rubbed in in small quantity. 
[■£ Hydrarg. bichloridigr. j. 
Lanolini; § j. 
M.-Terge bene. 
Sig.-Apply twice daily. 
In a comparatively short time a strong, healthy growth of 
hair could be observed. 
I desire to state that it is not always necessary to apply this 
last twice daily. It will be easily determined by the observer 8 
wnether this is necessary or not. Not infrequently one applica- 
tion a day or every other clay will, in a short time, be all that 
is necessary. I have had no occasion to change the composi- 
tion of this application, as in the few cases in which I employ- 
ed it, it proved satisfactory. 
In alopecia areata of neurotic origin, which, in my expe- 
rience, occurs much more frequently, I have given internal 
treatment in some instances and not at all in others. After 
trying various internal remedies with more or less success, I 
have finally adopted the same preparations as those I have 
spoken of in the treatment of presenile alopecia. They have 
seemed to serve the best purpose and gave the best final 
results. I have also observed that this internal treatment, is 
of positive and undoubted benefit. Discontinuing the remedy 
is followed by inferior results, and the effects of the resump- 
tion of the treatment become very quickly apparent. In 
some cases, however, general treatment appears to be entirely 
unnecessary, but I have found them to be very few in number. 
It would appear that they are such in which a general shock 
was experienced from a traumatism and the nerve equilibrium 
was regained in a comparatively short period of time. Even 
in these, however, if no form of treatment has been essayed 
for some considerable period of time after the injury, inter- 
nal treatment is found of benefit. Yet, cases of the last 
class, must of necessity be very infrequent. In those experi- 
mental cases in which nerves have been exercised, and the 
operation was followed by alopecia areata, the regeneration 
of the hair occurred spontaneously and local as well general 
treatment appeared unnecessary; but they certainly are not 
cases which could be given as a criterion by which to judge. 
To come to the local treatment of alopecia areata. The 
methods which I have found successful are essentially of the 
same character, although they differ materially in application. 
I do not claim any originality for either, as one is rather old 
and the other was suggested some little time since. They are 
essentially irritant in nature, but efficient in effect so far as my 
experience enables me to judge. The first one I employed is 
the suggestion of a French author, and consists in applying 
cantharidal collodion to the affected area. After vesication 9 
has been established, a dressing of some bland ointment is 
used. As is well known, cantharidal collodion varies much in 
its composition. We find that, in some instances, it acts very 
promptly, whereas in others its action is quite slow. Again, its 
effect in the same individual may be comparatively superficial 
or quite deep, depending upon the amount of the cantharides 
present, or the activity of the fly used in its composition. 
These circumstances necessarily acted as factors in controlling 
the frequency of application of the remedy. In some cases I 
applied the cantharidal preparation twice a week, and in others 
it could be used but once in the same length of time. The 
reaction was more or less prompt, and, in some cases, I have 
had the unfortunate experience of seeing no effect of a dis- 
tinct character beyond some superficial irritation of a rather 
mild character. However, by obtaining a good article I have 
been enabled to obtain excellent results in a comparatively 
short time. While the effects produced were of the best, the 
various inconveniences attending its use made the method any- 
thing but a pleasant one to the patient. The collodion is not a 
very easy method to manage. It mats the hair, does not look 
well, is very difficult to remove, and is inconvenient to handle. 
Added to this the disagreeable necessity of continuously apply- 
ing an ointment further increased the aversion of patients to the 
entire curative procedure of a local character. I often ex- 
perienced much difficulty in persuading patients to continue the 
treatment, and it was only the good results obtained which led 
them to submit to it, the hope of a speedy recovery and a 
proportionately short submission to the entire process. This 
difficulty was particularly marked in females, and it was with 
much trouble that they could be persuaded to continue a routine 
which was so distasteful in many respects. 
When a new method was announced which obviated many 
of these inconvenient accompaniments and which was claimed 
to be much superior in its results, I immediately adopted it, 
and desire here to express my complete satisfaction with the 
results attained through its use. I also desire to express my 
gratitude in a personal point of view to its originator; and, I 
have no doubt, every dermatologist who has given the method 
a fair trial will join me in this expression of thanks. I allude 10 
to the application of pure carbolic acid as advocated by L. 
Duncan Bulkley. His technique is about as follows : He ad- 
vises the application of pure carbolic acid once every two 
weeks to the affected areas. The amount of surface to be 
thus treated must not exceed two square inches. He further 
states that two, or, at the most, three, applications will suffice to 
effect a complete return of the hair. It may be Bulkley's 
experience to have had tractable cases; or, I may 
have been unfortunate enough to have had only stub- 
born ones. This much, however, is certain. As soon 
as the method was announced it struck me as a 
particularly good one to use. I had a patient to whom it 
was applied as directed, but I had no success. This led me 
to modify the treatment, which I did as follows: Instead of 
making an application once every fortnight I made it twice a 
week, and instead of limiting it to two square inches I applied 
it to the entire surface which was involved, this amounting to 
about ten square inches. Moreover, I was not at all satisfied with 
the ordinary 95 per cent, carbolic acid which I could obtain. It 
did not seem to be sufficiently strong. I obtained some pure 
English carbolic acid, and by this means obtained more rapid 
and marked effects. With this product it is unnecessary to 
rub forcibly into the skin, and the result obtained appears to 
me to be much more rapid. It is true, that my experience 
thus far has been limited to but a few cases; but they have 
proven so satisfactory that I will continue until something 
better is offered. The method of applying the agent consists 
in freely swabbing the affected area with it, no matter how 
much of the scalp is involved. Those portions which are 
affected by the acid turn milky white in a few moments, and 
if they are not thus affected they are touched again. This is 
all that is necessary. If the parts that turn white show 
very marked inflammatory reaction, they are passed over at 
the next sitting. Generally, however, there is at most but a 
slight amount of desquamation. 
Such a treatment, while rather painful, is efficacious. I 
have been in the habit of also employing it in presenile alope- 
cia, in a modified manner. Instead of applying the carbolic 
acid liberally I have done so sparingly, and at intervals of one 11 
•and two weeks. The impulse this procedure gave to the 
growth of hair was quite noticeable. 
I do not wish to take up more time with the subject. My 
object has been simply to submit an experience I have had, 
and one which, up to the present, has proved highly satisfac- 
tory to me. 
It is certainly to be presumed that, in the hands of others, 
the same results should follow the same line of treatment, and 
be attended by the same success. That the methods I 
have described are infallible I certainly do not want to claim ; 
but that they are sufficiently rational to induce a trial, I hope 
has been shown in the foregoing paper. 
I do not desire to detail any successful cases, as I have 
•already overstepped my limits in this paper. The methods I 
have described have been used upon quite a number of cases, 
and the successes which have been attained have led me to 
describe what might prove equally successful methods in the 
hands of others.