Medical hair loss conditions have a variety of etiologies such as nonscarring alopecias, scarring alopecias, and more. Although the etiology may vary, all types of alopecia can share the same negative social and psychological ramifications. Studies have demonstrated that patients with alopecia areata have a statistically significant propensity to develop psychiatric comorbidities such as depression, anxiety, and social phobia relative to the general population.1,2 Aside from psychiatric conditions, other factors that may negatively influence the quality of life include relatively younger age, the female sex, longer disease duration, and higher disease severity.1
Quantitative research has demonstrated that wearing wigs is one of the best ways to cope with hair loss due to the lack of consistently effective medical treatment to restore hair.3,4 These findings suggest that physicians who treat patients with alopecia need to have an understanding of wig use. The question of when a dermatologist discusses a wig purchase or wig use with an alopecia patient is not clearly defined, but is an important part of the armamentarium of hair loss treatment.
Though dermatologists do not routinely advise patients in management of chemotherapy-related alopecia, it is a good place to start to understand the role of wig use. Wig use during chemotherapy-related hair loss is a common first-line treatment. Patients who will be treated with chemotherapy known to cause hair loss are usually advised to obtain a wig before cancer treatment is started.5 This is to ensure that the synthetic or natural hair camouflage agent is similar to the original hair in terms of color and texture.5
There are social pressures to wear a wig or at least conceal hair loss in cancer patients because of self-perceived as well as external views of a balding head.6 Wigs are often seen as a “friend” and a part of the body as opposed to simply an accessory.7 Women with cancer sometimes choose a lower potency chemotherapy due to a fear of hair loss.8 The hair loss can often be seen as a mutilation of their body leading to a more negative self-perception that can lead to demoralization and other psychiatric comorbidities.
Psychosocial Aspects
The social setting in which a patient wears a wig is a major factor for individuals. Wiggins and colleagues6 identified that a wig user may categorize people into 3 major social strata: stranger, acquaintance, and close friends or family. Each group is treated differently by the wig user, and conversely the expectation of treatment by the group is also different. Wig users do not want strangers or acquaintances to be aware that a wig is being worn. Generally, if a wig is appropriately donned, then a stranger has little chance to decipher the use. However, the use of a wig demands assuming a persona that can be emotionally taxing. Wig users generally assume the onus of appropriate wig care, wear, and concealment of hair loss to be on themselves. They have to be “on guard” in public. Users expect strangers to assume that the hair is natural; therefore, they will be treated “normally” in usual circumstances.6
Acquaintances fall under similar expectations with the major caveat that an individual must use identical or similar wigs to lower suspicion, even if acquaintances are tacitly aware of the wig use. If a major wig change is desired like going from short blonde hair to long brunette hair in a brief time period, then an acquaintance might be aware that a wig might be in use. Furthermore, if a new wig is worn in a social setting away from acquaintances and, coincidentally an acquaintance is present, the wig user may be devastated, so he or she must plan accordingly to minimize that risk.
One example in Wiggins’ study involved a woman wearing a wig in her own home near a kitchen window. A neighbor passing by the kitchen window may greet the wig user while she is performing an innocuous chore like cleaning dishes. This unplanned, unpredictable social interaction with an acquaintance requires the individual to continue wearing the wig rather than be comfortable without one in her own home. The neighbor’s greeting is not seen as a violation of privacy, but as a friendly behavior. Nonetheless, it requires added effort by the individual.
The last social group identified is close friends and family. Hair loss is often a long-term process that requires substantial social and emotional effort while undergoing treatment. Thus, wig users often confide in close friends and family for support, and in order to not “deceive” them. The users expect this group to not only have knowledge about the wigs, but to also comment on their practices directly to support them with hair loss and wig use.
Article continues on page 2
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Multifaceted Treatment Plan
Hair loss and wig usage is much more complex than a simple recommendation of a wig shop to individuals. The complexity of picking the right wig, maintaining the wig, and proper utilization are aspects that need to be explored by the hair loss patient. Further care needs to be coordinated with the help of several professionals. At the initial dermatology visit for hair loss, patient reassurance is critical to ensure the individual is getting support for their hair condition.9 However, this is only the first step in a long-term treatment plan. The patient needs a multidisciplinary approach with their primary doctor, the specialty doctor associated with the hair loss such as a dermatologist or an oncologist, and a wig specialist/stylist that are all part of the treatment team that exists as long as the patient requires hair-concealment products.
Cost is another factor that is often overlooked in this multifaceted treatment plan. Natural hair wigs cost more than synthetic fiber ones and are sometimes preferred because they tend to look more natural.8,10 Natural hair wigs can range from $300 to $5000 depending on design and quality, while synthetic ones that last a few months generally are under $100.10 Styling wigs requires different techniques for natural vs synthetic fiber and may require an appropriate professional or adequate training for the wearer.8 These factors must be discussed with patients as an educational imperative early in the treatment course of severe hair loss instead of setting patients adrift in a sea of misinformation as they cope with hair loss (Figure 1).8
When hair loss is chronic, each subsequent visit by patients will require adequate attention to both the medical treatment and psychological component of the hair loss, which may include the maintenance and care of the scalp during wig use (Table). The patient must be told to arrive at the appointment with the scalp uncovered to allow complete visualization in order to monitor hair loss progression. Some patients may arrive at the appointment with wigs that are not easily removed and this impedes the evaluation process. The wig is removed by the patient for the duration of the clinic visit and set aside to expedite medical assessment.
Oftentimes, renewing prescriptions for anti-inflammatory medications and keen attention to the physical exam supersede inquiries about wig care and utilization. Dermatologists need to ask patients about the comfort level of the wigs in a physical and psychosocial sense. Assuring that no traction changes or occlusive phenomenon such as folliculitis is occurring under the wig is paramount. The burden is on the physician to engage the patient and determine the patient’s comfort level with this discussion.
Ethical Concerns
Wig-related ethical concerns can arise with patients that can be complex. One instance in our clinic is of a long-term alopecia totalis patient who works in an office that processes medical records. This patient had worn a wig for several years, and many work acquaintances were aware of this fact. One coworker acquaintance purposefully revealed the patient’s hair loss and wig status to a third party in a manner that negatively impacted the patient. Due to this violation of privacy, the patient lost confidence in her appearance, had difficulty collaborating with the coworker, as well as conducting further business with the third party. Her medical information and her privacy had been violated.
This instance borders on a Health Insurance Portability and Accountability Act (HIPPA) violation because the patient both worked at the office and saw one of the primary physicians in the office as patient, and the incident occurred with a medical records employee in the office. The patient was distraught and filed a complaint with human resources, but was not taken seriously. The patient then pursued a workplace harassment charge for the incident. While this was not a true HIPAA violation in the strictest sense, the minimal fine for such a violation is $50,000 and the maximum fine can be $1.5 million.11 Revealing medical information, including hair loss, about a person without consent is unethical. In an instance where medical information is released in a work setting, this can also be a legal problem.
HIPPA does not only apply to physicians.12 Records offices, law firms, accounting firms, insurance companies, and essentially anyone that processes medical information in a professional manner are subject to HIPPA laws.12 As the workplace harassment charges were being processed, the patient made an appointment with us to get a physician letter of support illuminating the necessity for wig use and the psychosocial importance of prosthesis. The patient’s organization is having an ongoing discussion about this violation of privacy.
Articles continues on page 3
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Pediatric Population
The pediatric population deserves special attention in the realm of alopecia. Alopecia areata can be more devastating in children than in adults.13 For indigent populations, referrals to non-profit organizations such as Locks for Love or the National Alopecia Areata Foundation can help children get proper wigs.10
While helpful in many circumstances, wig use can also prevent children from participating in certain activities like physical education classes or any kind of sports activities. Letters from the dermatologist can excuse children from being forced into these activities, but there is a social cost to sit out while other children interact. Letters can also expedite insurance coverage for wig or scalp prostheses, which may be required in a time-sensitive fashion so children can maintain their social, emotional, and educational development. The letters extend to the adult population, as well. The coverage for wigs varies between conditions, region of the United States, and insurance company coverage.10 Physicians who write prescriptions should use the phrase “a full cranial prosthesis,” but even these are not always accepted in the modern contentious environment of insurance denials.10
Changing Hair Trends
Modern hair perception is also evolving. Dermatologists must be aware of the current perceptions of hair styles. While traditionally short hair is the acceptable standard for men, longer hair, in cultures where is it accepted, is considered to be interesting.14 Men who desire long hair may have a negative self-evaluation that may lead to depression or fear of social intimidation.14
However, shaved heads are becoming popular as well. Males in Britain who shaved their head were once considered to be uncouth.15 Now with popular icons like Derek Jeter, Vin Diesel, Jason Statham, Kobe Bryant, Dwayne “The Rock” Johnson, and Michael Jordon sporting short hair, some men who are starting to bald may opt to immediately shave their head instead of considering a wig (Figure 2).15
Extensions and wig use are also becoming a more prevalent part of modern culture for individuals without hair loss.10 Rihanna, Lady Gaga, Beyonce, and Kylie Jenner have adorned wigs and hair extensions, which has altered perceptions of hair among youth. This has likely impacted wig use, which has increased by 20% in the past few years.16 Regardless of a medical or cosmetic impetus for wig use, getting a consultation from a professional wig stylist behooves anyone considering a wig or hair piece of any kind (Figure 3). There are a variety of chemicals, glues, and materials involved that could cause safety problems. Wig and extension hair needs to be properly cleaned and maintained. Inadequate knowledge and improper use may lead to hair and scalp damage.10 Anyone pursuing wig use must be informed that if injury does occur, then a dermatology visit will be required to adequately treat the problem.
While as a society we are not at a point where baldness in all genders and at all ages is accepted or even celebrated socially, there are indications we are evolving toward that culture. Actor Patrick Stewart who played Captain Jean-Luc Picard in Star Trek: Next Generation recalls when Gene Roddenberry, creator of Star Trek, was asked about why baldness was not cured in the future setting of the show.17 Mr Roddenberry replied that in the future no one would care about being bald.17
Mr Subash is a research fellow in the department of dermatology at Wake Forest Baptist Health in Winston-Salem, NC.
Dr McMichael, The Mane Point Section Editor, is professor and chair in the department of dermatology at Wake Forest Baptist Health in Winston-Salem, NC.
Disclosure: Dr McMichael has received grants from Allergan and Proctor & Gamble. She is a consultant for Allergan, eResearch Technology, Inc, Galderma, Guthey Renker, Johnson & Johnson, Keranetics, Merck & Co., Inc, Merz Pharmaceuticals, Proctor & Gamble, Samumed, and Incyte. She receives royalties from Informa Healthcare and UpToDate and also has conducted research for Samumed.
Mr Subash reports no relevant financial relationships.
References
1. Rencz F, Gulácsi L, Péntek M, Wikonkál N, Baji P, Brodszky V. Alopecia areata and health-related quality of life: a systematic review and meta-analysis. Br J Dermatol. 2016;175(3):561-571.
2. MacLean KJ, Tidman, MJ. Alopecia areata: more than skin deep. Practitioner. 2013;257(1764):29-32, 3.
3. Endo Y, Miyachi Y, Arakawa A. Development of a disease-specific instrument to measure quality of life in patients with alopecia areata. Eur J Dermatol. 2012;22(4):531-536.
4. Inui S, Inoue T, Itami S. Psychosocial impact of wigs or hairpieces on perceived quality of life level in female patients with alopecia areata. J Dermatol. 2013;40(3):225-226.
5. Yeager CE, Olsen EA. Treatment of chemotherapy-induced alopecia. Dermatol Ther. 2011;24(4):432-442.
6. Wiggins S, Moore-Millar K, Thomson A. Can you pull it off? Appearance modifying behaviours adopted by wig users with alopecia in social interactions. Body Image. 2014;11(2):156-166.
7. Zannini L, Verderame F, Cucchiara G, Zinna B, Alba A, Ferrara M. ‘My wig has been my journey’s companion’: Perceived effects of an aesthetic care programme for Italian women suffering from chemotherapy-induced alopecia. Eur J Cancer Care (Engl). 2012;21(5):650-660.
8. Roe H. Chemotherapy-induced alopecia: advice and support for hair loss. Brit J Nurs. 2011;20(10):S4-S11.
9. Vandegrift KV. The development of an oncology alopecia wig program. J Intraven Nurs. 1994;17(2):78-82.
10. McMichael AJ Hordinsky MK, eds. Hair and Scalp Diseases: Medical, Surgical, and Cosmetic Treatments. New York, NY: Informa Healthcare; 2008.
11. HIPAA violations and enforcement. American Medical Association website. https://www.ama-assn.org/practice-management/hipaa-violations-enforcement. Accessed December 28, 2016.
12. Your medical records. U.S. Department of Health & Human Services website. https://www.hhs.gov/hipaa/for-individuals/medical-records/index.html. Accessed December 28, 2016.
13. Iorizzo M, Oranje AP. Current and future treatments of alopecia areata and trichotillomania in children. Expert Opin Pharmacother. 2016;17(13):1767-1773.
14. Social-religious-cultural perceptions of hair & baldness. The Trichological Society website. https://www.hairscientists.org/human-hair/perceptions. Accessed December 28, 2016.
15. Perception of the close shaved hairstyle in modern Britain. HIS Hair Clinic website. https://www.hishairclinic.com/perception-of-the-close-shaved-hairstyle-in-modern-britain/. Accessed December 28, 2016.
16. Popularity of custom made wigs. HAIRFLEEK blog. https://blog.hairfleek.com/2016/04/08/popularity-of-custom-made-wigs/. Accessed December 28, 2016.
17. Pescovitz D. Star Trek creator’s perfect comment on casting a bald captain for ST: TNG. Boing Boing. July 8, 2015. https://boingboing.net/2015/07/08/star-trek-creators-perfect-c.html. Accessed December 28, 2016.
Medical hair loss conditions have a variety of etiologies such as nonscarring alopecias, scarring alopecias, and more. Although the etiology may vary, all types of alopecia can share the same negative social and psychological ramifications. Studies have demonstrated that patients with alopecia areata have a statistically significant propensity to develop psychiatric comorbidities such as depression, anxiety, and social phobia relative to the general population.1,2 Aside from psychiatric conditions, other factors that may negatively influence the quality of life include relatively younger age, the female sex, longer disease duration, and higher disease severity.1
Quantitative research has demonstrated that wearing wigs is one of the best ways to cope with hair loss due to the lack of consistently effective medical treatment to restore hair.3,4 These findings suggest that physicians who treat patients with alopecia need to have an understanding of wig use. The question of when a dermatologist discusses a wig purchase or wig use with an alopecia patient is not clearly defined, but is an important part of the armamentarium of hair loss treatment.
Though dermatologists do not routinely advise patients in management of chemotherapy-related alopecia, it is a good place to start to understand the role of wig use. Wig use during chemotherapy-related hair loss is a common first-line treatment. Patients who will be treated with chemotherapy known to cause hair loss are usually advised to obtain a wig before cancer treatment is started.5 This is to ensure that the synthetic or natural hair camouflage agent is similar to the original hair in terms of color and texture.5
There are social pressures to wear a wig or at least conceal hair loss in cancer patients because of self-perceived as well as external views of a balding head.6 Wigs are often seen as a “friend” and a part of the body as opposed to simply an accessory.7 Women with cancer sometimes choose a lower potency chemotherapy due to a fear of hair loss.8 The hair loss can often be seen as a mutilation of their body leading to a more negative self-perception that can lead to demoralization and other psychiatric comorbidities.
Psychosocial Aspects
The social setting in which a patient wears a wig is a major factor for individuals. Wiggins and colleagues6 identified that a wig user may categorize people into 3 major social strata: stranger, acquaintance, and close friends or family. Each group is treated differently by the wig user, and conversely the expectation of treatment by the group is also different. Wig users do not want strangers or acquaintances to be aware that a wig is being worn. Generally, if a wig is appropriately donned, then a stranger has little chance to decipher the use. However, the use of a wig demands assuming a persona that can be emotionally taxing. Wig users generally assume the onus of appropriate wig care, wear, and concealment of hair loss to be on themselves. They have to be “on guard” in public. Users expect strangers to assume that the hair is natural; therefore, they will be treated “normally” in usual circumstances.6
Acquaintances fall under similar expectations with the major caveat that an individual must use identical or similar wigs to lower suspicion, even if acquaintances are tacitly aware of the wig use. If a major wig change is desired like going from short blonde hair to long brunette hair in a brief time period, then an acquaintance might be aware that a wig might be in use. Furthermore, if a new wig is worn in a social setting away from acquaintances and, coincidentally an acquaintance is present, the wig user may be devastated, so he or she must plan accordingly to minimize that risk.
One example in Wiggins’ study involved a woman wearing a wig in her own home near a kitchen window. A neighbor passing by the kitchen window may greet the wig user while she is performing an innocuous chore like cleaning dishes. This unplanned, unpredictable social interaction with an acquaintance requires the individual to continue wearing the wig rather than be comfortable without one in her own home. The neighbor’s greeting is not seen as a violation of privacy, but as a friendly behavior. Nonetheless, it requires added effort by the individual.
The last social group identified is close friends and family. Hair loss is often a long-term process that requires substantial social and emotional effort while undergoing treatment. Thus, wig users often confide in close friends and family for support, and in order to not “deceive” them. The users expect this group to not only have knowledge about the wigs, but to also comment on their practices directly to support them with hair loss and wig use.
Multifaceted Treatment Plan
Hair loss and wig usage is much more complex than a simple recommendation of a wig shop to individuals. The complexity of picking the right wig, maintaining the wig, and proper utilization are aspects that need to be explored by the hair loss patient. Further care needs to be coordinated with the help of several professionals. At the initial dermatology visit for hair loss, patient reassurance is critical to ensure the individual is getting support for their hair condition.9 However, this is only the first step in a long-term treatment plan. The patient needs a multidisciplinary approach with their primary doctor, the specialty doctor associated with the hair loss such as a dermatologist or an oncologist, and a wig specialist/stylist that are all part of the treatment team that exists as long as the patient requires hair-concealment products.
Cost is another factor that is often overlooked in this multifaceted treatment plan. Natural hair wigs cost more than synthetic fiber ones and are sometimes preferred because they tend to look more natural.8,10 Natural hair wigs can range from $300 to $5000 depending on design and quality, while synthetic ones that last a few months generally are under $100.10 Styling wigs requires different techniques for natural vs synthetic fiber and may require an appropriate professional or adequate training for the wearer.8 These factors must be discussed with patients as an educational imperative early in the treatment course of severe hair loss instead of setting patients adrift in a sea of misinformation as they cope with hair loss (Figure 1).8
When hair loss is chronic, each subsequent visit by patients will require adequate attention to both the medical treatment and psychological component of the hair loss, which may include the maintenance and care of the scalp during wig use (Table). The patient must be told to arrive at the appointment with the scalp uncovered to allow complete visualization in order to monitor hair loss progression. Some patients may arrive at the appointment with wigs that are not easily removed and this impedes the evaluation process. The wig is removed by the patient for the duration of the clinic visit and set aside to expedite medical assessment.
Oftentimes, renewing prescriptions for anti-inflammatory medications and keen attention to the physical exam supersede inquiries about wig care and utilization. Dermatologists need to ask patients about the comfort level of the wigs in a physical and psychosocial sense. Assuring that no traction changes or occlusive phenomenon such as folliculitis is occurring under the wig is paramount. The burden is on the physician to engage the patient and determine the patient’s comfort level with this discussion.
Ethical Concerns
Wig-related ethical concerns can arise with patients that can be complex. One instance in our clinic is of a long-term alopecia totalis patient who works in an office that processes medical records. This patient had worn a wig for several years, and many work acquaintances were aware of this fact. One coworker acquaintance purposefully revealed the patient’s hair loss and wig status to a third party in a manner that negatively impacted the patient. Due to this violation of privacy, the patient lost confidence in her appearance, had difficulty collaborating with the coworker, as well as conducting further business with the third party. Her medical information and her privacy had been violated.
This instance borders on a Health Insurance Portability and Accountability Act (HIPPA) violation because the patient both worked at the office and saw one of the primary physicians in the office as patient, and the incident occurred with a medical records employee in the office. The patient was distraught and filed a complaint with human resources, but was not taken seriously. The patient then pursued a workplace harassment charge for the incident. While this was not a true HIPAA violation in the strictest sense, the minimal fine for such a violation is $50,000 and the maximum fine can be $1.5 million.11 Revealing medical information, including hair loss, about a person without consent is unethical. In an instance where medical information is released in a work setting, this can also be a legal problem.
HIPPA does not only apply to physicians.12 Records offices, law firms, accounting firms, insurance companies, and essentially anyone that processes medical information in a professional manner are subject to HIPPA laws.12 As the workplace harassment charges were being processed, the patient made an appointment with us to get a physician letter of support illuminating the necessity for wig use and the psychosocial importance of prosthesis. The patient’s organization is having an ongoing discussion about this violation of privacy.
Pediatric Population
The pediatric population deserves special attention in the realm of alopecia. Alopecia areata can be more devastating in children than in adults.13 For indigent populations, referrals to non-profit organizations such as Locks for Love or the National Alopecia Areata Foundation can help children get proper wigs.10
While helpful in many circumstances, wig use can also prevent children from participating in certain activities like physical education classes or any kind of sports activities. Letters from the dermatologist can excuse children from being forced into these activities, but there is a social cost to sit out while other children interact. Letters can also expedite insurance coverage for wig or scalp prostheses, which may be required in a time-sensitive fashion so children can maintain their social, emotional, and educational development. The letters extend to the adult population, as well. The coverage for wigs varies between conditions, region of the United States, and insurance company coverage.10 Physicians who write prescriptions should use the phrase “a full cranial prosthesis,” but even these are not always accepted in the modern contentious environment of insurance denials.10
Changing Hair Trends
Modern hair perception is also evolving. Dermatologists must be aware of the current perceptions of hair styles. While traditionally short hair is the acceptable standard for men, longer hair, in cultures where is it accepted, is considered to be interesting.14 Men who desire long hair may have a negative self-evaluation that may lead to depression or fear of social intimidation.14
However, shaved heads are becoming popular as well. Males in Britain who shaved their head were once considered to be uncouth.15 Now with popular icons like Derek Jeter, Vin Diesel, Jason Statham, Kobe Bryant, Dwayne “The Rock” Johnson, and Michael Jordon sporting short hair, some men who are starting to bald may opt to immediately shave their head instead of considering a wig (Figure 2).15
Extensions and wig use are also becoming a more prevalent part of modern culture for individuals without hair loss.10 Rihanna, Lady Gaga, Beyonce, and Kylie Jenner have adorned wigs and hair extensions, which has altered perceptions of hair among youth. This has likely impacted wig use, which has increased by 20% in the past few years.16 Regardless of a medical or cosmetic impetus for wig use, getting a consultation from a professional wig stylist behooves anyone considering a wig or hair piece of any kind (Figure 3). There are a variety of chemicals, glues, and materials involved that could cause safety problems. Wig and extension hair needs to be properly cleaned and maintained. Inadequate knowledge and improper use may lead to hair and scalp damage.10 Anyone pursuing wig use must be informed that if injury does occur, then a dermatology visit will be required to adequately treat the problem.
While as a society we are not at a point where baldness in all genders and at all ages is accepted or even celebrated socially, there are indications we are evolving toward that culture. Actor Patrick Stewart who played Captain Jean-Luc Picard in Star Trek: Next Generation recalls when Gene Roddenberry, creator of Star Trek, was asked about why baldness was not cured in the future setting of the show.17 Mr Roddenberry replied that in the future no one would care about being bald.17
Mr Subash is a research fellow in the department of dermatology at Wake Forest Baptist Health in Winston-Salem, NC.
Dr McMichael, The Mane Point Section Editor, is professor and chair in the department of dermatology at Wake Forest Baptist Health in Winston-Salem, NC.
Disclosure: Dr McMichael has received grants from Allergan and Proctor & Gamble. She is a consultant for Allergan, eResearch Technology, Inc, Galderma, Guthey Renker, Johnson & Johnson, Keranetics, Merck & Co., Inc, Merz Pharmaceuticals, Proctor & Gamble, Samumed, and Incyte. She receives royalties from Informa Healthcare and UpToDate and also has conducted research for Samumed.
Mr Subash reports no relevant financial relationships.
References
1. Rencz F, Gulácsi L, Péntek M, Wikonkál N, Baji P, Brodszky V. Alopecia areata and health-related quality of life: a systematic review and meta-analysis. Br J Dermatol. 2016;175(3):561-571.
2. MacLean KJ, Tidman, MJ. Alopecia areata: more than skin deep. Practitioner. 2013;257(1764):29-32, 3.
3. Endo Y, Miyachi Y, Arakawa A. Development of a disease-specific instrument to measure quality of life in patients with alopecia areata. Eur J Dermatol. 2012;22(4):531-536.
4. Inui S, Inoue T, Itami S. Psychosocial impact of wigs or hairpieces on perceived quality of life level in female patients with alopecia areata. J Dermatol. 2013;40(3):225-226.
5. Yeager CE, Olsen EA. Treatment of chemotherapy-induced alopecia. Dermatol Ther. 2011;24(4):432-442.
6. Wiggins S, Moore-Millar K, Thomson A. Can you pull it off? Appearance modifying behaviours adopted by wig users with alopecia in social interactions. Body Image. 2014;11(2):156-166.
7. Zannini L, Verderame F, Cucchiara G, Zinna B, Alba A, Ferrara M. ‘My wig has been my journey’s companion’: Perceived effects of an aesthetic care programme for Italian women suffering from chemotherapy-induced alopecia. Eur J Cancer Care (Engl). 2012;21(5):650-660.
8. Roe H. Chemotherapy-induced alopecia: advice and support for hair loss. Brit J Nurs. 2011;20(10):S4-S11.
9. Vandegrift KV. The development of an oncology alopecia wig program. J Intraven Nurs. 1994;17(2):78-82.
10. McMichael AJ Hordinsky MK, eds. Hair and Scalp Diseases: Medical, Surgical, and Cosmetic Treatments. New York, NY: Informa Healthcare; 2008.
11. HIPAA violations and enforcement. American Medical Association website. https://www.ama-assn.org/practice-management/hipaa-violations-enforcement. Accessed December 28, 2016.
12. Your medical records. U.S. Department of Health & Human Services website. https://www.hhs.gov/hipaa/for-individuals/medical-records/index.html. Accessed December 28, 2016.
13. Iorizzo M, Oranje AP. Current and future treatments of alopecia areata and trichotillomania in children. Expert Opin Pharmacother. 2016;17(13):1767-1773.
14. Social-religious-cultural perceptions of hair & baldness. The Trichological Society website. https://www.hairscientists.org/human-hair/perceptions. Accessed December 28, 2016.
15. Perception of the close shaved hairstyle in modern Britain. HIS Hair Clinic website. https://www.hishairclinic.com/perception-of-the-close-shaved-hairstyle-in-modern-britain/. Accessed December 28, 2016.
16. Popularity of custom made wigs. HAIRFLEEK blog. https://blog.hairfleek.com/2016/04/08/popularity-of-custom-made-wigs/. Accessed December 28, 2016.
17. Pescovitz D. Star Trek creator’s perfect comment on casting a bald captain for ST: TNG. Boing Boing. July 8, 2015. https://boingboing.net/2015/07/08/star-trek-creators-perfect-c.html. Accessed December 28, 2016.
Medical hair loss conditions have a variety of etiologies such as nonscarring alopecias, scarring alopecias, and more. Although the etiology may vary, all types of alopecia can share the same negative social and psychological ramifications. Studies have demonstrated that patients with alopecia areata have a statistically significant propensity to develop psychiatric comorbidities such as depression, anxiety, and social phobia relative to the general population.1,2 Aside from psychiatric conditions, other factors that may negatively influence the quality of life include relatively younger age, the female sex, longer disease duration, and higher disease severity.1
Quantitative research has demonstrated that wearing wigs is one of the best ways to cope with hair loss due to the lack of consistently effective medical treatment to restore hair.3,4 These findings suggest that physicians who treat patients with alopecia need to have an understanding of wig use. The question of when a dermatologist discusses a wig purchase or wig use with an alopecia patient is not clearly defined, but is an important part of the armamentarium of hair loss treatment.
Though dermatologists do not routinely advise patients in management of chemotherapy-related alopecia, it is a good place to start to understand the role of wig use. Wig use during chemotherapy-related hair loss is a common first-line treatment. Patients who will be treated with chemotherapy known to cause hair loss are usually advised to obtain a wig before cancer treatment is started.5 This is to ensure that the synthetic or natural hair camouflage agent is similar to the original hair in terms of color and texture.5
There are social pressures to wear a wig or at least conceal hair loss in cancer patients because of self-perceived as well as external views of a balding head.6 Wigs are often seen as a “friend” and a part of the body as opposed to simply an accessory.7 Women with cancer sometimes choose a lower potency chemotherapy due to a fear of hair loss.8 The hair loss can often be seen as a mutilation of their body leading to a more negative self-perception that can lead to demoralization and other psychiatric comorbidities.
Psychosocial Aspects
The social setting in which a patient wears a wig is a major factor for individuals. Wiggins and colleagues6 identified that a wig user may categorize people into 3 major social strata: stranger, acquaintance, and close friends or family. Each group is treated differently by the wig user, and conversely the expectation of treatment by the group is also different. Wig users do not want strangers or acquaintances to be aware that a wig is being worn. Generally, if a wig is appropriately donned, then a stranger has little chance to decipher the use. However, the use of a wig demands assuming a persona that can be emotionally taxing. Wig users generally assume the onus of appropriate wig care, wear, and concealment of hair loss to be on themselves. They have to be “on guard” in public. Users expect strangers to assume that the hair is natural; therefore, they will be treated “normally” in usual circumstances.6
Acquaintances fall under similar expectations with the major caveat that an individual must use identical or similar wigs to lower suspicion, even if acquaintances are tacitly aware of the wig use. If a major wig change is desired like going from short blonde hair to long brunette hair in a brief time period, then an acquaintance might be aware that a wig might be in use. Furthermore, if a new wig is worn in a social setting away from acquaintances and, coincidentally an acquaintance is present, the wig user may be devastated, so he or she must plan accordingly to minimize that risk.
One example in Wiggins’ study involved a woman wearing a wig in her own home near a kitchen window. A neighbor passing by the kitchen window may greet the wig user while she is performing an innocuous chore like cleaning dishes. This unplanned, unpredictable social interaction with an acquaintance requires the individual to continue wearing the wig rather than be comfortable without one in her own home. The neighbor’s greeting is not seen as a violation of privacy, but as a friendly behavior. Nonetheless, it requires added effort by the individual.
The last social group identified is close friends and family. Hair loss is often a long-term process that requires substantial social and emotional effort while undergoing treatment. Thus, wig users often confide in close friends and family for support, and in order to not “deceive” them. The users expect this group to not only have knowledge about the wigs, but to also comment on their practices directly to support them with hair loss and wig use.
Multifaceted Treatment Plan
Hair loss and wig usage is much more complex than a simple recommendation of a wig shop to individuals. The complexity of picking the right wig, maintaining the wig, and proper utilization are aspects that need to be explored by the hair loss patient. Further care needs to be coordinated with the help of several professionals. At the initial dermatology visit for hair loss, patient reassurance is critical to ensure the individual is getting support for their hair condition.9 However, this is only the first step in a long-term treatment plan. The patient needs a multidisciplinary approach with their primary doctor, the specialty doctor associated with the hair loss such as a dermatologist or an oncologist, and a wig specialist/stylist that are all part of the treatment team that exists as long as the patient requires hair-concealment products.
Cost is another factor that is often overlooked in this multifaceted treatment plan. Natural hair wigs cost more than synthetic fiber ones and are sometimes preferred because they tend to look more natural.8,10 Natural hair wigs can range from $300 to $5000 depending on design and quality, while synthetic ones that last a few months generally are under $100.10 Styling wigs requires different techniques for natural vs synthetic fiber and may require an appropriate professional or adequate training for the wearer.8 These factors must be discussed with patients as an educational imperative early in the treatment course of severe hair loss instead of setting patients adrift in a sea of misinformation as they cope with hair loss (Figure 1).8
When hair loss is chronic, each subsequent visit by patients will require adequate attention to both the medical treatment and psychological component of the hair loss, which may include the maintenance and care of the scalp during wig use (Table). The patient must be told to arrive at the appointment with the scalp uncovered to allow complete visualization in order to monitor hair loss progression. Some patients may arrive at the appointment with wigs that are not easily removed and this impedes the evaluation process. The wig is removed by the patient for the duration of the clinic visit and set aside to expedite medical assessment.
Oftentimes, renewing prescriptions for anti-inflammatory medications and keen attention to the physical exam supersede inquiries about wig care and utilization. Dermatologists need to ask patients about the comfort level of the wigs in a physical and psychosocial sense. Assuring that no traction changes or occlusive phenomenon such as folliculitis is occurring under the wig is paramount. The burden is on the physician to engage the patient and determine the patient’s comfort level with this discussion.
Ethical Concerns
Wig-related ethical concerns can arise with patients that can be complex. One instance in our clinic is of a long-term alopecia totalis patient who works in an office that processes medical records. This patient had worn a wig for several years, and many work acquaintances were aware of this fact. One coworker acquaintance purposefully revealed the patient’s hair loss and wig status to a third party in a manner that negatively impacted the patient. Due to this violation of privacy, the patient lost confidence in her appearance, had difficulty collaborating with the coworker, as well as conducting further business with the third party. Her medical information and her privacy had been violated.
,
Medical hair loss conditions have a variety of etiologies such as nonscarring alopecias, scarring alopecias, and more. Although the etiology may vary, all types of alopecia can share the same negative social and psychological ramifications. Studies have demonstrated that patients with alopecia areata have a statistically significant propensity to develop psychiatric comorbidities such as depression, anxiety, and social phobia relative to the general population.1,2 Aside from psychiatric conditions, other factors that may negatively influence the quality of life include relatively younger age, the female sex, longer disease duration, and higher disease severity.1
Quantitative research has demonstrated that wearing wigs is one of the best ways to cope with hair loss due to the lack of consistently effective medical treatment to restore hair.3,4 These findings suggest that physicians who treat patients with alopecia need to have an understanding of wig use. The question of when a dermatologist discusses a wig purchase or wig use with an alopecia patient is not clearly defined, but is an important part of the armamentarium of hair loss treatment.
Though dermatologists do not routinely advise patients in management of chemotherapy-related alopecia, it is a good place to start to understand the role of wig use. Wig use during chemotherapy-related hair loss is a common first-line treatment. Patients who will be treated with chemotherapy known to cause hair loss are usually advised to obtain a wig before cancer treatment is started.5 This is to ensure that the synthetic or natural hair camouflage agent is similar to the original hair in terms of color and texture.5
There are social pressures to wear a wig or at least conceal hair loss in cancer patients because of self-perceived as well as external views of a balding head.6 Wigs are often seen as a “friend” and a part of the body as opposed to simply an accessory.7 Women with cancer sometimes choose a lower potency chemotherapy due to a fear of hair loss.8 The hair loss can often be seen as a mutilation of their body leading to a more negative self-perception that can lead to demoralization and other psychiatric comorbidities.
Psychosocial Aspects
The social setting in which a patient wears a wig is a major factor for individuals. Wiggins and colleagues6 identified that a wig user may categorize people into 3 major social strata: stranger, acquaintance, and close friends or family. Each group is treated differently by the wig user, and conversely the expectation of treatment by the group is also different. Wig users do not want strangers or acquaintances to be aware that a wig is being worn. Generally, if a wig is appropriately donned, then a stranger has little chance to decipher the use. However, the use of a wig demands assuming a persona that can be emotionally taxing. Wig users generally assume the onus of appropriate wig care, wear, and concealment of hair loss to be on themselves. They have to be “on guard” in public. Users expect strangers to assume that the hair is natural; therefore, they will be treated “normally” in usual circumstances.6
Acquaintances fall under similar expectations with the major caveat that an individual must use identical or similar wigs to lower suspicion, even if acquaintances are tacitly aware of the wig use. If a major wig change is desired like going from short blonde hair to long brunette hair in a brief time period, then an acquaintance might be aware that a wig might be in use. Furthermore, if a new wig is worn in a social setting away from acquaintances and, coincidentally an acquaintance is present, the wig user may be devastated, so he or she must plan accordingly to minimize that risk.
One example in Wiggins’ study involved a woman wearing a wig in her own home near a kitchen window. A neighbor passing by the kitchen window may greet the wig user while she is performing an innocuous chore like cleaning dishes. This unplanned, unpredictable social interaction with an acquaintance requires the individual to continue wearing the wig rather than be comfortable without one in her own home. The neighbor’s greeting is not seen as a violation of privacy, but as a friendly behavior. Nonetheless, it requires added effort by the individual.
The last social group identified is close friends and family. Hair loss is often a long-term process that requires substantial social and emotional effort while undergoing treatment. Thus, wig users often confide in close friends and family for support, and in order to not “deceive” them. The users expect this group to not only have knowledge about the wigs, but to also comment on their practices directly to support them with hair loss and wig use.
Article continues on page 2
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Multifaceted Treatment Plan
Hair loss and wig usage is much more complex than a simple recommendation of a wig shop to individuals. The complexity of picking the right wig, maintaining the wig, and proper utilization are aspects that need to be explored by the hair loss patient. Further care needs to be coordinated with the help of several professionals. At the initial dermatology visit for hair loss, patient reassurance is critical to ensure the individual is getting support for their hair condition.9 However, this is only the first step in a long-term treatment plan. The patient needs a multidisciplinary approach with their primary doctor, the specialty doctor associated with the hair loss such as a dermatologist or an oncologist, and a wig specialist/stylist that are all part of the treatment team that exists as long as the patient requires hair-concealment products.
Cost is another factor that is often overlooked in this multifaceted treatment plan. Natural hair wigs cost more than synthetic fiber ones and are sometimes preferred because they tend to look more natural.8,10 Natural hair wigs can range from $300 to $5000 depending on design and quality, while synthetic ones that last a few months generally are under $100.10 Styling wigs requires different techniques for natural vs synthetic fiber and may require an appropriate professional or adequate training for the wearer.8 These factors must be discussed with patients as an educational imperative early in the treatment course of severe hair loss instead of setting patients adrift in a sea of misinformation as they cope with hair loss (Figure 1).8
When hair loss is chronic, each subsequent visit by patients will require adequate attention to both the medical treatment and psychological component of the hair loss, which may include the maintenance and care of the scalp during wig use (Table). The patient must be told to arrive at the appointment with the scalp uncovered to allow complete visualization in order to monitor hair loss progression. Some patients may arrive at the appointment with wigs that are not easily removed and this impedes the evaluation process. The wig is removed by the patient for the duration of the clinic visit and set aside to expedite medical assessment.
Oftentimes, renewing prescriptions for anti-inflammatory medications and keen attention to the physical exam supersede inquiries about wig care and utilization. Dermatologists need to ask patients about the comfort level of the wigs in a physical and psychosocial sense. Assuring that no traction changes or occlusive phenomenon such as folliculitis is occurring under the wig is paramount. The burden is on the physician to engage the patient and determine the patient’s comfort level with this discussion.
Ethical Concerns
Wig-related ethical concerns can arise with patients that can be complex. One instance in our clinic is of a long-term alopecia totalis patient who works in an office that processes medical records. This patient had worn a wig for several years, and many work acquaintances were aware of this fact. One coworker acquaintance purposefully revealed the patient’s hair loss and wig status to a third party in a manner that negatively impacted the patient. Due to this violation of privacy, the patient lost confidence in her appearance, had difficulty collaborating with the coworker, as well as conducting further business with the third party. Her medical information and her privacy had been violated.
This instance borders on a Health Insurance Portability and Accountability Act (HIPPA) violation because the patient both worked at the office and saw one of the primary physicians in the office as patient, and the incident occurred with a medical records employee in the office. The patient was distraught and filed a complaint with human resources, but was not taken seriously. The patient then pursued a workplace harassment charge for the incident. While this was not a true HIPAA violation in the strictest sense, the minimal fine for such a violation is $50,000 and the maximum fine can be $1.5 million.11 Revealing medical information, including hair loss, about a person without consent is unethical. In an instance where medical information is released in a work setting, this can also be a legal problem.
HIPPA does not only apply to physicians.12 Records offices, law firms, accounting firms, insurance companies, and essentially anyone that processes medical information in a professional manner are subject to HIPPA laws.12 As the workplace harassment charges were being processed, the patient made an appointment with us to get a physician letter of support illuminating the necessity for wig use and the psychosocial importance of prosthesis. The patient’s organization is having an ongoing discussion about this violation of privacy.
Articles continues on page 3
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Pediatric Population
The pediatric population deserves special attention in the realm of alopecia. Alopecia areata can be more devastating in children than in adults.13 For indigent populations, referrals to non-profit organizations such as Locks for Love or the National Alopecia Areata Foundation can help children get proper wigs.10
While helpful in many circumstances, wig use can also prevent children from participating in certain activities like physical education classes or any kind of sports activities. Letters from the dermatologist can excuse children from being forced into these activities, but there is a social cost to sit out while other children interact. Letters can also expedite insurance coverage for wig or scalp prostheses, which may be required in a time-sensitive fashion so children can maintain their social, emotional, and educational development. The letters extend to the adult population, as well. The coverage for wigs varies between conditions, region of the United States, and insurance company coverage.10 Physicians who write prescriptions should use the phrase “a full cranial prosthesis,” but even these are not always accepted in the modern contentious environment of insurance denials.10
Changing Hair Trends
Modern hair perception is also evolving. Dermatologists must be aware of the current perceptions of hair styles. While traditionally short hair is the acceptable standard for men, longer hair, in cultures where is it accepted, is considered to be interesting.14 Men who desire long hair may have a negative self-evaluation that may lead to depression or fear of social intimidation.14
However, shaved heads are becoming popular as well. Males in Britain who shaved their head were once considered to be uncouth.15 Now with popular icons like Derek Jeter, Vin Diesel, Jason Statham, Kobe Bryant, Dwayne “The Rock” Johnson, and Michael Jordon sporting short hair, some men who are starting to bald may opt to immediately shave their head instead of considering a wig (Figure 2).15
Extensions and wig use are also becoming a more prevalent part of modern culture for individuals without hair loss.10 Rihanna, Lady Gaga, Beyonce, and Kylie Jenner have adorned wigs and hair extensions, which has altered perceptions of hair among youth. This has likely impacted wig use, which has increased by 20% in the past few years.16 Regardless of a medical or cosmetic impetus for wig use, getting a consultation from a professional wig stylist behooves anyone considering a wig or hair piece of any kind (Figure 3). There are a variety of chemicals, glues, and materials involved that could cause safety problems. Wig and extension hair needs to be properly cleaned and maintained. Inadequate knowledge and improper use may lead to hair and scalp damage.10 Anyone pursuing wig use must be informed that if injury does occur, then a dermatology visit will be required to adequately treat the problem.
While as a society we are not at a point where baldness in all genders and at all ages is accepted or even celebrated socially, there are indications we are evolving toward that culture. Actor Patrick Stewart who played Captain Jean-Luc Picard in Star Trek: Next Generation recalls when Gene Roddenberry, creator of Star Trek, was asked about why baldness was not cured in the future setting of the show.17 Mr Roddenberry replied that in the future no one would care about being bald.17
Mr Subash is a research fellow in the department of dermatology at Wake Forest Baptist Health in Winston-Salem, NC.
Dr McMichael, The Mane Point Section Editor, is professor and chair in the department of dermatology at Wake Forest Baptist Health in Winston-Salem, NC.
Disclosure: Dr McMichael has received grants from Allergan and Proctor & Gamble. She is a consultant for Allergan, eResearch Technology, Inc, Galderma, Guthey Renker, Johnson & Johnson, Keranetics, Merck & Co., Inc, Merz Pharmaceuticals, Proctor & Gamble, Samumed, and Incyte. She receives royalties from Informa Healthcare and UpToDate and also has conducted research for Samumed.
Mr Subash reports no relevant financial relationships.
References
1. Rencz F, Gulácsi L, Péntek M, Wikonkál N, Baji P, Brodszky V. Alopecia areata and health-related quality of life: a systematic review and meta-analysis. Br J Dermatol. 2016;175(3):561-571.
2. MacLean KJ, Tidman, MJ. Alopecia areata: more than skin deep. Practitioner. 2013;257(1764):29-32, 3.
3. Endo Y, Miyachi Y, Arakawa A. Development of a disease-specific instrument to measure quality of life in patients with alopecia areata. Eur J Dermatol. 2012;22(4):531-536.
4. Inui S, Inoue T, Itami S. Psychosocial impact of wigs or hairpieces on perceived quality of life level in female patients with alopecia areata. J Dermatol. 2013;40(3):225-226.
5. Yeager CE, Olsen EA. Treatment of chemotherapy-induced alopecia. Dermatol Ther. 2011;24(4):432-442.
6. Wiggins S, Moore-Millar K, Thomson A. Can you pull it off? Appearance modifying behaviours adopted by wig users with alopecia in social interactions. Body Image. 2014;11(2):156-166.
7. Zannini L, Verderame F, Cucchiara G, Zinna B, Alba A, Ferrara M. ‘My wig has been my journey’s companion’: Perceived effects of an aesthetic care programme for Italian women suffering from chemotherapy-induced alopecia. Eur J Cancer Care (Engl). 2012;21(5):650-660.
8. Roe H. Chemotherapy-induced alopecia: advice and support for hair loss. Brit J Nurs. 2011;20(10):S4-S11.
9. Vandegrift KV. The development of an oncology alopecia wig program. J Intraven Nurs. 1994;17(2):78-82.
10. McMichael AJ Hordinsky MK, eds. Hair and Scalp Diseases: Medical, Surgical, and Cosmetic Treatments. New York, NY: Informa Healthcare; 2008.
11. HIPAA violations and enforcement. American Medical Association website. https://www.ama-assn.org/practice-management/hipaa-violations-enforcement. Accessed December 28, 2016.
12. Your medical records. U.S. Department of Health & Human Services website. https://www.hhs.gov/hipaa/for-individuals/medical-records/index.html. Accessed December 28, 2016.
13. Iorizzo M, Oranje AP. Current and future treatments of alopecia areata and trichotillomania in children. Expert Opin Pharmacother. 2016;17(13):1767-1773.
14. Social-religious-cultural perceptions of hair & baldness. The Trichological Society website. https://www.hairscientists.org/human-hair/perceptions. Accessed December 28, 2016.
15. Perception of the close shaved hairstyle in modern Britain. HIS Hair Clinic website. https://www.hishairclinic.com/perception-of-the-close-shaved-hairstyle-in-modern-britain/. Accessed December 28, 2016.
16. Popularity of custom made wigs. HAIRFLEEK blog. https://blog.hairfleek.com/2016/04/08/popularity-of-custom-made-wigs/. Accessed December 28, 2016.
17. Pescovitz D. Star Trek creator’s perfect comment on casting a bald captain for ST: TNG. Boing Boing. July 8, 2015. https://boingboing.net/2015/07/08/star-trek-creators-perfect-c.html. Accessed December 28, 2016.
Medical hair loss conditions have a variety of etiologies such as nonscarring alopecias, scarring alopecias, and more. Although the etiology may vary, all types of alopecia can share the same negative social and psychological ramifications. Studies have demonstrated that patients with alopecia areata have a statistically significant propensity to develop psychiatric comorbidities such as depression, anxiety, and social phobia relative to the general population.1,2 Aside from psychiatric conditions, other factors that may negatively influence the quality of life include relatively younger age, the female sex, longer disease duration, and higher disease severity.1
Quantitative research has demonstrated that wearing wigs is one of the best ways to cope with hair loss due to the lack of consistently effective medical treatment to restore hair.3,4 These findings suggest that physicians who treat patients with alopecia need to have an understanding of wig use. The question of when a dermatologist discusses a wig purchase or wig use with an alopecia patient is not clearly defined, but is an important part of the armamentarium of hair loss treatment.
Though dermatologists do not routinely advise patients in management of chemotherapy-related alopecia, it is a good place to start to understand the role of wig use. Wig use during chemotherapy-related hair loss is a common first-line treatment. Patients who will be treated with chemotherapy known to cause hair loss are usually advised to obtain a wig before cancer treatment is started.5 This is to ensure that the synthetic or natural hair camouflage agent is similar to the original hair in terms of color and texture.5
There are social pressures to wear a wig or at least conceal hair loss in cancer patients because of self-perceived as well as external views of a balding head.6 Wigs are often seen as a “friend” and a part of the body as opposed to simply an accessory.7 Women with cancer sometimes choose a lower potency chemotherapy due to a fear of hair loss.8 The hair loss can often be seen as a mutilation of their body leading to a more negative self-perception that can lead to demoralization and other psychiatric comorbidities.
Psychosocial Aspects
The social setting in which a patient wears a wig is a major factor for individuals. Wiggins and colleagues6 identified that a wig user may categorize people into 3 major social strata: stranger, acquaintance, and close friends or family. Each group is treated differently by the wig user, and conversely the expectation of treatment by the group is also different. Wig users do not want strangers or acquaintances to be aware that a wig is being worn. Generally, if a wig is appropriately donned, then a stranger has little chance to decipher the use. However, the use of a wig demands assuming a persona that can be emotionally taxing. Wig users generally assume the onus of appropriate wig care, wear, and concealment of hair loss to be on themselves. They have to be “on guard” in public. Users expect strangers to assume that the hair is natural; therefore, they will be treated “normally” in usual circumstances.6
Acquaintances fall under similar expectations with the major caveat that an individual must use identical or similar wigs to lower suspicion, even if acquaintances are tacitly aware of the wig use. If a major wig change is desired like going from short blonde hair to long brunette hair in a brief time period, then an acquaintance might be aware that a wig might be in use. Furthermore, if a new wig is worn in a social setting away from acquaintances and, coincidentally an acquaintance is present, the wig user may be devastated, so he or she must plan accordingly to minimize that risk.
One example in Wiggins’ study involved a woman wearing a wig in her own home near a kitchen window. A neighbor passing by the kitchen window may greet the wig user while she is performing an innocuous chore like cleaning dishes. This unplanned, unpredictable social interaction with an acquaintance requires the individual to continue wearing the wig rather than be comfortable without one in her own home. The neighbor’s greeting is not seen as a violation of privacy, but as a friendly behavior. Nonetheless, it requires added effort by the individual.
The last social group identified is close friends and family. Hair loss is often a long-term process that requires substantial social and emotional effort while undergoing treatment. Thus, wig users often confide in close friends and family for support, and in order to not “deceive” them. The users expect this group to not only have knowledge about the wigs, but to also comment on their practices directly to support them with hair loss and wig use.
Multifaceted Treatment Plan
Hair loss and wig usage is much more complex than a simple recommendation of a wig shop to individuals. The complexity of picking the right wig, maintaining the wig, and proper utilization are aspects that need to be explored by the hair loss patient. Further care needs to be coordinated with the help of several professionals. At the initial dermatology visit for hair loss, patient reassurance is critical to ensure the individual is getting support for their hair condition.9 However, this is only the first step in a long-term treatment plan. The patient needs a multidisciplinary approach with their primary doctor, the specialty doctor associated with the hair loss such as a dermatologist or an oncologist, and a wig specialist/stylist that are all part of the treatment team that exists as long as the patient requires hair-concealment products.
Cost is another factor that is often overlooked in this multifaceted treatment plan. Natural hair wigs cost more than synthetic fiber ones and are sometimes preferred because they tend to look more natural.8,10 Natural hair wigs can range from $300 to $5000 depending on design and quality, while synthetic ones that last a few months generally are under $100.10 Styling wigs requires different techniques for natural vs synthetic fiber and may require an appropriate professional or adequate training for the wearer.8 These factors must be discussed with patients as an educational imperative early in the treatment course of severe hair loss instead of setting patients adrift in a sea of misinformation as they cope with hair loss (Figure 1).8
When hair loss is chronic, each subsequent visit by patients will require adequate attention to both the medical treatment and psychological component of the hair loss, which may include the maintenance and care of the scalp during wig use (Table). The patient must be told to arrive at the appointment with the scalp uncovered to allow complete visualization in order to monitor hair loss progression. Some patients may arrive at the appointment with wigs that are not easily removed and this impedes the evaluation process. The wig is removed by the patient for the duration of the clinic visit and set aside to expedite medical assessment.
Oftentimes, renewing prescriptions for anti-inflammatory medications and keen attention to the physical exam supersede inquiries about wig care and utilization. Dermatologists need to ask patients about the comfort level of the wigs in a physical and psychosocial sense. Assuring that no traction changes or occlusive phenomenon such as folliculitis is occurring under the wig is paramount. The burden is on the physician to engage the patient and determine the patient’s comfort level with this discussion.
Ethical Concerns
Wig-related ethical concerns can arise with patients that can be complex. One instance in our clinic is of a long-term alopecia totalis patient who works in an office that processes medical records. This patient had worn a wig for several years, and many work acquaintances were aware of this fact. One coworker acquaintance purposefully revealed the patient’s hair loss and wig status to a third party in a manner that negatively impacted the patient. Due to this violation of privacy, the patient lost confidence in her appearance, had difficulty collaborating with the coworker, as well as conducting further business with the third party. Her medical information and her privacy had been violated.
This instance borders on a Health Insurance Portability and Accountability Act (HIPPA) violation because the patient both worked at the office and saw one of the primary physicians in the office as patient, and the incident occurred with a medical records employee in the office. The patient was distraught and filed a complaint with human resources, but was not taken seriously. The patient then pursued a workplace harassment charge for the incident. While this was not a true HIPAA violation in the strictest sense, the minimal fine for such a violation is $50,000 and the maximum fine can be $1.5 million.11 Revealing medical information, including hair loss, about a person without consent is unethical. In an instance where medical information is released in a work setting, this can also be a legal problem.
HIPPA does not only apply to physicians.12 Records offices, law firms, accounting firms, insurance companies, and essentially anyone that processes medical information in a professional manner are subject to HIPPA laws.12 As the workplace harassment charges were being processed, the patient made an appointment with us to get a physician letter of support illuminating the necessity for wig use and the psychosocial importance of prosthesis. The patient’s organization is having an ongoing discussion about this violation of privacy.
Pediatric Population
The pediatric population deserves special attention in the realm of alopecia. Alopecia areata can be more devastating in children than in adults.13 For indigent populations, referrals to non-profit organizations such as Locks for Love or the National Alopecia Areata Foundation can help children get proper wigs.10
While helpful in many circumstances, wig use can also prevent children from participating in certain activities like physical education classes or any kind of sports activities. Letters from the dermatologist can excuse children from being forced into these activities, but there is a social cost to sit out while other children interact. Letters can also expedite insurance coverage for wig or scalp prostheses, which may be required in a time-sensitive fashion so children can maintain their social, emotional, and educational development. The letters extend to the adult population, as well. The coverage for wigs varies between conditions, region of the United States, and insurance company coverage.10 Physicians who write prescriptions should use the phrase “a full cranial prosthesis,” but even these are not always accepted in the modern contentious environment of insurance denials.10
Changing Hair Trends
Modern hair perception is also evolving. Dermatologists must be aware of the current perceptions of hair styles. While traditionally short hair is the acceptable standard for men, longer hair, in cultures where is it accepted, is considered to be interesting.14 Men who desire long hair may have a negative self-evaluation that may lead to depression or fear of social intimidation.14
However, shaved heads are becoming popular as well. Males in Britain who shaved their head were once considered to be uncouth.15 Now with popular icons like Derek Jeter, Vin Diesel, Jason Statham, Kobe Bryant, Dwayne “The Rock” Johnson, and Michael Jordon sporting short hair, some men who are starting to bald may opt to immediately shave their head instead of considering a wig (Figure 2).15
Extensions and wig use are also becoming a more prevalent part of modern culture for individuals without hair loss.10 Rihanna, Lady Gaga, Beyonce, and Kylie Jenner have adorned wigs and hair extensions, which has altered perceptions of hair among youth. This has likely impacted wig use, which has increased by 20% in the past few years.16 Regardless of a medical or cosmetic impetus for wig use, getting a consultation from a professional wig stylist behooves anyone considering a wig or hair piece of any kind (Figure 3). There are a variety of chemicals, glues, and materials involved that could cause safety problems. Wig and extension hair needs to be properly cleaned and maintained. Inadequate knowledge and improper use may lead to hair and scalp damage.10 Anyone pursuing wig use must be informed that if injury does occur, then a dermatology visit will be required to adequately treat the problem.
While as a society we are not at a point where baldness in all genders and at all ages is accepted or even celebrated socially, there are indications we are evolving toward that culture. Actor Patrick Stewart who played Captain Jean-Luc Picard in Star Trek: Next Generation recalls when Gene Roddenberry, creator of Star Trek, was asked about why baldness was not cured in the future setting of the show.17 Mr Roddenberry replied that in the future no one would care about being bald.17
Mr Subash is a research fellow in the department of dermatology at Wake Forest Baptist Health in Winston-Salem, NC.
Dr McMichael, The Mane Point Section Editor, is professor and chair in the department of dermatology at Wake Forest Baptist Health in Winston-Salem, NC.
Disclosure: Dr McMichael has received grants from Allergan and Proctor & Gamble. She is a consultant for Allergan, eResearch Technology, Inc, Galderma, Guthey Renker, Johnson & Johnson, Keranetics, Merck & Co., Inc, Merz Pharmaceuticals, Proctor & Gamble, Samumed, and Incyte. She receives royalties from Informa Healthcare and UpToDate and also has conducted research for Samumed.
Mr Subash reports no relevant financial relationships.
References
1. Rencz F, Gulácsi L, Péntek M, Wikonkál N, Baji P, Brodszky V. Alopecia areata and health-related quality of life: a systematic review and meta-analysis. Br J Dermatol. 2016;175(3):561-571.
2. MacLean KJ, Tidman, MJ. Alopecia areata: more than skin deep. Practitioner. 2013;257(1764):29-32, 3.
3. Endo Y, Miyachi Y, Arakawa A. Development of a disease-specific instrument to measure quality of life in patients with alopecia areata. Eur J Dermatol. 2012;22(4):531-536.
4. Inui S, Inoue T, Itami S. Psychosocial impact of wigs or hairpieces on perceived quality of life level in female patients with alopecia areata. J Dermatol. 2013;40(3):225-226.
5. Yeager CE, Olsen EA. Treatment of chemotherapy-induced alopecia. Dermatol Ther. 2011;24(4):432-442.
6. Wiggins S, Moore-Millar K, Thomson A. Can you pull it off? Appearance modifying behaviours adopted by wig users with alopecia in social interactions. Body Image. 2014;11(2):156-166.
7. Zannini L, Verderame F, Cucchiara G, Zinna B, Alba A, Ferrara M. ‘My wig has been my journey’s companion’: Perceived effects of an aesthetic care programme for Italian women suffering from chemotherapy-induced alopecia. Eur J Cancer Care (Engl). 2012;21(5):650-660.
8. Roe H. Chemotherapy-induced alopecia: advice and support for hair loss. Brit J Nurs. 2011;20(10):S4-S11.
9. Vandegrift KV. The development of an oncology alopecia wig program. J Intraven Nurs. 1994;17(2):78-82.
10. McMichael AJ Hordinsky MK, eds. Hair and Scalp Diseases: Medical, Surgical, and Cosmetic Treatments. New York, NY: Informa Healthcare; 2008.
11. HIPAA violations and enforcement. American Medical Association website. https://www.ama-assn.org/practice-management/hipaa-violations-enforcement. Accessed December 28, 2016.
12. Your medical records. U.S. Department of Health & Human Services website. https://www.hhs.gov/hipaa/for-individuals/medical-records/index.html. Accessed December 28, 2016.
13. Iorizzo M, Oranje AP. Current and future treatments of alopecia areata and trichotillomania in children. Expert Opin Pharmacother. 2016;17(13):1767-1773.
14. Social-religious-cultural perceptions of hair & baldness. The Trichological Society website. https://www.hairscientists.org/human-hair/perceptions. Accessed December 28, 2016.
15. Perception of the close shaved hairstyle in modern Britain. HIS Hair Clinic website. https://www.hishairclinic.com/perception-of-the-close-shaved-hairstyle-in-modern-britain/. Accessed December 28, 2016.
16. Popularity of custom made wigs. HAIRFLEEK blog. https://blog.hairfleek.com/2016/04/08/popularity-of-custom-made-wigs/. Accessed December 28, 2016.
17. Pescovitz D. Star Trek creator’s perfect comment on casting a bald captain for ST: TNG. Boing Boing. July 8, 2015. https://boingboing.net/2015/07/08/star-trek-creators-perfect-c.html. Accessed December 28, 2016.
This instance borders on a Health Insurance Portability and Accountability Act (HIPPA) violation because the patient both worked at the office and saw one of the primary physicians in the office as patient, and the incident occurred with a medical records employee in the office. The patient was distraught and filed a complaint with human resources, but was not taken seriously. The patient then pursued a workplace harassment charge for the incident. While this was not a true HIPAA violation in the strictest sense, the minimal fine for such a violation is $50,000 and the maximum fine can be $1.5 million.11 Revealing medical information, including hair loss, about a person without consent is unethical. In an instance where medical information is released in a work setting, this can also be a legal problem.
HIPPA does not only apply to physicians.12 Records offices, law firms, accounting firms, insurance companies, and essentially anyone that processes medical information in a professional manner are subject to HIPPA laws.12 As the workplace harassment charges were being processed, the patient made an appointment with us to get a physician letter of support illuminating the necessity for wig use and the psychosocial importance of prosthesis. The patient’s organization is having an ongoing discussion about this violation of privacy.
Pediatric Population
The pediatric population deserves special attention in the realm of alopecia. Alopecia areata can be more devastating in children than in adults.13 For indigent populations, referrals to non-profit organizations such as Locks for Love or the National Alopecia Areata Foundation can help children get proper wigs.10
While helpful in many circumstances, wig use can also prevent children from participating in certain activities like physical education classes or any kind of sports activities. Letters from the dermatologist can excuse children from being forced into these activities, but there is a social cost to sit out while other children interact. Letters can also expedite insurance coverage for wig or scalp prostheses, which may be required in a time-sensitive fashion so children can maintain their social, emotional, and educational development. The letters extend to the adult population, as well. The coverage for wigs varies between conditions, region of the United States, and insurance company coverage.10 Physicians who write prescriptions should use the phrase “a full cranial prosthesis,” but even these are not always accepted in the modern contentious environment of insurance denials.10
Changing Hair Trends
Modern hair perception is also evolving. Dermatologists must be aware of the current perceptions of hair styles. While traditionally short hair is the acceptable standard for men, longer hair, in cultures where is it accepted, is considered to be interesting.14 Men who desire long hair may have a negative self-evaluation that may lead to depression or fear of social intimidation.14
However, shaved heads are becoming popular as well. Males in Britain who shaved their head were once considered to be uncouth.15 Now with popular icons like Derek Jeter, Vin Diesel, Jason Statham, Kobe Bryant, Dwayne “The Rock” Johnson, and Michael Jordon sporting short hair, some men who are starting to bald may opt to immediately shave their head instead of considering a wig (Figure 2).15
Extensions and wig use are also becoming a more prevalent part of modern culture for individuals without hair loss.10 Rihanna, Lady Gaga, Beyonce, and Kylie Jenner have adorned wigs and hair extensions, which has altered perceptions of hair among youth. This has likely impacted wig use, which has increased by 20% in the past few years.16 Regardless of a medical or cosmetic impetus for wig use, getting a consultation from a professional wig stylist behooves anyone considering a wig or hair piece of any kind (Figure 3). There are a variety of chemicals, glues, and materials involved that could cause safety problems. Wig and extension hair needs to be properly cleaned and maintained. Inadequate knowledge and improper use may lead to hair and scalp damage.10 Anyone pursuing wig use must be informed that if injury does occur, then a dermatology visit will be required to adequately treat the problem.
While as a society we are not at a point where baldness in all genders and at all ages is accepted or even celebrated socially, there are indications we are evolving toward that culture. Actor Patrick Stewart who played Captain Jean-Luc Picard in Star Trek: Next Generation recalls when Gene Roddenberry, creator of Star Trek, was asked about why baldness was not cured in the future setting of the show.17 Mr Roddenberry replied that in the future no one would care about being bald.17
Mr Subash is a research fellow in the department of dermatology at Wake Forest Baptist Health in Winston-Salem, NC.
Dr McMichael, The Mane Point Section Editor, is professor and chair in the department of dermatology at Wake Forest Baptist Health in Winston-Salem, NC.
Disclosure: Dr McMichael has received grants from Allergan and Proctor & Gamble. She is a consultant for Allergan, eResearch Technology, Inc, Galderma, Guthey Renker, Johnson & Johnson, Keranetics, Merck & Co., Inc, Merz Pharmaceuticals, Proctor & Gamble, Samumed, and Incyte. She receives royalties from Informa Healthcare and UpToDate and also has conducted research for Samumed.
Mr Subash reports no relevant financial relationships.
References
1. Rencz F, Gulácsi L, Péntek M, Wikonkál N, Baji P, Brodszky V. Alopecia areata and health-related quality of life: a systematic review and meta-analysis. Br J Dermatol. 2016;175(3):561-571.
2. MacLean KJ, Tidman, MJ. Alopecia areata: more than skin deep. Practitioner. 2013;257(1764):29-32, 3.
3. Endo Y, Miyachi Y, Arakawa A. Development of a disease-specific instrument to measure quality of life in patients with alopecia areata. Eur J Dermatol. 2012;22(4):531-536.
4. Inui S, Inoue T, Itami S. Psychosocial impact of wigs or hairpieces on perceived quality of life level in female patients with alopecia areata. J Dermatol. 2013;40(3):225-226.
5. Yeager CE, Olsen EA. Treatment of chemotherapy-induced alopecia. Dermatol Ther. 2011;24(4):432-442.
6. Wiggins S, Moore-Millar K, Thomson A. Can you pull it off? Appearance modifying behaviours adopted by wig users with alopecia in social interactions. Body Image. 2014;11(2):156-166.
7. Zannini L, Verderame F, Cucchiara G, Zinna B, Alba A, Ferrara M. ‘My wig has been my journey’s companion’: Perceived effects of an aesthetic care programme for Italian women suffering from chemotherapy-induced alopecia. Eur J Cancer Care (Engl). 2012;21(5):650-660.
8. Roe H. Chemotherapy-induced alopecia: advice and support for hair loss. Brit J Nurs. 2011;20(10):S4-S11.
9. Vandegrift KV. The development of an oncology alopecia wig program. J Intraven Nurs. 1994;17(2):78-82.
10. McMichael AJ Hordinsky MK, eds. Hair and Scalp Diseases: Medical, Surgical, and Cosmetic Treatments. New York, NY: Informa Healthcare; 2008.
11. HIPAA violations and enforcement. American Medical Association website. https://www.ama-assn.org/practice-management/hipaa-violations-enforcement. Accessed December 28, 2016.
12. Your medical records. U.S. Department of Health & Human Services website. https://www.hhs.gov/hipaa/for-individuals/medical-records/index.html. Accessed December 28, 2016.
13. Iorizzo M, Oranje AP. Current and future treatments of alopecia areata and trichotillomania in children. Expert Opin Pharmacother. 2016;17(13):1767-1773.
14. Social-religious-cultural perceptions of hair & baldness. The Trichological Society website. https://www.hairscientists.org/human-hair/perceptions. Accessed December 28, 2016.
15. Perception of the close shaved hairstyle in modern Britain. HIS Hair Clinic website. https://www.hishairclinic.com/perception-of-the-close-shaved-hairstyle-in-modern-britain/. Accessed December 28, 2016.
16. Popularity of custom made wigs. HAIRFLEEK blog. https://blog.hairfleek.com/2016/04/08/popularity-of-custom-made-wigs/. Accessed December 28, 2016.
17. Pescovitz D. Star Trek creator’s perfect comment on casting a bald captain for ST: TNG. Boing Boing. July 8, 2015. https://boingboing.net/2015/07/08/star-trek-creators-perfect-c.html. Accessed December 28, 2016.
