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Postpartum alopecia
CURRENT OPINION Re-evaluation Postpartum alopecia J . B. S K E L T 0 N, M . D . Glen Ridge/Montclair, New Jersey
involved in the process. 2 Anagen is the growing phase of a hair follicle estimated to last between 2 and 6 years with an average of 3 years ( 1,000 days) . Daily normal hair loss would amount to 40 hairs. Assuming the average scalp contains 100,000 hairs, at least 25 per cent or 25,000 hairs must be lost before definite noticeable thinning develops. 1 The growing follicle then goes through an intermediate phase (catogen) in which the highly specialized hair matrix cells regress (undergo dedifferentiation) into a small tuft of undifferentiated epithelial cells from which will spring the next hair "in a fashion which exactiy recapituiates the embryonal pattern of follicle development from the primary epithelial germ." 1 At the end point of the process of catogen, the follicle enters the resting state ( telogen) . If, under stress, the follicle completes this transition to telogen too rapidly, the process represents a premature terwination of the normal life cycle. It results in the shedding of perfectly normal club hairs from normal telogen follicles termed "telogen effluvium." It is this type of reversible hair loss which is seen in postpartum, postfebrile, and psy= chogenic hair loss states. Normal telogen count in scalp hair runs 15 per cent, with counts higher than 25 per cent telogen hair diagnostic of telogen effluvium, and counts above 20 per cent presumptively abnormal. 1 ' 3 Lynfield,a in an excellent and informative study of normal pregnancies, showed anagen
THRouGH the centuries almost every doctor delivering mothers of infants has faced the distraught new mother who says, "Doctor, my hair has been falling out." The more fortunate bald physicians can safely answer, "What do you expect me to be able to do about it?" Despite the prevalence of this cosmetically disturbing postpartum occurrence, there has been a startling paucity of information in the obstetrical literature. Through the years these patients have been offered uninformed reassurance, thyroid extract, vitamins, gelatin, lotions and oils, and equally unproductive VlSltations to the dermatologist or beauty saion entrepreneur. The present study was planned to investigate some factors involved in production of postpartum alopecia in hopes of offering a solution for this common but poorly understood condition. Background
As Kligman1 states, "Folk-lore and oldwives' tales give a better account of hair loss after childbirth than is to be found in the annals of medicine." "A peculiar deep silence prevails in the medical literature." There are several phases of hair growth, with alkaline phosphatase apparently being From ihe Department of Obstetrics
and Gynecology, Cornell University Medical College, and the New York Lying-In Hospital.
125
.Janll<~ty
126 Skelton
(growing) hair to comprise 85 per cent of scalp hair in a nonpregnant control group of :10 women. In the first trimester of pregnancy ( 5 women) it was 85 per cent; identical with that in the nonpregnant state. In the second trimester (5 women) it was 95 per cent, and in the third, 94 per cent ( 15 women), a significant rise in growing hair follicles. At 5 to 7 days post partum it was stiil 94 per cent; but at 6 weeks postpartum it was 76 per cent (9 women) and at 3 months 77 per cent, both values at a significant level below the nonpregnant mean. From these observations she postulates that normally during pregnancy, the conversion of hair from anagen to telogen is slowed do\,vn. An alternate possibility presented is that pregnancy is associated with a more rapid shedding of telogen hair although the former explanation seems more logical. Post partum, the conversion from anagen (growing) to telogen (resting) is accelerated, accounting for the decrease in percentage of anagen. This finding is in agreement with that of Van Scott. 4 In a study of 21 of 35 subjects with excessive shedding pu~~ panum, Kligman 1 found telogen counts of 20 per cent to 55 per cent with a mean of 32 per cent. One striking and constant feature of telogen effluvium pointed out by all authors is the latency period ranging from 2 to 4 months between the stress and the shedding. A second characteristic is the tendency for complete restitution of the hair unless some other process intervenes. Present study The present study consists of 10 patients seen post partum between December, 1959, and May, 1963, with symptoms of excessive hair loss. Age and parity
The range in age varied from 22 to 37 years. Parity ranged from i to v. Four patients developed alopecia after their first pregnancy and 6 were studied after repeat pregnancies. Of the 6 multiparas, post partum 4 had excessive shedding after previous
l, l9flh
.'\m. j. Ob . . L & Gyrwc.
deliveries and 2 did not, showing agreement with previous authors' statements that recurrence after future pregnancies may be expected. Complications
One patient developed scarlet fever at 30 weeks' gestation, was treated with Ilosone and developed hair loss; she was the only patient to have antepartum alopecia. She was delivered of a 4 pound, 14 ounce living male infant at 36 weeks' gestation. Four patients had excess tiredness post partum and 3 women stated they were excessively emotionally labile and "upset" post partum. One of these stated she was upset during this pregnancy but not 'Nith her previous pregnancy, and there was no post partum alopecia after the former pregnancy. Relation to other factors
l'1o relation vvas found to sex of infant, type of delivery, type of anesthesia, or maternal breast feeding. Location and appearance
The location of hair loss varied with 6 patients having diffuse shedding, especially in the temporal and frontal areas; 2 temporal only, 1 temporal and frontal, and 1 frontal only. This agrees with Kligman's 1 findings in 35 subjects but contrasts with Schiff and Kern 5 who found diffuse loss in only 20.4 per cent of 98 patients. Three women were blonde, 6 were brunette, and one had black hair. All of the patients were bothered by the shedding and most described it in dramatic terms such as, "my hair comes out by the handfuls," and, "I'm going bald." Two patients said they were bothered only slightly by it. The appearance of the patients was clinically changed, but only to a mild degree to casual observers. In only 2 cases \·vas it noticeable to others, including the husbands. No patients had seborrhea present, concurring with Schiff and Kern's opinion. 5 One subject noticed increased extremity hair gro\.vth during the pregnancy, but no other body hair changes were noted.
Volume 94 Nu1nber 1
In contrast to the optimistic prognosis for complete return to normal emphasized by all authors/• 3 • 5 3 of the subjects have not had return to normal full hair pattern after intervals of 1~ to 4 years despite the absence of any other apparent cause for the persistent alopecia. Two subjects were lost to long-term follow-up, and the remaining 5 have had a return to normal full hair pattern.
Postpartum alopecia
Table I. Onset, duration, and outcome Onset (month post partum)
Duration (mo.)
Antepartum
6
<1
12
Yes Yes
2
Yes
'l
...
V--
4
?
3
Yes (pregnant)
2
Onset, duration and outcome (Table II
One patient developed hair loss antepartum following scarlet fever. The earliest postpartum development was at 2 weeks, in 3 onset was within one month. The latest occurrence was at 4 months post partum. The early onset cases agree with Lynfield's findings of 3 cases within one month and are earlier than the onset usually quoted, 1 • 5 of 2 to 3 months post partum. The duration of the alopecia is seen to range from 2 to 12 months with 2 patients having recurrences of shedding at 18 and 36 months. These variations of duration agree with previous authors. There seemed to be no connection between the time of onset, and the amount, duration, or final outcome of the shedding; a fact not previously emphasized. Laboiatoiy studies (Table IU
In an attempt to see whether any basic hormonal deficiency in the postpartum state might be an etiologic factor, assays were run consisting of protein bound iodine determinations, and 17-ketosteroid, 17-hydroxycorticoid, and pituitary gonadotropin 24 hour urinary excretions. (Normal values in our laboratory; protein bound iodine, 3.5 to 7.5 gamma per cent; 17 -ketosteroid, 5 to 14 mg. per 24 hours; 17-hydroxycorticoid, 3 to 11 mg. per 24 hours, gonadotropins 6 to 50 :rvi.U.) .A.lthough the spectrum is obviously incomplete with the omission of estrogen and progesterone determinations, it nevertheless is more comprehensive than any previously reported in the literature. Behrman, 6 postulated the etiology might be the result of an estrogen deficiency state resulting from
127
3
6
Recurrence
>36
Recurrence
>18
4
7
Return normal
..,.
No
No No
inhibition effect on the gonadotrophic activities of the anterior pituitary gland by the elevated steroid levels during pregnancy, or a more general pituitary depression. He found a low basal metabolism rate in some of his patients. Schiff and Kern 5 found a normal basal metabolism rate in 8 patients and normal 17-ketosteroid levels in 11 subjects studied. In this series, 7 patients had 17-ketosteroid determinations, all within normal limits. It is of interest that, of the 3 patients with the highest 17 -ketosteroid values, 2 of them (Table II) are the patients who have had recurrences of alopecia, and one of these had increased growth of extremity hair during this pregnancy. This raises the provocative speculation whether these patients might, for some reason, have a predisposition to later male type baldness of the female which is becoming more common throughout the world. 7 • 8 17 -Hydroxycorticoid determinations and urinary gonadotropin levels were within normal limits in all patients studied. Therapy
It was decided first to place patients on thyroid therapy which has been a time honored treatment through the years. This \Vas done despite the normal protein bound iodine levels in these patients. Cytomel was
128
.J~nnar
Skelton
.\m .
.T.
ot.~r.
\ l. lqhf, '-" f;y,wc
Table II. Laboratory results Protein bound iodine
1 ?-Ketosteroid.,
Patient 2 3 4 5 7 9 10
5.8 4.8 4.8 6.3 6.7 4.6 5.H
11.3 9.1 9.0 12.1 *
(mg./24 hr.)
I 7 -H ydroxysteroid.1 (rng./24 hr.)
Urinary ganadotropin (M. U.)
9.1
34
7.1 7.+ 9.9
27 2:2
4.0
48
7. I
8.1
11.5* 9.0
32
*Cases of recurrent alopecia.
Table HI 1-----------.------~----~---I'_h_er_a~py~--------~--Patient 1 2
I
Thyroid
Cytomel 25-50 Thyroid 2 gr.
ment
Estinyl
Other
Return to normal
0 0
Yes Yes
0 0
Yes Yes
0 0
Ultrasol + Permanent and
No Yes
Yes Yes
0 Slight
Yes Yes Yes
0
Permanent +
Yes Yes
Recurrence
No
Recurrence
Yes No
Pregnant
Yes
1· Improve-!
IImprove-! ment
Estrogen + 1/mproue-1 progesterone ment
cut?
3
4 5
Cytomel 50
Slight
6
Cytomel 50 Cytomel 50-100 Thyroid % gr.* Cytomel 25-50 Synthroid 0.2 Cytomel 50
+ 0 0 Slight
'7
8 9
10
+
Slight ternporal
Yes
0
Yes
0
Yes
Slight
Yes
Slight
Slight
*On thyroid before and during pregnancy.
chosen in most patients because of the possibility of a relationship between postpartum alopecia and a possible hypometabolic state. Eight of the 10 subjects were treated with thyroid, 5 with Cytomel (Table III). One patient manifested a definite improvement on thyroid alone and 3 had only slight improvement. The remaining 4 cases showed no response. Estinyl and estinyl with progesterone lotions (Table Ill)
The stimulation for investigation of this subject arose from interesting work done by Dr. Jeanne Epstein and Dr. Herbert Kupperman at New York University Medical Center on treatment of alopecia arcata and totalis with stimulation of hair growth by topical use of steroids and corticosteroids, possibly by reversing an autoimmunization
process. It was elected to follow their plan, using estinyl and progesterone* by topical application. A lotion composed of 0.01 mg. estinyl per cubic centimeter in 70 per cent ethyl alcohol was used. The subjects were instructed to use the lotion liberally by scalp massage three times aauy for 3 to 4 weeks. Six patients followed this regime and there was slight improvement in 2 cases. No demonstrable change was apparent in the others. A second lotion was then prepared to be used in a similar fashion. To the estinyl lotion 0.5 Gm. of pure powdered progesterone per 4 ounce bottle was added.* Seven subjects applied this preparation. One woman who had shown slight response to the estinyl lotion alone had a dramatic response *Estinyl
and
progesterone
preparation
provided
Schering Corporation, Bloomfield, New Jersey.
hy
Volume 94 Number i
to the combined estinyl and progesterone preparation. Two additional patients showed slight improvement but in one of these, the improvement was transitory and reverted afier cessation of therapy; remammg so despite normal ovulatory cycles. The remaining 4 patients demonstrated no change. Miscellaneous therapy !Table Ill)
In a retrospective questionnaire, patients related improvement to other factors including Ultrasol treatment, permanent waves and hair cuts, and in one patient, an immediate reversal shortly after conception in a new pregnancy. The subsequent follow-up course has shov;n lack of return to normal hair pattern in 3 patients with no apparent intercurrent causative condition. This is in disagreement with most statements in the literature.
REFERENCES
1. Kligman, A. M.: Arch. Dermat. 83: 175, 1961. 2. Kopf, A. W., and Orentreich, N.: Arch. Dermat. 76: 288, 1957. 3. Lynfield, Y. L.: J. Invest. Dermat. 35: 323, 1960. 4. Van Scott, E. J.: Biology of hair growth. In Montagna and Ellis, editors: New York, 1958, Academic Press, Inc.
Postpartum alopecia
129
Summary
Thyroid, adrenal, and pituitary gonadotropic activities were found to be normal in the 10 cases of postpartum alopecia stu mea. Administration of thyroid and local applications of estrogen and estrogen plus progesterone substances did not correct the condition. This study group is smali and, while most cases will spontaneously revert to normal, no firm conclusions are drawn. Only the surface of the problem has been touched. If more investigators will accept the challenge of continued research, patients may then obtain a cure from their physicians rather than treatments and promises of cure from others. '
,.
1
5. Schiff, B. L., and Kern, A. B.: Arch. Dermat. 87: 609, 1963. 6. Behrman, H. T.: The scalp in health and disease, St. Louis, 1952, The C. V. Mosby Company. 7. Maguire, H. C., Jr., and Kligman, A. M.: Geriatrics 18: 329, 1963. 8. Lu Bowe, I. L.: M. Times 91: 383, 1962. 230 Sherman Avenue Glen .l?.idge/J1ontclairJ .lVew Jersey 07028
involved in the process. 2 Anagen is the growing phase of a hair follicle estimated to last between 2 and 6 years with an average of 3 years ( 1,000 days) . Daily normal hair loss would amount to 40 hairs. Assuming the average scalp contains 100,000 hairs, at least 25 per cent or 25,000 hairs must be lost before definite noticeable thinning develops. 1 The growing follicle then goes through an intermediate phase (catogen) in which the highly specialized hair matrix cells regress (undergo dedifferentiation) into a small tuft of undifferentiated epithelial cells from which will spring the next hair "in a fashion which exactiy recapituiates the embryonal pattern of follicle development from the primary epithelial germ." 1 At the end point of the process of catogen, the follicle enters the resting state ( telogen) . If, under stress, the follicle completes this transition to telogen too rapidly, the process represents a premature terwination of the normal life cycle. It results in the shedding of perfectly normal club hairs from normal telogen follicles termed "telogen effluvium." It is this type of reversible hair loss which is seen in postpartum, postfebrile, and psy= chogenic hair loss states. Normal telogen count in scalp hair runs 15 per cent, with counts higher than 25 per cent telogen hair diagnostic of telogen effluvium, and counts above 20 per cent presumptively abnormal. 1 ' 3 Lynfield,a in an excellent and informative study of normal pregnancies, showed anagen
THRouGH the centuries almost every doctor delivering mothers of infants has faced the distraught new mother who says, "Doctor, my hair has been falling out." The more fortunate bald physicians can safely answer, "What do you expect me to be able to do about it?" Despite the prevalence of this cosmetically disturbing postpartum occurrence, there has been a startling paucity of information in the obstetrical literature. Through the years these patients have been offered uninformed reassurance, thyroid extract, vitamins, gelatin, lotions and oils, and equally unproductive VlSltations to the dermatologist or beauty saion entrepreneur. The present study was planned to investigate some factors involved in production of postpartum alopecia in hopes of offering a solution for this common but poorly understood condition. Background
As Kligman1 states, "Folk-lore and oldwives' tales give a better account of hair loss after childbirth than is to be found in the annals of medicine." "A peculiar deep silence prevails in the medical literature." There are several phases of hair growth, with alkaline phosphatase apparently being From ihe Department of Obstetrics
and Gynecology, Cornell University Medical College, and the New York Lying-In Hospital.
125
.Janll<~ty
126 Skelton
(growing) hair to comprise 85 per cent of scalp hair in a nonpregnant control group of :10 women. In the first trimester of pregnancy ( 5 women) it was 85 per cent; identical with that in the nonpregnant state. In the second trimester (5 women) it was 95 per cent, and in the third, 94 per cent ( 15 women), a significant rise in growing hair follicles. At 5 to 7 days post partum it was stiil 94 per cent; but at 6 weeks postpartum it was 76 per cent (9 women) and at 3 months 77 per cent, both values at a significant level below the nonpregnant mean. From these observations she postulates that normally during pregnancy, the conversion of hair from anagen to telogen is slowed do\,vn. An alternate possibility presented is that pregnancy is associated with a more rapid shedding of telogen hair although the former explanation seems more logical. Post partum, the conversion from anagen (growing) to telogen (resting) is accelerated, accounting for the decrease in percentage of anagen. This finding is in agreement with that of Van Scott. 4 In a study of 21 of 35 subjects with excessive shedding pu~~ panum, Kligman 1 found telogen counts of 20 per cent to 55 per cent with a mean of 32 per cent. One striking and constant feature of telogen effluvium pointed out by all authors is the latency period ranging from 2 to 4 months between the stress and the shedding. A second characteristic is the tendency for complete restitution of the hair unless some other process intervenes. Present study The present study consists of 10 patients seen post partum between December, 1959, and May, 1963, with symptoms of excessive hair loss. Age and parity
The range in age varied from 22 to 37 years. Parity ranged from i to v. Four patients developed alopecia after their first pregnancy and 6 were studied after repeat pregnancies. Of the 6 multiparas, post partum 4 had excessive shedding after previous
l, l9flh
.'\m. j. Ob . . L & Gyrwc.
deliveries and 2 did not, showing agreement with previous authors' statements that recurrence after future pregnancies may be expected. Complications
One patient developed scarlet fever at 30 weeks' gestation, was treated with Ilosone and developed hair loss; she was the only patient to have antepartum alopecia. She was delivered of a 4 pound, 14 ounce living male infant at 36 weeks' gestation. Four patients had excess tiredness post partum and 3 women stated they were excessively emotionally labile and "upset" post partum. One of these stated she was upset during this pregnancy but not 'Nith her previous pregnancy, and there was no post partum alopecia after the former pregnancy. Relation to other factors
l'1o relation vvas found to sex of infant, type of delivery, type of anesthesia, or maternal breast feeding. Location and appearance
The location of hair loss varied with 6 patients having diffuse shedding, especially in the temporal and frontal areas; 2 temporal only, 1 temporal and frontal, and 1 frontal only. This agrees with Kligman's 1 findings in 35 subjects but contrasts with Schiff and Kern 5 who found diffuse loss in only 20.4 per cent of 98 patients. Three women were blonde, 6 were brunette, and one had black hair. All of the patients were bothered by the shedding and most described it in dramatic terms such as, "my hair comes out by the handfuls," and, "I'm going bald." Two patients said they were bothered only slightly by it. The appearance of the patients was clinically changed, but only to a mild degree to casual observers. In only 2 cases \·vas it noticeable to others, including the husbands. No patients had seborrhea present, concurring with Schiff and Kern's opinion. 5 One subject noticed increased extremity hair gro\.vth during the pregnancy, but no other body hair changes were noted.
Volume 94 Nu1nber 1
In contrast to the optimistic prognosis for complete return to normal emphasized by all authors/• 3 • 5 3 of the subjects have not had return to normal full hair pattern after intervals of 1~ to 4 years despite the absence of any other apparent cause for the persistent alopecia. Two subjects were lost to long-term follow-up, and the remaining 5 have had a return to normal full hair pattern.
Postpartum alopecia
Table I. Onset, duration, and outcome Onset (month post partum)
Duration (mo.)
Antepartum
6
<1
12
Yes Yes
2
Yes
'l
...
V--
4
?
3
Yes (pregnant)
2
Onset, duration and outcome (Table II
One patient developed hair loss antepartum following scarlet fever. The earliest postpartum development was at 2 weeks, in 3 onset was within one month. The latest occurrence was at 4 months post partum. The early onset cases agree with Lynfield's findings of 3 cases within one month and are earlier than the onset usually quoted, 1 • 5 of 2 to 3 months post partum. The duration of the alopecia is seen to range from 2 to 12 months with 2 patients having recurrences of shedding at 18 and 36 months. These variations of duration agree with previous authors. There seemed to be no connection between the time of onset, and the amount, duration, or final outcome of the shedding; a fact not previously emphasized. Laboiatoiy studies (Table IU
In an attempt to see whether any basic hormonal deficiency in the postpartum state might be an etiologic factor, assays were run consisting of protein bound iodine determinations, and 17-ketosteroid, 17-hydroxycorticoid, and pituitary gonadotropin 24 hour urinary excretions. (Normal values in our laboratory; protein bound iodine, 3.5 to 7.5 gamma per cent; 17 -ketosteroid, 5 to 14 mg. per 24 hours; 17-hydroxycorticoid, 3 to 11 mg. per 24 hours, gonadotropins 6 to 50 :rvi.U.) .A.lthough the spectrum is obviously incomplete with the omission of estrogen and progesterone determinations, it nevertheless is more comprehensive than any previously reported in the literature. Behrman, 6 postulated the etiology might be the result of an estrogen deficiency state resulting from
127
3
6
Recurrence
>36
Recurrence
>18
4
7
Return normal
..,.
No
No No
inhibition effect on the gonadotrophic activities of the anterior pituitary gland by the elevated steroid levels during pregnancy, or a more general pituitary depression. He found a low basal metabolism rate in some of his patients. Schiff and Kern 5 found a normal basal metabolism rate in 8 patients and normal 17-ketosteroid levels in 11 subjects studied. In this series, 7 patients had 17-ketosteroid determinations, all within normal limits. It is of interest that, of the 3 patients with the highest 17 -ketosteroid values, 2 of them (Table II) are the patients who have had recurrences of alopecia, and one of these had increased growth of extremity hair during this pregnancy. This raises the provocative speculation whether these patients might, for some reason, have a predisposition to later male type baldness of the female which is becoming more common throughout the world. 7 • 8 17 -Hydroxycorticoid determinations and urinary gonadotropin levels were within normal limits in all patients studied. Therapy
It was decided first to place patients on thyroid therapy which has been a time honored treatment through the years. This \Vas done despite the normal protein bound iodine levels in these patients. Cytomel was
128
.J~nnar
Skelton
.\m .
.T.
ot.~r.
\ l. lqhf, '-" f;y,wc
Table II. Laboratory results Protein bound iodine
1 ?-Ketosteroid.,
Patient 2 3 4 5 7 9 10
5.8 4.8 4.8 6.3 6.7 4.6 5.H
11.3 9.1 9.0 12.1 *
(mg./24 hr.)
I 7 -H ydroxysteroid.1 (rng./24 hr.)
Urinary ganadotropin (M. U.)
9.1
34
7.1 7.+ 9.9
27 2:2
4.0
48
7. I
8.1
11.5* 9.0
32
*Cases of recurrent alopecia.
Table HI 1-----------.------~----~---I'_h_er_a~py~--------~--Patient 1 2
I
Thyroid
Cytomel 25-50 Thyroid 2 gr.
ment
Estinyl
Other
Return to normal
0 0
Yes Yes
0 0
Yes Yes
0 0
Ultrasol + Permanent and
No Yes
Yes Yes
0 Slight
Yes Yes Yes
0
Permanent +
Yes Yes
Recurrence
No
Recurrence
Yes No
Pregnant
Yes
1· Improve-!
IImprove-! ment
Estrogen + 1/mproue-1 progesterone ment
cut?
3
4 5
Cytomel 50
Slight
6
Cytomel 50 Cytomel 50-100 Thyroid % gr.* Cytomel 25-50 Synthroid 0.2 Cytomel 50
+ 0 0 Slight
'7
8 9
10
+
Slight ternporal
Yes
0
Yes
0
Yes
Slight
Yes
Slight
Slight
*On thyroid before and during pregnancy.
chosen in most patients because of the possibility of a relationship between postpartum alopecia and a possible hypometabolic state. Eight of the 10 subjects were treated with thyroid, 5 with Cytomel (Table III). One patient manifested a definite improvement on thyroid alone and 3 had only slight improvement. The remaining 4 cases showed no response. Estinyl and estinyl with progesterone lotions (Table Ill)
The stimulation for investigation of this subject arose from interesting work done by Dr. Jeanne Epstein and Dr. Herbert Kupperman at New York University Medical Center on treatment of alopecia arcata and totalis with stimulation of hair growth by topical use of steroids and corticosteroids, possibly by reversing an autoimmunization
process. It was elected to follow their plan, using estinyl and progesterone* by topical application. A lotion composed of 0.01 mg. estinyl per cubic centimeter in 70 per cent ethyl alcohol was used. The subjects were instructed to use the lotion liberally by scalp massage three times aauy for 3 to 4 weeks. Six patients followed this regime and there was slight improvement in 2 cases. No demonstrable change was apparent in the others. A second lotion was then prepared to be used in a similar fashion. To the estinyl lotion 0.5 Gm. of pure powdered progesterone per 4 ounce bottle was added.* Seven subjects applied this preparation. One woman who had shown slight response to the estinyl lotion alone had a dramatic response *Estinyl
and
progesterone
preparation
provided
Schering Corporation, Bloomfield, New Jersey.
hy
Volume 94 Number i
to the combined estinyl and progesterone preparation. Two additional patients showed slight improvement but in one of these, the improvement was transitory and reverted afier cessation of therapy; remammg so despite normal ovulatory cycles. The remaining 4 patients demonstrated no change. Miscellaneous therapy !Table Ill)
In a retrospective questionnaire, patients related improvement to other factors including Ultrasol treatment, permanent waves and hair cuts, and in one patient, an immediate reversal shortly after conception in a new pregnancy. The subsequent follow-up course has shov;n lack of return to normal hair pattern in 3 patients with no apparent intercurrent causative condition. This is in disagreement with most statements in the literature.
REFERENCES
1. Kligman, A. M.: Arch. Dermat. 83: 175, 1961. 2. Kopf, A. W., and Orentreich, N.: Arch. Dermat. 76: 288, 1957. 3. Lynfield, Y. L.: J. Invest. Dermat. 35: 323, 1960. 4. Van Scott, E. J.: Biology of hair growth. In Montagna and Ellis, editors: New York, 1958, Academic Press, Inc.
Postpartum alopecia
129
Summary
Thyroid, adrenal, and pituitary gonadotropic activities were found to be normal in the 10 cases of postpartum alopecia stu mea. Administration of thyroid and local applications of estrogen and estrogen plus progesterone substances did not correct the condition. This study group is smali and, while most cases will spontaneously revert to normal, no firm conclusions are drawn. Only the surface of the problem has been touched. If more investigators will accept the challenge of continued research, patients may then obtain a cure from their physicians rather than treatments and promises of cure from others. '
,.
1
5. Schiff, B. L., and Kern, A. B.: Arch. Dermat. 87: 609, 1963. 6. Behrman, H. T.: The scalp in health and disease, St. Louis, 1952, The C. V. Mosby Company. 7. Maguire, H. C., Jr., and Kligman, A. M.: Geriatrics 18: 329, 1963. 8. Lu Bowe, I. L.: M. Times 91: 383, 1962. 230 Sherman Avenue Glen .l?.idge/J1ontclairJ .lVew Jersey 07028