**1. Introduction**

The social and sexual communication roles of hair as well as its protective function have absolutely undeniable for both sexes for many years [1, 2]. Although the loss of hair is not a life-threatening condition, the loss of hair at an early age or sudden onset hair loss may cause serious psychological distress, thus it may directly affect the quality of life negatively [1, 3]. For this reason, patients with suffering from hair loss should be considered finically in order to distinguish ordinary hair shedding from pathologic hair loss. A loss of 100 or less hair falling per day should not be considered as pathological hair loss. But in case of hair loss more than 100 per day, a pathological condition should be mentioned [3].

Hair loss is a common dermatological problem that has been estimated to affect between 0.2 and 2% of the world's population. There are several factors leading to hair loss including

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major physical-emotional stress, chemotherapy, genetic predisposition, dihydrotestosterone (DHT), excessive sebum, cardiovascular diseases, smoking, and endogenous substances [3]. The common hair diseases that dermatologists are often faced in daily practice are androgenetic alopecia (AGA), alopecia areata (AA), telogen effluvium, anagen effluvium, and traumatic alopecia such as trichotillomania and traction alopecia [1]. AGA, known as male pattern hair loss in men and as female pattern hair loss in women, is the most common form of hair loss in adults [1, 4, 5]. Approximately 60% of males between the ages 30 and 50 years and 17% of women under 50 years of age suffer from AGA [4]. The role of DHT which is reduced from testosterone by enzyme 5α-reductase is clearly known in the mechanism of AGA [6]. In early stage, the process begins with shortening of the anagen phase and continuous miniaturization of sensitive follicles [1]. During this process, terminal hairs are replaced by vellus hairs which are shorter, finer and nonpigmented in the frontal and vertex regions of the scalp [3, 4]. Year after year, permanent baldness occurs at the site of miniaturized hair [1]. AA is a common, chronic inflammatory disease that is characterized by non-scarring alopecic patches on the scalp. It affects approximately 2% of the United States (US) population [7, 8]. Although the mechanism of AA is exactly unknown, it is thought that a necessary secondary event or cofactor such as febrile illness, pregnancy, or a major life crisis in addition to genetic predisposition [8, 9]. Even though AA may regress spontaneously, the disease may remain stable or even may spread to the entire scalp (known as alopecia totalis) or body (known as alopecia universalis). Telogen effluvium is a disease that occurs as a result of passing of a portion of hair from anagen phase to telogen phase. It is characterized by diffuse hair shedding. While trichotillomania is an impulse control disorder, traction alopecia is association with patients' hairstyle. These two diseases that occur after recurrent and chronic trauma are frequently seen in females than males. Both of them can result with permanent scarring [9].

In recent years, complementary and alternative medicine (CAM) is becoming increasingly popular all over the world. In fact, CAM is still the only option to cure and treat some diseases in some regions of Africa, Asia, and South America [10]. Alternative medicine refers to the use of CAM in place of conventional medicine, while complementary medicine refers to the use of CAM along with conventional medicine [11]. According to The National Center for Complementary and Alternative Medicine (NCCAM) in the United States, CAM is defined as 'a group of diverse medical and health-care system, practices, and products that are not presently considered to be a part of conventional medicine' [12]. In some countries like Korea, oriental medicine has been officially approved and has gained support from legal system using the licensing system [13]. The number of visits to alternative care practitioners increased by about 1.5 times in 7 years (from 427 billion in 1990 to 629 billion in 1997) in the United States [14]. The National Health Interview Survey estimated that in 2007 alone, 38% of adults in the United States used CAM [15].

CAM is separated by NNCAM into four categories: alternative medical systems, biologically based therapies, manipulative and body-based therapies, and mind-body therapies. The details of these therapies are shown in **Table 1** [16]. In a survey study conducted in the United Kingdom (UK) in 2010, the most popular CAM therapies were reported as acupuncture, hypnotherapy, and chiropractic, while the least preferred CAM were noted as aromatherapy, reflexology, and medical herbalism [17]. The annual expenditure on CAM is about \$30 billion in the United States and £1.6 billion in the UK [18, 19].


**Table 1.** Various treatments used in complementary and alternative medicine.

major physical-emotional stress, chemotherapy, genetic predisposition, dihydrotestosterone (DHT), excessive sebum, cardiovascular diseases, smoking, and endogenous substances [3]. The common hair diseases that dermatologists are often faced in daily practice are androgenetic alopecia (AGA), alopecia areata (AA), telogen effluvium, anagen effluvium, and traumatic alopecia such as trichotillomania and traction alopecia [1]. AGA, known as male pattern hair loss in men and as female pattern hair loss in women, is the most common form of hair loss in adults [1, 4, 5]. Approximately 60% of males between the ages 30 and 50 years and 17% of women under 50 years of age suffer from AGA [4]. The role of DHT which is reduced from testosterone by enzyme 5α-reductase is clearly known in the mechanism of AGA [6]. In early stage, the process begins with shortening of the anagen phase and continuous miniaturization of sensitive follicles [1]. During this process, terminal hairs are replaced by vellus hairs which are shorter, finer and nonpigmented in the frontal and vertex regions of the scalp [3, 4]. Year after year, permanent baldness occurs at the site of miniaturized hair [1]. AA is a common, chronic inflammatory disease that is characterized by non-scarring alopecic patches on the scalp. It affects approximately 2% of the United States (US) population [7, 8]. Although the mechanism of AA is exactly unknown, it is thought that a necessary secondary event or cofactor such as febrile illness, pregnancy, or a major life crisis in addition to genetic predisposition [8, 9]. Even though AA may regress spontaneously, the disease may remain stable or even may spread to the entire scalp (known as alopecia totalis) or body (known as alopecia universalis). Telogen effluvium is a disease that occurs as a result of passing of a portion of hair from anagen phase to telogen phase. It is characterized by diffuse hair shedding. While trichotillomania is an impulse control disorder, traction alopecia is association with patients' hairstyle. These two diseases that occur after recurrent and chronic trauma are frequently seen in females than males. Both of them can result with permanent scarring [9]. In recent years, complementary and alternative medicine (CAM) is becoming increasingly popular all over the world. In fact, CAM is still the only option to cure and treat some diseases in some regions of Africa, Asia, and South America [10]. Alternative medicine refers to the use of CAM in place of conventional medicine, while complementary medicine refers to the use of CAM along with conventional medicine [11]. According to The National Center for Complementary and Alternative Medicine (NCCAM) in the United States, CAM is defined as 'a group of diverse medical and health-care system, practices, and products that are not presently considered to be a part of conventional medicine' [12]. In some countries like Korea, oriental medicine has been officially approved and has gained support from legal system using the licensing system [13]. The number of visits to alternative care practitioners increased by about 1.5 times in 7 years (from 427 billion in 1990 to 629 billion in 1997) in the United States [14]. The National Health Interview Survey estimated that in 2007 alone, 38% of adults in the

CAM is separated by NNCAM into four categories: alternative medical systems, biologically based therapies, manipulative and body-based therapies, and mind-body therapies. The details of these therapies are shown in **Table 1** [16]. In a survey study conducted in the United Kingdom (UK) in 2010, the most popular CAM therapies were reported as acupuncture, hypnotherapy, and chiropractic, while the least preferred CAM were noted as aromatherapy, reflexology, and medical herbalism [17]. The annual expenditure on CAM is about \$30 billion

United States used CAM [15].

348 Hair and Scalp Disorders

in the United States and £1.6 billion in the UK [18, 19].

Similarly, using of CAM is quite often among patients suffering from dermatologic disorders such as acne, atopic dermatitis, psoriasis, dermatophytes, actinic keratosis, vitiligo, hair loss, cosmetic indications, melanoma, and lupus erythematosus [20–27]. A survey data from UK indicated that 35–69% of patients who have various skin diseases have used CAM in their lifetime [27]. The prevalence of CAM use by dermatology patients were 25.7 and 41% in Singapore [28] and Taiwan [29], respectively, while it ranges from 33.5 [30] to 43.7% in Turkey [31]. As the most frequently complementary medicines used by patients to treat their dermatological diseases have been reported as homeopathy, herbalism, diets, and food supplements in the UK [19, 27], the most used types of CAM have been recorded as herbal remedies, special diet, and megavitamin in Taiwan [29]. In one study, positive feedbacks from patients using CAM, especially herbal therapies, were noteworthy for both skin-related and non-skinrelated conditions. Approximately 85% of patients with skin-related conditions, many of those with chronic diseases such as acne and eczema, noted improvement with CAM use [32]. To treat hair loss, the first two groups shown in **Table 1** are more preferred than the others.

Ideal treatment of hair loss should include the drugs that have both 5α-reductase inhibition effect and hair growth promoter substances, together. The most used conventional treatments are topical minoxidil, finasteride, dutasteride, combination of cyproterone acetate and estrogen, spironolactone, flutamide, topical progesterone, cimetidine, zinc sulfate, topical niacin, topical aminexil, topical ketoconazole, and cyclosporine-A [2]. In particular, minoxidil and finasteride are widely used for treating hair loss. But adverse effects of all of these agents have limited to their usage [1, 2]. Hence, patients suffer from hair loss have begun to turn to alternative therapies, even though there is little scientific evidence to prove their effectiveness.
