Dermatology Online Journal

A review of scalp camouflaging agents and prostheses for individuals with hair loss
Jeff C H Donovan^1,2,3 MD PhD, Ron L Shapiro^4,5 MD, Paul Shapiro⁴ MD, Matt Zupan⁴, Margareth Pierre-Louis⁵ MD, Maria K Hordinsky⁵ MD
Dermatology Online Journal 18 (8): 1

1. Division of Dermatology, University of Toronto, Ontario, Canada
2. Hair Club Medical Group, Toronto, Ontario, Canada
3. Cleveland Clinic Canada, Toronto, Ontario, Canada
4. Shapiro Medical Group, Bloomington, Minnesota
5. Department of Dermatology, University of Minnesota, Minneapolis, Minnesota

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Abstract

Hair loss is a common problem for both men and women and may impact negatively on self-esteem. A variety of medical and surgical treatment options are available depending on the type of alopecia. Many patients also seek the advice of their physicians about options to hide or reduce the appearance of hair loss with hair prostheses (wigs, hairpieces, and extensions) or hair camouflaging agents (hair fibers, powder cakes, lotions, sprays, hair crayons, and scalp tattooing). Herein, we review current methods to hide or reduce the appearance of hair loss and discuss their associated costs, advantages, and disadvantages. Knowledge of products available to cover scalp, eyebrow, and eyelash hair loss may not only better equip clinicians to respond to questions from concerned patients, but may provide additional options to help these patients best cope with their hair loss.

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Introduction

Hair loss causes distress for many individuals and frequently prompts evaluation from a dermatologist. Although a variety of medical and surgical treatment options are available to treat hair loss, scalp camouflaging agents and scalp prostheses may also be used by individuals to reduce the appearance of hair loss. These products may be used concurrently with various medical and surgical treatments and some individuals may choose to use them in lieu of treatment. Herein, we review a variety of available scalp camouflaging methods and prostheses to camouflage hair loss.

Scalp camouflaging agents

An individual may initially become concerned about hair loss or “thinning” when the appearance of the scalp first becomes visible through the existing hair fibers. The degree of contrast between the color of the scalp and hair is correlated with how much “hair thinning” an individual is perceived to have. Scalp camouflaging agents reduce the color contrast between an individual’s current hair color and the color of the scalp and produce a less visible scalp and an overall perception of increased hair density.

There are five categories of temporary scalp camouflaging agents available to reduce the appearance of hair loss: hair fibers, powder cakes, scalp lotions, scalp sprays, and hair crayons. The names of products, advantages and disadvantages and costs are shown in Table 1. Scalp tattooing represents an additional technique but provides permanent rather than temporary camouflage.

Each type of camouflaging agent is marketed in a variety of colors to closely match an individual’s natural or desired hair color. Not uncommonly, an individual may choose to combine two different camouflaging agents to further reduce the color contrast between the scalp and hair and thus further decrease the appearance of hair loss.

Topical hair fibers

Topical hair fibers usually consist of positively charged particles of wool keratin that cling by electrostatic forces to negatively charged terminal and vellus hair fibers on the scalp and function to make hair look thicker and fuller (Table 1) [1]. To apply these products, an individual sprinkles fibers from the supplied canister onto a dried, balding area of the scalp. If desired, a conventional hairspray may be used afterward to further increase the binding of the synthetic fibers to the individual’s scalp hairs. Topical hair fibers are not effective on areas of complete hair loss because the synthetic fibers require a minimal density of existing hair to bind. Application of hair fibers is usually done once daily; maintenance or “touch-up” applications throughout the day are usually not needed. In addition to wool keratin, other marketed hair fibers are derived from rice keratin, rayon, or human hair. The incidence of allergic or irritant contact dermatitis from topical fibers is unknown, but may be quite low. These products contain various FD&C and D&C dyes and some fibers contain DMDM hydantoin (a formaldehyde releaser) and iodopropynyl butylcarbamate (a cosmetic preservative) in addition to other ingredients.

Powder cakes

Figure 1
Figure 1. Scalp camouflage by use of a powder cake. (a) Before and (b) after photos of a man using a powder cake to camouflage hair loss. (c) Before and (d) after photos showing the use of a powder cake in a woman. Powder cake colors the scalp and binds to existing hair fibers. By reducing the contrast between the scalp and hair it gives the appearance of increased hair density. (Images from photo archives of Dr. R. Shapiro).

Powder cakes are sold as a circular disk of camouflaging product and they are applied to the scalp with a wet sponge applicator after an individual has showered and towel-dried the hair (Figure 1) [2]. These products not only coat the scalp but coat thin, vellus-like hairs to help them to also appear thicker. Following application, the hair is repeatedly brushed to ensure even distribution of the product throughout the thinning areas. The hair may be blow-dried and gelled or sprayed with hairspray, although this is not necessary. Depending on the degree of hair loss and the lighting of the room, the artificial scalp coloring may or may not be noticeable to an observer. Powder cakes are water-resistant and individuals are able to swim with the product on the scalp; however the product is removed with each shampooing. The incidence of irritant and allergic contact dermatitis to powder cakes is unknown. Potential allergens include ethylenediamine, propylene glycol, methyldibromo glutaronitrile, phenoxyethanol, methylparaben, fragrance, and FD& C and D&C dyes.

Camouflaging lotions

Camouflaging lotions function as scalp paint and act in a similar way to powder cakes to eliminate the color contrast between normal hair and scalp (Table 1). An individual needs to have some existing hair for these products to be useful. The incidence of allergic contact dermatitis to camouflaging lotions is unknown. Potential allergens include ingredients such as propylene glycol, triethanolamine, fragrance, imidazolidinyl urea, and parabens, but readers are encouraged to review product labels for specific information.

Camouflaging sprays

Individuals with hair loss may appreciate the ease and speed of application of various camouflaging sprays to cover thinning areas (Table 1). These products are applied to towel-dried, blow-dried, or completely dried hair. The sprays help to cover balding areas, to thicken hair, and to add texture. The hair is first styled and then the spray is applied 4-6 inches above the area to be thickened and allowed to dry for 30-60 seconds. Thereafter, a hairspray may be used to blend the product into existing hairs. These products are removed from hair with shampooing, although not as easily as hair fibers. Potential allergens in these sprays include such ingredients as propylene glycol and lanolin, but readers are encouraged to review labels for product specific details.

Scalp tattooing

Scalp tattooing continues to gain popularity as a more permanent option to camouflage hair loss. Small dots, resembling hair follicles in cross-section, are tattooed on the scalp. Tattooing can be used for men as well as women. Risks include allergic contact dermatitis, infection, granuloma formation, and color change over time.

Integrating scalp camouflaging agents into daily hair care and treatments regimes

Scalp camouflaging products can be safely used in conjunction with oral medications (i.e., finasteride), topical minoxidil, or following hair transplantation. For individuals using minoxidil, it is important that minoxidil is first applied to the scalp and allowed to dry before any of the camouflaging agents are applied [1]. Furthermore, it is important that products such as scalp lotions, sprays, and powder cakes are removed prior to the next minoxidil application.

Individuals undergoing hair transplantation can safely apply hair fibers as early as 1 week post-transplantation [2]. These products are useful to minimize the appearance of the transplant. Powder cakes, lotions, and sprays are also useful following hair transplantation to reduce the appearance of the post-transplant telogen effluvium. Because these products do not shampoo out of hair as easily as hair fibers, it is advised that individuals wait at least two weeks following hair transplantation before using powder cakes, lotions, or sprays [2].

Wigs

The term wig is an all-encompassing term that includes both the medical and non-medical uses of wigs. In contrast, the term cranial prosthesis is a more specific term to describe a wig worn to cover alopecia secondary to various hair disorders, medical conditions, or chemotherapy. We will use the term wig to refer to a scalp prosthesis, but recognize that some insurance companies will consider reimbursement for prescription of a scalp prosthesis, but not a wig.

A general understanding of the types of wigs, advantages and disadvantages, and associated costs can be helpful to clinicians who care for patients with hair loss (Table 2). Furthermore, a general knowledge of local wig salons can be helpful so that individuals can be directed to those with specific wig expertise. Other options for scalp cover which are becoming increasingly popular among individuals with more extensive hair loss include scarves, hats, and bandanas.

Basic wig terminology and design

Figure 2
Figure 2. Synthetic and Human Hair Wigs displayed on mannequins. The top panel shows the wig “top” and the bottom panel shows the wig “cap.” (a) Machine made, synthetic fiber standard weft wig. Wefted wigs consist of a cap made of rows (wefts) of synthetic hair and are typically the least expensive wigs. (b) Hand tied, synthetic fiber wig with monofilament top. The hand tying of fibers into a fine lace material known as a monofilament top imparts a natural look to the wig and enables hair to be brushed in any direction. (c) Hand tied human hair (Russian hair) wig with monofilament top. An attempt may be made to match the patient’s natural hair to the wig hair. Hair from Russia is less course and typically much lighter than more easily obtained hair from India or China. It is also more expensive. (d) Hand tied human hair integration wig. An individual’s existing hair is pulled through the cap and integrated with the fibers from the wig. (e) Hand tied, human hair vacuum wig with polyurethane base. These wigs are custom made and typically used by patients with more extensive alopecia. (f) Hand tied human hair men’s wig with monofilament top. (Images from photo archives of Dr. J. Donovan).

The wig “cap” refers to the foundation of the wig into which the human or synthetic fibers are weaved. Wigs either have either a “wefted” foundation (i.e. wefted wigs) or a “net” foundation (i.e. knotted wigs) [3]. As the most common type of wig foundation, wefted foundations (Figure 2a) consist of a cap made out of “wefts” or rows of synthetic hair and are usually the least expensive wig ($60-$300 USD) [4]. These wigs may be purchased online, in a department store, or at a wig shop. The wig is held on the scalp by an elastic band in the back of the wig. In contrast to wefted foundations, net foundations consist of a cap made out of mesh into which synthetic or human hair is knotted by hand. In general, hand-tied wigs give a much more natural look to the wig but are also more expensive ($300-$1000 USD). These wigs are more likely to be found in a specialty wig shop than in a department store. These wigs are usually attached to the scalp with double sided tape or barrette combs.

Many wigs, regardless of whether they have a wefted or a net foundation, have a top portion made out of a very fine lace material known as a “monofilament” (Figure 2b). Synthetic fibers or human hairs are individually hand-tied into the lace. This allows each of the tied hairs to be parted and brushed in any direction and this gives the wig a very natural look. Monofilament wigs are considered to be a high quality wig product and are considerably more expensive than a standard wefted cap. A well-constructed monofilament synthetic wig will range in price from $250 to over $1000 (Figure 2b) and a monofilament human hair wig may be considerably more costly (Figure 2c) [4]. Another type of wig, known as a lace front wig, differs from a standard wig in that a thin piece of lace extends from ear to ear across the frontal hairline. The lace is glued to the forehead and helps to give the appearance that hair is growing naturally from the frontal hairline. Finally, integration wigs are a special type of wig cap design that allows an individual’s own hair to be pulled through openings in the wig to blend with hair fibers from the wig (Figure 2d).

Most wigs have adjustment straps at the nape of the neck, which enable a snug fit. These adjustment straps usually have Velcro attachments, but instead may have hooks that fit into pockets. Some wigs have combs that allow the wig to fit snugly to the scalp. The combs are placed on existing hairs near the scalp to help secure the wig. Individuals with extensive alopecia cannot wear wigs with combs because there is not sufficient hair for the wig to attach. Other common methods of wig attachment include bonding and taping. Rarely, allergic contact dermatitis may develop to the components of wig adhesives, such as acrylates [5].

Custom-made wigs

Custom-made wigs may be purchased to ensure a precise fit. Although wigs can be custom-made with any of the wig bases discussed above, custom-made wigs are often constructed with a vacuum base. This involves making a custom plaster mold of an individual’s scalp and then manufacturing a wig with either a silicone or polyurethane vacuum base (Figure 2e). In order to achieve a good fit and maintain a good seal, it is important that the individual be bald or be willing to keep the scalp shaved [3]. To secure a vacuum wig to the scalp, an individual places the wig on the scalp and pushes down to expel air and form a seal. Vacuum base wigs are very secure and unless the seal is broken, the wig will remain tightly attached to the scalp. An individual may swim and engage in physical activities without concern that the vacuum seal will be broken. The vacuum wig can be removed by breaking the seal near the nape of the neck with one’s fingers. Custom-made vacuum wigs are among the most expensive wigs and may take up to 6 months to acquire.

Synthetic and human hair wigs

The types of fibers used in synthetic wigs have changed considerably over the past few decades in order to better approximate the look and feel of human hair. The fibers of a synthetic wig may be either machine-sewn or hand-sewn into the wig cap. Hand sewing makes the wig lighter and easier to style but also makes it more expensive. The advantages and disadvantages of synthetic wigs are listed in Table 2.

Most hair imported into the United States for the manufacture of human hair wigs comes from China, Thailand, Indonesia, and India. A very small proportion comes from Europe and Russia [6]. European and Russian hair is typically less coarse and much lighter than Indian and Chinese hair and is much more difficult to acquire. Consequently, wigs made from these fibers tend to be considerably more expensive. In order to blend texture and color and give a more realistic wig appearance, many wigs today are blended from a mix of different human hair sources and even a mix of human and synthetic fibers. The advantages and disadvantages of human hair wigs are listed in Table 2.

Wig care and wig replacement

The length of time that a wig will last before needing to be replaced is highly correlated with the level of care that is given to the wig and whether the hair is synthetic or human. Wigs are normally washed every 4-14 days. However, the frequency of wearing, the use of styling products, and the degree of sweating all influence the frequency that a wig should be washed. It is recommended that wigs be washed with lukewarm water according to the manufacturer’s instructions. Many wig experts recommend the use of a specifically designed wig cleaning solution. Many types of wig cleaners are available for purchase on the internet or at specialty wig stores. In general, the wig should be dipped in and out of the wig cleaning solution several times, rinsed well, and allowed to dry on a wig block or wig stand. Once the wig is dry it can be conditioned with a commercial conditioner and brushed with a wide-toothed comb to minimize damage to the wig. To extend the life of a wig and help the wig keep its shape, it is important to store the wig on a wig stand or styrofoam head. The individual’s scalp should be cleaned with a mild cleanser and rinsed well with each shower. Individuals may find that keeping the scalp as grease-free as possible may reduce the frequency with which a wig needs to be washed.

In general, the price of the wig is proportional to its quality and wig quality determines how long the wig will be expected to last before a replacement is needed. For a standard inexpensive synthetic wefted wig that is worn daily, a replacement may be needed every 3 to 6 months. However, this is only an approximation and a well cared-for synthetic wig has the potential to last much longer [4]. A hand-tied synthetic wig will last about 1 year and a well-made human hair wig will last 3-4 years. For a human wig, yearly repair of lost hair fibers can be arranged by a specialty wig store.

National organizations supporting wig purchases

Specific organizations offer wigs at no charge to children in the United States and Canada with alopecia secondary to a hair disorder or chemotherapy. These organizations include “Wigs for Kids,” “Locks of Love,” and “Hair Club for Kids” (Table 3). “Heavenly Hats” provides hats to children losing hair for medical reasons. There are several other groups that provide wigs specifically to individuals with cancer who could not otherwise afford them. These include Cancer Care, American Cancer Society, Headcovers, Wigs Unlimited, Cinderella Wigs, Y-ME National Breast Cancer Organization, and the Susan G. Komen for the Cure.

Scalp covering for patchy hair loss

Hairpieces

Hair-pieces are ideal for localized areas of hair loss and are attached to hair via clip, falls, wefts, tape, or glue. Hairpieces available for purchase in many varieties including bandeaus, cascades, falls, wiglets, cascades, ¾ cap wigs, and toupees [7]. Hairpieces are often made from animal hair, including hair from horse, sheep, agora, and yak. After purchasing a hairpiece, a hairstylist or barber will often need to cut and style the hair so that it blends in with existing hair. Integration wigs, as discussed above, can also be helpful to camouflage patchy hair loss.

Hair extensions

Hair extensions are strands or collections of synthetic or human hair products that are glued, braided, twisted, sewn, clipped, or fused onto existing hair fibers. In contrast to wigs, hair extensions require attachment to an individual’s existing natural hair. This type of camouflage is temporary but does not require daily maintenance as is needed with use of powder cakes, hair fibers, sprays, and certain wigs. Extensions can be worn daily or for an extended period of several months if given appropriate care. The prices for extensions vary considerably, with clip-on type extensions costing as little as $10 and single strand or fusion extensions costing upwards of several thousand dollars based on the quality of the human hair.

In the carefully selected patient with hair loss, extensions can be helpful, providing individuals with periods of hair and scalp rest from daily grooming. However, one must be aware that it is possible that the intertwined hair extension could further aggravate certain types of alopecia and increase traction and tension on existing hair. Therefore, hair extensions are not recommended for patients with hair loss associated with active inflammatory-related symptoms and signs (erythema, pruritus, burning, scaling) or active alopecia areata [8]. Although many individuals with hair loss have successfully used extensions to reduce the appearance of hair loss, the use of extensions should be discussed on an individual basis.

Crepe hair

Localized areas of hair loss can also be camouflaged using crepe wool hair. Crepe hair is artificial hair commonly used by theatrical performers to create moustaches, beards and eyebrows, and these techniques can also be used by those with localized areas of hair loss. Spirit gum is most commonly used as an adhesive. The crepe hair and adhesive can later be removed with alcohol.

Camouflage via hair styling

For patients with patchy hair loss, the chosen hairstyle may also have an important role in camouflaging hair loss. For some, this may require growing existing hair longer, whereas for others, the choice of a shorter hairstyle may give more lift to hair and facilitate camouflage. In addition, placing a hair part at the side rather than in the center of the scalp may provide a simple means to camouflage central hair loss. An experienced hair stylist can provide helpful advice for hairstyles most likely to be helpful.

Camouflage for eyebrows and eyelashes

Figure 3
Figure 3. Options for camouflage of eyebrow alopecia. (a) Before and (b) after photos showing results of permanent eyebrow tattooing in a woman with eyebrow alopecia. (Photos courtesy of Linda Dixon MD)

Loss of the eyebrows and eyelashes can be emotionally devastating for many individuals. To create realistic looking eyebrows, an array of pencils, stencils, and tattoos can be used. Tattooing may include both temporary and permanent tattoos (Figures 3a and 3b). Individuals seeking advice on permanent tattooing should be aware of the possibility of the tattoo changing color over time and the rare possibility of allergic contact dermatitis and infection. Eyebrow wigs with an adhesive backing can also be used to camouflage eyebrow loss; crepe hair can also be used in a similar manner. These products may need to be shaped with scissors to blend in with the patient’s eye structure. Eyelashes can also be attached with adhesives.

Conclusions

Scalp camouflaging agents and hair prostheses provide a cosmetically effective means for individuals with alopecia to improve their physical appearance. We find it helpful to discuss the many options of cover up with patients with alopecia. We find that they are often relieved to have these discussions and be guided to online resources or local experts to help them camouflage the hair loss.

ACKNOWLEDGEMENTS: The authors are indebted to Ms. Twila Donley of Fantasia Salon and Image Consultants, Crystal, MN, for helpful advice on wigs and wig care. Dr. Donovan gratefully acknowledges the Medical Dermatology Society for a Mentorship Award.

References

1. Kobren, S.D. The Truth About Women’s Hair Loss. New York: McGraw-Hill; 2000. pp 94-96.

2. Parsley WM. Management of the Postoperative Period. In: Unger W.P. and Shapiro R, editors. Hair Transplantation, Fourth Edition, New York: Marcel Dekker, Inc; 2004. pp 565-566.

3. Wigs. Available at: http://www.alopeciaonline.org.uk Accessed April 22, 2012.

4. Butler, LA. If Your Hair Falls Out, Keep Dancing. Mequon, WI: Nightengale Press, 2008. pp 70-85.

5. Torchia D, Giogini S, Gola M, Francalanci S. Allergic contact dermatitis from 2-ethylhexyl acrylate contained in a wig-fixing adhesive tape and its 'incidental' therapeutic effect on alopecia areata. Contact Dermatitis 2008; 58: 170-71.

6. Sherrow, V. Encyclopedia of Hair: A Cultural History. Santa Barbara, CA: Greenwood Press; 2006. pp 406-410.

7. Love T. The World of Wigs, Weaves & Extensions. Albany NY: Milady; 2002. pp 49-69.

8. Whiting DA, Olsen EA. Central Centrifugual Cicatricial Alopecia. Dermatologic Therapy, 2008; 21: 268-278.

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