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.
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.
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.