TREATMENT OF ALOPECIA

WITH CHINESE HERBS

by Subhuti Dharmananda, Ph.D., Director, Institute for
Traditional Medicine, Portland, Oregon

Alopecia may arise from numerous causes, including

stress reactions, hypothyroidism, exposure of the hair
follicles to topically-applied chemicals, therapies used for
cancer, and genetic male-pattern balding. The disorder is
often classified by its specific manifestation, such as patchy
balding (alopecia areata), total loss of head hair (alopecia
totalis), or total loss of body hair (alopecia universalis).
Alopecia areata and alopecia totalis frequently affect women,
and the disorder may persist for several months to about a
year, sometimes longer.
Generally, alopecia is interpreted by Chinese doctors as
the result of a deficiency syndrome, specifically involving
blood deficiency, with generation of internal wind or invasion
of external wind that affects the head; the situation is
sometimes complicated by blood stasis and/or blood heat.
The belief that there is an influence of wind in the etiology of
the hair loss is reflected in the Chinese name for the
disease, which is youfeng, literally oil-wind. The reference to
oil, which can also mean glossy, is an expression
characterizing the smooth, shiny scalp appearance where
the hair has been lost. The Chinese name has led to some
humorous translations; in the package insert for Alopecia
Areata Pills, the primary indication is for "grease hair
dropping."
The underlying pathological processes cause the hair
follicles to be undernourished. Blood deficiency can arise
from poor diet, excessive use of drugs, the aging process,
stress reaction (worry, anxiety, depression, which impairs
spleen function and thereby reduces nurturing of blood), and

debilitating diseases. Sudden hair loss, like other sudden

health changes, is interpreted as a consequence of "wind;"
in this case it is invading the channels that traverse the
scalp.
A typical description of the cause of alopecia is presented
in Practical Traditional Chinese Dermatology (1):
The hairs are the extension of blood, and the
normal growth and development of long, pliable,
and tough hairs depends on the sufficient supply of
nourishment from ying and blood. If the supply of
nutrients is reduced, the wind may be produced in
the body to cause loss of hairs. Nervousness,
depression, and mental instability may cause
production of internal heat, and the excessive heat
in the blood may produce wind and cause loss of
hairs due to reduced nutrition supply, and such
patients may show clinical manifestation of wind
syndrome due to blood heat. In patients with
chronic diseases and exhaustion of essence and
blood, the deficiency of blood may also produce
wind to cause loss of hairs, and such patients may
show the clinical manifestation of wind syndrome
due to deficiency of blood. In patients with their
diseases wrongly treated or refractory to any
treatment, the fresh blood can not be produced to
nourish the hairs because of the stagnation of blood
and obstruction of meridians, and such patients
may show clinical manifestations of wind syndrome
owing to blood stagnation.
According to the English-Chinese Encyclopedia of
Practical Traditional Chinese Medicine (2),
Alopecia is mostly caused by deficiency of liver and
kidney with subsequent failure of [blood to go up
and nourish] the hair. The hair pores are open when
the hair is poorly nourished, and wind invades the

pores on the occasion. Therefore, deficient blood

with wind [invasion] leads to hair loss. However,
stagnation of liver qi and impaired qi mechanism
will also result in hair loss because of the
malnutrition of hair due to stagnation of qi and
stasis of blood.
The same encyclopedia has an elaboration of the etiology
of alopecia in the volume of dermatology (16):
This disease is often caused by deficiency of blood,
which fails to cooperate with qi in nourishing the
skin. The striae of skin and muscles in turn become
loose, and the opening of the sweat glands is loose,
hence, pathogenic wind intrudes from outside,
causing blood-dryness and malnutrition of the hair.
Besides, the mood of depression, stagnation of liver
qi, and overwork may impair the heart qi and cause
stagnation of qi and blood stasis so that qi and
blood cannot nourish the hair, hence the occurrence
of the disease; deficiency of the liver qi and kidney
qi may also cause this disease, because the liver
stores the blood whose state can be manifested by
the hair, while the kidneys produce bone marrow
which is also responsible for the growth of hair.
RECOMMENDED PRESCRIPTIONS
In Practical Traditional Chinese Dermatology, three
basic formulas are recommended:
Wind Due to
Blood Heat

Wind Due to
Wind Due to
Blood Deficiency Blood
Stagnation
Rehmannia, raw Rehmannia,
Tang-kuei, tails
cooked
Moutan
Tang-kuei
Red peony
Scrophularia
Peony
Cnidium
Biota leaf
Cnidium
Persica
Morus leaf
Lycium
Carthamus

Anemarrhena
Vitex
Tang-kuei
Morus fruit
Dictamnus

Ligustrum
Cuscuta
Eclipta
Ho-shou-wu
Astragalus
Citrus

Biota leaf
Angelica
Green onion
Ginger, fresh
Jujube

A slightly different presentation of patterns and formulas

is offered in the book Manual of Dermatology in Chinese
Medicine (3)
Blood Heat
Giving
Rise
to Wind
Rehmannia,
raw
Ligustrum
Morus fruit
Moutan
Red peony

Deficiency Deficiency Deficiency Deficiency Blood

of Yin and of Yin and of Qi and
of Qi and Stasis
Blood
Blood
Blood
Blood
(Decoction) (Pill)
(Decoction) (Powder)
Tang-kuei
Ho-shou-wu Tang-kuei
Tang-kuei Red peony
Red peony
Peony
Cnidium
Rehmannia

Hoelen
Rehmannia
Achyranthes Peony
Tang-kuei Codonopsis
Lycium
Atractylodes

Cornus
Salvia
Cuscuta
Scrophularia Ho-shou-wu Psoralea
Sesame,
black
Cuscuta
Hematite
Fu-shen
Tang-kuei

Morinda
Cistanche
Ligustrum
Morus fruit
Chiang-huo
Schizonepeta

Peony
Cnidium
Citrus
Persica
Astragalus Carthamus
Cinnamon Bakeri
bark
Astragalus
Ginseng
Jujube
Hoelen
Atractylodes Ginger,
fresh
Ligustrum
Licorice,
Musk
baked
Ho-shou-wu Rehmannia
Soja
Schizandra
Cnidium
Hoelen
Typhonium Polygala
Licorice,
baked

Again, the English-Chinese Encyclopedia of Practical

Traditional Chinese Medicine offers yet another group of
formulas, the first three for "blood-deficiency and wind-

dryness" and the latter two for "activating blood flow to

remove blood stasis:"
Shenying Yangxue Qibao
Yangzhen Shengfa Meiran
g Dan,
Wan
Dan
Modified
Tang-kuei
Peony
Cnidium
Rehmannia

Tongqiao
Huoxue
Tang,
Modified

Carthamus

Tang-kuei Ho-shou-wu Tang-kuei

Peony
Hoelen
Red peony
Cnidium
Achyranthes Cnidium
Rehmannia, Tang-kuei Persica
raw
Ho-shouLycium
Carthamus
wu
Carthamus Cuscuta
Sparganium

Ligustrum
Cuscuta

Ligustrum
Cuscuta

Chiang-huo
Gastrodia

Eclipta
Salvia
Soja

Ho-shou-wu

Psoralea

Zedoaria
Bupleurum
Curcuma
Turmeric
Ginger, fresh
Green onion

Huoxue
Quyu
Pian
Tang-kuei
Red peony
Persica
Carthamus
Pangolin
Artemisia
(liujinu)
Gleditsia
Pyrolusite
(zhiwu)
Saussurea
Clove
Rhubarb
Eupolyphaga

In this last group, Qibao Meiran Dan is the same as the

Pill for Deficiency of Yin and Blood mentioned above. This
Chinese name of this formula is translated in Formulas and
Strategies (17) as "Seven-Treasure Special Pill for Beautiful
Whiskers." The prescription is attributed to a master
herbalist of the Ming Dynasty, Shao Yingjie, but it was
recorded by Wang An, in his book Yifang Jijie during the
early Qing Dynasty (1682 A.D.). By that time, the formula
had become quite popular.
One can see that in virtually all formulations (the
exception being the last two presented above), tonification
therapy is important, but there are distinctly different groups
of ingredients that are relied upon for different syndromes
and by different authorities. Ginseng Nutritive Combination
(Renshen Yang Rong Tang), similar to the decoction for qi

and blood deficiency related above, is a well-known

traditional prescription given for general weakness and
nutritional deficiency; that formula has been recommended
by Japanese doctors for treating alopecia (4).
While there are no individual herbs that stand out as
being essential to the treatment of alopecia, there is obvious
reliance on the ingredients of Siwu Tang (Tang-kuei Four
Combination, comprised of tang-kuei, peony, cnidium, and
rehmannia), as well as herbs that are characteristically
recommended for preventing graying of hair (a condition
also thought to be due to blood deficiency syndrome),
notably ho-shou-wu, ligustrum, morus fruit, and biota leaf.
Although mentioned only once among the ingredients for the
above formulas, eclipta is also used for preventing greying
of hair and is included in some of the formulas used in
clinical trials, as described below. For blood stasis, red
peony, cnidium, persica, and carthamus are the most
frequently used. Wind-dispelling herbs are broadly selected
from the range of available items, with dictamnus, chianghuo, morus leaf, schizonepeta, vitex, typhonium, and green
onion (congbai; Chinese chive) mentioned in the above
formulas. Some herbs that have black color (the color of
Chinese hair) are used: black sesame seeds, black soy
beans (soja), and psoralea are examples. Cuscuta is mainly
used for tonifying the kidney, a principle of therapy not
much relied upon other than through inclusion of cooked
rehmannia as part of the blood nourishing strategy.
An examination of the herb formulas reveals very few
ingredients in each formula for dispelling wind (sometimes
none) and no ingredients specific to calming internal wind
other than the single mention each of gastrodia and
hematite (this may have been included mainly as a blood
nourishing agent). The emphasis on wind in the etiology of
alopecia as described in modern texts appears to be more of
an academic nod to the ancient name of the disease than to
a persisting belief that wind is an important factor in the

disease. As with the formulas recommended above, those

prescriptions subjected to clinical trials rarely include winddispelling or wind-settling ingredients.
CLINICAL EVALUATIONS OF INTERNAL THERAPIES
Alopecia areata, the condition that is the subject of the
clinical evaluations, can spontaneously resolve. Therefore, it
is difficult to know the effectiveness of treatment in the
absence of a carefully controlled study. The reports in the
medical literature generally involve uncontrolled studies,
which means that one can not separate out cases of
improvements due to herb therapy from spontaneous
remission. According to the reported results (summarized
briefly below), with a treatment time of 1-3 months duration
(though sometimes longer), the majority of cases treated
are resolved or, at least, improved. An examination of
formula ingredients reveals that tonic therapies, especially
herbs that nourish the blood, are relied upon.
Shengfa Wan (literally, pill to generate hair), is a
modification of Qibao Meiran Dan, made by adding Erzhi
Wan (a formula comprised of just ligustrum plus eclipta).
According toFormulas and Strategies:
This formula [Erzhi Wan] is widely used in China,
both by itself and as an additive to other formulas
when the liver and kidney yin need to be tonified. It
is considered safe and relatively mild. It is often
compared to Liuwei Dihuang Wan [Rehmannia Six
Formula]....Erzhi Wan is considered by some to be
superior in treating premature graying or loss of
hair.
The complete formula, containing ho-shou-wu, ligustrum,
eclipta, lycium, cuscuta, tang-kuei, achyranthes, psoralea,
and hoelen, was made as large honey pills, 10 grams each,
and administered three times daily (5). The pills, which
provided about 20 grams of herbs in powder form and 10
grams of honey as binder, were administered before meals,

unless digestive disturbance occurred, in which case the pill

was given after meals instead. Treatment time was 1-3
months. It was stated that of 21 cases treated, 2 cases were
cured, 8 markedly improved, and 3 significantly improved
(with 8 cases not improved).
A similar formula, Shengfa Yin, a decoction comprised of
ho-shou-wu, rehmannia, tang-kuei, schizandra, morus fruit,
biota seed, ligustrum, and eclipta, was reported to cure 30
of 36 persons affected by alopecia areata, with 4 others
improved (6). The obviously better results, compared to the
report on Shengfa Wan, may have been due to use of a
higher dosage form of administration and longer therapy
(duration not specified in the report).
According to another report, all of 50 cases of alopecia
areata treated could be cured within 9 weeks with daily
ingestion of a decoction of ho-shou-wu, black sesame, soja,
astragalus, gelatin, atractylodes, longan, and jujube, taken
along with cystine (100 mg, three times daily), and topically
applying concentrated decoction of morus bark (7).
Specifically, 6 cases were resolved after three weeks,
another 32 cases after 6 weeks, and the remaining 12 by 9
weeks. Cystine is important to protein structure and was
given to promote good hair formation; it is an oxidized form
of the common amino acid cysteine. The high rate of success
might have been due to the combination of using a
decoction plus applying a topical preparation; the role of
cystine is questionable, and it is not included in the other
trials.
In a large-scale study (8), the internal treatment for
alopecia, Tuofa Zaisheng San, included ligustrum, ho-shouwu, rehmannia, biota twig, salvia, schizandra, peony, tangkuei, carthamus, cnidium, and chiang-huo, was given along
with topical application of the drug minoxidil. According to
the report, treatment time was 2-12 months, with 117 of
146 cases cured, and 11 cases improved. A follow-up after

one year showed that there was relapse in only 10 cases.

This formula is very similar to the patent remedy called
Alopecia Areata Pills (Trichogen), which was developed
during the 1970's and has been marketed worldwide since
the 1980's. According to the package labeling, the formula
is:
Ho-shou-wu
Rehmannia (raw and cooked)
Tang-kuei
Salvia
Peony
Schizandra
Codonopsis
Chaenomeles
Chiang-huo

20%
20%
10%
10%
10%
10%
10%
5%
5%

The herbs are extracted, formed into small pills (250 mg

each), and recommended to be taken 6 pills each time,
three times daily (daily dose of the extract is 4.5 grams), for
a course of treatment of 600 pills (if taken continuously, 6
bottles of the product, over a period of 33 days). Since the
body weight of the Chinese, at the time this package insert
was written, was quite a bit lower than most Westerners, the
dosage should probably be increased by as much as 50%.
The package insert proclaims "satisfactory results" were
attained with over 1,000 trial cases and that:
After treatment for a period of time, light color,
newly grown, soft hair gradually becomes darker
and black. But in a few occasions the patients have
recurrence of baldness. In order to reduce the
recurrence, one or two [additional] courses of
treatment is necessary to ensure efficacy.
Alopecia that occurs in the elderly is responsive to
treatment, according to one report (9). A double-blind
placebo-controlled study of an anti-aging mixture

named Huolisu, including astragalus, salvia, and ho-shouwu, was conducted with 507 subjects, 287 receiving the
herbs. The power of the placebo and the rate of spontaneous
remission was here demonstrated, with nearly 35% of the
control group showing some improvements in both
subjective and objective measures. However, the herb
treatment group had nearly 77% of patients showing
improvements, including a reduction in alopecia during a 3
month trial.
TOPICAL TREATMENTS
Alopecia often occurs in individuals who are relatively
healthy; they may suffer from substantial emotional stress
and poor nutrition, but the most evident symptom-or the
symptom of greatest immediate concern to them-is the
alopecia. In such cases, topical treatments are deemed
especially appropriate, because of the localization of the
symptom. Also, since the hair follicles are just below the
skin surface, topical treatment is deemed a means of
rectifying the problem even if an internal therapy is also
needed to improve the function of the internal organs,
nourish the blood, and overcome disorders such as blood
stasis.
There are three major approaches to topical treatment
with herbs:
1. Use strong circulatory stimulants, such as hot
pepper or ginger, to try and restore the scalp
circulation.
2. Use blood-vitalizing herbs, such as those used in
internal therapies, to promote microcirculation.
3. Employ herbs with a reputation for benefiting the
hair, such as ho-shou-wu, morus fruit, or
ligustrum.
The diversity of recommended topical treatments, which
includes some that are not easy to explain by the usual

interpretations of herb actions, makes it difficult to select

one that would be workable, and most Westerners are not
well disposed to making these unusual preparations and
using them regularly, so only brief mention will be made
here. In Practical Traditional Chinese Dermatology,
three topical treatments are described:

A mixture of dictamnus, biota leaf, ginger,

crataegus, and angelica is made as a tincture and
applied once or twice a day.

Fresh slices of ginger are rubbed onto the bald

area to produce a hot feeling, three times daily.
Powder of chuanwu (a type of aconite) is mixed
with vinegar or ginger juice and applied once a day
to the bald area.

In Manual of Dermatology in Chinese Medicine,

these topicals are mentioned:

A mixture of biota leaf, zanthoxylum, and pinellia is

made as a decoction and mixed with fresh ginger
root juice, and applied to the affected area twice
daily.

A mixture of artemisia, chrysanthemum, mentha,

siler, kao-pen, vitex, schizonepeta, and musk;
make a decoction (musk is added separately) and
wash the head with it; let it set in the head for 5
minutes, and repeat; then rinse with warm water.
Cordyceps tincture is applied to the affected area
3-5 times daily.
Brassica is powdered, mixed with oil to form an
ointment, and applied to the affected area once
daily.

In the English-Chinese Encyclopedia of Practical

Traditional Chinese Medicine, vol. 16: Dermatology,
these are suggested:

Psoralea tincture (Bugu Zhiding), applied three

times daily.

Fresh ginger roots slice: rub the affected part

rapidly.

According to the book Oriental Materia Medica (10),

the herb swertia is "80% effective in treating all cases of
hair loss." Research in Japan has shown that an extract of
swertia (a relative of gentiana that is used frequently in the
treatment of hepatitis) dramatically enhances the circulation
to the skin when applied topically. This herb has been
extracted in an essential oil base (geraniol) in the hair tonic
product Gentax that is produced and widely used in Japan
and is now available in the U.S. (via Kenshin Trading
Company, in Torrance, California). The crude herb swertia is
rarely exported from the Orient, so is difficult to obtain other
than in this prepared form.
A popular Chinese "hair growth" tincture-Lily Brand Hair
Tonic-is made with extract of capsicum (and other
undisclosed ingredients); this is similar to the home remedy
made by the Chinese with red chilies soaked in wine. The
action of capsicum, like that of ginger and zanthoxylum, is
to promote local circulation via "counterirritant" action (spicy
components cause the vessels to dilate).
The largest clinical evaluation of a topical treatment for
alopecia involved over 8,300 patients (11). The liquid,
known as "101 Hair Regenerating Alcohol" (which has been
made available in Chinese shops in the U.S.) contains ginger,
ginseng, astragalus, tang-kuei, cnidium, persica, carthamus,
salvia, and some undisclosed ingredients. The liquid was
applied 2-3 times per day, for 2-3 months. It was claimed in
the report that the "cure" rates for alopecia areata, alopecia
totalis, and alopecia universalis were 91.7%, 83.4%, and
62.1% respectively. Less than 6% of those treated in each
category failed to respond to the treatment.

In another large-scale clinical evaluation, 822 patients

suffering from alopecia areata or alopecia totalis were
treated with the topical formula, Suxiao Ketuling Shengfa
Jing (12). The ingredients, extracted in alcohol, include
capsicum, eclipta, ho-shou-wu, biota twig, drynaria,
ginseng, carthamus, and cnidium. According to the report,
630 patients were cured and others had partial regrowth of
hair; only 48 patients (less than 6%) showed no response.
Yet another topical treatment that was evaluated
is Jumei Renshen Shengfalu (13). The liquid extract of biota
twig, drynaria, ginseng leaf, and melia was applied topically
for 88 cases of alopecia areata resulting in improvement in
71 of those cases, and 74 cases of alopecia seborrheica,
with improvement in 52 cases. A control group was treated
with a "Western" style topical liquid containing salicylic acid,
resorcinol, glycerin, and carbolic acid. The effective rate for
that treatment was only 48%. Both the herb and drug
liquids were applied twice daily for 2-3 months.
HAIR LOSS ASSOCIATED WITH CHEMOTHERAPY
Chemotherapy for cancer and certain other drug treatments
may cause alopecia, which is difficult to prevent while the
drug is being used. In books about treating side effects of
cancer therapy (e.g., Cancer Treatment with Fu Zheng
Pei Ben Principle (14) and Treatment of Toxic Side
Effects Resulting from Radiation and
Chemotherapy (15)) there is no mention of alopecia.
Nonetheless, ITM received reports of some cases of patients
undergoing chemotherapy that did not result in hair loss or
resulted in less hair loss than was expected (these cases
were unexplained by Western doctors in the U.S.); the
patients were using Chinese herb tonic formulas to help
prevent leukopenia. One of the proposed mechanisms
involved in overcoming leukopenia is promoting
microcirculation in the bone marrow; the herbs that
accomplish this, such as millettia, hu-chang, and
salvia (see: Millettia (Jixueteng))may also promote

microcirculation in the skin and, thereby, help alleviate

alopecia. So, there is some preliminary and circumstantial
evidence, as well as theoretical basis, to expect that this
type of alopecia might be prevented by early intervention
with Chinese herbs. When the drug therapy or radiation is
stopped, the combination of tonic herbs and topical
application of circulation-promoting agents may help to
more quickly restore hair growth in those who begin the
herb treatment after hair loss has already occurred.
REFERENCES
1. Li
Lin, Practical
Traditional
Chinese
Dermatology, 1995 Hai Feng Publishing Company,
Hong Kong.
2. Xu Xiangcai (Chief ed.), The English-Chinese
Encyclopedia of Practical Traditional Chinese
Medicine, vol. 6: Therapeutics of Acupuncture
and Moxibustion, 1990 Higher Education Press,
Beijing.
3. Shen De-Hui, Wu Xiu-Fen, and Nissi Wang, Manual
of Dermatology in Chinese Medicine, 1995
Eastland Press, Seattle, WA.
4. Otsuka K, et al., Natural Healing with Chinese
Herbs, 1982 Oriental Healing Arts Institute, Long
Beach, CA.
5. Jiang Haiyan, Treatment of 21 cases of alopecia
with Shengfa Wan, Sichuan Journal of Traditional
Chinese Medicine 1987; 5(4): 47-48.
6. Lan Ke and Chen Huiren, Treatment of 36 cases of
alopecia areata with Shengfa Yin, Hubei Journal of
Traditional Chinese Medicine 1988; 6: 19.
7. Tang Bingguang, Treatment of alopecia areata
mainly with Chinese herbs, Hunan Journal of
Traditional Chinese Medicine 1987; 3(3): 55, 61.
8. Lu Jingbin, Treatment of 146 cases of hair loss
with Tuofa Zaisheng San and Shengfa Shui, Journal

of Integrated Traditional and Western Medicine

1987; 7(7): 438-439.
9. Du Xin, et al., Antiaging effect of Huolisu-A
controlled, double-blind study of 507 subjects of
middle and old age, Chinese Journal of Integrated
Traditional and Western Medicine 1986; 6(5): 271274.
10.
Hong-Yen Hsu, et al., Oriental Materia
Medica: A Concise Guide, 1986 Oriental Healing
Arts Institute, Long Beach, CA.
11.
Zhao Zhangguang, Treatment of 8324 cases
of alopecia with 101 Hair Regenerating Alcohol,
Journal of Traditional Chinese Medicine 1988;
29(9): 693-694.
12.
Zhang Zhongxing, Treatment of 822 patients
with alopecia areata with Suxiao Ketuling
Shengfajing, Hubei Journal of Traditional Chinese
Medicine 1991; 13(6): 9-10.
13.
Xiang Xirui and Xue Changhua, Treatment of
alopecia with Jumei Renshen Shengfalu, Chinese
Journal of Integrated Traditional and Western
Medicine 1989; 9(1): 39.
14.
Pan Mingji, Cancer Treatment with Fu
Zheng Pei Ben Principle, 1992 Fujian Science
and Technology Publishing House, Fujian.
15.
Cheung CS, Kaw UA, and Harrison H
(compilers), Treatment of Toxic Side Effects
Resulting from Radiation and Chemotherapy
by
Traditional
Chinese
Medicine,
1980
Traditional
Chinese
Medical
Publisher,
San
Francisco, CA.
16.
Xu Xiangcai (Chief ed.), The EnglishChinese Encyclopedia of Practical Traditional
Chinese Medicine, vol. 16: Dermatology, 1990
Higher Education Press, Beijing.
17.
Bensky D and Barolet R, Chinese Herbal
Medicine: Formulas and Strategies, 1990 rev.
ed., Eastland Press, Seattle, WA.

June 1999