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Hypnotherapeutic management of alopecia areata

Article  in  Journal of the American Academy of Dermatology · September 2006

DOI: 10.1016/j.jaad.2005.09.025 · Source: PubMed

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Hypnotherapeutic management of alopecia areata

Ria Willemsen, MD,a Johan Vanderlinden, PhD,b Arlette Deconinck, MD,a
and Diane Roseeuw, MD, PhDa
Brussels and Leuven, Belgium

Background: Only limited data exist on the role of psychotherapy in alopecia areata (AA).

Objective: We sought to document the influence of hypnotherapy on psychologic well-being and clinical
outcome in AA.

Methods: Hypnosis was used in 28 patients with extensive AA who were refractory to previous
conventional treatments. It was added as a complementary treatment or used as the only treatment.

Results: In all, 21 patients, 9 with alopecia totalis or alopecia universalis and 12 with extensive AA, were
analyzed during a 5-year period. After treatment, all patients had a significantly lower score for anxiety and
depression. Scalp hair growth of 75% to 100% was seen in 12 patients after 3 to 8 sessions of hypnotherapy.
Total growth occurred in 9 of these 12 patients, including 4 patients with alopecia universalis and 2 with
ophiasis. In 5 patients, a significant relapse occurred.

Limitations: This is a preliminary study with a limited number of patients. A larger randomized study is
necessary.

Conclusion: Hypnotherapy may enhance the mental well-being of patients with AA and it may improve
clinical outcome. ( J Am Acad Dermatol 10.1016/j.jaad.2005.09.025.)

R esearch in the last few years is contributing

to a better understanding of alopecia areata
(AA). AA is an organ-specific autoimmune
disease mediated by T lymphocytes directed to the
Abbreviations used:
AA:
AT:
AU:
alopecia areata
alopecia totalis
alopecia universalis
hair follicles, especially expressing the T-helper type SCL: Symptom Check List
1 cytokines.1,2 Besides autoimmunity, psychologic
factors may play a role in the pathogenesis of AA.
Some authors have found that acute psychotrauma,
In contrast to the comprehensive literature on the
stressful events, and negative familial circumstances
results of conventional treatment of AA, data on the
have been associated with the onset of AA.1,3-5 Not
outcome with psychologic treatments are very lim-
surprisingly, patients with AA have other symptoms.
ited. Some encouraging results were described with
They are at an increased risk for psychiatric disorders
antidepressant drugs such as imipramine8 or selec-
such as a major depression, generalized anxiety
tive serotonin reuptake inhibitors9,10 and with psy-
disorder, social phobia, or paranoid disorder.6,7
chotherapy.5,11 Data on hypnosis in the treatment of
AA are even scantier. Harrison and Stepanek12 treated
From the Department of Dermatology, Academic Hospital, Free 5 patients with extensive AA using hypnotherapy.
University (VUB), Brusselsa; and University Center Sint Jozef and A cosmetic hair growth was only seen in one patient.
Catholic University of Leuven, Faculty of Psychology.b Randomized trials have shown hypnosis to be of
Funding sources: None.
Disclosure: Drs Willemsen and Vanderlinden are members of the value in asthma and in irritable bowel syndrome.
board of the Flemish Society of Hypnosis. There is strong evidence from randomized trials
Accepted for publication September 27, 2005. of the effectiveness of hypnosis for cancer-related
Reprint requests: Ria Willemsen, MD, Broekstraat 28, 1860 Meise, anxiety, pain, nausea, and vomiting, particularly
Belgium. E-mail: [email protected]. in children.13 In addition, hypnotherapy has been
Published online March 17, 2006.
0190-9622/$32.00
used in a number of important skin diseases.14,15
ª 2006 by the American Academy of Dermatology, Inc. Taking the psychologic factors of AA into con-
doi:10.1016/j.jaad.2005.09.025 sideration, we investigated the therapeutic effect of

1
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2 Willemsen et al J AM ACAD DERMATOL

Table I. Hypnotherapy in alopecia areata/universalis/totalis (N = 21); dropout = 7

Other treatment Result, scalp
Sex, age, y AA type during hypnotherapy No. sessions hair growth Evolution
Significant responders (N = 12)
F, 23 Patchy AA CorticoT loc 3 100% Minimal relapse
since 5 mo after 6 mo
F, 36 Patchy AA CorticoT IL 5 90% Significant relapse
since 3 mo after 8 mo
F, 24 Patchy AA CorticoT IL 5 100% Significant relapse
since 3 mo after 10 mo
F, 50 Patchy AA CorticoT IL 5 100% Minimal relapse
since 3 mo after 2 mo
M, 24 Patchy AA CorticoT IL 4 90% Minimal relapse
since 3 y after 2 mo
F, 68 Ophiasis CorticoT IL 3 100% Minimal relapse
since 1 y after 1.5 y
F, 32 Ophiasis CorticoT IL 3 100% Minimal relapse
since 5 mo after 2 mo
F, 25 Ophiasis 3 y Minoxidil, ditranol 7 Ongoing 90% Ongoing
F, 66 AU since 1.5 y None 6 100% from Significant relapse
session 4 after 4 y
F, 33 AU since 1.5 y None During 5 y 100% from Significant relapse
intermittently session 13 after 4 mo
F, 28 AU since 4 y Acupuncture 4 100% from Significant relapse
session 4 after 6 mo
F, 17 AU since 6 wk ImmunoT loc, SSRI 8 Ongoing 100% from Minimal relapse
(Escitalopram) session 4 after 2 m
Non-/poor responders (N = 9)
M, 26 Patchy AA CorticoT IL, SSRI 7 50%
since 16 mo (Sertraline)
F, 18 Ophiasis since ImmunoT loc 7 Evolution to AU
3 mo
F, 21 Ophiasis since CorticoT IL, SSRI 7 Evolution to AT
6.5 mo (Sertraline)
F, 35 Ophiasis ImmunoT loc 5 Evolution to AT
since 6 mo
F, 36 AT since 14 mo CorticoT loc 4 Vellus
M, 25 AU since 3 mo ImmunoT loc 16 Vellus
F, 54 AU since 4 y ImmunoT PO During 3 y 10%
intermittently
M, 38 AU since 9 mo ImmunoT loc 7 0%
M, 15 AU since 8 mo SSRI (Sertraline) 8 0%

AA, Alopecia areata; AT, alopecia totalis; AU, alopecia universalis; corticoT, corticotherapy; F, female; IL, intralesional; immunoT,
immunotherapy; loc, local; M, male; PO, oral; SSRI, serotonin reuptake inhibitor antidepressive medication.

hypnotherapy in a group of patients with extensive 1999 and April 2004. The study was approved by the
AA, alopecia totalis (AT), or alopecia universalis hospital institutional review board.
(AU). All gave informed consent. Inclusion criteria
included extensive (minimally 30%) scalp hair loss
METHODS of at least 3 months’ duration. Patients must have
In all, 28 patients with severe AA, AT, or AU, failed a treatment of topical or systemic steroids.
refractory to standard treatment, were invited to take Clinical evaluation, including relevant medical his-
part in this open clinical trial. They were seen in an tory, assessment of scalp involvement, and baseline
outpatient dermatology clinic (the Academic Hospi- photographs, was performed at the initial study visit.
tal, Free University [VUB], Brussels) between April Hypnosis was used as the only treatment or was
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J AM ACAD DERMATOL Willemsen et al 3

Table II. Differences between Symptom Check List scores at the start and follow-up
Normal population
mean value Prehypnosis Posthypnosis
Score SD Score SD Score SD P*
Anxiety 13-14.6 9.5-10.2 21.4 (21.8*) 8.7 (9.1*) 15.0 (14.8*) 4.8 (5.3*) .01 (.01)
Depression 20.7-23.8 14.4-15.2 34.3 (34.3*) 11.7 (12.4) 22.1 (21.9*) 5.3 (6.0*) .001 (.001)
SCL total 117-129 62.1-67.6 175.8 (178.2*) 66.6 (72.5*) 125.3 (124.2*) 32.8 (36.1*) .001 (.001)

Wilcoxon matched pairs test (nonparametric) total group (n = 17).

SCL, Symptom Check List.
*Exclusion of patients with serotonin reuptake inhibitor antidepressive medication intake (n = 13).

added as a complementary treatment. Efficacy was Symptom Check List (SCL)-90,16 translated and
graded by direct clinical examination. Hair growth validated in Dutch by Arrindell and Ettema,17 was
was assessed on a percentage scale ranging from administered. This tool measures, besides a total
0% to 100% of the total scalp surface. psychoneuroticism score, 8 different psychologic
Significant hair growth was defined as 75% to symptoms (ie, phobia, anxiety, depression, somati-
100% scalp growth. Patients who interrupted their zation, psychoticism, interpersonal sensitivity, hos-
treatment after 1 to 3 sessions without clinical results tility, and sleep problems) and has good reliability
were considered as dropouts. All responders were and validity. In this study only the total score and
followed up for a minimum of 6 months (range two subscale scores, namely anxiety and depression
6 months-6 years). Scalp hair loss during follow-up (the most disturbing psychologic characteristics in
was defined as minimal (\25%) or significant patients with AA), were taken into consideration.
([25%) relapse. Analyses were carried out using software (Statistica,
Version 6.0, StatSoft, Inc, Tulsa, Okla). The scores
Hypnotic technique on the SCL-90 were compared at the start and the end
Hypnosis can be used for general relaxation and of the hypnotic treatment using Wilcoxon matched
ego strengthening. Moreover, it can be oriented to pairs test (nonparametric) for dependent samples.
a specific symptom.15 In our hypnotic AA approach, The level of significance was set at P less than .05.
hypnosis was introduced by means of relaxing sug-
gestions. After the hypnotic induction, patients were
invited to visualize a place where they felt safe and RESULTS
secure. In addition, symptom-oriented suggestions A total of 28 patients (10 male, 18 female) were
were given (eg, to imagine the healing effects of the enrolled in the study. Patients ranged in age from
warmth of the sun on the skin of the scalp). Patients 15 to 66 years (mean 33.4 years). In all, 7 patients
were invited to find a personal metaphoric or sym- withdrew because of lack of motivation; 21 patients
bolic image of their growing hairs. Patients who completed the treatment. There were 8 AU, 1 AT,
showed symptoms of social phobia or agoraphobic 6 ophiasic, and 6 patchy AA cases. For patients with
reactions (avoiding public places because they felt patchy or ophiasic AA, duration of the current
ashamed with their hair loss) received additional episode ranged from 3 months to 3 years (mean: 10
suggestions for improving their self-esteem. months) whereas duration for AT or AU ranged from
By doing so, we tried to attenuate the negative 3 months to 4 years (mean: 19 months). More details
feelings such as shame, embarrassment, low self- including additional conventional treatment are
esteem, and anxiety experienced in public places. given in Table I.
Hypnotic sessions were held once every 3 weeks. All The data of SCL-90 subscales could be analyzed in
patients were asked to practice self-hypnosis twice 17 of 21 patients. Results at the last session (Table II)
a week. show a significant decrease on both the total SCL-90
To illustrate our hypnotherapeutic approach, score (P \ .001) and the two subscales of anxiety
a hypnotic relaxation and symptom-oriented ap- (P \ .01) and depression (P \ .001). Of these 17
proach for one particular patient with AA is included patients, 4 were treated with a serotonin reuptake
(Addendum). inhibitor during their hypnotic treatment. Exclusion
of their questionnaires yielded the same significant
Questionnaires decrease in all scores for the 13 remaining patients.
To measure the result of the hypnotherapeutic Significant hair growth was found in 12 patients
interventions on the patients’ well-being, the (Figs 1 and 2) after 4 to 13 (mean 5.5) sessions of
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4 Willemsen et al J AM ACAD DERMATOL

Fig 1. A 68-year-old woman with alopecia universalis.

Regrowth of vellus hair from fourth hypnotic session.
No other treatment was used.
Fig 2. Evolution to generalized hair regrowth.

hypnosis. Total growth of scalp hair occurred in 9 and in 4 of 7 patients with AT/AU. Full recovery from
of these 12 patients, including 4 patients with AU and severe forms of AA is unusual. Only 17% of AT/AU
2 with ophiasis. The treatment was unsuccessful in respond to contact immunotherapy and fewer than
9 patients. Adverse events of the hypnotic treatment 10% of those with ophiasic disease and AT/AU
could not be detected, nor were they reported by respond to pulsed corticosteroids.18 Our most sur-
the patients. Minimal relapses were observed in all prising result was observed in 4 patients with AU
significant responders. Five of them showed a sig- who had a total growth shortly after the start of the
nificant relapse in a follow-up period ranging from hypnotic sessions. All 4 patients had previously
4 months to 4 years (range 10.4 months) posttreat- failed to respond to topical immunotherapy.
ment. Of these 5 patients, 4 returned to the pretreat- The exact working mechanism of hypnosis in AA
ment status. has not been elucidated, nor is it understood yet.14,19
Some researchers20,21 have demonstrated by ther-
mography that the hypnotic suggestion to improve
DISCUSSION the blood flow in the skin of the scalp was associated
The efficacy of hypnosis in AA is still controver- with an objective increase in blood flow and an
sial. The clinical results of this study must be increase in skin temperature of the scalp. In addition
interpreted in light of several limitations. First, most to this hypothesis, we assume that hypnosis could
of our patients received hypnosis in addition to lead to a change in cytokine expression by lympho-
another treatment as a result of ethical consider- cytes leading to a local immunomodulation. However,
ations. Therefore, it is not possible to evaluate how until today, data on the influence of hypnotic inter-
much of the changes and improvement in the hair ventions on cytokine production are very scarce.22
growth was caused by the hypnotic interventions. Our results indicate that a limited number of
Secondly, because a control group is lacking, it is hypnotic sessions do not prevent relapses of the
not possible to evaluate the benefit of incorporating disease. It is not known whether the combination of
hypnosis into the treatment of this often therapy- long-lasting hypnotherapy, eventually with an addi-
resistant disease. A randomized controlled trial with tional serotonin reuptake inhibitor, will be more
a sufficient number of patients is indicated before effective in these treatment-resistant diseases. This
this question can be answered. Despite these limi- will be the subject for future research. We conclude
tations, our first observations are encouraging. that these preliminary results indicate that a larger
Hypnotherapy significantly improved the psycho- and randomized study would be useful in evaluating
logic well-being of our patients. After treatment, all the benefit of hypnotherapy in severe cases of AA.
patients had a significantly lower score for anxiety
and depression and a lower total SCL-90 score.
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