Wigs and hair prosthetics

Key points

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Patients with androgenetic alopecia and other types of alopecia may turn to hair prosthetics when other medical and procedural interventions have been aesthetically unsatisfying and hair loss negatively affects their quality of life.
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When recommending a wig style to a patient, it is important to consider the patient’s face shape, lifestyle, goals, and environment.
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Wigs and hair prosthetics should be considered important therapeutic treatment options for many diagnoses and severities of scarring and nonscarring alopecia.
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Synthetic wigs are usually less expensive, less prone to environmental wear, and easier to maintain than natural wigs. However, natural wigs may look more natural and are less susceptible to damage from heat-styling.
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Wigs are often categorized by the type of foundation to which the hair is attached. Wig foundations include wefted (less expensive, less natural looking) and netted or lace (more expensive, more natural looking).
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For patients with patchy hair loss, beneficial hair prosthetics include demi wigs, toupees, lace fronts, and integration wigs.
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Adverse events with respect to wigs and hair prostheses typically occur as a result of improper fixation to the scalp or existing hair. Hair extensions and partial prostheses may cause traction alopecia if the braids to which they are affixed are too tight, or the extensions themselves are too heavy.

Background, definitions, and history

Wigs and hair prosthetics have been used for centuries to conceal hair disorders and to enhance existing hair. The earliest wigs date back to Ancient Egypt, where they were worn by nobility to dually signify elite social status and confer sun protection. Since then, they have been worn as status symbols throughout history by Roman emperors and European royalty. The word “wig” derives from the word “periwig,” which first came into use in the English language in the 1670s. King Louis XIII of France, who reportedly wore a wig to cover his premature balding, is credited with popularizing the wearing of powdered wigs, which were dusted with white starch to combat odor and parasites. During the late 18th century, wealthy women in Western Europe fashioned their hair in elaborate arrangements with decorations that sometimes even included birdcages.

Wigs may also have religious significance, as is the case with sheitels for married women in Orthodox Jewish communities. Today, the wigs and hair prosthetics market forms a multimillion-dollar industry. Hair prosthetics include, but are not limited to, wefted wigs, netted wigs, integration wigs, partial hair pieces, and hair extensions or weaves.

Patients with androgenetic alopecia (AGA) and inflammatory alopecia may turn to hair prosthetics when other medical and procedural interventions have been aesthetically unsatisfying and hair loss negatively affects their quality of life. Therefore, it is critical that dermatologists are aware of characteristics and variations of wigs and hair prosthetics.

Indications and patient selection

Rather than a mere cosmetic accessory, wigs and hair prosthetics should be considered important therapeutic treatment options for many diagnoses and severities of scarring and nonscarring alopecia. The recommendation of a hair prosthetic is not mutually exclusive of continuing medical or procedural therapy for hair loss. Some patients may want to save wispy strands even as they realize that hope for regrowth to the effect of a socially acceptable natural hairstyle is unattainable.

Many patients may initially present with personal experience of using hair prosthetics prior to any prescribed medical or procedural intervention for hair loss. Providers should feel comfortable asking about a history of prior wig or hair prosthetic use when considering adding a hair prosthetic to the treatment plan for hair loss.

Some patients may use hair prosthetics as a bridge until medical or procedural therapies for their alopecia take effect. In the case of chemotherapy-induced hair loss, wigs typically serve as a temporary solution to alopecia during treatment.

When recommending a wig style to a patient, it is important to consider the patient’s face shape, lifestyle, goals, and even environment. For example, patients living in a warmer climate may be best suited with lower-density and shorter wigs to avoid overheating and perspiration of the scalp under the wig. Patients with drug-induced hair loss and progressive hair loss disorders may often want to recapitulate the texture, color, and length of their natural hair style. Human hair wigs can be dyed, cut, and styled, while synthetic hair wigs may have more limited flexibility of daily styling.

Wig cap sizing is also important, and the authors recommend patients have measurements of head circumference, frontal hairline to occiput, and coronally from ear to ear to ensure a proper fit. The typical wig cap size is about 22 inches for an adult.

Patients with chronic and progressive forms of hair loss, such as AGA, may view wigs and hair prosthetics as a sign of giving up on treating their hair loss, and the contrary should be emphasized. Initiating a discussion on wigs and hair prosthetics early on in the course of disease is important, as end-stage scarring alopecia or severe AGA may progress to a state where there is little hope for aesthetically acceptable regrowth, despite maximizing medical and procedural therapy.

Just like any other medical or dermatologic treatment, dermatologists recommending wigs and hair prosthetics must take into account a patient’s natural anatomy, lifestyle, goals, and profession, and ensure that the patient is happy with the treatment, that the treatment is effective, and, most of all, that the treatment fits seamlessly into their life.

Expected outcomes

Hair loss has the capacity to significantly affect all aspects of a patient’s quality of life, regardless of the cause or severity of alopecia. Numerous studies have demonstrated the negative effect of hair loss on quality of life, including emotional well-being and financial potential. Studies have demonstrated increased prevalence of psychological disorders in patients with alopecia. Patients may experience depression, anxiety, and neuroticism scales, regardless of the duration of the disease, age at disease onset, number of relapses, and intensity of disease.

Considering economic stability of patients with hair loss, the Canadian Hair Research Foundation found that, among 1502 men and women responders, 1 in 8 believed hair loss to be a barrier to getting hired. In addition, studies have shown it is important to patients that the wig or hair prosthetic look as close as possible to natural hair with minimal noticeability for strangers and acquaitenances. The ideal outcomes with use of a wig or hair prosthetic are improved quality of life in all aspects of a patient’s well-being and reduction of stigma.

Wigs have demonstrated positive effects on social anxiety in patients with alopecia areata and may be an important coping strategy to dealing with hair loss disorders. Wearing wigs has been associated with increased social confidence in patients with alopecia, and patient concerns about not being able to wear a wig when needed have been associated with higher levels of depression and anxiety.

Treatment techniques and best practices

Wig hair composition

Wig hair may be synthetic or natural ( Pearl 6.1 ). Among synthetic wigs, the hair material is typically composed of uniform fibers of nylon acetate or Dynel, which is a copolymer of acrylonitrile and vinyl chloride. Benefits of synthetic hair wigs include that they are typically less expensive than natural hair, less prone to environmental wear, and easier to maintain. The pitfalls of synthetic hair wigs are their unnatural look as a result of uniform fiber diameter and their lower melting point, which makes them vulnerable to damage with heat styling. The benefits of wigs containing human hair fibers are their natural look and ability to be heat styled ( Fig. 6.1 , Pearl 6.2 ). They are typically more expensive and must be replaced more frequently because of their susceptibility to environmental damage, such as UV-induced fading. Human hair fibers are most frequently sourced from China, Thailand, Indonesia, and India, and more expensive hair fibers are sourced from Europe.

Pearl 6.1:

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