All that a Dermatotrichologist needs to know about Hair Camouflage: A Comprehensive Review.

Hair loss can impact a person's quality of life in ways incomprehensible. People value hair for different reasons, but value it nonetheless. There is a myriad of conditions that impede hair growth or cause hair to grow in an unattractive manner such as androgenetic alopecia, alopecia areata, and chemotherapy-induced hair loss. For conditions like cicatricial alopecia, there are hardly any options available once permanent loss of hair sets in. The role of hair transplantation too is limited in such cases where the donor area has been compromised. Thus, addressing the concern of hair loss and presenting all possible options available even after medical and surgical options flounder due to their limitations is a responsibility every dermatotrichologist carries and a plethora of camouflage options are available to improve the appearance of hair right from hairpieces to more permanent methods like scalp micropigmentation. Copyright:

INTRODUCTION

The Roman poet Ovid wrote Ars Amatoria (“The Art of Love”) in which he expressed “Ugly are hornless bulls, a field without grass is an eyesore, So is a tree without leaves, so is a head without hair.”

The desire to wear hairpieces is caused in part by a long-standing bias against balding that crosses cultures. A topic often dealt in hushed tones, the hairpiece is either flaunted with pomp or worn discreetly behind closed doors. The use of the hairpiece originates as early as 3000 BC by the Egyptians. The fact that Mary Queen of Scots used to wear an auburn-colored wig became known only after she was beheaded and her wig fell off revealing her short gray hair. This highlights the reluctance that often conquers the human mind when it comes to accepting the loss of our prized treasure-”hair,” that might be attributed to untreatable trichological conditions. Camouflaging is a procedure or technique where the illusion of hair is created by decreasing the contrast between bald skin and hair and is grouped into temporary and semipermanent techniques [Figure 1].

Figure 1

Classification of Camouflage techniques for the scalp, eyebrow, and eyelashes

TEMPORARY METHODS OF HAIR CAMOUFLAGE

These include hairpieces such as wigs, demiwigs, toupees, cascades, wiglets, and others such as hair thickening fibers, hair styling products, pigmented concealing powders, and sprays [Table 1].

Table 1

Glossary of all terminologies related to temporary methods of hair camouflage

Terminology	Description
Artificial hair integrations	Also known as hair extensions or hair weaves. Used to add length and/or fullness
Bandeau	Used to cover the natural hairline. Comes in different colors and is sewn into a headband, which is worn over the natural hair
Bonding	A method of applying hair extensions using an adhesive (hot glue gun or latex-based glue) to “bond” i.e., to fuse the hairpiece to natural hair
Braiding	Making use of braids (cornrows), adapted from traditional African hairstyles, to attach large volumes of hair in the form of wefts or other hairpieces to existing hair
Cascade	It is larger than a wiglet with curled locks of hair or a bun. Has an oval base and is worn in the upper and lower crown areas designed to rest on the posterior scalp
Chignons	A hair accessory over a bun or ponytail to enhance the hair volume
Demi wig	Covers most of the scalp except the hairline. It blends with the existing hairline in the front, sides, and the behind
Fall	Long pieces of hair of varied sizes and lengths. The base is usually secured in the crown area
Hair additions	A semi-permanent way of hair camouflage wherein hair fibers is sewn, braided, or glued to existing hair that remains in place for approximately 8 weeks. Remains in place even while bathing, sleeping, and exercising
Hair integration systems	A term used to describe customized hairpieces in which synthetic or human hair fibers of the desired color and length are tied to a meshwork in the desired location and the patients’ existing hair is pulled through the fenestrations in the net
Postiche	Small hairpieces having a round base, usually made from angora and yak hair
Toupee	Popular among men to cover an area of baldness or thinness. They come in short and medium-length hair and primarily covers the top of the male head
The vent	The in-built vents allow the natural hair to be pulled through and styled. Gives a look of fullness over the entire head
Switch	Long pieces of hair that may be worked into braids or woven through the hair to enhance the hair volume
Weft	Hair fibers are sewn together into a strip
Wig	Designed to cover the entire scalp
Wiglet	Has a flat or cone-shaped base used to cover localized areas of baldness or to enhance volume over the scalp. Some have a waffle base that allows natural hair to pass through the holes in the bases

WIGS

A wig worn by a patient with alopecia for treatment purposes is not merely ornamental, but a necessity for daily life, similar to a prosthesis used by a patient who has lost a leg or an eye. Hence, it is called a “scalp or hair prosthesis” to differentiate it from a fashion wig.[1] Scalp prosthesis can be classified based on the extent of hair loss, the type of fiber, and the method of fixation[2] [Figure 2].

Figure 2

Classification of scalp prosthesis (Further figures have been added as supplemental material for review due to limitation in their number. They are specially drawn and designed to give the readers a better understanding and create a visual impact)

Depending on the extent of hair loss, the type of coverage can be selected. Those who have lost a significant proportion of their scalp hair may select a complete scalp coverage wig, whereas others with more localized loss may elect to wear a wiglet. Wigs can be made either from synthetic or real human hair.[3] While human hair used in wigs is obtained predominantly from Indian and Chinese women (known to grow their hair for sale), synthetic hair fibers for wigs are formed from modacrylic, composed of two polymerized monomers: acrylonitrile and vinyl chloride. Human hair is more expensive and requires greater care; however, they both look and feel better as compared to their synthetic counterparts. Both types of wigs have their upside and downsides and the choice of using either is based on individual needs and affordability [Table 2].[34]

Table 2

Advantages and disadvantages of human hair wigs versus synthetic hair wigs

Human hair wig	Synthetic hair wig
Advantages  Gives a more natural appearance  May be styled like natural hair  Less susceptible to heat damage	Advantages  Comparatively cost-effective (50-75% less than a human hair wig)  Longer lasting (3-5 years)-less prone to breakage  Does not require frequent styling
Disadvantages  Expensive  Shorter life (2-3 years)-more prone to hair breakage  Greater care - shampoo, comb, and style every 2 weeks  More uncomfortable to use (heavier and hotter)	Disadvantages  Does not give a natural look  Not able to color or perm like human hair  More susceptible to heat damage

In addition to the variety in wig fibers, hairpieces can be constructed using two different fiber attachment methods: hand-tied and machine-wefted. In hand-tied hairpieces, the fibers are individually knotted into a woven mesh, thereby making it expensive, whereas machine-wefted wigs are made by sewing the fibers onto strips of material and then attaching wefts to the mesh.[3] A recent addition-Vacuum-fit (suction) wigs are made from a plaster mold taken off the patient's head. There are hard vacuums made from inert hard plastic or fiberglass, which gives a helmet-like feel and soft vacuums that are generally considered more comfortable as they are flexible, usually made of medical-grade silicone, and feel like real scalp. The wearer can take the vacuum off at any time by breaking the seal with their fingers at the nape of the neck. These last for 2 to 4 years. Care should be taken to not sleep in a vacuum.[5] India is one of the largest suppliers of human hair for different camouflage preparations. With six hundred and fifty barbers sitting in lines shaving the heads of the women seated in front of them at the Hindu temple of Tirumala Venkateswara located in Tirupathi, India every day, it serves as the starting place and principal provider for an astonishing industry of trade in human hair.[6] The quality of Indian hair is known to be extraordinarily good and hence it has rightfully created its demand world over.

DEMIWIGS

A demiwig is limited to the crown and some extent the vertex of the scalp. It just covers the top of the scalp and allows the patient's existing hair on the sides and back of the scalp to extend beyond. It can also be used when the alopecia affects the upper posterior scalp because the cap can be designed to come down over the superior occipital hair loss.

WIGLET

A wiglet is useful for localized camouflage as it has a flat or cone-shaped base used to cover localized areas of baldness over the scalp. Some wiglets have a waffle base that allows the natural hair to pass through the holes in the bases such that it becomes integrated with the existing hair if present.

TOUPEE

Toupée related to the French words “top,” or “tuft.

Toupees have been a source of humor in virtually all forms of media; remember a strong gust of wind, whipping a man's toupee from his head![7] It is a type of demiwig designed for male patients with hair loss, especially over the top of the scalp [Figure 3]. They are available in a variety of colors. The feature of having the appropriate percentage of gray hair to match the patient's state of canities is a bonus. There also are toupees available uncut, which allows the patient to take the toupee to the barber for styling along with the patient's natural hair.[3]

Figure 3

Top panel: Advanced male pattern hair loss (Grade V) and after application of toupee covering the bald area of the scalp; Below panel: Inside of a toupee consisting of lace in the center and silicone at the periphery and the final toupee hairpiece

CASCADE

A cascade is larger than a wiglet. It has an oval base and is worn in the upper and lower crown areas designed to rest on the posterior scalp. Hence, it is useful to camouflage localized apical and posterior scalp hair loss.

After having acquired the knowledge about different types of hairpieces, it is pertinent to determine which hairpiece shall be suitable for a given condition. We have enumerated conditions in which different types of hairpieces find utility in the field of trichology [Table 3]. The list is not exhaustive and is only representative. Nonprofit-based organizations such as “Locks of Love,” “Wigs for Kids,” “Hair that Cares, Inc.,” and many others are present in the United States of America and throughout the world that specializes in providing hairpieces for children who have lost hair due to chemotherapy, medical treatment, or head injury.

Table 3

Conditions in which different types of hairpieces find utility in

Hairpiece type	Indications in trichology
Wig	1. Alopecia Areata - (alopecia areata subtotalis, alopecia totalis, or alopecia universalis)
	2. Androgenetic alopecia (grade VI and VII) and female pattern hair loss
	3. Cicatricial alopecia (central centrifugal cicatricial alopecia, Lichenplanopilaris)
	4. Chemotherapy-induced hair loss
	5. Others - congenital atrichia, burns
Demiwigs	1. Focal alopecia areata
	2. Patterned hair loss - especially involving the vertex
	3. Cicatricial alopecia - Discoid lupus erythematosus, lichen planopilaris
	4. Scars secondary to surgery, accidents, burns (provided the hairline is preserved)
Toupee	1. Androgenetic alopecia - grade IV, V
	2. Alopecia areata-localised
	3. Chemotherapy-induced hair loss
	4. Scars secondary to surgery, accidents, burns

HAIRPIECE ATTACHMENT METHODS

While a full scalp wig can be easily worn as a cap over the head, other hairpieces can be attached with the help of clips, tape, or surgical solution. Braiding and bonding are other ways by which a hairpiece can be attached to existent hair if present. A clip offers the convenience of removing the hairpiece whenever desired. However, clips used at the same site may cause breakage of the existing hair. Furthermore, the weight of the hairpiece tugging over normal hair may precipitate traction alopecia. Skin-friendly tapes are available to attach any form of hairpiece and the use of glue is limited when the fixation of the hairpiece is desired for a longer period. The patient should be counseled about the need for appropriate care of the hairpiece and scalp hygiene to avert any discomfort.

HANDLE WITH CARE! MAINTENANCE OF THE HAIRPIECE

Every hairpiece requires adequate care for good hygiene and longer shelf life. Human hair products require greater attention and care. The cleaning is done in much the same manner as a head of hair. Synthetic pieces require little more than mild shampoo and human hairpieces should be given the same care that is applied to human hair. The hairpiece is turned inside out and a drop of mild shampoo is placed in the center and gently agitated under a stream of warm water. Once the shampoo is completely removed, a drop of instant conditioner is placed in the wig and again rinsed. The hairpiece is allowed to air-dry inside out by attaching it with a clothespin to an indoor clothesline. Once dry, the hairpiece may be styled with a specially designed wig brush. Human hair products must be curled and set, whereas synthetic hairpieces are ready to wear and can be simply brushed after positioning on the scalp. Removal of a hairpiece in a proper manner is as important as care of the hairpiece itself. A hairpiece added by braiding or sewing is simply removed by undoing the braid and cutting off the attachment thread, respectively. Removal of the glue is done by the use of specially designed solvents. Massaging peanut oil helps facilitate the removal of any remaining material.[3]

OTHER METHODS OF TEMPORARY CAMOUFLAGE

A dermatotrichologist should keep in mind and give advice regarding hair grooming tips to hair loss patients, focused on using the patient's remaining natural hair to camouflage thinning where possible. Hairstyling products such as styling gels, sculpturing gels, mousses, and hair sprays can keep the hair in place and add volume by allowing the hair to stand away from the scalp, defying gravity, and creating an illusion of fullness.[8]

HAIR THICKENING FIBERS

An addition to the world of hair camouflage in recent years, hair thickening fibers are rapidly becoming popular for their convenience in masking small areas of alopecias. These tiny microfibers are made of the same keratin protein as real hair blends. A study published by Cossman et al.[9] highlighted the effectiveness of hair-thickening fibers in camouflaging alopecic areas affected by androgenetic alopecia. This technique has been successfully used to conceal alopecia caused due to scarring in three patients of epidermolysis bullosa as well.[10] These fibers bind to existing hair by static electricity as the positively charged particles of wool keratin are attracted to the negatively charged terminal and vellus hair on the scalp, thereby giving an illusion of thicker and fuller hair.[11] Hair thickening fibers are sprinkled over the alopecic areas using an applicator similar to a saltshaker and then combed through the hair to facilitate distribution [Figure 4]. The major disadvantage is the limited utility of these fibers in areas of complete baldness as their principal mechanism of functioning involves the bonding of existing hair. They are sourced from keratin or other plant materials and can be dyed in convenience to the patient's hair color. There are sprays available in addition to ensuring the fixity of these fibers. Adverse reactions in the form of scalp irritation or allergy to the dyes used within the fibers can occur as is true with all hairpieces.

Figure 4

Before and after application of hair thickening fibers over the scalp in a male patient. (Inset. Attachment of hair thickening fibers to the shaft of hair follicle after application)

PIGMENTED CONCEALING POWDERS

Powder cakes are an alternative cosmetic camouflage that forms a coat over thin hair. It is simply dusted over the desired area and brushed to evenly distribute it throughout the naturally existing hair. The result is relatively thicker hair that stands and spreads out giving an appearance of increased fullness. Like hair thickening fibers, this technique is limited by the need for existing hair. Although it can be used over a completely bald area, it might not appear very pleasing and the primary aim of camouflage is defeated. Furthermore, they have to be applied daily and may get washed away in water activities or due to excessive sweating. The major advantage of concealing powders is that it can effectively conceal the frontal hairline. Modifications with water-resistant materials are becoming available.[4]

SEMIPERMANENT METHODS OF HAIR CAMOUFLAGE: SCALP MICROPIGMENTATION

Scalp micropigmentation (SMP) uses a tattoo in a stippling pattern that mimics hair follicles that are cut close to the scalp. The process includes insertion of a microdroplet of pigment through the skin and into the upper dermis, using a standard tattoo instrument, which supports between one and six needles cycling between 100 and 150 cycles per second.[12] The targeted artistic effect is similar to the visual effect of a stippled painting as dots are created between the pores of a balding scalp. This technique is particularly helpful in men and women who are balding or thinning and do not qualify for hair transplantation or in whom hair transplants have failed to achieve the amount of “fullness” expected. It can also help disguise scalp scars after transplantation surgery.[4] However, scalp micropigmentation is a skill that has to be acquired. Pigment bleeding, color changes from poor choices in pigments, and poor postprocedure follow-through are some of the problems caused by novices that reflect poor judgments in the technical and artistic delivery of SMP.[12]

CAMOUFLAGE TECHNIQUES FOR THE LASH AND BROW

It is often said, “may your coffee be strong and your lashes be long” and rightfully so, as absent lashes make the eyes appear older and more recessed in the orbit. Artificial eyelashes provide a form of temporary camouflage, whereas tattooing and microblading offer more permanent solutions. Artificial eyelashes are available as lash singlets, demi lashes, and complete eyelashes popularly known as individuals, clusters, and strips, respectively, in the world of fashionistas. Lash singlets are very easy to wear and are simply glued to the existing lashes to fill areas of focal loss of eyelashes. Demi lashes contain fewer hair as compared to the complete lash set, are lighter, and are designed to blend with the remaining eyelashes. Although complete eyelashes look very dramatic, they seem to be a blessing for patients who have lost all their eyelashes. The lashes are typically applied with lash adhesive and tweezers or lash applicators. Artificial eyelashes are often difficult to wear and may lead to irritation of the eye, tarsal plate, and eyelid.[3]

Eyebrows too hold a special semblance as they help accentuate the eyes, shape the face, and play a powerful role in nonverbal communication. Hence, the loss of eyebrows is particularly disfiguring. Artificial eyebrows are available that can be customized from synthetic or natural human hair knotted onto a thin netting in the appropriate amount and shape for a patient's face. The netting is glued on the superior orbital ridge with a waterproof adhesive that helps keep the brow secure.[3] Eyebrows can be reconstructed or thickened with the use of eyebrow pencils that provide temporary coverage or tattoo pigments that last for a longer time. Microblading, the most popular method of cosmetic eyebrow tattooing, is a form of semipermanent tattooing that involves the use of tiny, fine-point needles that make up a small disposable blade and a handle that helps scratch and deposit micropigment simultaneously under the skin [Figure 5]. The key difference between microblading and tattooing is that microblading creates a more natural result, makes use of specialized micropigments unlike the inks used in tattooing, is comparatively less painful, and lasts for about 6 months to a year. Like any other tattooing technique, the most common complications associated with it include misapplication of the pigment, pigment migration, color change, and, in some cases, unintended hyperpigmentation.[13]

Figure 5

Before and after microblading in a case of focal alopecia areata of the eyebrow

CONCLUSION

Hair loss is a traumatic condition for any patient. Guiding the patient is important and it is pertinent to remember that as a person matures, changes in the skin texture and color begin to appear. A hairpiece suitable for a child may not seem appropriate when adorned by an adult. Hence, guidance to choose hairpieces in shades that complement the patient's skin and style is a must. While waves and curls and lighter shades may complement a young face, shades in salt-and-pepper or the dark brown range may suit our adult population. Choosing the right kind of hairpiece individually will make the hairpiece look more natural and the patient appears younger. Alternatively, the patient can opt for more permanent methods of camouflage available. Attention to minute details can instill a lot of confidence in the patient and improve his overall attitude and sense of well-being, further helping to cope with the condition he is suffering from.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.