Alopecia is one of the most common dermatologic conditions where the hair follicles shrink with growth hindrance due to various factors, including genetic predisposition, hormonal imbalance, and senescence. Although finasteride and minoxidil have been approved by U.S. Food and Drug Administration as androgenetic alopecia (AGA) treatment and used widely, drug-induced side effects such as sexual adverse events or hypertrichosis make AGA patients hesitant to treat [1,2]. Therefore, there have been many clinical trials for new agents in hair loss. Past studies have yielded some important insight into botanical extracts in alopecia treatment [3]. The purpose of this study was to evaluate the efficacy and safety of the botanical shampoo containing Morus alba root extract (MARE) in non-scarring alopecia.

From August 2021 to August 2022, Korean subjects in the age range of 20 to 65 years with non-scarring alopecia were enrolled. Any patients who had cosmetic procedure such as hair dyes within 2 months were excluded. Any patients who received oral finasteride or topical minoxidil within 2 months were also excluded. Subjects were instructed not to take any conventional or alternative treatments for hair loss, including oral finasteride, topical minoxidil, or nutritional supplements, during the study period. The C3 Shampoo^® (Caron Bio Corp.) containing MARE, Camellia sinesis, and Ficus carica was tested. The shampoos were used once a day for 8 weeks, an appropriate amount (3-5 g) was evenly applied to the scalp to massage and left in for 3 minutes or more. The scalp and hair were then rinsed with lukewarm water.

At 0, 4, 8, and 12 weeks, photo-documentation and folliscope analysis were performed. Changes of hair density and hair shaft thickness were assessed by folliscope (ASW200; AramHuvis Corp.). Improvement was evaluated representatively in the hairless area of the vertex and the seemingly normal-appearing area of the occiput, and tattooed for reproducibility. The outcome measures were the improvements in hair density and hair shaft diameter in the two assessed areas at every follow-up visit compared with baseline. Two dermatologists used quartile improvement scale (QIS) to assess clinical improvements at 12 weeks after treatment: worse (0); little or no change (1); mildly improved (2); moderately improved (3); and markedly improved (4). Participants were asked to assess subjective satisfaction score as follows: dissatisfied (0); somewhat dissatisfied (1-4); neutral (5); moderately satisfied (6-9); and very satisfied (10). Possible adverse events were recorded at each visit. Statistical analysis were performed using IBM SPSS Statistics 24.0 software (IBM Corp.) and paired Student t-test was used. A p-value of <0.05 was considered statistically significant.

Out of total enrolled (n = 20) subjects, two subjects were lost to follow-up during the coronavirus disease 2019 outbreak in Republic of Korea, and 18 subjects with a mean age of 53.5 ± 5.9 years completed all follow-up assessments. Eight subjects (44.4%) were female and ten subjects (55.6%) were male (Table 1). After 12 weeks, the total average hair density in the vertex was 103.33 ± 19.87 hairs/cm² compared with 81.1 ± 22.07 hairs/cm² at baseline, demonstrating a statistically significant increase of approximately 22 hairs/cm² (Fig. 1A). Hair density in the vertex was significantly increased at each visit compared with baseline. Hair density in the occiput was also significantly increased over baseline after 8 weeks. Fig. 2 shows a photographic images of each visit of a patient who exhibited marked improvements. After 12 weeks, the average hair diameter increased from 50.83 ± 8.97 µm to 55.56 ± 9.31 µm in the vertex and from 60.06 ± 9.84 µm to 64.56 ± 6.79 µm in the occiput (Fig. 1B). Study investigators reported an average QIS of 3.1 ± 0.4, corresponding to moderate improvement in overall alopecia. The subjective satisfaction with the treatment outcome was 7.2 ± 1.4. This score corresponds to moderate satisfaction, which was similar to the study investigators’ QIS scores. During the study period, no significant adverse events were reported.

Table 1 . Baseline characteristics of the participants

Variable	Value (n = 18)
Age (yr)	53.5 ± 5.9 (42-61)
Female	57.0 ± 2.7 (52-60)
Male	50.7 ± 6.4 (42-61)
Sex
Female	8 (44.4)
Male	10 (55.6)
Diagnosis
Pattern hair loss	5 (27.8)
Pattern hair loss and telogen effluvium	10 (55.6)
Telogen effluvium	3 (16.7)

Values are presented as mean ± standard deviation (range) or number (%).

Figure 1. Average change in (A) hair density, (B) hair diameter. The variables with statistically significant differences were connected by brackets at the top of the graph (*p < 0.05).

Figure 2. Representative images of clinical improvement with treatment follow-up in a 47-year-old male subject. (A) week 0, (B) week 4, (C) week 8, and (D) week 12.

The use of herbal extracts for the treatment of hair loss has gained significant attention in recent years [3]. Several herbal extracts have been studied for their potential in mitigating hair loss. For example, Serenoa repens, also known as Saw Palmetto, has been widely investigated for its anti-androgenic properties and 5-alpha-reductase inhibitory properties [4]. The extract of S. repens has shown promising results in improving hair growth and reducing hair loss in both animal models and clinical trials [5]. Another herbal extract commonly studied for hair loss is Eclipta alba, also known as False Daisy. The extract of E. alba has been shown to possess hair growth-promoting effects by stimulating the proliferation of dermal papilla cells [6] and down-regulating transforming growth factor-β1 [7]. Furthermore, E. alba extract has demonstrated antioxidant and anti-inflammatory properties, which may contribute to its hair growth effects [8]. Along with these herbal extracts, the effects of MARE on hair growth have also been investigated. MARE contains chlorogenic acid and umbelliferone, which have been associated with antioxidant effects [9] and hair growth-promoting effects [10].

In the present open label study, daily botanical shampoo containing MARE, C. sinesis, F. carica is significantly effective in improving the hair density and hair diameter. The mechanism of action of this botanical formulation appears to be multidimensional. In a recent in vitro study, MARE extract increased β-catenin expression with translocation of β-catenin to the nucleus in dermal papilla cells, which upregulated various growth factor secretion [10]. In addition, MARE also induced dermal fibroblasts to secrete paracrine factors related to angiogenesis, including vascular endothelial growth factor and fibroblast growth factor-7 [11]. Additionally, Polyphenol and flavonoid from C. sinesis, especially epigallo-catechin gallate, have been reported to have anti-inflammatory effect and stimulate hair growth via its proliferative and anti-apoptotic effects on dermal papilla cells [3].

Although the studies on herbal extracts for hair loss are promising, it is important to note that the efficacy of these extracts may vary depending on the underlying cause of hair loss. Additionally, the formulations and concentrations of the extracts, as well as the duration of treatment, may impact their effectiveness. Furthermore, it is essential to conduct well-designed clinical trials with larger sample sizes and longer follow-up periods to assess the long-term efficacy and safety of herbal extracts for hair loss. In this study, the clinical and folliscopic improvement were observed, but small sample size, absence of controlled group were the limitations in our study and further multicenter studies are needed.

In this study, we found that daily botanical shampoo formulation containing MARE showed some measurable efficacy in patients with non-scarring alopecia. Further research is needed to elucidate the optimal formulations, concentrations, and treatment protocols for botanical shampoo containing MARE. The findings from these studies can contribute to the development of effective and natural interventions for individuals experiencing non-scarring alopecia.

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Conceptualization: all authors. Data curation: JSK. Formal analysis: all authors. Funding acquisition: WSK. Investigation: WSK. Methodology: WSK. Project administration: WSK. Software: WSK. Validation: WSK. Visualization: WSK. Writing–original draft: all authors. Writing–review & editing: all authors.

No potential conflict of interest relevant to this article was reported.

This work was supported by the Caron bio Corporation. The funders had no role in the design and conduct of the study or the collection, analysis, and interpretation of the data. The company had no role in manuscript preparation or publication.

Contact the corresponding author for data availability.