Hair and scalp disorders in ethnic populations

Support for dermatological research in Sub-Saharan Africa: insights from African hair and skin research programs

BACKGROUND

The structure and physiology of skin and hair in people of African ancestry are different from other ethnic categories and studies from other continents cannot necessarily be extrapolated to Sub-Saharan Africa (SSA) due to the differences in genetics, lifestyle, climate, cultures, and hair and skin care practices. The aim of this report is to highlight the recent advances in local skin and hair research in SSA from a grant program.

METHODS

African Hair and Skin Research Grants from an industrial sponsor were awarded between 2013 and 2022 on five main topics: acne, hair and scalp, keloid scars, atopic dermatitis, and air pollution. A literature search in Scopus identified publications on these topics in African or black skin in SSA and worldwide to provide insight into the impact of the program.

RESULTS

The number of publications from around the world on the skin and hair of people of African ancestry has increased significantly over the past 30 years on all five topics, especially as a result studies conducted in the United States. Fewer studies have been conducted in SSA but there has been an increasing number of publications over the past 10 years, especially from South Africa.

CONCLUSIONS

Scientific and clinical partnerships between the industry, academia, and public healthcare sectors have contributed to a steady increase in hair and skin publications from SSA, which may be useful for the development of tailored products and public educational campaigns to raise awareness of the risks of using inappropriate products.

The dermatologist's guide to beards: a review of structure, function, care and pathology

Facial hair is a commonly desired feature for many individuals. Despite a breadth of dermatology literature covering strategies for removing facial hair, there are no known articles summarizing strategies for facial hair growth or reviewing common facial hair pathologies. Here, we assess Google Trends to describe significant increases in search terms related to facial hair growth and maintenance over the last decade, suggesting an increased public interest in this topic. Next, we review ethnic differences that may affect facial hair distribution, growth, and predisposition to certain facial hair pathologies. Lastly, we review studies on agents used for facial hair growth and review common facial hair pathologies.

A community-based study of hair care practices, scalp disorders and psychological effects on women in a Suburban town in Southwest Nigeria

Introduction

The scalp hairs on an average African is dry with low tensile strength and a tendency to break easily. This is mostly due to poor penetration of the natural oils on the scalp and the very curly hair texture. Various techniques developed to manage African hair are associated with certain hair and scalp disorders and are sources of distress.

Objectives

This was a cross-sectional survey to compare natural African hair and chemically processed (relaxed) hair to determine the effect of hair care and grooming practices on common scalp disorders and the psychological effect in Nigerian women.

Subjects and Methods

Questionnaires were administered to women at the market, churches and outreaches with many women in attendance to document the hair grooming practices, common scalp symptoms and psychological effects experienced. They were also examined for the presence of seborrhoeic dermatitis and traction alopecia.

Results

The study involved 452 women (62.17%) with relaxed hair and 275 women (37.83%) with natural (untreated) hair. Women with relaxed hair experienced significantly more flaking of the scalp (P = 0.046, x² = 6.16), hair breakage (P = 0.023, x² = 11.35) and hair loss (P = 0.020, x² = 7.87) than those with natural hair. The most common psychological effects of hair scalp disorders in all participants were feeling of uneasiness 142 (19.5%), frustration 49 (6.7%), poor body image 40 (5.5%) and anger 38 (5.2%). Significantly more women with relaxed hair experienced moderate hair loss from traction than women with natural hair (P = 0.014, x² = 8.52).

Conclusion

Nigerian women experienced clinical and psychological distress consequent to their hair grooming practices. Individuals with relaxed hair had more physical symptoms, hair loss and psychological disturbances than those with natural hair.

Facial hair shaving behavior and skin problems of shaved areas of males

Unwanted facial hair is a common problem and requires different grooming regimens or treatments. Shaving beard hair can cause undesirable skin effects, such as irritation, razor burn, razor nick, and pseudofolliculitis barbae. This study explores male behaviors related to shaving facial hair and the consequential effects on the shaved skin. A questionnaire-based, cross-sectional, analytical study was conducted on 340 healthy men. Most of the participants were manual shavers. Approximately one-third of the manual shavers prepared their skin for shaving, compared to 13% of the electric shavers. The most common shaving-related skin problems were irritation and dryness, razor burn, razor nicks, and pseudofolliculitis barbae. The shaving-related skin problems resulted from individual skin conditions and their shaving techniques. Appropriate skin preparation should be undertaken before shaving, and post-shaving care products should be used to avoid problems.

Central Centrifugal Cicatricial Alopecia: Challenges and Treatments

Central centrifugal cicatricial alopecia (CCCA) is the most common form of primary scarring alopecia diagnosed in women of African descent. Although the etiology was originally attributed exclusively to hairstyling practices common among women of African descent, more recent research on CCCA supports the concept that there are several contributing factors, including variants in gene expression, hair grooming practices that increase fragility on the hair follicle, and associations with other systemic conditions. Treatment of CCCA involves a combination of patient counseling and education on alternative hairstyles, medical therapies, and procedural methods when necessary.

Current and emerging treatment strategies for hair loss in women of color

Hair loss is common in women of color, and is associated with significant psychosocial complaints. Early clinical recognition and prompt initiation of intervention with medical treatment is critical to halt the disease process. In this article, we review the clinical presentations of nonscarring and scarring alopecias in women of color, use of dermoscopy for early recognition of the disease process, and medical, procedural, and surgical interventions. In conditions that result in scarring alopecia, such as late-stage traction, frontal fibrosing, or central centrifugal cicatricial alopecia, patients may benefit from procedural interventions, such as hair transplantation, platelet rich plasma injections, low-level laser therapy, or scalp therapy.

Scalp Pruritus: Review of the Pathogenesis, Diagnosis, and Management

Scalp pruritus is a frequent problem encountered in dermatological practice. This disorder is caused by various underlying diseases and is a diagnostic and therapeutic challenge. Scalp pruritus may be localized to the scalp or extended to other body areas. It is sometimes not only associated with skin diseases or specific skin changes, but also associated with lesions secondary to rubbing or scratching. Moreover, scalp pruritus may be difficult to diagnose and manage and may have a great impact on the quality of life of patients. It can be classified as dermatologic, neuropathic, systemic, and psychogenic scalp pruritus based on the potential underlying disease. A thorough evaluation of patients presenting with scalp pruritus is important. Taking history and performing physical examination and further investigations are essential for diagnosis. Therapeutic strategy comprises removal of the aggravating factors and appropriate treatment of the underlying condition. All treatments should be performed considering an individual approach. This review article focuses on the understanding of the pathophysiology and the diagnostic and therapeutic management of scalp pruritus.

Trichoscopy of Dark Scalp

Trichoscopy (dermoscopy of the hair and scalp) is a technique that improves diagnostic accuracy and follow-up with hair and scalp disorders. Although several studies of trichoscopy have been made in Caucasian and Asian populations, little has been published regarding trichoscopy findings in skin of color, despite the great prevalence of hair diseases in populations with this kind of skin. The aim of this review was to describe the trichoscopic features of normal scalp and of hair disorders in patients with dark skin phototypes. This will help dermatologists to distinguish between unique trichoscopic features of dark skin, and allow them to provide more accurate diagnoses and treatments for these patients.

Traction alopecia: the root of the problem

Traction alopecia (TA) affects one-third of women of African descent who wear various forms of traumatic hairstyling for a prolonged period of time. The risk of TA is increased by the extent of pulling and duration of traction, as well as the use of chemical relaxation. The frequent use of tight buns or ponytails, the attachment of weaves or hair extensions, and tight braids (such as cornrows and dreadlocks) are believed to be the highest risk hairstyles. TA can also occur in the setting of religious and occupational traumatic hairstyling. In its later stages, the disease may progress into an irreversible scarring alopecia if traumatic hairstyling continues without appropriate intervention. The most common clinical presentation includes marginal alopecia and non-marginal patchy alopecia. A clue to the clinical diagnosis is the preservation of the fringe sign as opposed to its loss in frontal fibrosing alopecia (FFA). Dermoscopy can be helpful in the diagnosis and can detect the ongoing traction by the presence of hair casts. Histopathology can distinguish TA from alopecia areata, FFA, and patchy central centrifugal cicatricial alopecia. Currently, there is no cure. Therefore, it is imperative that clinicians educate high-risk populations about TA and those practices that may convey the risk of hair loss.

Considerations When Treating Cosmetic Concerns in Men of Color

BACKGROUND

Men of color include a diverse population encompassing individuals with Fitzpatrick skin Types IV through VI. Yet, there is a paucity of data describing the cosmetic concerns of this population.

OBJECTIVE

To review the basic science of advantages and disadvantages of skin of color and pathophysiology, incidence, and treatment of disorders of cosmetic concern in men of color.

METHODS

A MEDLINE search was performed for publications on sex and racial differences in basic science of skin, common disorders in men of color, and evidence-based treatments.

RESULTS

There are intrinsic differences in skin and hair of darker-complexioned men, particularly in Hispanics, African Americans, Asians, and Afro-Caribbeans. Advantages of darker skin include increased photoprotection, slowed aging, and a lower incidence of skin cancer. However, the increased content of melanin is associated with myriad dyschromias including melasma and postinflammatory hyperpigmentation (PIH). Additional common skin conditions of concern in men of color include pseudofolliculitis barbae, acne keloidalis nuchae, and keloids.

CONCLUSION

A skin color conscious approach should be administered in caring for the cosmetic concerns of men of color that is cognizant of differences in biology of the skin and hair, associated PIH of disorders, and cultural/social practices among this population.

Evaluation of clinical signs and early and late trichoscopy findings in traction alopecia patients with Fitzpatrick skin type II and III: a single-center, clinical study

BACKGROUND

Traction alopecia refers to (often permanent) hair loss caused by prolonged physical damage. No study has yet described the unique trichoscopic findings of the condition. We describe the trichoscopic findings of traction alopecia and its relationships with the duration of traction.

METHODS

We studied 25 patients who were clinically diagnosed with traction alopecia. The patients were divided into two groups in terms of traction duration. Trichoscopy was performed at a minimum of two scalp locations in each patient.

RESULTS

Reduction in hair density, hair diameter diversity, empty follicles, and vellus hairs were observed in all patients. In addition, the following were observed: loss of follicular openings in 19 (76%) patients, yellow dots and broken hairs in 17 (68%), black dots in 12 (48%), hair casts in 7 (28%), circular hairs in 5 (20%), and arborizing red lines in 3 (12%). The trichoscopic findings varied with the duration of traction.

CONCLUSIONS

Traction alopecia is a chronic condition that is difficult to treat. Trichoscopy can be used for diagnosis. Our study is the first to identify the early and late trichoscopic features of traction alopecia. The limitation of the study is the lack of histologic diagnosis.

Central centrifugal cicatricial alopecia: challenges and solutions

Central centrifugal cicatricial alopecia (CCCA) is the most common scarring alopecia among African American women. Data about epidemiology, etiology, genetic inheritance, and management are scarce and come from individual reports or small series. CCCA has been associated with hot combing and traumatic hair styling for years; however, studies fail to confirm it as the sole etiologic factor. It has been shown in a small series that CCCA can be inherited in an autosomal dominant fashion, with a partial penetrance and a strong modifying effect of hairstyling and sex. CCCA presents clinically as a central area of progressive irreversible hair loss that expands to the periphery. A patchy form has also been described. Dermoscopy is helpful to identify the optimal site for the biopsy, which establishes the diagnosis. Well-designed randomized controlled trials are needed to discover the optimal management. At this point, patients are advised to avoid traction and chemical treatments; topical and intralesional steroids, calcineurin inhibitors, and minoxidil can be helpful in halting the progression.

Hair care practices and structural evaluation of scalp and hair shaft parameters in African American and Caucasian women

How African American hair fragility relates to hair care practices and biologic differences between races is not well understood. To assess the differences between perceptions of hair health, hair care practices, and several biologic hair parameters between Caucasian and African American women. A questionnaire on perceptions of hair health and hair care practices was administered. Biological and structural parameters of hair shaft and scalp, including growth, density, diameter, cycle, breakage, and scalp blood flow were also assessed in this case-control study. Significant differences between the Caucasian and African American women were observed in the questionnaire and biologic study data. Regarding self-reported perceptions of hair health, there were differences in the following: hair shaft type (P < 0.001), hair breakage (P = 0.040), and desire to change hair (P = 0.001). Regarding self-reported hair care practices, there were differences in the following: location of haircutting (P = 0.002) and washing (P = 0.010), washing frequency (P < 0.001), chemical relaxer use (P < 0.001), hooded hair dryer use (P < 0.001), and hair shaft conditioner use (P = 0.005). The two groups had similar practices in regard to the use of hair color, frequency of hair color use, chemical curling agents, and handheld blow dryer use. Regarding biological and structural parameters, there were differences in the following: hair growth rate (P < 0.001), density (P = 0.0016), diameter (P = 0.01), number of broken hairs (P < 0.001), and blood flow (P = 0.03). There was no significant difference in hair cycle parameters.The differences in hair care practices and hair fiber morphology among African American women may contribute to clinically observed variation in hair fragility and growth.

Folliculitis keloidalis nuchae and pseudofolliculitis barbae: are prevention and effective treatment within reach?

Pseudofolliculitis barbae and folliculitis keloidalis nuchae are chronic follicular disorders disproportionately affecting men of African ancestry. This article explores the etiology, pathogenesis, treatment, and prevention strategies of these conditions. Effective treatment and prevention of these disorders involves pharmacologic and procedural interventions as well as behavioral modifications.

Follicular and scarring disorders in skin of color: presentation and management

Skin of color, also known as ethnic skin, is described as skin of individuals of African, Asian, Hispanic, Native-American, Middle Eastern, and Pacific Island backgrounds. Differences in hair morphology, hair grooming, cultural practices, and susceptibility to keloid scarring exist within these populations and have been implicated in hair, scalp, and skin disorders. Acne keloidalis (AK), central centrifugal cicatricial alopecia (CCCA), dissecting cellulitis of the scalp (DCS), pseudofolliculitis barbae (PFB), traction alopecia (TA), and keloids are the most prevalent follicular and scarring disorders in skin of color. They have been associated with disfigurement, permanent hair loss, emotional distress, and decreased quality of life. Hair grooming practices, such as the use of chemical relaxers, heat straightening, and tight braiding and weaving can cause scalp irritation and follicular damage and are linked to the pathogenesis of some of these conditions. Consequently, patient education and behavior modifications are integral to the prevention and management of these disorders. Scarring disorders are also of concern in ethnic populations. Keloid scarring is more prevalent in individuals of African, Asian, and Hispanic descent. The scarring alopecia CCCA is almost exclusively seen in patients of African descent. Therapeutic regimens such as intralesional corticosteroids, surgical excision, and laser therapy can be effective for these follicular and scarring disorders, but carry a risk of dyspigmentation and keloid scarring. Ethnic skin and hair may present unique challenges to the clinician, and knowledge of these differences is essential to providing quality care.

Prospective histologic examinations in patients who practice traumatic hairstyling

OBJECTIVES

Alopecia is the fifth most common dermatologic diagnosis in African-American patients. Central centrifugal cicatricial alopecia (CCCA) is the most common form of scarring alopecia in this group. This study sought to evaluate clinical and histologic findings in patients without clinical alopecia who use chemical and/or thermal straighteners to determine whether follicular damage is evidenced histologically.

METHODS

Eight African-American women with no clinical evidence of alopecia or scalp inflammation were included in the study. All participants had engaged in some form of traumatic hair care within the previous month. Participants submitted to clinical photography and 4-mm punch biopsy. Histologic examination was performed and the characteristics of each case recorded.

RESULTS

There were no clinical signs of alopecia or inflammation in any patient. Histopathology showed peri-infundibular lymphocytic inflammation in all patients and mild superficial perivascular lymphocytic inflammation in three. Concentric infundibular fibrosis was observed in each hair follicle in all specimens. One sample showed additional focal peri-isthmus fibrosis. There was no evidence of complete follicular dropout, follicular epithelial thinning, or premature desquamation of inner root sheaths. The mean number of hair follicles was 4.88 per 4-mm punch. Hair cycling was consistently within normal ranges.

CONCLUSIONS

Biopsy findings characteristic of CCCA suggest that a clinical prelude exists histologically. Further follow-up may provide a longitudinal timeframe for the potential progression, halting, or reversal of disease if hairstyling practices are, respectively, continued or discontinued. Central centrifugal cicatricial alopecia is likely to represent a common pathway of inflammation and scarring that can be instigated by traumatic hairstyling practices in genetically predisposed subjects.

The itchy scalp--scratching for an explanation

Scalp pruritus is a common complaint that is considered a diagnostically and therapeutically challenging situation. Scalp skin has a unique neural structure that contains densely innervated hair follicles and dermal vasculature. In spite of the recent advances in our understanding of itch pathophysiology, scalp itching has not been studied as yet. In this review, we summarize the current knowledge on the neurobiology of scalp and hair follicles as well as itch mediators and provide a putative mechanism for scalp itch with special emphasis on neuroanatomy and pathophysiology.

Hair care practices and their association with scalp and hair disorders in African American girls

BACKGROUND

Few studies have extensively examined the prevalence of hair care practices and their association with scalp and hair conditions in African American girls.

OBJECTIVES

We sought to determine the prevalence of hair care practices and their association with traction alopecia, seborrheic dermatitis (SD), and tinea capitis (TC).

METHODS

A questionnaire was administered to caregivers of African American girls aged 1 to 15 years. Multivariate analyses were performed to determine the association of hair care practices with reported disorders.

RESULTS

A total of 201 surveys were completed from dermatology (n = 98) and nondermatology (n = 103) clinics. Mean patient age was 9.8 ± 4.4 years. Essentially all respondents reported use of hair oils/grease (99%). Ponytails, braids, and cornrows were worn by 81%, 67%, and 49% of girls, respectively, within the past 12 months. In all, 61% reported hair washing every 2 weeks; 80% used hot combs; and 42% used chemical relaxers. Cornrows were significantly related to traction alopecia among respondents from nondermatology clinics only: adjusted odds ratio = 5.79 (95% CI 1.35-24.8, P = .018). Hair extensions and infrequent hair oil use were significantly related to SD: adjusted odds ratio = 2.37 (95% CI 1.03-5.47, P = .04) and 3.69 (95% CI 1.07-12.7, P = .039), respectively. No significant associations were observed for TC.

LIMITATIONS

Small sample size and disorders reported by caregivers were limitations.

CONCLUSIONS

Certain hair care practices were strongly associated with development of traction alopecia and SD. No association was found between hair washing frequency and SD or TC, or between hair grease use and TC. These results can be used to inform practitioners, advise parents, and adapt treatment regimens to accommodate cultural preferences.

Managing common dermatoses in skin of color

The demographics of the United States continue to evolve, with a growing proportion of the population consisting of non-Caucasian racial and ethnic groups. As darker skin types become more prevalent, so will the need to better understand their skin, the conditions that affect it, and optimal approaches for treatment. This population poses a special challenge for practitioners in part as a result of the sequelae often associated with the conditions in their own right - postinflammatory hyperpigmentation and scarring - and potential iatrogenic adverse effects that may occur during treatment. Through careful consideration of cultural, clinical, and therapeutic nuances, safe and effective management of common disorders in skin of color is achievable.

Hair loss: is there a relationship with hair care practices in Nigeria?

BACKGROUND Hair loss occurs in all ethnic populations, but the etiology varies considerably from group to group. In black women, many forms of alopecia are associated with hair care practices. However, the causes of alopecias in African women have not been extensively investigated. OBJECTIVE This descriptive, cross-sectional, hospital-based study was undertaken to document common complaints on initial presentation for hair loss, hair care practices and patterns of hair loss, and to determine if there is a relationship between hair loss and hair care practices. METHODS A total of 39 female patients seen over a 12 month period were enrolled in the study. Demographic information recorded included age, sex, marital status and occupation. Information regarding medical history included initial presenting complaints, duration of hair loss, site of hair loss, whether there was skin or systemic involvement, hair care practices and the duration of these practices. Examination of the scalp, a hair-pull test, documentation of the pattern of hair loss, relevant laboratory tests and biopsies were carried out. RESULTS All 39 patients were adults. Major complaints at initial presentation, apart from hair loss, included itchy scalp in 17 patients (43.6%), painful scalp in 11 patients (28.2%), hair breakage in seven patients (17.9%) and flaking scalp in four patients (10.3%). All the women relaxed their hair at some point in time. Chemical relaxants were consistently used by 22 patients (53.7%), eight patients (20.5%) alternated these with plaits/braids, and nine patients (23.1%) wore extensions. The use of local concoctions in hair care management was reported by three patients (7.7%). Scarred alopecias were observed in 20 patients (51.3%), while 19 (48.7%) had non-scarred alopecias. Those who reported prolonged and frequent use of chemical relaxants [mean duration (+/- standard deviation) 23.2+/-9.3 years] exhibited scarred alopecia more commonly than those who did not often use chemical relaxants (P<0.001). The application of local concoctions or pomades was also a regular practice amongst females with scarred alopecias. CONCLUSIONS Itchiness, pain, ready hair breakage and flaking scalp were common complaints at initial presentation. A range of alopecias were documented, and it was also observed that duration of hair care practice and hair styling were relevant to hair loss, particularly for women with central centifugal cicatricial alopecias (CCCAs), which resulted in scarring.