The unique qualities of African-American hair require special handling, says the co-author of a recent study showing that some African-American women avoid exercise due to hair care concerns.
A recent survey reveals a dichotomy between some hair care concerns of African-American patients and their overall health, says its author.
In the survey of 200 African-American women, 45 percent reported avoiding exercise at some point in the past due to hair care concerns, says study co-author Raechele Cochran Gathers, M.D., senior staff member in the Henry Ford Health System Department of Dermatology's Multicultural Dermatology Center.
"Much more troubling is that 22 percent of these women felt that their hair itself prevented them from maintaining a healthy weight.1 According to the Centers for Disease Control and Prevention, 50 percent of black women over age 20 are overweight or obese. This compares with 33 percent of white women and 43 percent of Hispanic women."
For women and men, says Dr. Gathers, "Hair is an important aspect of self-image. It can express wellness, youth and physical appeal. It helps define identity, ethnicity and sometimes even social status."
However, "In our study, we found that 59 percent of African-American women reported suffering a history of 'excessive hair loss,' usually shedding or breakage." In dermatology, she adds, alopecia has been found to be the fourth most common presenting complaint of African-Americans.
The impact of hair loss on quality of life has been shown to rival that of severe psoriasis.2 Also in this study, 40 percent of respondents expressed dissatisfaction with the way their current physician had managed their hair loss.
Physiologically, Dr. Gathers says that when viewed in cross-section, African textured hair is in elliptical rather than cylindrical like Asian and Caucasian hair types. (She uses the term African hair to designate the flat, spring-like type common to African-Americans and Africans who derive their heritage from sub-Saharan Africa.) Along with irregularities in diameter, "African-American hair has the greatest variability of phenotype among all ethnic groups. Among your African-American patients, you're likely to see a wide variety of hair textures, including wavy, curly, kinky, woolly or very tightly coiled, spring-like hair."
African hair has less tensile strength than Asian and Caucasian hair, says Dr. Gathers. "One thought is that that's very likely due to the many twists that occur in this hair type. African hair can have up to 12 times as many twists per centimeter as Caucasian hair." These twists can contribute to simple and complex knots that further undermine tensile strength, she adds. In one study, "The ends of African hair tended to be serrated or frayed, indicating a history of breakage."3 In contrast, she says that the ends of Asian and Caucasian hair generally appeared cleanly cut.
Tackling the Big 3
"When I approach African-American women with hair loss," says Dr. Gathers, "I refer to the big three. These are things I see every day: traction alopecia, chemical or traumatic alopecia and CCCA."
Traction hair loss usually appears in the temporal and parietal areas, "But I also commonly see it at the frontal scalp and occipital scalp, as well as the vertex. Usually it's due to prolonged tension from tight braiding or weaving." Traction hair loss also can stem from use of tight rollers, ponytail extensions and aggressive combing or relaxer application, she says. "When relaxers are applied, they're often pulled through with a very fine-toothed comb to straighten the edges. This can exacerbate traction alopecia."
Sometimes pruritus accompanies alopecia. More specifically, "One might see perifollicular erythema, hyperkeratosis and sometimes follicular pustules. It's very important to identify these patients and initiate some form of treatment regimen, because chronicity is associated with permanence. When caught early, traction alopecia can be treated."
In this regard, says Dr. Gathers, "It's important to discontinue traction-inducing hairstyles," and to educate patients about their dangers. Therapeutically, "We treat traction alopecia with a combination of intralesional (once monthly) and topical (once or twice daily) steroids. We also utilize doxycycline, then sometimes topical clindamycin for any pustular component. Also, we commonly prescribe off-label minoxidil, which is quite helpful." However, says Dr. Gathers, patients who straighten their hair might not comply with this part of the regimen due to minoxidil's liquid vehicle.
Regarding chemical or traumatic alopecia, she says, patients often present with the complaint that their hair won't grow. "It appears not to grow because of breakage. When you examine the hair, it has very uneven lengths. The ends are often thinned and transparent, and when you perform a tug test, the hair will fracture at the ends."
Causes of chemical and traumatic alopecia include relaxers, coloring, heat, traction and dryness. Accordingly, says Dr. Gathers, treatment begins with a chemical holiday - no relaxers for at least six to 12 months. "Heat avoidance would be best. However, in the real world, I tend to recommend heat application no more than once weekly, along with gently combing or finger combing the hair, and gradually cutting damaged hair as new, healthy hair grows out." She also recommends a weekly shampoo plus a moisturizing conditioner.
CCCA begins on the scalp vertex and extends centrifugally with time. "It's characterized by a shiny scalp and loss of the follicular openings. The etiology of CCCA is debatable. We believe it's likely due to traction secondary to braided or weaved hairstyles." Evidence also suggests that damage from chemical relaxers may play a role, as might a genetic link,4 she says.
Along with stopping the damaging hair care practices, "We treat CCCA with a combination of topical and intralesional corticosteroids," the latter typically for a six-month course. As with traction alopecia, "We also use doxycycline and off-label minoxidil."
Catching CCCA early and preventing its progression can be especially gratifying, says Dr. Gathers. "Look for those patients who are just beginning to present with itching and tenderness at the crown, and those who present with the chief complaint that hair won't grow at the crown." Additionally, one study suggests that that hair breakage presages CCCA. Researchers analyzed nine patients who presented with hair breakage and found that 63 percent of hair samples analyzed showed histological changes consistent with CCCA.5
Similarly, a study involving eight African-American women who had engaged in traumatic hair care practices within the previous month but had no evidence of alopecia or scalp inflammation showed changes consistent with CCCA on scalp biopsies.6 "This suggests there is a possible histologic prelude to our clinical acknowledgment of CCCA."
Finally, in an analysis of C nerve fibers in CCCA, researchers induced itch on the scalp of subjects with and without CCCA. "Investigators found a positive correlation between CCCA severity and peak itch ratings to cowhage, but not to histamine peak itch on the lesional scalp."7 Because cowhage induces itch and inflammation via protease-activated receptor (PAR)-2, says Dr. Gathers, "There may be a role for this receptor in the pathogenesis or treatment of CCCA."
Dr. Gathers reports no relevant financial interests.
1. Gathers RC, Mahan MG. African american women, hair care, and health barriers. J Clin Aesthet Dermatol. 2014;7(9):26-9.
2. Williamson D, Gonzalez M, Finlay AY. The effect of hair loss on quality of life. J Eur Acad Dermatol Venereol. 2001;15(2):137-9.
3. Khumalo NP, Doe PT, Dawber RP, Ferguson DJ. What is normal black African hair? A light and scanning electron-microscopic study. J Am Acad Dermatol. 2000;43(5 Pt 1):814-20.
4. Dlova NC, Jordaan FH, Sarig O, Sprecher E. Autosomal dominant inheritance of central centrifugal cicatricial alopecia in black South Africans. J Am Acad Dermatol. 2014;70(4):679-682.e1.
5. Callender VD, Wright DR, Davis EC, Sperling LC. Hair breakage as a presenting sign of early or occult central centrifugal cicatricial alopecia: clinicopathologic findings in 9 patients. Arch Dermatol. 2012;148(9):1047-52.
6. Uhlenhake EE, Mehregan DM. Prospective histologic examinations in patients who practice traumatic hairstyling. Int J Dermatol. 2013;52(12):1506-12.
7. Bin saif GA, Mcmichael A, Kwatra SG, Chan YH, Yosipovitch G. Central centrifugal cicatricial alopecia severity is associated with cowhage-induced itch. Br J Dermatol. 2013;168(2):253-6.