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Chemically induced cosmetic alopecia
Abstract
Cosmetic causes of scarring alopecia are poorly documented. They include traction alopecia and hot-combing. Recently, another group has presented in the South London area, related to misuse of chemical hair straightening agents. Affected patients are young, female, of Afro-Caribbean origin, and typically display hair loss on the vertex of the scalp. Histology shows a pattern of fibrosis and inflammation characteristic of the physical damage seen with other cosmetic procedures. This histological pattern is distinguishable from other non-cosmetic causes of scarring alopecia.
... Different histological and clinical manifestations of ATGinduced dermatitis were highlighted in the literature. Many TGA-related ACD patients showed chronic parafollicular inflammatory cellular infiltrate with fibrotic dermis on histology [34]. Furthermore, experimental studies demonstrated that sodium thioglycolate has led to epidermal hyperplasia, hyperkeratosis, ulceration, and thickening of the skin [22]. ...
... Several studies have delved into the intricate association between chemical hair treatments and their impact on both hair health and scalp condition, particularly focusing on the modulation of interleukin-alpha (IL-α) cytokine levels [34,36]. These studies have illuminated a complex interplay wherein certain chemical hair treatments may lead to an exacerbation of inflammation via the upregulation of IL-α cytokines [36]. ...
... These studies have illuminated a complex interplay wherein certain chemical hair treatments may lead to an exacerbation of inflammation via the upregulation of IL-α cytokines [36]. This increase in inflammatory signaling pathways can contribute to diverse adverse effects on the hair and scalp, ranging from heightened sensitivity and irritation to more severe conditions such as dermatitis or alopecia ( Figure 2) [34]. Specifically, the findings highlight that the use of strong alkaline compounds found in relaxers, notably those containing ATG, can trigger chemical burns, hair loss, and even severe conditions like chemical misuse-induced scarring alopecia and acute central centrifugal cicatricial alopecia (CCCA)-like scarring alopecia ( Figure 2) [36]. ...
Background
The side effects of two related chemicals, ammonium thioglycolate (ATG) and thioglycolic acid (TGA) have been widely highlighted in the world of cosmetics. These thioglycolate compounds are considered essential ingredients in a new technique known as brow lamination. This technique is widely used nowadays, with the aim of changing the eyebrow shape.
Aims
To our knowledge, this is the first study to address the possible side effects of brow lamination.
Results
The hydrophilic characteristic of ATG and TGA reflects their transdermal absorption through the intracellular and transappendageal pathways. These compounds can affect the skin through allergic contact dermatitis (ACD), characterized by skin irritation, dryness, and erythema. Moreover, these thioglycolates can alter several mechanical and chemical reactions in the eyebrows' hair, therefore affecting their shape, structure, and pigmentation. In addition, these chemicals contained in brow lamination can exert systemic manifestations, at the level of the reproductive, ocular, respiratory, and endocrine systems.
Conclusion
More studies should be elaborated to shed light on the possible side effects of this trend. Additionally, further regulations should be taken into consideration to ensure the concentration and the measures applied are convenient to minimize these side effects.
... Central Centrifugal Cicatricial Alopecia (CCCA), a chronic, progressive and inflammatory form of hair loss, seen more commonly in women of African descent and rarely in men (Sperling and Sau, 1992). It has been previously known as "follicular degeneration syndrome, " " hot comb alopecia," and chemically induced scarring alopecia (Sperling and Sau, 1992;LoPresti et al., 1968;Nicholson et al., 1993). The currently recognized term, CCCA, was later coined by the North American Hair Research Society (NAHRS) (Olsen et al., 2003). ...
... The true etiology of CCCA remains to be elucidated and is most likely multifactorial. Possible contributing factors include intense heat and traction to the scalp, the application of chemical relaxers, the intrinsically curly nature of African hair follicles and the decreased number of dermal elastic fibers in African hair compared with that of white individuals (Nicholson et al., 1993;Gathers et al., 2009;Nnoruka, 2005;Ackerman et al., 2000;Montagna and Carlisle, 1991). Genetics also appears to play a significant role, and an autosomal dominant inheritance pattern with partial penetrance has been proposed (Dlova and Forder, 2012;Dlova et al., 2014). ...
Skin of color comprises a diverse and expanding population of individuals. In particular, women of color represent an increasing subset of patients who frequently seek dermatologic care. Acne, melasma, and alopecia are among the most common skin disorders seen in this patient population. Understanding the differences in the basic science of skin and hair is imperative in addressing their unique needs. Despite the paucity of conclusive data on racial and ethnic differences in skin of color, certain biologic differences do exist, which affect the disease presentations of several cutaneous disorders in pigmented skin. While the overall pathogenesis and treatments for acne in women of color are similar to Caucasian men and women, individuals with darker skin types present more frequently with dyschromias from acne, which can be difficult to manage. Melasma is an acquired pigmentary disorder seen commonly in women with darker skin types and is strongly associated with ultraviolet (UV) radiation, genetic factors, and hormonal influences. Lastly, certain hair care practices and hairstyles are unique among women of African descent, which may contribute to specific types of hair loss seen in this population, such as traction alopecia, trichorrhexis nodosa and central centrifugal cicatricial alopecia (CCCA).
... Central Centrifugal Cicatricial Alopecia (CCCA), a chronic, progressive and inflammatory form of hair loss, seen more commonly in women of African descent and rarely in men (Sperling and Sau, 1992). It has been previously known as "follicular degeneration syndrome, " " hot comb alopecia," and chemically induced scarring alopecia (Sperling and Sau, 1992;LoPresti et al., 1968;Nicholson et al., 1993). The currently recognized term, CCCA, was later coined by the North American Hair Research Society (NAHRS) (Olsen et al., 2003). ...
... The true etiology of CCCA remains to be elucidated and is most likely multifactorial. Possible contributing factors include intense heat and traction to the scalp, the application of chemical relaxers, the intrinsically curly nature of African hair follicles and the decreased number of dermal elastic fibers in African hair compared with that of white individuals (Nicholson et al., 1993;Gathers et al., 2009;Nnoruka, 2005;Ackerman et al., 2000;Montagna and Carlisle, 1991). Genetics also appears to play a significant role, and an autosomal dominant inheritance pattern with partial penetrance has been proposed (Dlova and Forder, 2012;Dlova et al., 2014). ...
Skin of color comprises a diverse and expanding population of individuals. In particular, women of color represent an increasing subset of patients who frequently seek dermatologic care. Acne, melasma, and alopecia are among the most common skin disorders seen in this patient population. Understanding the differences in the basic science of skin and hair is imperative in addressing their unique needs. Despite the paucity of conclusive data on racial and ethnic differences in skin of color, certain biologic differences do exist, which affect the disease presentations of several cutaneous disorders in pigmented skin. While the overall pathogenesis and treatments for acne in women of color are similar to Caucasian men and women, individuals with darker skin types present more frequently with dyschromias from acne, which can be difficult to manage. Melasma is an acquired pigmentary disorder seen commonly in women with darker skin types and is strongly associated with ultraviolet (UV) radiation, genetic factors, and hormonal influences. Lastly, certain hair care practices and hairstyles are unique among women of African descent, which may contribute to specific types of hair loss seen in this population, such as traction alopecia, trichorrhexis nodosa and central centrifugal cicatricial alopecia (CCCA).
... Central centrifugal cicatricial alopecia (CCCA) (Fig. 2) is a primary lymphocytic cicatricial alopecia, affecting the crown and/or vertex. [43][44][45][46][47] The aetiology of CCCA remains unknown, although hair grooming practices have been implicated including the use of hot comb and chemical relaxers. 44,45,47 Recent data also links CCCA with the use of sewn-in weaves and artificial hair extensions. ...
... [43][44][45][46][47] The aetiology of CCCA remains unknown, although hair grooming practices have been implicated including the use of hot comb and chemical relaxers. 44,45,47 Recent data also links CCCA with the use of sewn-in weaves and artificial hair extensions. Dlova and co-workers have also recently demonstrated an autosomal dominant pattern of inheritance for CCCA, with hair grooming practices, such as use of chemical relaxers and traction-related hairstyles, affecting the expression of the disease. ...
The culturally engrained practice of 'relaxing' afro-textured hair has been linked with hair and scalp disorders. Herein, we discuss the evolution of human hair types, focusing in particular on afro-textured hair. We explore the biological features of this hair type, and discuss the different methods employed to straighten afro-textured hair, focusing in particular on chemical straightening. We also examine clinical, anthropological, and psychological issues associated with this latter practice. Examples of common scalp pathologies associated with chronic hair relaxing, such as alopecia, hair breakage, caustic burns and irritant contact dermatitis, are also highlighted. The data presented herein should enable clinicians to engage in culturally appropriate discussions with their patients about issues of appearance and conformity.
© 2015 European Academy of Dermatology and Venereology.
... Several of these practices have been implicated as risk factors for scalp and hair dermatoses. 3,4,[7][8][9][10][11][12][13][14][15] Prolonged tension on the hair root by certain hairstyles lead to TA, which can over time result in irreversible scarring alopecia. 16,17 Permanent chemical relaxers (straighteners), waves, and dyes may cause contact allergic or irritant dermatitis, chemical burns, scarring alopecia, and increased hair breakage. ...
... 16,17 Permanent chemical relaxers (straighteners), waves, and dyes may cause contact allergic or irritant dermatitis, chemical burns, scarring alopecia, and increased hair breakage. 9,[11][12][13][14] Sewn-in weaves and artificial hair extensions have been associated with central centrifugal cicatricial alopecia. 15 For other hair and scalp dermatoses, such as tinea capitis (TC), which has a high prevalence in African American children, 18,19 the role of hair care and styling practices is unclear. ...
Few studies have extensively examined the prevalence of hair care practices and their association with scalp and hair conditions in African American girls.
We sought to determine the prevalence of hair care practices and their association with traction alopecia, seborrheic dermatitis (SD), and tinea capitis (TC).
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.
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.
Small sample size and disorders reported by caregivers were limitations.
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.
... [4][5][6][7][8][9] Hair straightening (thermal or chemical), braiding (incorporation of synthetic hair with own hair), and weaving are other examples of styling techniques used by women of African descent, 4 which have also been associated with scalp concerns. 2,4,10,11 Weaving is the addition of articial or synthetic hair to one's own hair by sewing or plaiting. ...
Dandruff and scalp discomfort are common concerns for women and men in Africa. Moreover, women with afro‐textured hair are prone to scalp discomfort owing to irregular hair washing, frequent use of oil‐based products on their scalp, and harsh chemical treatments. Current literature does not, however, provide data on the pathophysiological mechanisms of these conditions in this population. In this study, we investigated the mechanisms behind scalp discomfort and dandruff in women of African descent before and after hair washing. We conducted the in Durban, South Africa, over a 3‐week period with 60 women of African descent aged 20–40 years. The respondents were equally divided into a “dandruff” and a “no dandruff” group, based on clinical grading of adherent dandruff by a dermatologist. Malassezia spp. and bacterial loads were quantified by quantitative polymerase chain reaction. Evaluations of scalp condition and sample collection were performed at five time points during the 3 weeks. Data on discomfort symptoms were collected via a self‐assessment questionnaire. We observed that the dandruff severity peaked at the end of the first week after hair washing and plateaued from thereon in both groups. Dandruff was associated with higher Malassezia and bacterial load counts and there was a direct correlation between the Malassezia spp. load and dandruff score. Via self‐assessment questionnaire responses submitted by participants, we observed that itching was the most pronounced scalp discomfort, compared with the sensation of tingling and burning at baseline, while an improvement of the scalp symptoms of dandruff and itch was observed in both groups after one hair wash. The study also showed that higher colonization with Malassezia spp. and bacteria is associated with dandruff independently of the time point, confirming a scalp microbiome contribution to the dandruff pathophysiology in the study population. The benefits of washing were, however, not sustained after 1 week and we thus recommend weekly hair washing for long‐term management of dandruff and scalp itchiness in this population.
... Nicholson et al. [4] point out to the possibility of a diffuse frontal-parietal affection, although they attribute it to possible concomitant traction alopecia (TA). In 2007, Khumalo's group reported cases of CCCA directly related to the use of hair relaxers, with involvement of vertex [5] and both sides of the scalp or with "patterned hair loss"; however, the absence of histopathological information did not allow for the rejection of androgenetic alopecia. ...
Central centrifugal cicatricial alopecia (CCCA) is included among the primary lymphocytic cicatricial alopecias. The current nomenclature of CCCA suggested by the North American Hair Research Society refers to the traditional clinical presentation pattern of this type of alopecia, which begins in the central area of the scalp and has a progressive and symmetric centrifuge evolution. However, some exceptions should be highlighted, and a new clinical variety of CCCA presenting with patches of hair loss affecting the lateral and posterior scalp has been recently described. Here, we report a new case of CCCA presenting with a patchy pattern. In addition to the fact that this new patchy presentation of CCCA is not contemplated in the current terminology, it has a difficult differential diagnosis with other alopecias that have patches as their presentation. In these cases, both the trichoscopy and the histopathology are indispensable for diagnosis that will allow a targeted treatment and avoid an unfortunate prognosis.
... [5,6] It has been proven that straighteners and dyes may cause allergic or irritant dermatitis, chemical burns, scarring alopecia, and increased hair breakage. [7][8][9] We found in our study that most of the Malay females do not employ any hairstyling techniques while most of the Indian and Chinese female did various hairstyling methods such as straightening and curling. These students also opined that hairstyling methods did worsen their hair condition to some extent. ...
Introduction: Scalp care is essential because it determines the health and condition of the hair
and prevents the diseases of scalp and hair. The objectives of our study were to correlate race
and hair types, to determine the awareness of hair care among Malaysian medical students,
and to distinguish the factors that affect the health of hair and scalp. Methodology: It was a
cross‑sectional study wherein validated questionnaires were given to 240 medical undergraduate
students who belonged to three ethnic races of Malaysia, i.e., Chinese, Malay, and Malaysian
Indians after their informed consent. The results were then analyzed using percentage statistics.
Results: Chinese students had comparatively healthier scalp without dandruff. Most Chinese
and Indians had silky type of hair while Malay had dry, rough hair. Chinese and Indians colored
their hair and used various styling methods; while among the Malays, this percentage was very
less. Regarding hair care practices, males used only shampoo and females used shampoo and
conditioner for hair wash. Students also faced dietary and examination‑related stress. Conclusion:
Results indicate that there exist morphological differences in hair among the studied population.
Since most students color their hair and employ various hairstyling methods, they should be
educated regarding best hair care practices to improve their scalp hair condition and health.
... LoPresti et al. 66 first described this disorder as 'hot comb alopecia' in 1968, owing to the initial incorrect association with the use of hot combs. Other names have also been used to describe this entity (chemically induced cosmetic alopecia by Nicholson et al. in 1993;67 follicular degeneration syndrome; 68 central centrifugal scarring alopecia by Sperling et al. in 2000), 69 and finally the term 'central centrifugal cicatricial alopecia' used by the North American Hair Research Society in 2001. 70 This is classified as a lymphocytic primary scarring alopecia that predominantly affects, but is not exclusive to women of African descent. ...
Introduction Pathogenesis Prevalence of hair and scalp disease Clinical assessment Clinical features and management of specific hair and scalp disorders Conclusions References
... This partly explains the great length to which uncombed virgin Afro hair (dreadlocks) grows. Relaxers also cause contact dermatitis and alopecia (10)(11)(12). Finally, the authors(1) make conclusions that are not substantiated by the data presented. ...
... LoPresti et al. 66 first described this disorder as 'hot comb alopecia' in 1968, owing to the initial incorrect association with the use of hot combs. Other names have also been used to describe this entity (chemically induced cosmetic alopecia by Nicholson et al. in 1993;67 follicular degeneration syndrome; 68 central centrifugal scarring alopecia by Sperling et al. in 2000), 69 and finally the term 'central centrifugal cicatricial alopecia' used by the North American Hair Research Society in 2001. 70 This is classified as a lymphocytic primary scarring alopecia that predominantly affects, but is not exclusive to women of African descent. ...
We present an overview of hair and scalp disorders in women of African descent, discussing the biological features of afro-textured hair, as well as hair-grooming practices in this cohort and their association with specific hair and scalp disorders. A practical approach to diagnosing and managing common hair and scalp disorders in this cohort is also presented.
... The severity of the adverse effects from this particular product prompted the Food and Drug Administration (FDA) to remove it from the market. 7 Nicholson et al. 8 documented chemically induced alopecia in young Afro Caribbean females related to the misuse of chemical hair straightening agents. They typically displayed hair loss in the vertex. ...
Background The use of chemical hair relaxers has found widesp read use in African Negroid women because of the desire to straighten their cur ly hair. The hair texture in Negroids is essentially coily and the process of straightening makes easier to comb and style. This beautification process, however, is not without its own hazards to the users. We document the adverse outcomes of this practice in a group of Nig erian Negroid women who had been exposed to repeated regular professional application of chemic al hair relaxers for a period of greater than one year. Patients and methods Women who were exposed to regular professional use of chemical hair relaxers for greater than one year were selected fr om hairdressing saloons with trained hairdressers in the city of study. Self-administered questionnai re was developed to elicit socio-demographic data, motivation for this practice, duration of exp osure and various self-reported side effects experienced. Exclusion criteria for respondents inc luded history of hair loss prior to initiating the chemicals, history of use of hair dyes, and history of previous scalp disease. Results Two hundred and fifty women were subjected to the questionnaire over a period of three months. Their ages ranged between 11-60years with a peak between 21-40years. Sixty two percent of the women were married. The duration of first ex posure was 1-20years with repeated application every two to three months. Reasons for the use of c hemical hair relaxers included beauty, social acceptability and ease of management of the relaxed hair. Major side effects were documented despite professional handling and these included it chy scalp, dandruff, burnt/scarred scalp, thinning and weakening of hair shaft, hair discolouration, h air loss, and allergic reactions to the chemicals. Conclusion The practice of hair straightening with chemical h air relaxers is still relevant and still has widespread use among Nigerian Negroid women for beauty and convenient hair management. The various self-reported side effects have health implications and might call for a greater emphasis on safer modes of application and stiffer market legislation concerning these chemicals.
... Chemical hair straightening, usually with sodium or guanidine hydroxide commonly called lye or no-lye 'relaxers', respectively, 13 is the hairstyle worn by at least two thirds of African females including children, in Cape Town 14,15 ; chemical hair straightening is also common in the diaspora. Allergic reactions, 16 suspected misuse, 17 and incorrect formulations 18 are associated with alopecia. However, data on the extent of damage, if any, with proper use of hair relaxers are lacking. ...
'Relaxers' are used by more than two thirds of African females to straighten hair, with easy grooming and increased length often cited as reasons. A recent study reported relaxed hair lengths much shorter than expected, suggesting increased fragility; the potential for scalp inflammation and scarring alopecia remains unclear.
To investigate the biochemical effects of 'relaxers' on hair.
With informed consent, included participants represented 3 groups: natural hair, asymptomatic relaxed hair, and symptomatic (brittle) relaxed hair. Biochemical analysis was performed by using a Biochrom 30 amino acid analyzer. Differences in amino acid levels were assessed using either Wilcoxon rank sum test or matched-pairs signed-rank test.
There was a decrease in cystine, citrulline, and arginine; however, an increase in glutamine was found in all relaxed compared to natural hair. Cystine levels (milligram per gram amino acid nitrogen) were similar in natural proximal and distal hair: 14 mg/g (range, 4-15 mg/g) versus 14 mg/g (range, 12-15 mg/g); P = .139. In asymptomatic relaxed hair, cystine levels were higher in less frequently relaxed samples proximal to scalp: 7.5 mg/g (5.6-12) versus 3.3 mg/g (1.3-9.2); P = .005. Cystine levels in distal asymptomatic relaxed and symptomatic relaxed hair were similar to each other and to those in the genetic hair fragility disease trichothiodystrophy.
It was not possible to analyze lye and no-lye 'relaxers' separately.
'Relaxers' are associated with reduced cystine consistent with fragile damaged hair. A decrease in citrulline and glutamine has been associated with inflammation; prospective studies are needed to investigate whether or how 'relaxers' induce inflammation.
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.
In this article, the author focuses on 4 common hair loss disorders that occur in both men and women. The author discusses research related to androgenetic alopecia, telogen effluvium, alopecia areata, and scarring alopecia and provides details on how to approach and manage these diseases according to patient gender. There are a range of tools and tests that can assist with the diagnostic process and help ensure that relevant and high standards of patient care are maintained. In some cases, no medical intervention is always a treatment option. However, appropriate medical treatments, although still relatively limited in some cases, are safe and have proven efficacy. Hair loss has immense emotional and psychological impact in both genders, and it is always important to consider this when planning hair loss management pathways.
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In this article, the author focuses on 4 common hair loss disorders that occur in both men and women. The author discusses research related to androgenetic alopecia, telogen effluvium, alopecia areata, and scarring alopecia and provides details on how to approach and manage these diseases according to patient gender. There are a range of tools and tests that can assist with the diagnostic process and help ensure that relevant and high standards of patient care are maintained. In some cases, no medical intervention is always a treatment option. However, appropriate medical treatments, although still relatively limited in some cases, are safe and have proven efficacy. Hair loss has immense emotional and psychological impact in both genders, and it is always important to consider this when planning hair loss management pathways.
Background
Central centrifugal cicatricial alopecia (CCCA) is the most common form of scarring alopecia among women of African ancestry. The disease is occasionally observed to affect women in families in a manner that suggests an autosomal dominant trait and usually manifests clinically after intense hair grooming. We sought to determine whether there exists a genetic basis of CCCA and, if so, what it is.
Methods
We used exome sequencing in a group of women with alopecia (discovery set), compared the results with those in a public repository, and applied other filtering criteria to identify candidate genes. We then performed direct sequencing to identify disease-associated DNA variations and RNA sequencing, protein modeling, immunofluorescence staining, immunoblotting, and an enzymatic assay to evaluate the consequences of potential etiologic mutations. We used a replication set that consisted of women with CCCA to confirm the data obtained with the discovery set.
Results
In the discovery set, which included 16 patients, we identified one splice site and three heterozygous missense mutations in PADI3 in 5 patients (31%). (The approximate prevalence of the disease is up to 5.6%.) PADI3 encodes peptidyl arginine deiminase, type III (PADI3), an enzyme that post-translationally modifies other proteins that are essential to hair-shaft formation. All three CCCA-associated missense mutations in PADI3 affect highly conserved residues and are predicted to be pathogenic; protein modeling suggests that they result in protein misfolding. These mutations were found to result in reduced PADI3 expression, abnormal intracellular localization of the protein, and decreased enzymatic activity — findings that support their pathogenicity. Immunofluorescence staining showed decreased expression of PADI3 in biopsy samples of scalp skin obtained from patients with CCCA. We then directly sequenced PADI3 in an additional 42 patients (replication set) and observed genetic variants in 9 of them. A post hoc analysis of the combined data sets showed that the prevalence of PADI3 mutation was higher among patients with CCCA than in a control cohort of women of African ancestry (P=0.002 by the chi-square test; P=0.006 by Fisher’s exact test; and after adjustment for relatedness of persons, P=0.03 and P=0.04, respectively).
Conclusions
Mutations in PADI3, which encodes a protein that is essential to proper hair-shaft formation, were associated with CCCA. (Funded by the Ram Family Foundation and others.)
Human hair has commonly been classified based on ethnic origin, with three conventional subgroups recognized, including Caucasian, Asian, and African hair (Franbourg et al. in J Am Acad Dermatol 48:S115–S119, 2003; McMichael in Dermatol Clin 21(4):629–644, 2003; Loussouarn et al. in Int J Dermatol 46:2–6, 2007). These ethnic subgroups have compositional and structural variations, as well as distinct hair-grooming practices (Rook in Br J Dermatol 92(5):599–600, 1975). Such broad classification does not account for the great complexity of human hair but provides a basic framework for description. These ethnic differences are important to comprehend the pathophysiology of scalp and hair disorders in the context of ethnicity.
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.
Der menschliche Haarfollikel ist ein komplexes Anhangsgebilde der Haut, das sich aus zahlreichen verschiedenen Zellpopulationen zusammensetzt. Während des Wachstumsprozesses folgt der menschliche Haarfollikel einem charakteristischen, lebenslang sich wiederholenden Wechselspiel zwischen 2–6 Jahre dauernder Wachstumsphase (Anagen), einer in wenigen Wochen ablaufenden Übergangsphase (Katagen) und einer 2–3 Monate anhaltenden Ruhephase (Telogen). Jeder einzelne Haarfollikel durchläuft diese 3 Phasen individuell, sodass das Haarwachstum aller Haarfollikel asynchron verläuft und beim Menschen einem nur noch gering zu bemerkenden Jahreszyklus unterliegt.
The International Society of Hair Restoration Surgery (ISHRS)’s practice census survey reports that in 2009 there were approximately 252,002 hair transplant surgeries worldwide, which include surgeons from the United States, Canada, Mexico/Central and South America, Europe, Asia, Australia, and Middle East. The majority of these procedures were performed in men (85%), and the numbers of racial or ethnic patients were not available. There are several surgical procedures available to treat hair loss in men and women. These include follicular unit transplantation (FUT), follicular unit extraction (FUE), scalp reduction, and scalp flaps. The latter two methods are not commonly performed and will not be discussed in this chapter.
• Group of largely uncommon disorders. • Result from primary destruction of the hair follicle, often affecting the scalp. • Cause and pathogenesis incompletely understood. • Clinical hallmark loss of follicular ostia. • Classified provisionally by primary inflammatory cell infiltrate. • Prompt intervention key to thwarting continued hair loss. • In general, formal, controlled studies on treatment are lacking.
This chapter outlines racial differences in the structure and function of the skin and how these relate to susceptibility and presentation of cutaneous disease. The chapter discusses diseases with a strong racial, ethnic or cultural predisposition and highlights common dermatoses in which the presentation may be distinct in different ethnic groups. Specific problems related to dyschromia in certain racial groups are presented
For the purpose of this chapter African hair refers to:
• tightly curly black hair
• ellipse or flat on cross-section
• spiral hair follicles by computer-aided three-dimensional reconstruction of biopsy samples
• asymmetric bulb differentiation on immunohistochemistry
• variable fragility with mechanical manipulation.
Hair loss in skin of color patients can vary from the very simplest of diagnoses to a unique diagnostic challenge requiring extensive knowledge of historical symptoms, haircare practices, and previous treatments. There are several disorders in the literature that are noted to be more common in patients of African descent as compared to Caucasian populations. These disorders include central centrifugal cicatricial alopecia, dissecting cellulitis, discoid lesions of lupus erythematosus, traction alopecia, seborrheic dermatitis, and hair breakage. While there is no definitive prevalence data for the various forms of hair loss in the skin of color population, it is clear that these disorders are a concern for many patients in this population along with common hair loss concerns, such as telogen effluvium and pattern hair loss. A careful detailed clinical examination, history, and potential histopathology will guide the clinician to appropriate management. Hair disorders in skin of color patients may present unique challenges to the clinician, and knowledge of accurate clinical presentation and treatment approaches is essential to providing quality care.
©2015 Frontline Medical Communications.
Increased shedding of hair and noticeable hair thinning or baldness (alopecia) are increasingly cited as side effects of exogenous chemicals/drugs. This chapter reviews some drugs implicated as well as mechanisms that may be responsible and describes criteria for defining the mechanism, and proposes animal and human assay models. This background provides the basis of similar judgment as relates to percutaneous penetration (and inhalation) of chemicals at the work site. Hair anatomy: A hair represents complete maturation of follicular matrical cells and is a fully cornified structure that emanates from a follicle and extends above the surface of the skin from varying distances. It has three components: an outer cuticle, a cortex, and an inner medulla. Hair grows in three phases: (1) growing or anagen, (2) involution or catagen, (3) resting or telogen. Nonchemical-related hair loss: Few endogenous events affecting hair growth are delineated. Extreme starvation or protein deprivation may result in formation of sparse or brittle hair through diminished mitotic activity. Also major systemic insult, such as high fever, major surgery, illness, or trauma may result in hair follicles being thrown into an untimely telogen effluvium. Anagen versus telogen hair loss: Chemicals or medications may either cause excessive hair shedding by precipitating telogen development, directly poison the anagen root, or work in other undetermined ways. The phase of hair loss may be determined by examining the shed or easily plucked hair. Proving that alopecia in an individual is caused by a chemical/drug may be difficult; the most conclusive demonstration of chemical/drug-related hair loss is reproduction of hair loss with repeated administration of the putative materials. However, the pathobiology of the response of the human hair follicle to chemotherapy is largely unknown. Hair loss is discussed in detail. Among the subjects of discussion are types of hair loss (e.g., anagen, medications precipitating telogen), chemicals causing hair loss (e.g., antimitotic agents, phenyl glycidyl ether), medications causing hair loss of unknown type (e.g., antithyroid drugs), medications possibly associated with hair loss, as well as chemically induced cosmetic alopecia, and typical scenarios in alleged occupational hair loss.
The hair cosmetic industry has undergone a revolutionary change over the last two decades. The focus has dramatically veered from merely cleaning to repair, increasing the tensile strength, reducing oxidative damage, and stimulating growth. Newer shorter procedures to make hair look naturally more lustrous, smooth, and manageable have evolved. Specialized grooming products have been formulated to cleanse, calm, and condition the hair, and are tailored for different hair-types, for example, dry, dry-damaged, oily, colored, and gray hair. Other products are formulated to alter the color or structure of the hair shaft, for example, hair dyes, perming/relaxing. Hair sprays and waxes/gels, can alter the 'lift' of the hair-shaft. Although dermatologists are experts in managing scalp and hair diseases, the esthetic applications of newer cosmetic therapies still remain elusive. This article attempts to fill the lacunae in our knowledge of hair cosmetics and esthetic procedures relevant in today's rapidly changing beauty-enhancing industry, with special emphasis on the Indian scenario for chemical and 'natural' hair products.
Zusammenfassung: Eine mikroskopische Untersuchung der Haare kann die Ursache des Haarausfalls aus einer Vielfalt von möglichen Diagnosen klären. Die meisten dieser Ursachen hängen mit dem Abbrechen der Haare zusammen, die übrigen stehen in Beziehung zu Wachstumsstörungen. Haare können aufgrund von exzessiven Traumata oder einer besonderen Empfindlichkeit, z. B. durch strukturelle Anomalien, abbrechen. Ein Fehlen des Wachstums spiegelt die follikuläre Dynamik wider und stellt den zentralen Mechanismus der häufigsten Ursachen einer Alopezie dar. Unter solchen Bedingungen erlaubt die Mikroskopie lediglich die unspezifische Bestätigung einer verkürzten Anagenphase. Auch wenn dies für die klinische Diagnose hilfreich sein kann, bietet die Mikroskopie bei einer Alopezie nur den Ausschluss verschiedener Diagnosen im Zusammenhang mit Haarbruch.Verlässliche Ergebnisse der Haarmikroskopie sind vom Umfang der entnommenen Haarprobe, der Haarlänge, den zu beurteilenden Merkmalen und der Erfahrung des Untersuchers abhängig.
Summary: Hair microscopy can clarify the cause of hair loss in a range of diagnoses. Most of these are associated with hair breakage, the rest are related to lack of growth. Hair breakage may be due to excessive trauma or underlying susceptibility, where structural clues may be present. Lack of growth reflects follicular dynamics and represents the central mechanism of most common causes of alopecia. In such conditions, microscopy only reveals non-specific confirmation of short anagen. Although this may assist clinical diagnosis, microscopy in alopecia only allows exclusion of diagnoses related to hair breakage.Confidence in the outcome of hair microscopy is based on the size of the sample of hairs, the length of the hair, the characteristics of the observations and the experience of the person undertaking the microscopy.
Physicians should be prepared to provide professional guidance to black individuals with both chemically treated and natural (ie, nonchemically treated) hair. Patients may seek advice from physicians if they decide to discontinue use of chemical relaxers or if they have sustained damage such as chemical burns, breakage, or hair loss from the misuse of various hair care products. Properly advising this patient population requires a basic understanding of hair morphology in black individuals as well as the unique characteristics of this hair type and the products used to address its needs. Although some products may promote healing properties, misusing or overusing them may cause adverse effects. This article will provide clinicians with a basic understanding of chemically treated and natural hair in black individuals. We also discuss hair care products that are ideal for this patient population and the potential adverse effects based on their chemical formulations.
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.
Itch is a common sensation and a component of numerous disease states. Itch can be classified according to its origin and may be modulated by both endogenous and exogenous factors. The purpose of this chapter is to classify the common causes of exogenous itch in humans. These factors were classified into mechanical, chemical, and environmental components. A better understanding of the various mechanisms of pruritus is critical to effective research into the treatment of itch.
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.
Zusammenfassung: Viele Verbraucher machen bei Haarausfall verschiedene kosmetische Haarpflegeprodukte dafür verantwortlich. Doch wird weltweit von einem Großteil der Menschen eine Vielfalt kosmetischer Produkte regelmäßig, oft sogar täglich, angewendet, ohne irgendwelche unerwünschten Kurzzeit- oder Langzeitwirkungen. So kann man, ausgehend von einer Fülle von Daten aus kommerziellen Archiven und der großen Menge der Verbraucher, letztlich schließen, dass kosmetische Haarpflegeprodukte bei sachgemäßer Anwendung keinen Haarausfall verursachen können.
Summary: Cosmetic hair care products are often implicated by the user in cases of hair loss. However, a large variety of cosmetic products are used on a regular and often daily basis by most of the world's population without any short or long term adverse effects. Therefore, based on the plethora of data particularly within commercial archives and the huge consumer exposure, one can conclude that when used correctly, cosmetic hair care products do not cause hair loss.
This discussion contributes to emergent literature on teacher biographies and on the schooling of black girls. The author examines some childhood experiences of a contemporary woman African-Caribbean Canadian teacher, Ese, who grew up in England. The author traces the development of Ese's present consciousness by examining how her experiences of marginality at the intersections of her race, gender, and class have informed her current practice in predominantly African Canadian, low-income settings in southern Ontario. The data are drawn from a larger ethnographic study on black women teachers' lives and practices. Based on her findings, the author concludes with a discussion of future research agendas for young black girls.
Central centrifugal cicatricial alopecia (CCCA) is an inflammatory form of hair loss seen more commonly in women of African descent. It has been referred to as “hot comb alopecia, ”¹ chemically induced scarring alopecia,² and follicular degeneration syndrome,³ but the term CCCA was later coined by the North American Hair Research Society (NAHRS).⁴ This form of primary scarring alopecia occurs mainly on the vertex of the scalp, spreads peripherally, and produces permanent destruction of the pilosebaceous unit. Treatment is focused on halting the progression of disease and typically consists of topical and intralesional corticosteroid therapy and antibiotics such as doxycycline.⁵ In stable disease, hair transplantation in some cases has shown promise, although graft survival is low, and regrowth of the transplanted hair is slow.⁶,7 To our knowledge, there currently are no evidence-based published studies on therapeutic outcome in patients with CCCA, and further investigation is definitely needed.
Few studies have investigated central centrifugal cicatricial alopecia (CCCA). Thus, our understanding of CCCA is largely based on anecdotal evidence.
The purpose of this study was to investigate clinical characteristics and hair care practices in CCCA patients.
We conducted a single-center retrospective chart review of patients with a clinicopathologic diagnosis of CCCA.
Medical records of 69 patients were reviewed. Of these, 97% were female. The mean ages at onset and presentation were 38.2 and 42.4 years, respectively. All subjects for whom hair care data were available had used a traumatic practice at least once, the most common being chemical relaxer. Family history data were available for 27 subjects (39%). Of these, 56% had a positive family history of hair loss. Seborrheic dermatitis was the leading concurrent diagnosis.
Limitations include lack of a control group, retrospective design, and selection bias.
Our results confirm that CCCA primarily affects adult women of African descent. The majority of patients presented several years after onset, suggesting that efforts to encourage earlier diagnosis are warranted. Although the role of hair care remains unclear, traumatic practices were reported in all patients in our study for whom hair care was documented.
Traumatic hair loss is a scalp injury that can cause secondary scarring alopecia. It can result from different types of physical and chemical injury. Hair loss induced by certain hair-styling techniques has been discussed, but we describe a preceding ulcerative process. We describe 3 black adolescent girls with hairpin-induced alopecia that started with an ulcer and ended with a scar. We also review the dermatologic literature.
Cicatricial or scarring alopecia results in the destruction of hair follicles and is a significant cosmetic concern in African-American women.
To correlate the clinical examination and histologic findings in African-American women with scarring alopecia with a history of hairstyling practices.
We reviewed retrospectively the medical records and scalp biopsy specimens of 54 women with scarring alopecia. Patients were selected from two dermatologic practices in the Detroit Metropolitan area.
Alopecia commonly presents in patients who use a variety of traumatic haircare techniques, including chemical and physical straighteners, traction, braiding, hair extensions, hair gluing, and chemical curls. Histologic findings are centered around the follicular infundibulum with a lymphocytic infiltrate and perifollicular fibrosis.
Traumatic hairstyling techniques are common in African-American women, and all result in a similar picture of a peri-infundibular lymphocytic infiltrate and fibrosis, leading to alopecia.
Clinical scarring alopecia in African American women has been recognized for years. The classification of this unique form of alopecia dates back to Lopresti, who first described the entity called "hot comb alopecia." More recently, the term "central centrifugal cicatricial alopecia" has been adopted to describe a progressive vertex-centered alopecia most common in women of African descent. While this form of hair loss is widely recognized, and may even be on the rise, the causes of central centrifugal cicatricial alopecia are a constant source of debate and remain to be elucidated. This review outlines the descriptive evolution of central centrifugal cicatricial alopecia and the historical controversies ascribed to its pathoetiology; it also examines African hair structure and discusses how hair structure along with common physical and chemical implements utilized by individuals with African hair type may play a causal role in the development of central centrifugal cicatricial alopecia.
• Background.—
The history, physical examination, and histologic findings in 10 black women with a common, distinctive form of scarring alopecia (formerly called hot comb alopecia) were retrospectively studied. A detailed history of hair care habits was obtained, and scalp biopsy specimens were examined after both vertical and transverse sectioning.
Observations.—
Poor correlation is noted between the usage of a hot comb and the onset or progression of disease. The earliest observable histologic abnormality is the premature desquamation of the inner root sheath. In severely affected follicles this is followed by a chain of histologic events leading to complete follicular degeneration.
Conclusions.—
The term follicular degeneration syndrome (FDS) is proposed for this clinically and histologically distinct form of scarring alopecia. Historical information is incompatible with the hypothesis that hot comb usage causes the alopecia. It remains unclear whether the use of any of a variety of hair care products and techniques plays a role in the pathogenesis of this condition. Premature desquamation of the inner root sheath serves as a histologic marker for FDS follicular degeneration syndrome, and may be an important pathogenetic factor.(Arch Dermatol. 1992;128:68-74)
An irreversible alopecia of the scalp occurs in Negro women who straighten their hair with hot combs. The disease is common and distinctive, clinically and histopathologically. The hair loss is incomplete and strictly limited to the crown. The follicles between the surviving hairs are completely obliterated.
The hot petrolatum used with the iron causes a chronic inflammation around the upper segment of the hair follicle leading to degeneration of the external root sheath. Ultimately, the entire follicle is destroyed and replaced with a band of dense collagen, a follicular scar.
The clinical importance of weathering has been greatly increased by the recent popularity of wearing the hair long. An important factor in the weathering process is exposure to sunlight, which causes some degradation of hair keratins and a loss of tensile strength. The degree of damage correlates with the total radiation received, rather than with the character of this radiation. Normal hair, if it is long, may be damaged sufficiently by the combination of cosmetic procedures even when properly applied, and natural weathering, for it is to show such defects as 'split ends' and 'brittleness' and 'dryness', for which the patient may seek medical advice. In such cases segments of hair near the scalp and segments cut from the tips should be examined microscopically; even the light microscope shows distinctive changes. Congenitally abnormal hair tends to show even greater susceptibility to weathering and to cosmetic trauma. The reduction of hairdressing trauma of all kinds and the avoidance of unnecessary sun exposure may allow the hair to grow to a cosmetically more acceptable length in patients to whom the dermatologist can at present offer nothing other than this advice.
The history, physical examination, and histologic findings in 10 black women with a common, distinctive form of scarring alopecia (formerly called hot comb alopecia) were retrospectively studied. A detailed history of hair care habits was obtained, and scalp biopsy specimens were examined after both vertical and transverse sectioning.
Poor correlation is noted between the usage of a hot comb and the onset or progression of disease. The earliest observable histologic abnormality is the premature desquamation of the inner root sheath. In severely affected follicles this is followed by a chain of histologic events leading to complete follicular degeneration.
The term follicular degeneration syndrome (FDS) is proposed for this clinically and histologically distinct form of scarring alopecia. Historical information is incompatible with the hypothesis that hot comb usage causes the alopecia. It remains unclear whether the use of any of a variety of hair care products and techniques plays a role in the pathogenesis of this condition. Premature desquamation of the inner root sheath serves as a histologic marker for FDS follicular degeneration syndrome, and may be an important pathogenetic factor.
A 21-year-old man presented with an erythematous pruritic plaque on the right parietal scalp of 2 years'evolution. Physical examination disclosed multiple bundles of hairs emerging from single dilated follicular openings. The disorder followed a relapsing and progressive course, in spite of several topical and systemic treatments. New tufts of hairs appeared in previously non-involved areas only after inflammatory changes occurred. The clinicopathological features, aetiological mechanisms and management of tufted-hair folliculitis are discussed.
Tufted-hair folliculitis (THF) is a localized, inflammatory and exudative disease of the scalp characterized by a tutted appearance of the scalp hair, that may result in permanent and irreversible scarring alopecia.
This condition was initially described by Smith and Sanderson1 in 1978 who coined the term THF to illustrate the phenomenon of multiple hairs emerging from single follicular openings. Only nine additional cases of THF have been reported elsewhere2-5. We present herein a patient with recurrent and progressive THF resistant to several therapeutic strategies.
This report reviews the results of scalp biopsies in 66 (38%) of 174 patients with trichotillomania seen at the Mayo Clinic from 1978 through 1988. The most important findings included catagen hairs in 74%, pigment casts in 61%, and traumatized hair bulbs in 21%. Bulbar inflammation and atrophic anagen hairs were not seen. The most characteristic features most often were noted in specimens from areas that had been affected for usually less than 8 weeks. It is important to examine many sections stained with hematoxylin and eosin because only a few sections may show the characteristic changes. The study points out the usefulness of scalp biopsy for making or excluding a diagnosis of trichotillomania.