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Citation: Asbeck, S.; Riley-Prescott,
C.; Glaser, E.; Tosti, A. Afro-Ethnic
Hairstyling Trends, Risks, and
Recommendations. Cosmetics 2022,9,
17. https://doi.org/10.3390/
cosmetics9010017
Academic Editor: Enzo Berardesca
Received: 12 December 2021
Accepted: 19 January 2022
Published: 26 January 2022
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cosmetics
Review
Afro-Ethnic Hairstyling Trends, Risks, and Recommendations
Sara Asbeck *, Chelsi Riley-Prescott, Ella Glaser and Antonella Tosti
Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami Hospital,
University of Miami, Miami, FL 33125, USA; car365@med.miami.edu (C.R.-P.); ella.glaser@jhsmiami.org (E.G.);
ATosti@med.miami.edu (A.T.)
*Correspondence: smp268@med.miami.edu
Abstract:
Hairstyling trends among Black women fluctuate with social, cultural, and environmental
pressures. Dermatologists should be aware of current trends and their associated risks in order to
provide the best care to this population. In order to summarize the updated trends and associated
health risks for the most common hairstyles worn by Black women, a literature review was performed.
PubMed and EMBASE were used to identify articles related to hair styling practices, studies on the
effects or risks of various styling practices, and magazine articles citing current styling trends among
women of African descent. All hairstyles were found to have associated health risks; however, natural
styles had the fewest adverse associations of all styles reviewed. Central Centrifugal Cicatricial
Alopecia (CCCA) is the most cited hair disorder in this population, possibly linked to both chemical
relaxants and traction styles. Additional studies are needed to further establish causality between
these styles and CCCA. Additionally, while acceptance of natural hairstyles is on the rise, there is
more work to be done throughout society to help protect and encourage women who choose to
wear Afrocentric styles. Dermatologists should be well versed in these hairstyles and ready to lend
appropriate advice to patients when it is requested.
Keywords:
hairstyle trends; African-ethnic hair; Afrocentric hair; chemical hair relaxing; central
Centrifugal cicatricial alopecia; traction alopecia
1. Introduction
Hair is an essential part of a person’s identity, self-perception, and can be a way they
communicate with those around them. It can reflect not only someone’s health but their
sense of style, and can be changed often and easily to portray an individual’s changing
attitudes and trends. Hairstyles among women of African descent, thus, vary considerably
by country, region, occupation, generation, and personal style. Today, the Black hair care
industry is a half-trillion-dollar industry. In fact, Black women spend more on their hair
than any other ethnic group [
1
]. Social and environmental pressures continue to influence
what society views as beautiful and culturally acceptable. There has been substantial
debate and discussion regarding the association between certain hairstyles worn by Black
women and their connection to hair disorders and other health conditions common to this
population. Given the underrepresentation of Black dermatologists in clinical practice,
it is crucial to remain up to date on current trends in this community and consider how
they may be influencing and/or potentially harming patients’ dermatological as well as
overall health. In this educational literature review we aim to identify and summarize
the current trends, potential risks, and updated recommendations for the most commonly
cited hairstyles worn by women with Afro-ethnic hair. We hope to investigate and clarify
the associations between these styles and the hair and health conditions common to this
population, drawing connections between the various studies included in the review. The
results will be organized by subsection according to the hairstyle being discussed.
Cosmetics 2022,9, 17. https://doi.org/10.3390/cosmetics9010017 https://www.mdpi.com/journal/cosmetics
Cosmetics 2022,9, 17 2 of 11
2. Methods
A total of 59 articles and case reports pertaining to Black or Afro-ethnic hairstyles were
included in this literature review. Articles were collected primarily through PubMed and
EMBASE databases using the following key words: Black hair, Afrocentric hair, ethnic hair,
Afro-ethnic hair, Afro-textured hair, African-American hair, African-American hairstyles,
hairstyle trends, chemical hair relaxing, hair straightening, hair braids, cornrows, dread-
locks, protective hairstyles, and hair weave. Inclusion criteria for this review: (1) Studies or
reports related to hair styling practices in women of African descent, (2) studies or reports
on the effects/implications/risks of various hair styling practices in Afro-textured hair,
(3) magazine articles citing current styling trends among women of African descent, and
(4) articles in English or translated to English. Articles on the pediatric population, or not
explicitly relevant to the topic of study were excluded.
3. Results
3.1. Chemically “Relaxed” Hair
3.1.1. Introduction
Since the advent of chemical hair relaxers in the 1940s, the trend among women of
African descent to achieve long, straight, socially desirable hairstyles has fluctuated, but
nonetheless remained very popular. In studies discussing hair relaxer use among African-
American women, prevalence of those who endorsed having ever using relaxers ranged
from 71% in a group of 1693 African-American women from Detroit [
2
], to 95% in the
Black Women’s Health Study, a prospective cohort of 59,000 self-identified Black American
women [
3
]. Reasons cited for the use of relaxers include increased hair manageability [
4
],
decreased work of combing [5], and improved self-esteem [6].
Hair relaxing or “perming” has generally been viewed as a way for Black women to
assimilate into Eurocentric standards of beauty and professionalism. In fact, relaxer use
is highest in the Southern states, a region where, historically, resistance to de-segregation
and discrimination against Black individuals was very widespread [
7
]. Many women here
may have felt increased social pressures to blend in and de-emphasize their African traits.
A trend toward more natural or “Afrocentric” hairstyles briefly re-appeared in the late
1960s and 1970s, during the historic Black Power movement, when women who wore
their natural hair texture were seen as a making a radical political statement [
8
]. This
movement was short lived, however, and popular movies and television shows throughout
the decades have continued to perpetuate the idea that Black hair is more beautiful when
chemically altered by predominantly casting Black women with long, flowing, straight
hair [
9
]. Additionally, in many professional contexts, having Afro-textured hair is associ-
ated with negative stereotypes and lower expectations, with Eurocentric hairstyles more
frequently adopted in the workplace in order to facilitate social acceptance [6].
Despite these social pressures, the use of relaxers has been on a general decline over
the past decade, as the wearing of natural hair has become more acceptable, and many have
begun to realize the harmful side effects that frequent chemical exposure may cause [
7
].
In fact, consumer studies have demonstrated that between 2008 and 2012, the market for
hair relaxers declined by twenty percent [
10
]. There have been small pockets of resistance
to the modern natural hair movement, with Black women who tried to “go natural,” only
to find the process confusing and extremely time consuming [
11
]. Understandably, since
many women have worn relaxed hair for the majority of their lives, they may find natural
curly hair difficult to manage as they are not used to the hairstyling process and perhaps
the additional time and products needed to be able to style and maintain their curls [
8
].
Still, there is a general trend toward less hair relaxer use, and more natural or “protective”
hairstyles, as will be discussed in the subsequent pages.
3.1.2. Associated Risks
Permanent straightening of Afro-textured hair can only be accomplished through the
breaking and rearranging of disulfide bonds in the hair shaft [
12
]. The original method of
Cosmetics 2022,9, 17 3 of 11
hair relaxing, also called lanthionization, involved ingredients such as sodium hydroxide
or potassium hydroxide mixed with potato starch [
12
]. Modern curl relaxers can be divided
into lye and no-lye formulations, with lye relaxers most common in professional hair salons,
and no-lye more popular for at-home use [
13
]. Lye-based relaxers are found to penetrate
the hair shaft more quickly, resulting in rapid straightening and reduced susceptibility to
scalp dryness and irritation than the no-lye relaxers [
12
]. The most frequently cited risks
associated with the use of hair relaxers included hair damage, skin irritation, carcinogen
exposure, endocrine-disrupting chemical exposure, hair loss, and lack of exercise-friendly
hairstyle options.
The chemicals used during lanthionization are extremely alkaline. Not only does this
pose a risk for chemical skin burns, but when left on the hair too long, relaxers begin to
digest the hair itself [
14
]. Additionally, relaxer use results in a decreased sulfur content of
the hair, which can lead to weakening, increased fragility, hair breakage, and thinning [
15
].
In a study of 715 African-American women aged 18 and over, 90% of women experiencing
hair breakage reported using chemical treatments. Of the women who did not report
breakage, they endorsed having a less involved grooming process with fewer products,
fewer appliances, and longer intervals between straightening treatments, if used at all [
16
].
The potentially carcinogenic nature of hair relaxers is still being researched, but there
have been several studies demonstrating an association between regular use of hair relaxers
and tumorigenesis. Numerous chemicals present in hair relaxer formulations have been
found to be carcinogenic in animal studies [
10
] and are hypothesized to increase cancer
risk via exposure to hormonally active or endocrine-disrupting chemicals through dermal
absorption [
3
]. Use of relaxers and hair oils have been associated with early menarche, a
risk factor for breast cancer [
3
], and duration of relaxer use was positively associated with
risk of uterine leiomyomata, also known as fibroids, another hormone-dependent disease
process [
17
]. In a large case study of 2998 women with breast cancer, overall duration of
relaxer use > 10 years and use of relaxers before age 12 was significantly associated with
larger tumor size [
18
]. Another study found little evidence to support an association of
overall hair relaxer use with risk of breast cancer but did find an association of heavy use
of lye-based relaxers with increased risk of ER+ breast cancer [3].
When women with chemically relaxed hair complain of “hair loss,” they are most
often describing hair breakage resulting from overprocessed and brittle hair strands [
12
].
There is, however, substantial debate as to the role chemical hair relaxers play in the disease
processes of hair loss disorders such as Central Centrifugal Cicatricial Alopecia (CCCA),
the most common type of scarring alopecia in this population [
19
]. This type of alopecia,
formerly known as “hot comb alopecia,” begins at the crown and vertex, and progresses
centrifugally, leaving behind a shiny smooth scalp with follicular dropout [
19
]. Although
the relationship between chemical relaxers and CCCA is uncertain, several case studies
have been published linking the two together.
A study on 1018 patients presenting to an alopecia clinic demonstrated that patients
with cicatricial alopecia were significantly more likely to report any previous chemical
hair straightening than patients with non-cicatricial alopecia, and that patients with CCCA
reported a significantly higher cumulative exposure to chemical straightening than con-
trols [
20
]. In a prospective study by Uhlenhake et al. [
19
], biopsies were examined from
subjects at random without clinical evidence of alopecia, but who reported use of either
chemical relaxants or thermal straighteners within the past month. Interestingly, peri-
infundibular lymphocytic inflammation and concentric infundibular fibrosis, some of the
histopathologic findings characteristic of, but not necessarily unique to CCCA, were found
in all biopsies [
19
]. These data suggest that there may be a histological prelude to the
clinical signs of CCCA and lends plausibility to the association between relaxer use and
scarring alopecia. It is also important to note that some studies found no association be-
tween relaxer use and CCCA [
21
], or a weak, but statistically insignificant association [
22
],
further suggesting that more studies are needed to elucidate the true relationship between
the two.
Cosmetics 2022,9, 17 4 of 11
Another less commonly discussed relationship, but one that has profound health im-
plications, is the exercise-prohibitive nature of chemically relaxed hairstyles. An estimated
80% of African-American women are overweight or obese, so the avoidance of exercise due
to one’s hairstyle could be a notable public health challenge [23]. In a study on 61 women
of self-reported African, Afro-Caribbean, or African-American race, 18% of women stated
that they exercised less than they would like because of their hair, for fear of “sweating
out” hairstyles, and due to the time needed to restyle hair [
24
]. Another study, this time on
1558 self-identified African-American women from Detroit, MI, found that in adulthood,
women who used chemical relaxers at least two times per year were 10% less likely to
report intense physical activity compared to their counterparts reporting rarely/never
use [
25
], suggesting this may be implicated as a contributor to the poor cardiometabolic
health outcomes among Black/African-American women.
3.1.3. Recommendations
Several recommendations have been proposed in response to the research conducted
on chemically relaxed hair to ensure the process is carried out in the safest and least dam-
aging way possible. It is important for dermatologists and other health care providers to
be knowledgeable of these recommendations in order to best advise their patients. First
off, relaxers are best applied by experienced professionals with training in the appropriate
application method and processing time [
26
]. The condition of the client’s hair and scalp
should be evaluated prior to application, and if the scalp is in any way compromised,
relaxer use should be avoided, even if a base is used [
15
]. Thin and/or porous hair process
faster and, therefore, relaxer should be left on for as little time necessary to achieve the
desired results [
15
]. Careful application to the new growth only and deep conditioning
treatments can help prevent breakage [
27
]. Advice for how frequently to relax hair var-
ied from every six to eight weeks [
6
] to eight to 12 weeks [
28
], with the general theme
being that if treatments are applied too frequently, the risk of hair damage and break-
age is increased. Following hair relaxation, high-tension styles [
29
], as well as excessive
combing or styling [
12
] should be avoided to prevent traction alopecia (TA) and excessive
breakage, respectively. TA will be discussed more in depth in the section titled “Traction
Hairstyles” below.
3.2. Keratin Treatment
3.2.1. Introduction
The Brazilian Keratin Treatments (BKTs) are a newer hair straightening method that
has recently gained popularity due to its ability to straighten the hair with additional claims
of decreasing frizz and increasing shine for up to five months [
30
]. The technique began in
Brazil and involves applying a formaldehyde or formaldehyde-releasing solution to the
hair, followed by blow drying and flat ironing to seal the straightened hair appearance [
23
].
The formaldehyde is necessary for the synthetic hydrolyzed keratin to properly cross-link
and adhere to the natural keratin in the hair shaft [
31
]. Manufacturers claim that it can be
safely used on chemically relaxed, highlighted, and color-treated hair [23].
This semi-permanent treatment is increasingly being used as an alternative to tradi-
tional chemical relaxers [
6
], and is attractive to women of African descent, as it makes
naturally curly hair more manageable and frizz-free for several months at a time [30]. For
many Black women, it is touted as a good option when transitioning from relaxed to natural
hair, as it offers a way to camouflage new growth until the relaxed hair grows out [
32
].
However, as this is a relatively new hair treatment, there are very little published data on
the overall popularity and frequency of use of BKTs among African-American women.
3.2.2. Associated Risks
Although, on the surface, Brazilian Keratin Treatments appear to be a safer alternative
to chemical hair relaxing, they are not without risk. Perhaps the most concerning charac-
teristic of BK treatments is their relatively high concentration of formaldehyde, a known
Cosmetics 2022,9, 17 5 of 11
human carcinogen [
6
]. Formaldehyde is known to cause respiratory irritation, contact
dermatitis, headaches, pregnancy complications, and is associated with respiratory and
hematopoietic malignancies at high concentrations [33]. A cohort study conducted by the
National Cancer Institute found an increased incidence of lymphoproliferative malignan-
cies, particularly myeloid leukemias, among factory workers in formaldehyde-producing
and formaldehyde-using plants [
30
]. Although the percentage used in cosmetics is much
lower than those in industrial usage, it still raises the question as to what level, if any,
formaldehyde exposure can be considered “safe.”
With the concern surrounding the use of formaldehyde, formaldehyde-releasing BKT
formulations (marketed as formaldehyde-free) such as glyoxylic acid have grown in popu-
larity, with no scientific proof that they are any safer than formaldehyde formulations [
31
].
The US Cosmetic Ingredient Review Expert Panel set a maximum safe concentration of
formaldehyde at 0.2%, a level that is often well surpassed by commercial BKT brands [
33
].
In a study done on seven different BKT brands marketed in South Africa in 2012, six had
concentrations of formaldehyde five times higher than the recommended level, including
five brands that were labelled “formaldehyde-free” [
33
]. Another study carried out in Brazil
examined 23 brands, and all exceeded 0.2% formaldehyde, ranging from 18 to
54 times
the
permitted levels [31].
3.2.3. Recommendations
There is a clear concern for false labelling of Brazilian Keratin Treatments, and further
regulation needs to be enforced surrounding the use and concentration of formaldehyde in
these products. Many recommend avoiding these treatments altogether, due to the risks of
formaldehyde and the discrepancies between listed ingredients and the actual presence
of this carcinogenic ingredient in BKT preparations [
31
]. Additionally, during treatment,
a strong odor of formaldehyde along with irritation of the eyes and oropharynx should
prompt immediate suspension of treatment, as it indicates very high concentrations of
formaldehyde that are likely unsafe and dangerous to health [
31
]. More research is needed
on the health and safety implications of long-term keratin treatment use before this can be
recommended to patients as a safe alternative to chemical relaxers.
3.3. “Natural” Hair
3.3.1. Introduction
Natural hairstyling refers to the discontinuation and/or avoidance of chemical relaxers
to straighten the curl pattern of the hair [
34
]. As mentioned previously, natural hairstyles
have been gaining substantial popularity over the past few decades. A study on 200 African-
American women from Detroit reported a 10% increase (26% to 36%) among women
reporting wearing non-chemically relaxed hair between 2010 and 2011 [
35
]. Consumer
trends research has documented a 26% decrease in relaxer sales between 2008 and 2013,
and a 17% decrease between 2006 and 2011 [
23
]. Another study on 242 women of African
descent from London, UK, found that natural hairstyles were actually the predominant
hairstyle (52.6%) in their study population, with respondents citing their desire for healthy
hair and self-directed hair grooming as reasons for going natural [36].
With the dearth of natural hair care products currently on the market and the internet
overrun with hair blogs and YouTube tutorials, “going natural” has never been easier. How-
ever, many Black women continue to face professional and social pressures to chemically
straighten their hair. Even in the current times, women continue to face discrimination for
wearing their natural hair texture. Additionally, natural hair may be time-consuming and
difficult to maintain, especially for women who have worn straight hair their entire lives.
3.3.2. Associated Risks
Discrimination, and subsequent psychological damage, were the most poignant iden-
tified risks that women of African descent experience when choosing to wear their hair
natural. Starting from a very young age, Black children are faced with racially biased hair
Cosmetics 2022,9, 17 6 of 11
grooming policies at their schools, and begin to experience harassment from their peers
based on the appearance of their hair [
37
]. This continues into adulthood, where people
of color are excluded from certain jobs or even sent home from work on the premise that
certain hairstyles, such as dreadlocks, do not meet the company’s standards of profession-
alism [38].
One interesting study whereby participants were asked to rate photos of Black women
with different hairstyles found that employment candidates with Afrocentric hairstyles
were rated as less professional and less likely to succeed in Corporate America than employ-
ment candidates with Eurocentric hairstyles [
39
]. One perhaps unexpected outcome of this
study was the discovery that Black evaluators, compared to their White counterparts, gave
higher penalties to the Black employment candidates who wore Afrocentric vs. Eurocentric
hairstyles, and rated them as more dominant and less professional. This suggests that,
at least in the corporate workforce, much of the discrimination towards Afrocentric or
natural hairstyles may be from Black individuals themselves, who may be particularly
judgmental toward traits exhibited by other Black people that are deemed to be socially
unacceptable—a phenomenon called horizontal hostility [39].
Afrocentric hairstyles may be labeled as unprofessional, unkempt, and messy, and
may even be considered radical or political to wear in certain environments [
9
]. A qual-
itative investigation of 90 African-American guided hair autobiographies examined the
psychological significance of hair discrimination among this community, and found that
emotional responses surrounding hair discrimination were present in about half of the
narratives collected, with sadness and self-conscious emotions such as shame and embar-
rassment common among participants [
37
]. Participants in this study frequently resorted
to chemically or thermally changing their hair texture or changing the length of their hair
in response to discrimination [37].
Among the literature, the other most identified barrier among women deciding to “go
natural” was unfamiliarity and or frustration with their natural tresses. As explained by one
author [
35
], many women of African descent have had their hair chemically straightened
since they were young girls and never learned to care for their hair in its natural state. For
many Black women, they have had straightened hair longer than they have had natural
hair, and many prefer the manageability associated with relaxed hair, or simply prefer the
way straight hair looks [11].
3.3.3. Recommendations
Recommendations regarding caring for natural hair include washing hair with a
shampoo-containing product at least every two weeks [
40
], detangling with detangling
conditioners and a wide-tooth comb [
41
], and frequent moisturization with conditioning
agents to prevent breakage [
34
]. Author Biakolo says that persistence is required to maintain
natural hairstyles and cautions women that it may take time for them to become skillful at
meeting the demands of their natural hair [
8
]. Collectively as a society, we need to continue
to promote and embrace natural hairstyles both among the Black community and as allies
among the majority population. As of October 2020, the CROWN (Create a Respectful
and Open World for Natural Hair) Act bill, created to ensure protection against race-based
hair discrimination in the workplace and in public schools, was passed by 7 states and the
House of Representatives, as well as being considered for the US Senate [
38
]. It’s continued
success will depend on increasing support from allies, especially influential leaders such as
health care professionals, given the underrepresentation of people of color in legislative
positions [38].
3.4. “Traction” Hairstyles: Braids, Weaves, Wigs, Twists, and Dreadlocks
3.4.1. Introduction
Braids, weaves, wigs, twists, cornrows, and dreadlocks are examples of low-maintenance,
chemical-free hairstyling techniques popular among women of African descent. These
hairstyles typically require a time commitment upfront, ranging from hours to even days
Cosmetics 2022,9, 17 7 of 11
for more elaborate styes, but can be kept in place for long periods of time and require
minimal daily effort to maintain [
14
]. Additionally, none of these hairstyles utilize chemical
straightening, and apart from dreadlocks, are considered “protective hairstyles” because
they do not require excessive daily manipulation. They can be used to help transition from
chemically treated hair to natural hair, effectively masking any differences in structure or
texture along the shaft of the hair [42].
Braids are one of the most versatile of the traction hairstyles. Cornrows are achieved
by braiding the hair tightly along the scalp, loose braids can be done with one’s own
natural hair, or with the addition of synthetic or natural hairs to create the illusion of length,
twists can be created by interweaving two strands rather than three, and braids or twists
themselves can be further twisted around themselves and worn in numerous patterns,
styles, and up-dos [
13
]. They are especially exercise-friendly, and can be shampooed
regularly, as exposure to water or moisture will not alter the style [
43
]. The use of braids is
popular among women with Afrocentric hair and is often seen as an expression of Black
culture and style, commonly worn by African-American entertainers such as Beyoncé, and
sports stars such as Venus and Serena Williams [14].
Hair weaves involve parting and cornrowing natural hair along the scalp, followed
by sewing, braiding, clipping, or gluing hair extensions into the cornrow [
14
]. Women
of all ethnicities use hair extensions or weaves, but they are particularly popular among
Black women, as they can be used to simulate longer, fuller, and/or straighter hair [
43
].
Hair extensions can be made from either human or synthetic hair and are more resistant
to moisture than natural straightened hair [43]. Weaves typically last around two months,
and can be very convenient for wearers, as their hair and scalp are protected but easily
accessible for washing, conditioning, and moisturizing [
6
]. Wigs are similar to weaves
in that they are a way to cover one’s natural texture and simulate length but are much
less permanent as they can be removed at any point in time. They are often worn over
short hair or cornrowed hair as a quick and easy protective style, decreasing the amount of
manipulation and damage to the underlying hair [34].
Dreadlocks and sisterlocks involve sectioning natural hair and palm rolling, twisting,
or using tools such as crochet hooks to “lock” the hair [
23
]. “Dreads” or “locs” have a long
history within Jamaican Rastafarian culture, but are quite popular among all Black men
and women today, as they are extremely low-maintenance and easy to maintain for a long
period of time [
23
]. They are typically considered permanent until the decision is made
to cut them off, but recent techniques have also been developed to untwist and pick out
locks using water and conditioners [
23
]. Faux-locs are another option where synthetic hair
is tightly wrapped around natural hair strands to create the illusion of dreadlocks without
the same level of commitment. They are exercise friendly and offer another chemical-free
alternative to daily styling.
3.4.2. Associated Risks
Common to all the aforementioned “traction hairstyles” is the risk for traction alopecia.
Traction alopecia (TA) is hair loss secondary to tension placed on the follicles, often appear-
ing as thinning along the hairline with preservation of hair at the anterior border, termed
the “fringe sign” [
23
]. Any hairstyle that involves continuous pulling of the hair in one
direction can result in significant breakage and TA, and when combined with additional
hair extensions as are commonly used in braids, twists, and weaves, can add significant
extra weight to the hair follicle [
34
]. In a 2008 cohort study on 574 girls and 604 women from
South Africa, it was found that the highest risk of TA occurred when traction hairstyles were
performed on chemically relaxed hair [
44
]. Additionally, TA prevalence was highest with
traction from artificial extensions compared with that from natural long hair (dreadlocks),
suggesting that artificial extensions may be more damaging to the hair follicle, perhaps
due to their additional weight [
44
]. Mechanical insult from excessive braiding (>eight
times/year) was associated with the highest marginal traction alopecia severity scores in a
small cohort study done in Johannesburg, South Africa [42].
Cosmetics 2022,9, 17 8 of 11
The use of bonding glues for the attachment of weaves to the scalp carries additional
risks as well. These adhesives use ingredients such as latex and polyacrylates, which
have been associated with allergic contact dermatitis [
34
]. One case report described a
case of a severe anaphylactic reaction that resulted from the use of hair glue containing
natural rubber latex [
45
]. In addition, the removal of these bonding glues is known to
cause hair breakage and damage, which may further contribute to hair loss and traction
alopecia [
34
]. Another risk is that of seborrheic dermatitis. Dadzie et al. found that on
average, braid or weave hairstyles are worn for 63 days, and time between washes ranged
from 18 to
32 days
[
36
]. This is in contrast with the 14-day average between washes for Black
women with natural non-traction hairstyles. The infrequent shampooing and/or difficulty
shampooing around braids, weaves, and twists can increase the risk for or exacerbate
existing seborrheic dermatitis [14,40].
Another possible association to be aware of is that of Central Centrifugal Cicatricial
Alopecia (CCCA) with traction hairstyles. CCCA was mentioned previously in the section
on chemical relaxers, but has also been found to be associated with wearing braids, corn-
rows, and sewn-in or glued-in weaves for cumulative years [
23
]. It is believed that hair
styles causing traction can clinically produce folliculitis of the scalp (colloquially called
“hair bumps”), which can cause scarring if the inflammation is prolonged [
22
]. A study by
Gathers et al. on women diagnosed with scarring alopecia and matched controls found
that for every 10-year increment that a woman wore sewn-in weaves at least once, she
was 2.8 times more likely to develop CCCA (p= 0.003), and for every 10-year increment
that a woman wore glued-in weaves, she was 2.2 times more likely to develop CCCA
(
p= 0.02
) [
21
]. Another cross-sectional study on 326 African-American women from Cleve-
land, Ohio found that the presence of diabetes mellitus type 2 (p= 0.01), bacterial skin
infections (p= 0.045), and hair styles associated with traction (p= 0.02) were all significantly
higher in those diagnosed with CCCA [
22
]. One study, whereby Khumalo et al. reanalyzed
data from a previous study on traction alopecia, found no association between traction
hairstyles and CCCA, but acknowledged that they were limited by the small number of
participants with CCCA included in the study (n= 16) [46].
3.4.3. Recommendations
With all these considerations in mind, recommendations have been suggested for
how women may decrease their risk for complications when wearing traction hairstyles.
Haskin et al.
[
34
] suggests loosening the application of braids, especially along the hairline,
opting for larger diameter braids and dreadlocks to better distribute the weight placed on
each individual hair fiber, and leaving braids in for no longer than two to three months.
Mayo et al. [
29
] recommends leaving edges out when getting hair braided and instead using
edge-control gel to style edges, as well as avoiding tight braided up-dos or excessively
long braids, and loosening braids if pain or stinging is felt at the time of placement. Other
recommendations include avoiding the use of tension hairstyles on chemically relaxed
hair [
23
], opting for looser twists rather than braids when possible [
6
], washing hair with
shampoo at least every two weeks no matter what style is being used [
40
], and avoiding
bonding glue in the application of weaves, opting for sewn-in options instead [29].
4. Discussion
The use of relaxers has been on a general decline, but it is still quite popular among
African-American women. The association between relaxer use and breast cancer is possibly
the most concerning of all the health risks identified in our review. The majority of the
studies utilized in our review had some association if not to an overall increased risk for
breast cancer, than to a larger tumor size or a higher risk for a subtype of breast cancer. This
remains a topic of debate and further studies will be needed to solidify this relationship
and establish causality. The most pressing dermatological risk associated with relaxer
use is CCCA. All but one study on the topic reported an association between relaxer use
Cosmetics 2022,9, 17 9 of 11
and CCCA, but further studies with greater sample sizes will be needed to solidify this
relationship as well.
There is a clear concern for false labelling of Brazilian Keratin Treatments, and further
regulation needs to be enforced surrounding the use and concentration of formaldehyde in
these products. It is probably best to avoid these treatments altogether, due to the risks of
formaldehyde and the discrepancies between listed ingredients and the actual presence of
this carcinogenic ingredient in BKT preparations. More research is needed on the health
and safety implications of long-term keratin treatment use before this can be recommended
to patients as a safe alternative to chemical relaxers.
Traction hairstyles, although considered “protective” and low-maintenance, are not
without risk. They carry increased risks of traction alopecia, and cumulative use was also
found to be associated with the development of CCCA. Of all traction hairstyles, those
without the use of artificial extensions (natural braided hair, twists, or dreadlocks) carry a
lower risk of traction alopecia and should be recommended above those with the addition
of heavy artificial hair additions.
Natural hairstyling carries with it numerous health benefits. Natural hair may lead to
decreased risks of cancer via reduced chemical exposure, and when heavy or excessively
tight protective styles are avoided, damage to the scalp and hair follicles is more easily
prevented. Women with natural hair are also more likely to engage in physical activity,
as they are able to wash and re-style their hair more easily at home, without incurring a
significant expense while doing so. While it may be difficult for someone who is new to
styling their hair naturally to find what works best for them in terms of daily management,
an abundance of user-friendly resources and tutorials are available both on the internet
and in books world-wide. Discrimination is the most poignant identified barrier that Black
women face when choosing to wear their hair natural, and dermatologists need to be aware
of this so that they may approach the topic with care, and also to be aware of ways they
may be able to make a lasting change, for example in supporting and promoting legislation
such as the CROWN act.
5. Conclusions
Although each style discussed comes with an associated risk (summarized in Table 1),
it appears that natural hair carries the fewest adverse health effects of all the hairstyles
included in our review. Dermatologists should continue to recommend natural hairstyles
to their patients, especially to those struggling with TA, CCCA, or seborrheic dermatitis;
however, they need to be aware of the potential psychological implications and discrimina-
tion that patients may face when choosing to wear natural hairstyles. The recommendation
to choose natural hairstyles should be made gently and with sensitivity, recognizing that it
is not always as easy to make the switch as it may seem. While acceptance of these natural
hairstyles is on the rise, there is more work to be done throughout social and legal spheres
to help protect women making not only a personal style choice, but a health-conscious one.
Table 1. Health risks associated with various hairstyles.
Hairstyle Associated Risks
Chemically Relaxed
Hair damage, skin irritation, carcinogen exposure,
endocrine-disrupting chemical exposure, CCCA, exercise
avoidance
Brazilian Keratin Treatment Carcinogen exposure, respiratory irritation, contact dermatitis
headaches, pregnancy complications
Natural Hair Psychological damage, discrimination, frustration with styling
Braids, Weaves, Wigs, Twists,
Dreadlocks
Traction alopecia, allergic contact dermatitis (weaves), hair
breakage and damage, seborrheic dermatitis, CCCA
Cosmetics 2022,9, 17 10 of 11
Central Centrifugal Cicatricial Alopecia (CCCA) remains one of the greatest dermato-
logical threats among the hairstyles included in our review, being found in both users of
chemical relaxants and those who opt instead for longer protective styles, such as braids
and weaves. However, while CCCA is widely described in this population, we still lack
substantial research on this topic, with some studies supporting its connection to traction
and chemical styles, and some finding no association. More studies with larger sample
sizes need to be conducted in order to further elucidate the risk factors and origins of this
still very mysterious disease process.
Author Contributions:
Conceptualization, S.A. and A.T.; methodology, S.A. and C.R.-P.; writing,
S.A.; review and editing, C.R.-P. and E.G.; supervision, E.G. and A.T. All authors have read and
agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.
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