Hair type has traditionally been divided into three main categories: Caucasian, Asian/Mongolian and African. There is great diversity in the phenotype of African hair, which, in Africa, varies from very tightly coiled in the south to very straight in the north of the continent. For the purpose of this article, ‘African hair’ refers to the tightly curled black hair that is typical of people who originate from sub-Saharan Africa.
Hair loss in black women in the UK is likely to be more common than previously acknowledged. A study conducted in a West London dermatology clinic in 2015, which explored hair loss in women with ‘Afro-textured’ hair, concluded that hair loss in black women should be considered a public health issue, as it found that approximately 50% of its sample of women of African descent experienced some form of hair loss (Dadzie and Salam, 2015). Clinicians are increasingly encountering skin and hair conditions in people of colour, and it has been acknowledged that there is a significant gap in education in the UK (Ashman, 2021).
The third L'Oréal African hair and skin workshop took place in 2010, and it was acknowledged that the physiology of African hair and skin was not fully investigated until the past two decades, when dedicated laboratories aimed to identify its specificities (Verschoore, 2012).
Black women experience the same forms of hair loss as other hair types. However, there are certain forms of hair loss that are recognised to affect black women more commonly. Three of the most common types of hair loss discussed in this article are:
- Acquired proximal trichorrhexis nodosa
- Traction alopecia (TA)
- Central cicatrising cicatricial alopecia (CCCA).
Additionally, there is discoid lupus of the scalp, which needs to be medically managed by a dermatologist. It is important to be able to recognise the main features of these conditions to prevent further hair loss. In cases where there is doubt, it is important to have a low threshold for referring to a dermatologist with expertise in hair loss, particularly if there is a concern about a potential scarring form of alopecia. Suspicion should be raised when smooth areas of scalp are visible. Scarring alopecias should be seen as a trichological emergency. Early intervention can potentially avert scarring and secondary complications and need a prompt referral to a dermatologist for management, which may include confirming the diagnosis with a scalp biopsy. Trichoscopy helps in following up progress, and technology such as TrichoLab is available to doctors, which can be useful in quantifying hair measurements.
Dissecting cellulitis of the scalp and acne keloidalis nuchae are more commonly seen in men of African descent and will not be covered in this article.
Properties of African hair and hair care practices
African hair is fragile compared with other ethnic groups (as measured by the tensile force needed to break the hair fibre). The hair has a tendency to form knots and appear broken compared with hair shafts from other ethnic groups, with interlocking of hair shafts (Khumalo et al, 2000).
Afro hair breakage is most commonly attributed to grooming practices, such as braiding, hair extensions and weaves, both for chemically treated and natural Afro hair
Afro hair breakage is most commonly attributed to grooming practices, such as braiding, hair extensions and weaves, both for chemically treated and natural Afro hair. The excessive structural damage observed in the African hair shafts is consistent with physical trauma (resulting from grooming), rather than an inherent weakness due to any structural abnormality (Khumalo et al, 2005). Research published in 2021 on female subjects in South Africa with African hair used qualitative and quantitative techniques, such as scanning electron microscopy, cuticle cohesion and tensile testing, to determine the effects of frequent braiding on the integrity of female Afro hair in 15 frequent braiders and 15 occasional braiders (control group). All measurements showed a relationship between surface and internal hair fibre damage and braiding frequency (Molamodi et al, 2021).
When African hair is very short, it is easy to comb, but, as it grows longer, each time a comb is pulled through it, the hair springs back and intertwines, and knots form within and between adjacent fibres. The only way the comb will pass through some of the knots is by fracturing the hair. A point is reached where daily breakage is equivalent to new growth, and, at this steady state, the hair appears not to grow any longer. The hair of different people reaches a steady state at different lengths, possibly dependent on individual genetic factors, and those who are happy with this length can go for many years without a haircut. In fact, combing is like a daily haircut (Khumalo, 2005; Khumalo, 2006).
Chemical relaxers
Chemical relaxers are products marketed to straighten the hair and have been principally used by African Americans since the early twentieth century. In 2010 in Africa, it was estimated that chemical relaxers are used by more than two-thirds of African females to straighten hair, with easy grooming and increased length often cited as reasons. Chemical relaxers are associated with reduced cystine consistent with fragile damaged hair (Khumalo et al, 2010). They contain alkaline agents that break and reform hydrogen and disulfide bonds, leaving hair permanently straightened. Relaxers cause a loss of tensile strength and increased fragility of the hair shaft, which leads to increased risk of hair breakage and thinning. When used improperly, they can also cause local irritant contact dermatitis and chemical burns to the scalp and hairline that can potentially lead to a scarring alopecia (Richardson et al, 2017). Reduction in cystine content was consistent with increased straightness (Mamabolo et al, 2013).
» Low levels of vitamin D are associated with a wide range of hair loss conditions, including alopecia areata, telogen effluvium and frontal fibrosing alopecia, so it is important to be aware of vitamin D status, which, in the UK, is likely to be lower in those with darker skin «
Lace front wigs
Lace front wigs have become a popular protective style for black women in recent years. Adhesive products are used to secure the wig to the scalp. Active ingredients can include alcohol, xanthan gum, acrylate copolymer and nonylphenol oxylate. It is widely recommended by hairstylists to tie a scarf or hair tie around the hairline to keep the wig in place during the night and to only leave the lace wigs installed for 2 weeks at a time; however, in reality, it can sometimes be much longer. This practice, coupled with the ingredients found in the adhesive sprays and glues, raises concerns for the potential to cause TA and contact dermatitis
Hair loss conditions
It is important to remember that common hair loss conditions are experienced in those with Afro-textured hair, including androgenetic alopecia, alopecia areata and telogen effluvium. As with all hair types, if the focus of the interaction is to identify all of the factors that could be contributing to hair loss, it is important to allow sufficient time to find out and understand the impact of the patient's general health, medications, genetics, hair care practices, family history, lifestyle, nutrition and supplements. The evidence base is constantly changing, and it is important that the practitioner is aware of the limitations of most generic clinic training in hair loss. However, there will be additional factors to consider.
A broad knowledge of the common hair loss conditions is important to reduce the chances of losing the opportunity to treat. These include:
- Alopecia areata: an autoimmune hair loss condition, which is probably more common than appreciated. The ophiasis form extensively affects the back and sides of the scalp. This can sometimes be incorrectly attributed to traction alopecia. The important distinguishing factor is absence of the fringe sign
- Anagen effluvium: following chemotherapy, although scalp cooling is now standard, there are issues to consider for women with African hair, as, due to the differences in hair texture and shape, there is a higher risk of decreased effectiveness of the cooling effect of the cap. There is a helpful published letter in the Journal of Clinical Oncology on this matter, which contains some helpful recommendations about what to consider when preparing for a visit (Araoye et al, 2020a)
- Frontal fibrosing alopecia: smooth hair loss at the frontal/temporal hairline, which is more common in postmenopausal women. The band of alopecia is often readily distinguishable from the sun-damaged skin of the forehead. It is associated with eyebrow loss, facial papules and pigmentation changes in those with darker skin. This can sometimes be incorrectly attributed to TA because of hair loss at the frontal temporal line. The important distinguishing factor is absence of the fringe sign
- Lichen planopilaris: patches of hair loss, lichen planus of the hair resembling moss growing
- Telogen effluvium: in the author's practice, this appears to be due to low iron stores as a result of menorrhagia. Often, there is a history of fibroids. It is important to check the ferritin levels, which should be above 70 mcg/ml.
Additionally, low levels of vitamin D are associated with a wide range of hair loss conditions, including alopecia areata, telogen effluvium and frontal fibrosing alopecia, so it is important to be aware of vitamin D status, which, in the UK, is likely to be lower in those with darker skin.
Hair loss conditions more commonly found in black women
Acquired proximal trichorrhexis nodosa
Trichorrhexis nodosa refers to the appearance under the microscope of a fracture of the hair with splaying out of the individual cortical cells from the main body of the hair shaft, producing an appearance suggestive of two brushes pushed together. There are three main types: the primary congenital form, trichorrhexis nodosa, as part of other syndromes, and the acquired form (Rogers, 1995), which can occur in any ethnicity, but is most common in women of African descent (Lawson et al, 2017). It is a focal defect in the hair fibre that is characterised by thickening or weak points (nodes) that cause the hair to break off easily. Hair care practices can precipitate, including relaxers and flat irons (Mirmirani, 2010; Ogunbiyi et al, 2014).
The practitioner should look out for abnormally fragile hair that breaks easily at any point along the hair shaft. Investigation is carried out through polarised light microscopy of the cut hair. It is important to do a skin scrape/cut the hair. Check thyroid function test (TFT) (Lurie et al, 1996) and zinc levels and consider a scalp biopsy, as hair breakage can be an early sign of CCCA.
The main treatment that can help is the appropriate use of cleansing and conditioning agents (Haskin et al, 2017) and washing and conditioning the hair with appropriate products once a week. Leave-in hair moisturisers should be used daily. Hair should be air dried, rather than blow dried, and relaxers, processing and excessive heat should be avoided.
Referral is not necessary, other than for blood tests or to a professional with expertise in Afro-textured hair care, which may include recommendations of protein or moisturising treatments.
Traction alopecia
TA is a preventable form of hair loss that most commonly affects women of African descent. It is due to excessive prolonged traction leads to conversion of the anagen phase to the telogen phase. In South Africa, TA affects up to 32% of women and 22% of high school girls with Afro-textured hair, but it can start in preschool years. The high prevalence rates infer either a genetic susceptibility or persistent environmental factors not addressed by clinical practice. This genetic susceptibility may be due to the asymmetrical shape of the African hair follicle. It has a retrocurvature at the hair bulb and an S-shaped hair shaft, which creates geometric points of weakness along the hair shaft (Akingbola and Vyas, 2017).
It is the result of chronic use of hairstyles that put chronic tension on hair in the fronto-temporal area. This includes during the night, so it is important to ask patients how they wear their hair when they sleep (Samrao et al, 2021). Avoiding both hairdressing symptoms and the addition of traction, especially to chemically processed hair, may reduce the risk of developing TA (Khumalo et al, 2008). Traction induces inflammation and follicle damage. The risk of TA increases with symptomatic traction and combined hairstyles. To influence the practice of hairdressers and at-risk individuals, as well as helping to narrow the knowledge, attitudes, and practices (KAP) gap, scientific data should be translated into simple messages, such as ‘tolerating pain from a hairstyle can risk hair loss’ and ‘there should be no braids or weaves on relaxed hair’. With appropriate education and public awareness, TA could potentially be eradicated (Mirmirani et al, 2014).
High-risk hairstyles include application of weaves and/or braids on relaxed hair and any hairstyles causing symptoms, such as pain, stinging, crusting, tenting and pimples. Low-risk styles are loose, low-hanging ponytails and buns and natural unprocessed hair.
TA typically manifests with hair loss, usually along the marginal hairline (frontal, temporal or occipital) with decreased retained follicular markings and the presence of a ‘fringe’ of finer or miniaturised hairs. The characteristic finding is the retention of hair follicles of lesser diameter along the frontal and/or temporal hairline. This is called the fringe sign (Khumalo, 2012) (Figure 1), and it correlates with the presence of vellus hairs seen in the histology. The other findings that may also occur include folliculitis, hair casts, reduction in hair density and replacement of few with vellus hairs and the occasional presence of broken hairs in the affected areas, which finally proceeds to alopecia that leaves scars. The hair casts due to TA are nonadherent, white or brown in colour, cylindrical in shape and tend to encircle the proximal hair shaft. The presence of hair casts at the periphery of the patch indicates active traction. It can be associated with a headache, which is relieved when the hair is loosened. The pattern of the alopecia is characteristic and reflects the distribution of the traction.
Figure 1. Fringe sign in traction alopecia
If there is no fringe sign, consider frontal fibrosing alopecia, particularly if there is a history of pigmentation change and facial papules, or ophiasis alopecia areata, which affects the sides and the back of the scalp, and is sometimes misattributed to traction alopecia in this group (Heath and Taylor, 2012).
For practical purposes, TA has been classified into three stages, namely:
- Stage of prevention: where avoidance of high-tension hairstyles is important in reversing the hair loss (Haskin and Aguh, 2016)
- Stage of early traction alopecia: medical treatments, including topical and intralesional steroids (Uwakwe et al, 2020) or topical antibiotics, if appropriate, can be used. Topical minoxidil (Khumalo and Ngwanya, 2007) or even oral minoxidil (Beach, 2018) can be used where the cosmetic acceptability of the formulation and cost may be a factor
- Stage of longstanding traction alopecia: surgical treatments, such as hair transplantation, can be considered (Earles, 1986; Ozcelik, 2005).
Microneedling with platelet-rich plasma (PRP) treatments shows promise for this condition along with alopecia areata and some scarring alopecias (El-Fakahany et al, 2016).
Thought should be given to referring to a dermatologist to consider intralesional steroid injections along the hairline.
Central centrifugal cicatricial alopecia
CCCA is a progressive form of lymphocyte predominant scarring alopecia. It is a condition known for delayed presentation and treatment, and it is thought to affect one in 20 black women. Questionnaire surveys of black women in the US found that factors considered to be important when seeking medical care include the physician's experience with black hair and CCCA, the physician's compassion, the patient's personal hairstyling practices, subjective hair loss severity and treatment cost (Akintilo et al, 2018). It can run in families, so it is important to increase awareness in family members. More recently, a new study has identified a gene variant of peptidyl arginine deiminase 3 (PADI3), which plays an important role in hair shaft formation that is present in approximately one-quarter of studied patients with CCCA (Malki et al, 2019). Hair care practices can have a strong modifying effect (avoiding processing and tension improves outcomes). In many cases, the area of hair loss is not accompanied by any symptoms. However, itching, burning, pain, tingling or tenderness can be a feature. Hair breakage in the area can be an early sign.
CCCA typically starts at the crown/scalp vertex and spreads in a peripheral or centrifugal pattern. Generally, it is identified in women aged between 40 and 60 years. It can sometimes be confused with androgenetic alopecia (AGA) in women, which results in diffuse thinning of hair on the scalp due to increased hair shedding, a reduction in hair volume or both. While patients may present with CCCA or AGA, a number may have a mixed picture of CCA/AGA, which may present a diagnostic challenge. Using dermoscopy, a perihilar blue-grey halo is pathognomonic of the condition and is useful for identifying high-yield biopsy sites (Okereke et al, 2020) (Figure 2).
Figure 2. TrichoLab image of peripilar grey/white halo in central centrifugal cicatricial alopecia
CCCA cases should be promptly referred to a dermatologist for confirmation. In the inflammatory stage, this needs to be reduced using topical or intralesional steroids. Good results have been seen after 14 weeks of using clobetasol foam (Callender et al, 2020), and treatment should be continued until the patient is symptom-free. Post-inflammatory treatment includes long-term topical steroids (this should be continued at the very least), topical minoxidil for prolongation of anagen (some success has been documented using oral minoxidil) (Alame et al, 2019), surgical restoration once the disease has burnt out and 5-alpha reductase inhibitors should be considered (helping underlying pattern hair loss).
It is thought that even low-grade inflammation may precipitate disease, so it is important to aggressively treat seborrhoeic dermatitis. Additionally, antifungal shampoos should be recommended to help with any pruritus or scaling, and more frequent shampooing should be encouraged, up to a maximum of once weekly. In some cases, tetracycline antibiotics could be prescribed to help reduce hair follicle inflammation and disease burden.
It is important to manage expectations when dealing with a patient with scarring alopecia, as treatment can lead to disappointing outcomes. The aim is to try to rescue and recruit hairs that are undecided in their fate, and the hair that regrows with treatment is very fragile.
Treatment from a dermatologist that may be offered includes steroid injections around the margins of the active area of disease, the antimalarial hydroxychloroquine or, more rarely, mycophenolate mofetil or ciclosporin. For those who do not respond, it is worth considering non-traditional treatments, such as PRP. Hair transplantation could be considered once the disease has burnt out and there is no evidence of inflammation (Callender et al, 2014).
An exploratory study looking at the impact of wounding with CO2 laser found that, while the general trend was toward increased hair counts in all areas, the most significant change was noted at peripheral sites treated at the highest energy setting (Clemetson et al, 2020).
Camouflaging hair loss
Wigs can have a profoundly positive effect on self-esteem, but it can be challenging to find a range of high-quality, affordable wigs that mimic African hair. Smaller patches of hair loss can be masked using various products. The author has found that cosmetic camouflage fibres (for example, MS Hair and Toppik) create convincing camouflage.
Crochet styling, cornrow braids and frontal, closure and braided lace wigs are among the styling techniques that are widely employed for CCCA and advertised by hairstylists across social media. It is really important to use grooming that avoids tension, processing and heat (Agor and Ward, 2021).
Conclusion
Hair loss disorders in black women can cause significant distress and morbidity, and there are disparities in the level of confidence that new dermatologists have in managing these conditions (Salam and Dadzie, 2013). These patients may delay seeking help for their hair loss due to a perceived lack of expertise in clinicians.
The evidence base has increasingly demonstrated the negative impact of certain hair care practices, and more focus is needed on developing products and disseminating consistent advice to reduce the impact of grooming. Reaching out to hairstylists whose clients fall within this group is part of the solution.
More evidence is emerging about the use of natural products for androgenetic alopecia and alopecia areata, but this is lacking in CCCA and other hair loss conditions (Ezekwe et al, 2020).
In CCCA cases, an association with diabetes has been noted. Successful regrowth has been documented in patients using topical metformin (Araoye et al, 2020b).
Using lasers for peripheral wounding in CCCA shows promise. However, more randomised controlled trials on the use of PRP =/- microneedling would be invaluable in providing alternative options for treatment for CCCA that do not involve potent medications.
In the author's practice, dermoscopic changes that are typical of CCCA without hair loss have been seen. Surveillance of CCCA in those with a positive family history may be an area for future development.
Treatment considerations
In female pattern hair loss, low-level light therapy is within recommendations for androgenetic alopecia, but there is no acknowledgement within these guidelines of the absence of data on Fitzpatrick skin types 5 and 6, so the mainstream devices, such as HairMax and Theradrome, contain no guarantees for this cohort, citing the absence of imaging. However, as imaging techniques evolve, it would be helpful for the manufacturers to gather data for this cohort.
Key Points
- Hair loss in black women is a major public health issue, which is under-recognised and undertreated
- African hair is fragile, and low levels of trauma from some grooming practices can cause damage to the hair fibre
- Types of hair loss more commonly experienced in black women are trichorrhexis nodosa, traction alopecia, central centrifugal cicatricial alopecia and discoid lupus
- Early recognition and prompt referral is crucial to prevent the hair loss from becoming a permanent scarring alopecia
- Unpublished data from the US indicates benefits from platelet-rich plasma and low-level light therapy.
CPD reflective questions
- What are the causes of hair loss that occur in black women?
- How commonly do you think central centrifugal cicatricial alopecia has been attributed solely to hair care practices, rather than acknowledging the impact of genetics?
- Which hair loss conditions do you think could be misattributed to being solely traction alopecia? Do you document the presence or absence of the fringe sign?