UPDATE ON HAIR LOSS IN AFRICAN AMERICAN WOMEN - MARKALLEN EVERETT MDSKIN OF COLORSYMPOSIUM UNIVERSITYOF OKLAHOMA APRIL23, 2021
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Update on Hair Loss in African American Women V ic to ria B arb o s a MD, MP H, MBA M ark Alle n Eve rett M D S k i n o f Co l o r Sy m p o siu m U n ive rs ity o f O k l ah om a A p ril 2 3 , 2 0 2 1
Introduction Associate Professor, University of Chicago Department of Medicine Section of Dermatology Director of the Hair Loss Program Email: vbarbosa@uchicago.edu Phone 773-702-5525 FB, IG: @drvickibarbosa
Disclosure Consultant for Ambi Skincare Will not be discussing any skin care products in this lecture
Professional Practice Gap Most providers are have limited education on hair care and hair loss in African American women Providers should be comfortable in discussing hair care practices and diagnosing and managing hair loss in African American women
Learning Objectives ➢What are the unique properties of Black hair? ➢What are the hair styling and hair care practices that we need to be aware of to be culturally competent and to aid in diagnosis and management of hair loss? ➢What are the common causes of hair loss in African American women? ➢How do I diagnose and manage these diseases? ➢What role do hair care and hair products play in disease in African American women?
Black Hair, Hair Styles and Hair Care
Black Hair: Curl Pattern
Black Hair: Breakage & Growth
BREAKAGE GROWTH
Survival Probability of Different Ethnicities Loussouarn G. African hair growth parameters. Br J
1
Dermatol. 2001 Aug;145(2):294-7
Survival Probability
0.9
0.8
0.7
0.6 ◦ 256 (+/- 44) vs 396 (+/- 55) micrometers per day
0.5
0.4
for Blacks vs. Caucasians
0.3
0.2
0.1
0 ◦ 3.68” per year vs. 5.74” per year
0 1000 2000 3000 4000 5000
Cycles to Failure
Black Asian Caucasian Latino
The influence of African-American hair's curl pattern on its mechanical
properties
Crystal E Porter 1, Stephane Diridollou, Victoria Holloway Barbosa
Porosity
How easily does hair retain moisture?
Hair Grooming: Key Questions Frequency of shampooing Conditioning on wash day and in between Natural vs relaxed ◦ Not all hair that is straight is relaxed ◦ Relaxer, texturizer, hair color Use of Heat Use and frequency of “protective” styling Use of additional synthetic or human hair extensions
What Is Natural Hair? ◦ Natural hair is hair that has not been chemically treated ◦ Relaxers are universally considered chemicals and relaxed hair is never considered “natural” ◦ Texturizers are in fact mild relaxers; some people consider themselves to have natural hair even if they use a texturizer because their hair is still curly ◦ Some purists think that if you have hair color then you do not have natural hair; others think that you can have hair color and still be “natural” because hair color does not alter hair texture
Loose Hair Styles
Wash and go → shrinkage
Short natural
Twist out
Braid outBraided Hair Styles aka “Protective Styles”
Hair Weaving: Sew-in or Glued-in
Hair Straightening ◦ Use of heat ◦ Hair relaxers ◦ Japanese straightening ◦ Brazilian blowout
Hair Care Products Shampoo: Traditional, co-wash/no-poo Conditioner: Rinse-out, leave-in oils, lotions and creams Hair Color: Permanent, semi-permanent, temporary Relaxers: Lye (sodium hydroxide; pH 12-14) , no-lye (calcium, lithium, potassium or guanidine hydroxide, pH 9-11) Styling: Heat protectors, detanglers, curl enhancers, anti-frizz, shine, oils, gels (hold, twists/locs), etc.
What Should I Use on My Hair?
Popular Black-Owned Hair Care Brands
TGIN Lusters
Mielle Organics Design Essentials
Girl + Hair Curl Mix
Jane Carter Solution Coils By Nature
Kinky-Curly Uncle Funky’s Daughter
Mixed Chicks Eden Bodyworks
Camille Rose Naturals Black Girl Long Hair
Miss Jesse’s Rucker Roots
Taliah Wajiid Briogeo
Curls Hair RulesOther Popular Brands
Shea Moisture
Cantu
Carol’s Daughter
ORS
Dark & Lovely
Soft Sheen Carson
African PrideKey Points
Reduced frequency of shampooing based on structure and fragility of hair
Increased focus on moisturizing
Use of “protective” styles to reduce breakage at the ends but also to
decrease time spent of daily care
Hair care is time consuming and expensive“I need to examine your scalp…”
Do you feel comfortable to let me examine your scalp?
Your hair looks beautiful. Are you wearing any extensions
today?
How can I best see your scalp?
“I need you to come back after you take your
weave/braids/crochet down…”
Avoid “Is that your hair?”Traction Alopecia
Traction Alopecia
Hair loss due to prolonged or
recurrent tension on the hair
Initially a non-scarring alopecia,
traction may become scarring over
time
Mostly reported in women of
African descent, also seen in AA
men, ballerinas, Sikhs, recently
reported in Orthodox Jewish
woman,TA: Prevalence
SOUTH AFRICAN WOMEN SOUTH AFRICAN GIRLS
Dr Khumalo et al studied 874 adults in Capetown, Dr. Khumalo et al studied 1042 school children in
including a survey and physical exam: Capetown, including a survey and physical exam:
◦ TA found in 31.7% of women and 2.2% of men ◦ TA found in 8.6% of girls in their first year of school vs.
21.7% of girls in their last year of high school
◦ TA found in 48% of women with relaxed hair and braided
extensions ◦ TA was found in 22.9% of girls with no relaxer and 32.1% of
girls with a relaxer
◦ This trend was not statistically significant
Khumalo NP, Jessop S, Gumedze F, Ehrlich R. Hairdressing and the
prevalence of scalp disease in African adults. Br J Dermatol. 2007 Khumalo NP, Jessop S, Gumedze F, Ehrlich R. Hairdressing is
Nov;157(5):981-8. associated with scalp disease in African schoolchildren. Br J
Dermatol. 2007 Jul;157(1):106-10.TA: Associations in African American Girls
Dr. Rucker Wright et al surveyed 201 caregivers of AA girls to
evaluate hair care practices and association with disease:
◦ N=98 from derm clinic, n=103 from non-derm clinic
◦ Mean age 9.6 +/- 4.4
◦ Ponytails worn by 81%, braids worn by 67% and cornrows worn by 49% in
the last 12 months
◦ Cornrows were statistically significantly related to TA, OR 5.79
Rucker Wright D, Gathers R, Kapke A, Johnson D, Joseph CL. Hair care practices and their association with scalp
and hair disorders in African American girls. J Am Acad Dermatol. 2011 Feb;64(2):253-62.Traction Alopecia: Clinical Presentation
Traction Alopecia: Management Discontinue hair styles that cause the hair to pull Protect the hair from rubbing on hats and wigs Topical or intra-lesional steroids Topical minoxidil Oral antibiotics Hair transplant
What’s New? Frequent braiding contributes to damage to the hair fiber as well as to traction alopecia (IJCS) Prevalence of TA 7.4% in a study of 428 Nigerian secondary school students (PAMJ) Report of oral minoxidil use for TA (DT) Quantifying the impact of braiding and combing on the integrity of natural African hair. Molamodi K, Fajuyigbe D, Sewraj P, Gichuri J, Sijako B, Galliano A, Laurent A. Int J Cosmet Sci. 2021 Feb 19. Cutaneous disorders of adolescence among Nigerian secondary school students. Oyedepo JT, Katibi OS, Adedoyin OT. Pan Afr Med J. 2020 May 27;36:36. Case series of oral minoxidil for androgenetic and traction alopecia: Tolerability & the five C's of oral therapy. Beach RA. Dermatol Ther. 2018 Nov;31(6):e12707
Traction: Be Prepared Traction alopecia is 100% preventable Every interaction with an African American patient is an opportunity for 30 seconds of life changing education Encourage patients to rotate hair styles Have a list of “go to” cosmetologists Keep an open mind to the differential
Alopecia Areata
Alopecia Areata: Ophiasis Pattern
Alopecia Areata: Clinical Presentation
Alopecia Areata: Management
Topical steroids Systemic Treatments
◦ Prednisone
Anthralin .5 - 1%
◦ Azathioprine
Intralesional triamcinolone ◦ Methotrexate
◦ ILK 5-10 mg/cc ◦ Cyclosporin
◦ Sulfasalazine
Topical Immunotherapy
◦ Squaric acid dibutylester* ◦ Ezetimibe-simvastatin
◦ Diphenylcyclopropenone ◦ JAK Inhibitors (topical, oral)
◦ Dinitrochlorobenzene Adjunctive Treatments
◦ Minoxidil
*Penn State Hershey Protocol ◦ PRPAlopecia Areata in African Americans: What’s New? 9340 AA Patients from the NAAR registry identified (JAAD) ◦ African Americans had a higher odds of AA compare to Caucasians (OR 1.77; 95% CI, 1.37-2.2 ◦ Asian Americans had a lower odds of AA compared to Caucasians (OR 0.40; 95% CI, 0.32-0.50 63,960 women from the Nurses' Health Study (NHS) and 88,368 women from the Nurses' Health Study II (NHSII); 418 and 738 cases of AA, respectively (JID) ◦ NHS: OR 2.72 (95% CI 1.61-4.61) amongst black women as compared with white women ◦ NHSII: OR 5.48 (95% CI 4.10-7.32) amongst black as compared with white women. ◦ NHSII Hispanic Women: OR 1.94 (95% CI 1.24-3.02) in Hispanic compared with non-Hispanic white women. Racial characteristics of alopecia areata in the United States. Lee H, Jung SJ, Patel AB, Thompson JM, Qureshi A, Cho E. J Am Acad Dermatol. 2020 Oct;83(4):1064-1070. Race and Alopecia Areata amongst US Women. Thompson JM, Park MK, Qureshi AA, Cho E. J Investig Dermatol Symp Proc. 2018 Jan;19(1):S47-S50.
Frontal Fibrosing Alopecia
Frontal Fibrosing Alopecia Primary lymphocytic cicatricial alopecia Affects anterior hairline, eyebrows; may have loss of body hair May have facial papules or hyperpigmentation associated First reported in 1994, seeing increase in frequency
FFA: Clinical Presentation
FFA: Management
Topical
◦ Steroids
◦ Calcineurin inhibitors
◦ Minoxidil
Intralesional steroids
Systemic treatment
◦ Anti-inflammatory doxycycline or hydroxychloroquine
◦ 5 alpha reductase inhibitors
Recalcitrant disease
◦ Retinoids
◦ Immunosuppressive medicationsFFA: What’s New Lots of questions! -Why are we seeing an increase in the prevalence of this condition -Sunscreen controversy
Central Centrifugal Cicatricial Alopecia
CCCA: Etiology & Epidemiology
Limited understanding of the role of genetics, androgens,
grooming, sources of inflammation
Dlova et al, JAAD 2014
◦ Studied 14 families with 31 family members; pedigree
analysis suggested AD inheritance
Suchinwanit et al: IJD 2016
◦ 38 women with bx proven CCCA
◦ Severity was correlated with duration
◦ Androgen related conditions were prevalentCCCA: Etiology & Epidemiology
Gaithers et al conducted a retrospective survey
◦ 21% had noticed thinning by age 30; 44% by 40
◦ CCCA patients were more likely to have a sister with hair
loss than non-CCCA patients
◦ No correlation with hot combs, relaxer use, h/o burns
◦ CCCA patients more likely to have had cornrows/braids
with added hair & weaves, and have worn them for a
longer timeCCCA: Clinical Presentation
Complaint of hair loss,
breakage or pruritus
Often sent by hair stylist
Several years duration
May have seen other
dermatologists
Usually have not used any
treatment
+/- family historyCCCA: Physical Examination
Thinning at the vertex
Progression centrifugally
Loss of hair follicles
No inflammation noted
+/- scale
Some have itching, burning
or tinglingEarly CCCA
End Stage CCCA
CCCA: Breakage at the Crown
Management Goal #1:
Halt Progression
Topical or intralesional steroids
◦ High potency topicals used qd or bid
◦ Give patient a choice as to which vehicle, solution, ointment
or foam
◦ ILK 5 to 10 mg/cc as tolerated monthly
◦ Depends on amount of scalp involved and patients
willingness
Oral
◦ Doxycycline 100 mg bid or minocycline 100 mg bid
◦ PlaquenilManagement Goal #2:
Encourage Regrowth
Topical or oral minoxidil
Spironolactone
Finasteride
Supplements
PRP
Hair transplantation when stableCCCA: What’s New?
Variant PADI3 in Central Centrifugal Cicatricial Alopecia.
Malki L et al. N Engl J Med. 2019 Feb 28;380(9):833-841.
Exome sequencing, protein modeling, immunofluorescence
staining, etc.
1 splice site and 3 mutations in PADI3
PADI3 encodes peptidyl arginine deiminase, type III
This enzyme is involved in post-translational protein
modification of proteins involved in hair shaft formationHair Care and Health
Are Relaxers Harmful to Our Health?
No data demonstrating an association between relaxer use and CCCA
One study showing that women diagnosed with fibroids are more likely to have used hair relaxers
Hair relaxer use and risk of uterine leiomyomata in African-American women (Wise, et al, American Journal of Epidemiology 2012)
BWHS: 23,580 premenopausal women IRR 1.17 (95% CI 1.06-1.30)
Two recent studies demonstrating an association between relaxer use and the development of breast cancer
Skin lighteners and hair relaxers as risk factors for breast cancer: results from the Ghana breast health study (Brinton et al, Carcinogenesis
2018)
1131 invasive breast cancer patients and 2106 population controls. OR of 1.58 (95% CI 1.15–2.18)
Hair dye and chemical straightener use and breast cancer risk in a large US population of black and white women (Eberle et al, International
Journal of Cancer 2020)
46,709 women ages 35-74, 2003 -2009; 2,794 breast cancers identified. Relaxer use was associated with breastcancer risk (OR =
1.18, 95% CI 0.99-1.41Is Hair Dye Harmful to Our Health?
Lymphoma
◦ Conflicting data
◦ Women who started using hair dye before 1980 had a 30% increased risk
of developing NHL compared to women who never used hair dye
Leukemia
◦ Conflicting data
Bladder cancer
◦ Small increase in risk among cosmetologists but not among hair dye
users
Breast Cancer
◦ Conflicting data
◦ Historically, thought leaned against an association
◦ Recent data suggests an association between hair dye use and
African American womenEndocrine Disruptors
Natural or man-made chemicals that mimic or interfere Atrazine: weed killer, water contaminant
with the body’s hormones Bisphenol A (BPA) : canned foods, plastic bottles
Linked with developmental, reproductive, neurological, Dioxins : forms in industrial processes, found in animal products
immunological and other problems.
Estrogens: hair growth products
Glycol ethers: found in sunscreen and cosmetics (humectant, emollient)
Parabens: preservative in hair care products
Perchlorate : rocket fuel, water contaminant, produce
Polyfluoroalkyl Substances (PFAS): water contaminant, non-stick pans
Phthalates: plastic containers, “fragrance”
Phytoestrogens: soy
Polybrominated diphenyl ethers (PBDE) : flame retardant
Polychlorinated biphenyls (PCB) : banned coolant, contaminant
Triclosan: antimicrobial soapsEstrogens and Anti-Estrogens
in Hair Products
Estrogenic and anti-estrogenic activity of off-the-shelf hair and skin
care products (Myers et al, Journal of Exposure Science and
Environmental Epidemiology 2015)
◦ Evaluated 8 hair and skin care products commonly used by AA
women for estrogenic and antiestrogenic activity using a cell
proliferation assay
◦ 4/8 products, including a hair oil, demonstrated estrogenic
activity
◦ 3/8 products, including a placenta conditioner and a tea tree
oil hair conditioner, demonstrated anti-estrogenic activityEndocrine Disruptors in Hair Products
Measurement of endocrine disrupting and asthma-associated
chemicals in hair products used by Black women (Helm et al,
Environmental Research 2018)
◦ Used GC/MS to test 18 hair products in 6 categories used by
Black women: hot oil treatment, anti-frizz/polish, leave-in
conditioner, root stimulator, hair lotion, and relaxer
◦ Tested for 66 chemicals belonging to 10 chemical classes:
ultraviolet (UV) filters, cyclosiloxanes, glycol ethers, fragrances,
alkylphenols, ethanolamines, antimicrobials, bisphenol A,
phthalates, and parabens
◦ 45 chemicals were found, belonging to all 10 classes
◦ Root stimulators, hair lotions, relaxers, anti-frizz
◦ 84% of ingredients found were not listed on the labelsEarly Menarche
Childhood hair product use and earlier age at menarche in a
racially diverse study population: a pilot study (James-Todd et
al, Annals of Epidemiology 2011)
◦ 300 AA, African-Caribbean, Hispanic, and white women ages 18-77 years
of age.
◦ Data collected retrospectively on hair oil, lotion, leave-in conditioner,
perm, and other types of hair products used before age 13.
◦ Women reporting childhood hair oil use had an increased risk for early
menarche (RR 1.4, 95% CI 1.1-1.9)
◦ Hair perm users had an increased risk for earlier menarche (ARR 1.4, 95%
CI 1.1-1.8)Early Menarche
Hair product use, age at menarche and mammographic breast
density in multiethnic urban women (McDonald et al,
Environmental Health, 2018)
◦ 248 women from 2 cohorts
◦ Examined childhood and adulthood use of hair oils, lotions, leave-in
conditioners, root stimulators, perms/relaxers, and hair dyes
◦ Childhood “ever use” of any hair product and specifically use of hair oil
were associated with a higher probability of reaching menarche before
11 years of age
◦ Postulates product use may increase risk of breast cancerConclusion
More information is needed regarding etiology and pathogenesis of
these diseases
Clarification of the role of grooming practices in disease progression is
needed
Evidence-based treatment approaches are lacking for many conditions
Education of patients, stylists and the general population is key to early
diagnosis and treatment compliance
More and better treatments are neededYou can also read
