Update on Hair Lossin African American WomenVictor ia Barbosa MD, MPH, MBA

Mark Al len Everett MD Skin of Color Symposium

Univers ity of Oklahoma

Apri l 23, 2021

Introduction

Associate Professor, University of Chicago Department of Medicine Section of Dermatology

Director of the Hair Loss Program

Email: vbarbosa@uchicago.eduPhone 773-702-5525FB, 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

Survival Probability of Different Ethnicities

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GROWTH

Loussouarn G. African hair growth parameters. Br J Dermatol. 2001 Aug;145(2):294-7

◦ 256 (+/- 44) vs 396 (+/- 55) micrometers per day for Blacks vs. Caucasians

◦ 3.68” per year vs. 5.74” per year

The influence of African-American hair's curl pattern on its mechanical propertiesCrystal 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 out

Braided 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

Mielle Organics

Girl + Hair

Jane Carter Solution

Kinky-Curly

Mixed Chicks

Camille Rose Naturals

Miss Jesse’s

Taliah Wajiid

Curls

Lusters

Design Essentials

Curl Mix

Coils By Nature

Uncle Funky’s Daughter

Eden Bodyworks

Black Girl Long Hair

Rucker Roots

Briogeo

Hair Rules

Other Popular Brands

Shea Moisture

Cantu

Carol’s Daughter

ORS

Dark & Lovely

Soft Sheen Carson

African Pride

Key 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

Dr Khumalo et al studied 874 adults in Capetown, including a survey and physical exam:

◦ TA found in 31.7% of women and 2.2% of men

◦ TA found in 48% of women with relaxed hair and braided extensions

Khumalo NP, Jessop S, Gumedze F, Ehrlich R. Hairdressing and the prevalence of scalp disease in African adults. Br J Dermatol. 2007 Nov;157(5):981-8.

SOUTH AFRICAN GIRLS

Dr. Khumalo et al studied 1042 school children in Capetown, including a survey and physical exam:

◦ 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 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 is 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

Anthralin .5 - 1%

Intralesional triamcinolone◦ ILK 5-10 mg/cc

Topical Immunotherapy◦ Squaric acid dibutylester*

◦ Diphenylcyclopropenone

◦ Dinitrochlorobenzene

*Penn State Hershey Protocol

Systemic Treatments◦ Prednisone

◦ Azathioprine

◦ Methotrexate

◦ Cyclosporin

◦ Sulfasalazine

◦ Ezetimibe-simvastatin

◦ JAK Inhibitors (topical, oral)

Adjunctive Treatments◦ Minoxidil

◦ PRP

Alopecia 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 medications

FFA: 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 prevalent

CCCA: 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 time

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 history

CCCA: Clinical Presentation

Thinning at the vertex

Progression centrifugally

Loss of hair follicles

No inflammation noted

+/- scale

Some have itching, burning or tingling

CCCA: Physical Examination

Early 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

◦ Plaquenil

Management Goal #2:Encourage Regrowth

Topical or oral minoxidil

Spironolactone

Finasteride

Supplements

PRP

Hair transplantation when stable

CCCA: 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 formation

Hair 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 0.99-1.41

Is 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 women

Endocrine DisruptorsNatural or man-made chemicals that mimic or interfere with the body’s hormones

Linked with developmental, reproductive, neurological, immunological and other problems.

Atrazine: weed killer, water contaminant

Bisphenol A (BPA) : canned foods, plastic bottles

Dioxins : forms in industrial processes, found in animal products

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 soaps

Estrogens 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 activity

Endocrine 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 labels

Early 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 cancer

Conclusion

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 needed