Chapter 23: Ethnic Hair Disorders

SUMMARY

• African hair has unique morphology where the hair follicle is curved/twisted with variable shaft diameter rather than straight with consistent diameter as found in Asians and Caucasians. African hair also has low lipid content. This renders the hair more brittle and susceptible to hair breakage.

• Hairstyles play an important role for many hair disorders in patients of African descent. Traumatic practices such as hot combing, chemical relaxers and dyes lead to acquired trichorrhexis nodosa (hair breakage) while tension-producing hair styles such as braids and weaves lead to traction alopecia.

• The helical nature of African hair can lead to ingrown hairs that penetrate back into the skin, causing inflammatory papules, pustules, and nodules found in pseudofolliculitis barbae in the beard or acne keloidalis nuchae in the occipital scalp.

• Central centrifugal cicatricial alopecia (CCCA) and dissecting cellulitis are primary inflammatory cicatricial hair disorders with higher prevalence in patients of African descents.

TIPS FOR DIAGNOSIS

• Perform a thorough history, including grooming practices.

• Presence of vellus hair at dermoscopy distinguishes traction (vellus hair preserved) from frontal fibrosing alopecia (vellus hair are lost).

• Take a dermoscopy guided punch biopsy for histologic examination on horizontal sections in possible scarring alopecia.

TIPS FOR TREATMENT

• Discuss traumatic hair styling and offer safe alternatives such as twisting. Discuss measures to reduce hair damage and breakage.

• Seborrheic dermatitis is very common and requires a tailored approach that considers differences in hair texture and hair washing frequency.

• Early detection and initiation of treatment for CCCA and dissecting cellulitis with steroids, antibiotics, and/or other steroid-sparing anti-inflammatory agents is critical to prevent end-stage scarring of hair follicles

• Use of clippers or razor foil guards is useful for patients with pseudofolliculitis barbae and acne keloidalis nuchae to allow for close shaving while maintaining hair lengths > 0.5 millimeters to prevent both transfollicular and extrafollicular penetration.

DON’T FORGET

• Always ask about hair styling practices as they may predispose to hair damage, breakage, and inflammation.

PITFALLS AND CAUTIONS

• Dermoscopy of early-stage dissecting cellulitis resembles that of alopecia areata with black dots, broken hairs, and exclamation point hairs.

• Patchy CCCA may be mistakenly considered as traction alopecia. Dermoscopy is helpful for identifying peripilar white/gray halos which are a sensitive and specific sign for CCCA.

EXPERT PEARLS

• Pigmentary changes and facial papules are a prominent clinical finding in FFA.

• Always ask if patient changed hairdresser and experience pain during the hairstyle.

• Early intervention for inflammatory primary cicatricial alopecias is critical to prevent irreversible scarring and hair loss.

PATIENT EDUCATION POINTS

• Patients must be aware of which hairstyles can cause/worsen their problems.

• Areas of hair loss combined with other symptoms such as tingling, loss of sensation, burning, or stinging pain are clues to an inflammatory type of hair loss disorder that can lead to irreversible scarring.