At the Society of Dermatology Physician Assistants Annual Summer Dermatology Conference 2021 in Chicago, IL, Heather Woolery-Lloyd, MD, emphasized the need for dermatologists to familiarize themselves with hair practices for patients with skin of color.

“You really need to understand hairstyling methods, because they significantly contribute to the hair loss and scalp disorders that we see in our patients,” stressed Dr Woolery-Lloyd. Unprocessed hair styles include afros, locs, twists, and braiding with either cornrows or multitufted braids. Additional styles include extensions, hot combing, chemical relaxers, and keratin.

“The only hair style that’s not associated with any type of hair loss is the afro,” Dr Woolery-Lloyd explained. “Afros are very popular right now, which is wonderful from a dermatologic standpoint because really they’re the best hair style that offers the healthiest hair.” However, this means that other hair styles have been associated with hair loss.

Extensions are also popular and can be either braiding or gluing hair onto existing hair or cap. A cap is what a patient may refer to as a “sew in,” in which cornrows are applied to the scalp and the extensions are sewn onto the scalp. Locks are a natural hairstyle in which the hair is not combed and forms knots spontaneously, though smaller locks can be created by twisting hair. Cornrows and multitufted braiding are also well-known styles. These take hours to create and last a while, though stylists need to be careful not to place too much tension in the braids.

“Again, in a culturally sensitive way, you can tell your patients to just avoid tight styles because that can contribute to the loss of edges,” said Dr Woolery-Lloyd. “Our patients won’t use the term traction alopecia. They’ll say ‘I’m losing my edges,’ which is the frontal hairline,” she explained further. Prevention is key when it comes to traction hair loss, and looser styles should be encouraged.

Chemical relaxers, while not as popular a tool as in the past, are made with either lye (sodium hydroxide) or no-lye (guanidine hydroxide). Both break down disulphide and create more brittle hair prone to breakage, and these products can also cause chemical burns. Keratin is another product that typically uses some level of formaldehyde, and the FDA is now working to regulate these products and their labels. Lastly, hot combing is another technique to straighten the hair. While it has not been proven, hot combing is thought to be a cause of scarring alopecia in African American women.

Dr Woolery-Lloyd discussed central centrifugal cicatricial (“scarring”) alopecia (CCCA). Her treatment algorithm includes:

• Intralesional triamcinolone for three to five sessions

• Topical class I steroid in a formulation that is chosen by the patient and is alcohol-free (eg, patients with braids may prefer a cream whereas a patient with relaxed hair may want a foam)

• Biotin

• Minoxidil 5%

• “Other” hair vitamins on the market

• Oral antibiotics for patients with severe inflammation

• Platelet-rich plasma in stable patients

For patients with CCCA, it is important to set realistic expectations with patients, said Dr Woolery-Lloyd. It is necessary to explain that the first goal of treatment is to prevent further hair loss because CCCA is a progressive condition. The second goal is the possible growth of new hair, with 10% to 30% regrowth considered a clinical success depending on the stage.

In addition to discussing common hair styles and CCCA, Dr Woolery-Lloyd spoke about frontal fibrosing alopecia as well as various cutaneous conditions in skin of color, including acne, melasma, drug-induced facial hyperpigmentation, ochronosis, postinflammatory hyperpigmentation, acanthosis nigricans, and lichen planus pigmentosus.

Reference
Woolery-Lloyd H. Skin of color. Presented at: Society of Dermatology Physician Assistants Annual Summer Dermatology Conference 2021; July 22-25, 2021; Chicago, IL.