Approach to Treating Common Hair Conditions In An Ethnic Population

Approach to Treating Common Hair Conditions In An Ethnic Population Crystal Aguh, MD Assistant Professor of Dermatology, Johns Hopkins School of Medicine

PHOTOGRAPHY & VIDEOTAPING ARE STRICTLY PROHIBITED IN ALL EDUCATIONAL SESSIONS CELL PHONES MUST BE PLACED ON VIBRATE OR TURNED OFF Violations of this policy will result in removal from the session and possible revocation of meeting registration. Session directors will be closely monitoring such occurrences. FOTOGRAFIA E FILMANDO SÃO ESTRITAMENTE PROIBIDOS EM TODAS AS SESSÕES EDUCACIONAIS TELEFONES CELULARES DEVEM SER COLOCADOS EM VIBRAR OU DESLIGADOS Violações desta política resultará na remoção de sessão e possível revogação do registo da reunião. Diretores de sessão irão acompanhar de perto tais ocorrências.

PHOTOGRAPHIE & ENREGISTREMENT VIDÉO SONT STRICTEMENT INTERDITS DANS TOUTES LES SESSIONS ÉDUCATIVES LES TÉLÉPHONES CELLULAIRES DOIVENT ÊTRE PLACÉS À VIBRER OU DÉSACTIVÉ Violation de cette politique se traduira par la suppression et la possibilité de la révocation de la session et, éventuellement de l'enregistrement de la réunion. Directeurs des sessions observeront de près ces occurrences. LA FOTOGRAFÍA Y EL GRABAR ESTÁN ESTRICTAMENTE PROHIBIDOS EN TODAS LAS SESIONES EDUCATIVAS LOS TELÉFONOS CELULARES DEBEN PONERSE EN MODO PARA VIBRAR O DEBEN APAGARSE Violaciones de esta norma resultará en la eliminación de la sesión y la posible revocación del registro de la reunión. Directores de las sesiones observaran acerca tales ocurrencias.

DISCLOSURE OF RELATIONSHIPS WITH INDUSTRY Crystal Aguh, MD U047 - Approach to Treating Common Hair Conditions In An Ethnic Population DISCLOSURES I do not have any relevant relationships with industry.

January 30, 2018 5

Lecture Overview In this talk we will go over: Physical properties of Curly hair Common Hairstyling Practices Common Hair Disorders in Black Patients The Science of Hair Care

Which of the following is the best choice to be included as part of the treatment regimen for this condition? a) Ketoconazole shampoo daily b) Topical steroid in a solution base c) Topical steroid in an oil base d) Removal of braids and avoidance of tight hairstyles Pre-Test #1

Pre-Test #2 Which of the following is the most likely cause of hair loss in this patient? a) Tinea Capitis b) Relaxers c) Extensions d) Alopecia areata

Pre- Test #3 What is the most likely diagnosis? a) Acquired Trichorrhexis Nodosa b) Monilethrix c) Congenital Trichorrhexis Nodosa d) Androgenetic Alopecia January 30, 2018 9

Pre-Test #4 Which of the following treatment options would be most effective in this patient presenting with hair loss? a) Avoidance of tight hairstyles b) Topical steroids c) Intralesional steroid injection d) Topical anthralin

Pre-Test #5 Which of the following is NOT an anionic surfactant? a) Sodium Lauroyl Sarcosinate b) Ammonium Lauryl Sulfate c) Sodium Lauryl Sulfate d) Behentrimonium Methosulfate January 30, 2018 11

Hair Basics The hair follicle contains many components, including the hair shaft. The cortex is responsible for the tensile strength of the shaft The cuticle is responsible for the shine and texture

Hair Basics Similar chemical structure amongst all major racial groups Different physical properties Parameter Asian Caucasian African Growth rate (um/day) 411 367 280 Hair Density (hairs/cms2) 175 226 161 Ellipticity 90% (circular) 75% (less circular) 60% (oval) Loussouarn, Geneviève, Charles El Rawadi, and Gilles Genain. "Diversity of hair growth profiles." International journal of dermatology 44.s1 (2005): 6-9.

Hair Basics Permanent treatments work by affecting the cortex To permanently change the shape of the hair, disulfide bonds must be altered Sebum, a product of the scalp sebaceous glands, is a natural moisturizer that protects the scalp from normal weathering Sebum has a more difficult time traveling down the shaft of curly hair making it more susceptible to breakage

Hair Fragility Fig. 1. A, Detail of knot in the African hair. Note complex nature of the knot with damage to the cuticle exposing the cortical fibers. B, Detail of the only knot observed in the Caucasian hair, which appears to be looser with no damage to the cuticular layer. C and D, Details from African hair mat shows the longitudinal fissures of the shafts (arrows) plus examples of splitting (C) and breaking (D) of the hair shaft. (A-D, Scale bar = 0.1 mm.) Khumalo, N. P., et al. "What is normal black African hair? A light and scanning electronmicroscopic study." Journal of the American Academy of Dermatology 43.5 (2000): 814-820. A, SEM of an African hair shows serrated appearance of a fractured tip with exposure of the cortical fibers. B, SEM of Caucasian hair shows original tip with loss of cuticular pattern resulting from weathering. C, Tip of Caucasian hair with flattened end, probably as a result of cutting. Note extensive wearing of the hair shaft with loss of the cuticular pattern. D, Tip of Asian hair exhibits a cut end and relatively little weathering of the hair shaft. E, Part of mid-portion of an African hair shaft shows the well-preserved cuticular pattern with no evidence of weathering. F, Mid-portion of Caucasian hair shaft shows the well-preserved cuticular pattern. (A-F, Scale bar = 0.1 mm.).

Common Ethnic Hair Practices January 30, 2018 16

Chemical Relaxers

It is estimated that up to 70% of black women chemically straighten their hair regularly;; up to 90% have chemically straightened their hair at least once Alkaline product typically containing one of two ingredients: Sodium Hydroxide (lye, ph 12-14) or guanidine hydroxide (no-lye- a mix of calcium hydroxide and guanidine carbonate, ph of 11-13) Following application of alkaline agent, the hair is mechanically straightened using a comb during the reducing phase to restructure the position of disulfide bonds between new polypeptide keratins. Conclude by consolidating bonds using an oxidizing agent (neutralizing agent). Must be repeated every 4-8 weeks Chemical Relaxers

Chemical Relaxers

Relaxer Types Lye Relaxer No-Lye Relaxer Typically available only in a salon Available at local retail stores Sodium Hydroxide Guanidine Hydroxide, Lithium Hydroxide Irritates the scalp quickly Less likely to irritate the scalp during application à more likely to overprocess Less likely to leave calcium deposits over time More likely to leave calcium deposits, dull hair over time

Side Effects of Relaxer Treatments Contact dermatitis Scalp burns Traction alopecia Staphylococcus aureus abscess formation Diffuse hair loss

Tips to minimize damage from chemical straighteners 1-Have a professional stylist apply the relaxer 2-Have the stylist apply a base to the entire scalp before application 3-Decrease the frequency of touch ups to every 8-10 weeks 4- Take a relaxer holiday for 2-3 months at a time (can wear weaves or wigs during this break) 5- suggest a chemical free natural hairstyle *adapted from Callender, Valerie D., Amy J. McMichael, and George F. Cohen. "Medical and surgical therapies for alopecias in black women." Dermatologic therapy 17.2 (2004): 164-176.

Systemic Implications of Relaxer Use: A Word on Fibroids The relationship between relaxers and fibroids in black women has been explored extensively by researchers. So far, there s no definitive link suggesting that relaxers CAUSE fibroids. The Black Women s Health Study prospectively followed 24,000 black women and asked them how often they relaxed their hair, the age they started using relaxer, the number of scalp burns they had from relaxers and several other questions. Women who relaxed their hair at least 7 times a year (every 6-8 weeks), were more likely (incidence rate ratio 1.15) to develop fibroids than women who relaxed their hair fewer than 2 times a year. Suggests an association between relaxers and fibroids, though causality is not established January 30, 2018 23

Braiding (with extensions)

Braiding Synthetic hair is attached (braided) onto hair to create a seamless blending of the two textures Style typically left in place for 2-6 weeks Versatile hair choice

Weaves

Weaves Estimated that 60% of black women are wearing wigs, weaves or extensions at some point during the year Create a similar final appearance as wigs but meant to be worn up to 2-3 months at a time Client s hair is typically braided underneath weave forming a track Synthetic hair is sewn onto tracks with thread Can lead to traction alopecia, scalp infection, contact dermatitis

Weave Installation

Thermal Straightening

Thermal Straightening Can be achieved with a variety of devices including hot combs and flat irons Temporarily rearranges hydrogen bonds in the cortex to allow hair to take temporary straighter shape When done repeatedly, can lead to breakage/permanent hair damage

Common Hair Disorders In Black Patients

Traction Alopecia

Traction Alopecia Occurs along the crown of the scalp as a result of tight hair styles Though considered a type of non-scarring hair loss, over time hair loss can become permanent One study estimated a prevalence of 32% among black women. Women with relaxed hair were more than 3.5 times more likely to develop traction alopecia compared to those with natural hair Pruritus, folliculitis, hyperkeratosis and erythema can all precede hair loss Ask patients about pain relievers and get a good history! Treatment- discontinuation of tight braiding hair styles, antibiotics for folliculitis and/or topical or intralesional steroids for inflammation

All Extensions Are Not Created Equal BAD January 30, 2018 BAD OKAY 34

Low Risk Braided Extensions January 30, 2018 35

Acquired Trichorrhexis Nodosa

Acquired Trichorrhexis Nodosa ATN is recurrent hair breakage that occurs as a result of damaging hair practices Common culprits include chemical relaxers, thermal styling and hair coloring Patients will often complain of lack of hair growth Can involve all parts of the scalp but nape of the neck is often affected

How to Care for Black Hair Important to condition hair at least weekly, with deep conditioning at least biweekly Recommend use of leave-in conditioners several times weekly Have relaxers applied by a stylist Avoid use of thermal straighteners Minimize use of tight hair styles Recommend removal of weaved or braided hairstyles after 6-8 weeks maximum Recommend cleansing the hair at least bi-weekly with a sulfate free shampoo

Seborrheic Dermatitis

Seborrheic Dermatitis Related to Malessezia though the exact relationship is unclear. Likely an abnormal immune reaction to Malessezia in the skin Most common in young adulthood and adolescence due to increased sebaceous gland activity though unrelated to sebum levels Increased cleansing frequency has been shown to decrease inflammation in patients with seborrheic dermatitis but may not be feasible in curly hair types Have increased reaction to sodium lauryl sulfate, found in a majority of shampoos (including Nizoral)

Seborrheic Dermatitis- Treatment Options Gupta, A. K., and R. Bluhm. "Seborrheic dermatitis." Journal of the European Academy of Dermatology and Venereology 18.1 (2004): 13-26.

Special Considerations Consider the qualities of black hair when prescribing medications. For instance, when treating seborrheic dermatitis or psoriasis BAD: Ketoconazole shampoo, coal tar shampoo, salicylic acid shampoo GOOD: Zinc Pyrithione, Ciclopirox, Fluocinolone oil (derma-smoothe) Consider normal hair care practices when discussing treatment options BAD: Asking patients to wash their hair daily GOOD: prescribing scalp oils or asking them to increase frequency to weekly Consider hair styling when prescribing topical steroids Ointments and oils: women with thermally straightened hair may prefer Foams and oils- may be preferred for women with chemically straightened hair

The Science of Hair Care January 30, 2018 43

Shampoos vs Conditioners Shampoos Remove excess product and/or sebum buildup Strips the hair of natural moisturizers used to protect the shaft Creates a negative charge on the hair shaft Can cause hair breakage and damage through repeated swelling and shrinking of the hair shaft (hygral fatigue) Conditioners Temporarily repair dry damaged hair Mimic the action of sebum on the hair Improve frizz and minimize fly-aways Decrease the friction between hair strands Increase manageability Temporarily mend split ends by re-aligning the cortex and medulla to halt further damage Poor cleansing/buildup January 30, 2018 44

How Shampoo Works Shampoos are formulated with special detergents aimed at uniquely expelling dirt and oils from the hair shaft without damaging the shaft or leaving behind a calcified build up Modern shampoos are formulated with surface active ingredients, or surfactants, that are able to work well in all types of water Surfactants consist of a lipophilic group and hydrophilic group and are classified according to the latter

Surfactants

Types of Surfactants- Anionic Anionic surfactants contain a negatively charged hydrophilic group Considered to be the most effective at removing sebum when compared to other classes of surfactants Most popular brand of ingredients found in shampoos Common examples include: lauryl sulfates, laureth sulfates, sarcosines and sulfosuccinates This class of surfactants should be avoided in dry, damaged hair or color treated hair

Types of Surfactants-Cationic Cationic surfactants are differentiated by their positively charged hydrophilic group Unlike anionic surfactants, cationic surfactants increase the softness and manageability of the hair Cationic surfactants are particularly attracted to negatively charged acids in the hair Poor cleansing ability Examples: long chain amino esters and ammonioesters

Types of Surfactants-Amphoteric Amphoteric surfactants contain both an anionic group and a cationic group Shampoos containing amphoteric surfactants have moderate cleansing ability Popular in tear-free shampoo formulations Also common in baby shampoos Common amphoteric surfactants include betaines, sultaines and imidiazoliniums

Types of Surfactants-Non-Ionic Non-ionic surfactants contain no polar groups Compatible with all other surfactant types They are the mildest of all of the surfactants and leave the hair manageable Examples of non-ionic surfactants include decyl glucoside, fatty alcohol ethoxylates (such as cetyl alcohol and stearyl alcohol) and sorbitan ether esters

Types of Conditioners-Rinse Out Rinse out conditioners are applied to the hair immediately after shampooing The most common conditioning agents are quaternary ammonium compounds which are positively charged cationic compounds that balance out the anionic charge of shampoos. In addition to increasing manageability as noted above, these conditioners also help the scales of the hair cuticle lie flat, increasing the shine and luster of the hair

Protein Conditioners Over time, damaging styling habits can lead to flattening of the cuticular scales and the creation of holes within the shaft Hydrolyzed proteins are small enough to enter the hair shaft and repair these holes to increase the strength of the hair shaft by up to 10% May be formulated as rinse-out or deep conditioner formulations Essential to the regimen of patients with dry and/or damaged hair Common hydrolyzed proteins include: keratin, collagen, and elastin among others

What is a sulfate-free shampoo? Amphoteric and Non-Ionic sulfate-free Surfactants Less drying than anionic surfactants;; ideal for regular use especially in curly/kinky or damaged hair Benzalkonium Chloride Cetrimonium Chloride CocamidopropylBetaine DecylGlucoside Lauryl Glucoside Stearamidopropyl Dimethylamine Cocamide MEA Disodium Cocoamphodipropionate Behentrimonium Methosulfate Anionic Surfactants The products are the best at removing product buildup but can be drying. Use sparingly Sodium Lauryl Sulfate Sodium Laureth Sulfate Sodium Lauroyl Sarcosinate Ammonium Lauryl Sulfate Sodium Myreth Sulfate Sodium C14-16 Olefin Sulfonate Disodium laureth sulfosuccinate January 30, 2018 53

For the Physician: Do s and Don ts for patients with curly hair Do s Do talk to your patient about their typical styling habits Do recommend products that may help them with dry hair/scalp Do discuss the benefits of less traumatizing hair styles Do prescribe oils and ointments whenever possible to help with ease of use Don ts Don t recommend your patient stop certain styling techniques if it is unnecessary Don t recommend a patient go natural without providing them tips on how to do so Don t (if avoidable) prescribe shampoos and topical agents that will dry out their hair- they will not use it!

Post-Test #2 Which of the following is the most likely cause of hair loss in this patient? a) Fungal infection b) Relaxers c) Extensions d) Autoimmune mediated destruction of the hair shaft

Post Test #3 What is the most likely diagnosis? a) Acquired Trichorrhexis Nodosa b) Monilethrix c) Congenital Trichorrhexis Nodosa d) Androgenetic Alopecia January 30, 2018 57

Post-Test #4 Which of the following treatment options would be most effective in this patient presenting with hair loss? a) Avoidance of tight hairstyles b) Topical steroids c) Topical Antifungal d) Topical anthralin

Pre-Test 5 Which of the following is NOT an anionic surfactant? a) Sodium Lauroyl Sarcosinate b) Ammonium Lauryl Sulfate c) Sodium Lauryl Sulfate d) Behentrimonium Methosulfate January 30, 2018 59

References Bernard, Bruno A. "Hair shape of curly hair." Journal of the American Academy of Dermatology 48.6 (2003): S120-S126. Loussouarn, G. "African hair growth parameters." British Journal of Dermatology 145.2 (2001): 294-297. Loussouarn, Geneviève, Charles El Rawadi, and Gilles Genain. "Diversity of hair growth profiles." International journal of dermatology 44.s1 (2005): 6-9. Khumalo, Nonhlanhla P., et al. "Determinants of marginal traction alopecia in African girls and women." Journal of the American Academy of Dermatology 59.3 (2008): 432-438. Bolduc, Chantal, and Jerry Shapiro. "Hair care products: waving, straightening, conditioning, and coloring." Clinics in dermatology 19.4 (2001): 431-436. Khumalo, N. P., et al. "What is normal black African hair? A light and scanning electron-microscopic study." Journal of the American Academy of Dermatology 43.5 (2000): 814-820. Bhushan, Bharat, Guohua Wei, and Paul Haddad. "Friction and wear studies of human hair and skin." Wear 259.7 (2005): 1012-1021. McMichael, Amy J. "Ethnic hair update: past and present." Journal of the American Academy of Dermatology 48.6 (2003): S127-S133. Franbourg, A., et al. "Current research on ethnic hair." Journal of the American Academy of Dermatology 48.6 (2003): S115- S119. Gupta, A. K., and R. Bluhm. "Seborrheic dermatitis." Journal of the European Academy of Dermatology and Venereology 18.1 (2004): 13-26.