Alopecia or hair loss is one of the primary reasons that African American females seek out dermatologic care. This resonates with dermatologists because this primary concern is different than other populations, where acne, eczema, warts, moles, and skin cancers are the more common reasons for dermatologic visits. In the Black community, hair is a prominent expression of culture, and bold hairstyles are a source of pride for many as well. Unfortunately, these hairstyling practices can lead to harm that may not be limited to the scalp. In fact, the use of relaxers has been shown to increase the risk of uterine fibroids amongst African-American females, for example. Moreover, there seems to be a lack of education that treatment for alopecia can be quite successful, when pursued early.
Traction alopecia is the most common type of hair loss amongst African-Americans, with gradual hair loss after the use of tight hair styling practices, such as braids, weaves, tight ponytails, and dread locks. Combining these hairstyles with the use of a relaxer increases the risk of traction alopecia. In addition, any symptomatic traction that leads to pain, pustules, or crusting also increases the risk.
Medical therapy for traction alopecia can be successful if early treatment is sought. If the thinning areas do not respond to medical therapy and the hair loss is considered permanent, then hair transplantation is a viable option to restore the hair in the affected areas.
Traction alopecia is highly prevalent at 18% amongst African American girls. The high prevalence is a disconcerting realization, as traction alopecia is a very preventable form of hair loss. In all other populations, androgenetic alopecia, is the most prevalent type of alopecia, which has a strong genetic predisposition and is not considered preventable. Therefore, acknowledging that traction alopecia is an unnecessarily common form of alopecia that is entirely self-induced is important when considering how to educate the public. In addition, compared to androgenetic alopecia, traction alopecia can become cosmetically disfiguring which can truly influence affected individuals’ quality of life. Because it can lead to significant embarrassment, often affected individuals will attempt to mask the thinning areas with braids, weaves, and wigs, for example, which can further compound the perceived trauma around the hair follicles and lead to further hair loss.
Dermatologists and hairstylists alike need to work together to educate the public about preventing traction alopecia. Studies show that the preteen age is best for public health education. We ought to reinforce that traction-based hairstyles should be painless and that pain is an indication to undo the hairstyle, not to apply damp scarves or ingest aspirin. In addition, if relaxers are used, traction-based styles should be avoided for at least two weeks.
In addition to traction alopecia, a progressive, scarring form of hair loss, termed central centrifugal cicatricial alopecia (CCCA), is almost exclusively seen in females of African descent. If left untreated, CCCA can lead to an incredibly cosmetically disfiguring bald scalp. The etiology is unclear; however, there is an association with the use of relaxers, pomades, tight hairstyling practices, as well as a possible genetic predisposition. In addition, CCCA is often seen in individuals that also exhibit evidence of traction alopecia.
CCCA may be asymptomatic or associated with mild tenderness, itching, or burning sensations around the vertex scalp. Initially, it begins as a small area of thinning and shortened hairs that if left untreated can lead to progressive scarring and eventual smooth, larger scarring areas of hair loss.
As with traction alopecia, treatment for CCCA should be sought as early as possible. It is important that the affected individual understands that the goal of treatment is to stop or at least slow down the progression of the disease and that any hair regrowth is an added benefit.
End-stage CCCA is difficult to treat medically, as the disease is inactive and these scarring areas will not likely achieve regrowth. Therefore, hair transplantation may be considered.
In summary, because our hair is part of the way we present ourselves to the world, hair loss can be particularly devastating. It is concerning that these cosmetically disfiguring forms of alopecia are so prevalent amongst the African-American community; particularly, because these conditions are mostly preventable. Therefore, education is vital. Dermatologists and hairstyling experts should do work on outreach to better inform the community to not only prevent these forms of hair loss with healthy hair care practices, but to also seek care as early as possible, to decrease the likelihood of permanent alopecia. Braids, dreadlocks, and other hairstyles popular in African- American culture can be beautiful cultural expressions that if cared for properly, can be maintained without damage.