Hair Loss (Alopecia)

Alopecia, which means hair loss, is of epidemic proportion for many women of color. Although there have been magazine articles and television segments about alopecia, it continues to be poorly understood by many women. There are many different causes of alopecia that affect women with brown skin. However, there are two types of hair loss that women with curly or tightly coiled hair are plagued with: central centrifugal cicatricial alopecia (Figure 1 and Figure 2).

Fig 1. Mild CCCA

Fig 2. Traction alopecia


Alopecia is a devastating condition for all women, despite the cause. All women want to have their own healthy hair. Hair loss effects self-esteem, social interactions and relationships.

Central centrifugal cicatricial alopecia (CCCA) was previously called follicular degeneration syndrome or hot comb alopecia. CCCA is a form of hair loss that has the following features:

  • Central (crown) portion of the scalp is were the problem begins
  • Centrifugal (circular) pattern is the outward pattern in which this problem progresses
  • Cicatricial (scarring) of the hair follicles occurs
  • Alopecia (hair loss) is progressive

Fig 3. Moderate CCCA

With CCCA, the hair loss may appear suddenly and progress relentlessly (Figure 3). It occurs in women of all ages, from as young as 20 to as old as 60. The cause of CCCA is unknown but it is felt to be related to repeated and frequent but unnoticed damage to the hair follicles. There may be a hereditary component to CCCA and for Black and some Latina women, a combination of hair care habits and practices may cause or contribute to the condition. Some dermatologists theorize that the following factors may play a role in the cause or CCCA:

  • Genetics
  • Hot combing (microscopic droplets of hot hair oil drip onto and damage the hair follicles)
  • Chemical relaxing (the severe tingling and burning that occurs when the application directions are not followed may produce inflammation and destruction of the hair follicles)
  • Tight rollers or curlers used to set the hair (the chronic pulling or traction of the hair may produce inflammation and destruction of the follicles)
  • Braids with extensions or weaves to style the hair (the chronic pulling or traction of the hair may produce inflammation and destruction of the follicles)
  • Blow drying (excessive heat applied to the scalp and hot oil droplets may destroy the follicles)
  • “Oiling or greasing the scalp” (may block the follicles and cause inflammation in the follicles)

Once the hair follicles become damaged or destroyed, scar tissue (cicatrix) forms and hair will never regrow. Therefore, if you suspect that you may have CCCA, it is important to see your dermatologist immediately. An evaluation by the dermatologist will include blood tests to eliminate other causes of hair loss and a scalp biopsy. A scalp biopsy is a simple procedure in which a small area of the scalp is removed after numbing medication is administered. A stitch is then placed to close the areas. When the biopsy is analyzed by the pathologist, features typical of CCCA may be seen: a decrease or absence of hair follicles, scar tissue formation and inflammatory cells surrounding the hair follicles.

Treatment
Since dermatologists do not know the exact cause of CCCA, outlining a treatment is difficult. The first step is to stop any styling practice that may be causing or contributing to the hair loss. Often that means no hot combs, no tightly applied rollers or braids, blow drying or relaxers for a period of time. If the hair follicles have not been damaged beyond repair, you may, for example, be able to resume your hair care practices but with modifications. Your dermatologist can help you determine when—and if—you can resume these styling practices. Taking a break from harsh styling and substituting gentler techniques may allow the inflammation to resolve, the scalp to heal and hair growth to resume.

Your dermatologist may prescribe medications to decrease the inflammation that is seen in the hair follicles of those affected by CCCA. Oral or topical antibiotics are sometimes prescribed because they help to reduce inflammation. Likewise, topical cortisones applied to the scalp or cortisones directly injected into the scalp may also be used to treat or reduce scalp inflammation. Finally, once the inflammation is minimized, your dermatologist may recommend over-the-counter Minoxidil (Rogaine) to stimulate grow of follicles that have not been destroyed.

Fig 4. Severe CCCA

With severe CCCA (Figure 4), the hair follicles are destroyed and neither topical or injected medications will help the condition. Hair transplantation may be a solution for some women although the severe scarring may make this procedure technically difficult.

Sometimes CCCA is confused with the hereditary form of alopecia, called androgenic alopecia. This form of alopecia is also characterized by thinning in the central portion of the scalp with extension toward the hairline. With androgenic alopecia, the underlying scalp appears normal and the follicles are not scarred. Therefore, there is a greater likelihood that hair will regrow. The over the counter medication, Minoxidil (Rogaine), may help improve the particular condition.

Bottom line
CCCA is a devastating condition for women with brown skin and the best chance of reversing the process and restoring hair is early diagnosis and prevention. Therefore, it is important to see a dermatologist who is knowledgeable in tightly coiled or curly hair at the first sign of hair loss.

Traction Alopecia

Traction alopecia is hair loss that occurs as a result of continuous pulling of the hair. Pulling may occur from hairstyles such as tight cornrows or braids, weaves, ponytails or even hair rollers or curlers. Traction alopecia may also be due to excessive weight from long extensions or locks. Signs that the hair is being pulled too tightly are difficulty moving your forehead or temples, headache, and scalp soreness. Side effects of pulling too hard are breakage of hair strands and hair loss from the follicle. An even more serious side effect of chronically pulling the hair is an inflammation of the follicle and the appearance of small bumps (folliculitis). Inflammation can lead to destruction of the hair follicle and permanent hair loss. Over time, bald spots may develop along the hairline and in the area above the ears. Since the hair loss happens gradually, you may not even notice it until the bald spot develops or your hairline recedes significantly. If traction alopecia continues for a prolonged period of time, the follicles may become destroyed and hair loss permanent.

Treatment
It may seem obvious but it’s time to stop pulling your hair out. To save your hair, you may need to switch hairstyles altogether. However, if your hair loss is minimal and you want to continue to braid your hair or plait your child’s hair, for instance, you can make adjustments, such as wearing looser braids, plaiting the hair loosely and wearing shorter weaves or locks. Women of color often pull tightly on hair to make it look smooth or straighter in a ponytail or bun. A better solution might be to apply a hair gel or a dab of conditioner to the hair to help it to lie flatter and straighter. More manageable hair will look smooth and neat without all that pulling, so wash and deep condition regularly. To camouflage bald spots or a receding hairline you might consider brushing your hair towards the hairline or coloring the scalp with a scalp pencil. You can find scalp pencils at a local beauty supply store; apply as you would an eyebrow pencil, with short strokes in the direction of hair growth.

Once the pulling and tension have been eliminated, if there is active folliculitis, your dermatologist may prescribe an oral or topical antibiotic to reduce the inflammation. In addition, potent cortisone containing creams or cortisone injections may reduce inflammation. If severe scarring is present, hair transplantation may be an effective treatment.

Bottom Line

Traction alopecia can also be a devastating condition for women with brown skin in much the same way as CCCA. Although women may think that they look terrific with tight hair styles, they can and do lead to permanent loss of hair. The key with traction alopecia is simply to avoid tight hair styles. Also, it is important to see a dermatologist at the first sign of hair loss.

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