Alopecia, regardless of the type, can be difficult to treat and emotionally devastating for patients. Treatment options not only vary based on the type of alopecia, but also patient’s personal hair care routine and their cultural practices surrounding hair and hair styles.
At the Skin of Color Update, Amy McMichael, MD, discussed diagnostic approaches for patients with skin of color experiencing hair loss.1 In an interview with The Dermatologist, she shared ways to identify scarring vs nonscarring alopecia and important clinical pearls and pitfalls dermatologists should keep in mind when working with patients with hair loss.
Dr McMichael is the chair and professor of the department of dermatology at Wake Forest School of Medicine in Winston-Salem, SC.
The Dermatologist: What are some of the common types of hair loss, and are there any that are more prevalent among patients with skin of color?
Dr McMichael: The most common form of hair loss is female-pattern hair loss, and we see this pretty evenly among different ethnicities. Alopecia areata and telogen effluvium also appear to occur in everyone, regardless of gender or ethnicity.
However, there are some that affect patients with skin of color more frequently, particularly African American patients. This includes central centrifugal cicatricial alopecia (CCCA) and traction alopecia, which are both scarring forms of alopecia. Once a patient is diagnosed with this type of alopecia and it is progressed, there is very little we can do. We try to diagnosis patients with scarring forms of alopecia early in order to start treatment to reduce the inflammation and potentially slow its progression because once the hair follicles are completely damaged, they cannot grow new hairs.
The Dermatologist: What clinical features or diagnostic tools can help differentiate the different types of hair loss?
Dr McMichael: The key to diagnosing the type of hair loss is by identifying the location. If it is around the hairline, it could be traction alopecia, frontal fibrosing alopecia, or even alopecia areata. If unsure, then a biopsy could help confirm the diagnosis. For example, CCCA has the general distribution of female-pattern hair loss. I have been treating patients with alopecias for over 25 years and I still cannot always tell the difference. Thus, a biopsy can be helpful to identify whether it is a scarring or nonscarring alopecia because the treatments will be different depending on the type of hair loss.
In the last 10 years, we found that using a dermatoscope can also be very helpful for identifying the type of alopecia. Dermatoscopes can help us distinguish forms of alopecias because they have typical findings that are slightly different. One study showed that CCCA does have typical findings under a dermatoscope, even in places that do not appear to be affected by CCCA, and it correlates well with biopsy outcomes.2 This tool can help us diagnosis types of alopecia and also reduce the number of biopsies we need, which is beneficial for patients who face stitches and downtime for healing with biopsies.
The Dermatologist: What clinical pearls and/or common pitfalls should dermatologists keep in mind when treating hair loss among patients of different ethnicities?
Dr McMichael: Dermatologists have to come into the exam, diagnosis, and treatment thinking about the patient’s hair care practices. If they do not understand the patient’s hair care practices, then they are going to potentially make recommendations that the patient will not be able to follow.
It is important to be cognizant of the whole patient and not just what is being treated, and to ask patients:
- How frequently do you wash your hair?
- What products do you use on your scalp?
- What is your hair care regimen?
- Do you have your hair done at a salon?
For people with skin of color who have seborrheic dermatitis, for instance, it is best not to recommend patients wash their hair every night, because they will not wash it every day. Most patients will wash it maybe every week or 2 weeks, and there are some who do not wash their hair for an even longer period of time, such as 4 weeks. If a dermatologist prescribes a shampoo, but the patient only washes their hair every 2 weeks, then another option may be needed as a part of the treatment regimen. I do tell all of my patients that they need to wash their hair at least every 2 weeks if they are under my care, because I think your scalp is just healthier that way.
Dermatologists also have to take into consideration that patients might not be using the right products and washing more frequently may cause another issue with their hair. For example, if a dermatologist recommends a shampoo that has no moisturizers in it to treat an inflammatory scalp condition, it could cause the hair shafts to become dry and break.
For products, knowing which ones the patient uses and the order these products are applied is important, because the process could exacerbate their hair loss disorder or impact therapy delivery. For example, the natural hair care products that use lots of oils or are labeled as butters can prevent topical corticosteroids from penetrating the scalp. In addition, asking patients about whether they see a stylist is important because stylists may be conditioned to not use certain products.
The vehicle of the therapy is also important. A solution that is alcohol-based may not work for someone who has thicker hair or wears heat-related styles, because it will cause the hair to revert back to its curly pattern. For these patients, an ointment may be a better option because they may be more likely to adhere to the product. Other patients may want something lighter, like a foam.
Another pitfall is false assumptions. If the dermatologist does not ask or say anything about the products a patient is using, then the patient will think these products are fine. This is true for everything in dermatology. It is important to ask about facial, scalp, and body products, even if the patient does not bring it up.
Also, dermatologists should be careful in explaining to patients how to apply the products. For example, I do not just tell a patient who I prescribed minoxidil to “just apply it every day,” because there are many ways it can be applied. The foam box recommends using the cap to measure the amount and applying from the cap to the scalp, but that will not necessarily work for patients with thicker hair. In that case, the patient may want to use a solution or drops and follow the method designed by Jerry Shapiro, MD, in which the patient applies the foam as five lines to the scalp.
Essentially, the best therapy is going to be the therapy the patient uses, and it is best to start treatment with something they will use regularly.
The Dermatologist: Are there any other aspects of hair care and practices that should be considered when treating hair loss?
Dr McMichael: Hairstyling is important. In the last 10 years, there have been a lot of different styles among people of African descent that are really accepted and look beautiful. These include braided, twisted, and natural styles; styles that use some heat; others that use a fair amount of tension; and some styles that require adding hair.
Some people never have to worry hair loss; their hair and scalp are strong, and they do not experience any adverse effect or complication. However, some of these products can cause problems with the hair and scalp in others.
The key for patients is to not continue using anything, such as hair extensions, to cover or camouflage the issue but to see a dermatologist immediately. This is where most people miss out on early diagnosis and treatment because they will see a small area of hair loss and use camouflage techniques to cover it. Also, their stylists may not be aware of medical treatment or warn their client about hair loss. When patients do see a dermatologist, we can treat their hair loss and also give them ideas for how to wear their hair so it will not contribute to their condition, such as not using glue or tension.
I have a patient with CCCA that I treated with several anti‑inflammatory treatments, including topical therapy and steroid injections. She experienced significant improvements once we took care of the inflammation, and her hair follicles were able to regrow.
She decided that it would be easier for her to wear a hairpiece and had one that stayed in place for about 4 to 6 weeks. When she removed it and washed her hair, she lost tremendous amounts of hair. She had not been washing her scalp, she had not been using her topical treatments, and we had to start all over again in order to try to regain what she had lost. Unfortunately, we have never gotten back to her original improvement.
The moral of the story is that if a patient makes gains with their hair, they should never go back to the really damaging hair care practices they had been doing before because the new hair will not be able to handle it. As a matter of fact, gentler hair care practices are better to prevent further damage and possibly recurrence of hair loss.
The Dermatologist: What recommendations do you offer patients when steering them away from damaging hair styles?
Dr McMichael: I discuss styles with patients that are similar to their look and what they would want to wear but does not have the damaging component to give them some semblance of normalcy.
For instance, if a patient likes to wear their hair in a braided style, but the braiding style appears to be contributing to some of their hair loss, then I suggest something called crochet braids. In this braiding style, the hair is braided down in cornrows along the scalp, and webs of hair are crocheted into those braids. This does not require the braid to be tight and does not cause traction. Crochet braids can be done in all kinds of styles and in such a way that the patient can get to the scalp for treatments, if necessary, in between washes.
If they have hair breakage and damaged hair, I may tell them to avoid chemical relaxers for a while but suggest they use a demi- or semipermanent hair dye. We know that chemical relaxers cause more damage than hair dyes, and permanent hair dyes are worse than demi- or semipermanent hair dyes. The approach is similar with heat. If a patient uses a flat iron every day, then we may ask they only use it once a week.
1. McMichael A. Hair & scalp disorders in SOC: diagnostic approaches. Presented at: Skin of Color Update; September 13, 2020; virtual.
2. Miteva M, Tosti A. Dermatoscopic features of central centrifugal cicatricial alopecia. J Am Acad Dermatol. 2014;71(3):443-449. doi:10.1016/j.jaad.2014.04.069