Clinical examination of scalp hair shows dry, brittle hairs, with breakage seen on hair pull test. Light microscopy examination of the hair shows distal splitting of the hair (trichoptilosis) and node-like formation with fraying (trichorrhexis nodosa). What should her dermatologist tell her?
Studies in men have shown that there is often a long hair preference playing a role in attraction to women, thought to be due to long hair acting as a surrogate for health and youth.1,2 Coupled with the current popularity of long hair and heat styling the hair, psychosocial pressures may play a role in patients presenting with a chief complaint of hair breakage.
Hair breakage is either due to hereditary or acquired hair shaft disorders, known as trichodystrophies. Most commonly, trichodystrophies are acquired through mechanical and chemical forces from hair care practices.3,4
The fall is often the time that dermatologists see complaints of damaged hair after a summer of fun in the sun. The most common summer causes of hair breakage are sun/ultraviolet (UV) light and pool water exposure.
CAUSES OF BREAKAGE
First, UV rays cause dryness, brittleness, rough surface texture and decreased luster of the hair shaft.5 The damage to the hair is thought to be due to UV light-induced oxidation of the structural proteins and lipids in hair. The amino acids and hydrocarbons in the cuticle, or outer surface of the hair shaft, are most at risk because the cuticle receives the highest intensity of radiation.6 Damage to the cuticle results in detachment of the cuticle from the inner layers of the hair shaft — the cortex and medulla — and presents with split ends, thinning and subsequent breakage.
Additionally, oxidation causes a loss of hydrophobicity, making hair more susceptible to tangles and breakage.7 Like on our skin, melanin in the hair absorbs and filters the damaging rays of UV light. Thus, fair and gray hair, which lack melanin, is more susceptible to UV light-induced damage than dark hair.
Chlorine and bleach in pool water also cause hair dryness and damage through oxidation, similar to UV light exposure. Copper-contaminated tap water or pool water from copper-containing algicides or copper pipes is of special concern. Cooper levels even as low as 30 ppm can accelerate oxidative damage from future coloring treatments and UV light exposure.8
Unfortunately, there really is no good way to identify copper levels in hair because usually only light colored hair develops a greenish hue from elevated copper levels (>500 ppm). However, there are antichelating agents for purchase that can remove copper from the hair.
Some of the common “year-round” causes of hair breakage are chemical treatments, heat application and physical processes. Chemical treatments including perms, straightening treatments, hairs dyes and bleaches all interfere with the chemical structure of hair and thus are notably the most damaging to the hair. Damage through heat implementation occurs through blow-dryers, and worse, hair irons and curling irons that can reach exceedingly high temperatures of >400°F. Finally, physical forces include repeatedly brushing and vigorous rubbing when shampooing or towel drying.
In the case presented, the patient’s hair damage is likely an accumulation of damage through hair dying, heat application and recent increased exposure to UV light and pool water.
What are some recommendations and treatments options for our patient’s hair breakage?
The primary recommendation is avoidance, but there are other options if complete avoidance is not possible. These include:
- Wash hair infrequently with conditioning shampoos followed by a moisturizing conditioner.
- Deep condition every 2 weeks.
- Comb damp-to-dry hair with wide-set, blunt-tooth combs because wet hair is more elastic and subject to fracture.
- Let hair air dry when possible.
- When styling hair, blow-dryers are much less damaging than flat irons or curling irons.
- Curling and flat irons should never be used on wet hair.
- Use heat protectant products on the hair before styling.
- Keep the temperature of the styling tool below 375°F.
- Limit the number of chemical treatments to no more than 2 to 3 a year.
- Experienced stylists should perform chemical treatments with the product selectively applied to the roots if the ends were previously treated.
- Wear a hat or apply a leave-in conditioner with zinc oxide for UV light protection.
- Wear a swim cap in the pool (may not be in style, but it works).
- Rinse hair immediately after swimming.
- Use shampoos and conditioners with trisodium ethylenediamine disuccinic acid to remove copper from the hair.
- Trim damaged hair frequently to help minimize breakage.
A thorough history of hair care practices stretching back to at least 6 months can provide insight into potential causes of hair damage and areas for intervention. Luckily, there are several options for intervention and potential for improvement.
Keeping in mind some of these unique environmental causes of hair damage may better help patients, who experience increased breakage during and/or following the summer.
Ms. Eginli is research fellow in the department of dermatology at Wake Forest Baptist Health in Winston-Salem, NC.
Dr. McMichael is professor and chair in the department of dermatology at Wake Forest Baptist Health in Winston-Salem, NC.
Disclosure: Dr. McMichael has received grants from Allergan and Proctor & Gamble. She is a consultant for Allergan, eResearch Technology, Inc. Galderma, Guthey Renker, Johnson & Johnson, Keranetics, Merck & Co., Inc., Merz Pharmaceuticals, Proctor & Gamble, Samumed and Incyte. She receives royalties from Informa Healthcare and UpToDate and also has conducted research for Samumed.
Ms. Eginli reports no relevant financial relationships.
1. Baktay-Korsos, G. The long-hair effect. Rev Psychol. 1999;6:37-42.
2. Bereczkei T, Mesko N. Hair length, facial attractiveness, personality attribution: A multiple fitness model of hairdressing. Rev Psychol. 2006;13(1):35-42.
3. Whiting DA. Structural abnormalities of the hair shaft. J Am Acad Dermatol. 1987;16(1 Pt 1):1-25.
4. Olsen EA. Disorders of Hair Growth: Diagnosis and Treatment. 2nd ed. New York, NY: McGraw-Hill Professional; 2003.
5. Jeon SY, Pi LQ, Lee WS. Comparison of hair shaft damage after UVA and UVB irradiation.
J Cosmet Sci. 2008;59(2):151-156.
6. Nogueira AC, Dicelio LE, Joekes I. About photo-damage of human hair. Photochem Photobiol Sci. 2006;5(2):165-169.
7. Marsh JM. Hair coloring. In: Evans R, Wickett R, eds. Practical Modern Hair Science. Carol Stream, IL: Allured Business Media; 2012:chap 4.
8. Marsh, JM, Iveson R, Flagler MJ, et al. Role of copper in photochemical damage to hair. Int J Cosmet Sci. 2014;36(1):32-38.