The document discusses common hair practices in ethnic populations, focusing on chemical relaxers. It notes that up to 70% of black women regularly chemically straighten their hair. Chemical relaxers use alkaline products like sodium hydroxide or guanidine hydroxide to break and restructure disulfide bonds in hair to change its shape. Regular use can lead to side effects like scalp burns, traction alopecia, and hair loss. Tips are provided to minimize damage when using relaxers. While no definitive link between relaxers and fibroids has been found, some studies associate frequent relaxer use with a higher risk of developing fibroids.

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

2. 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.
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.

3. 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.

4. 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.

5. February 9, 2019 5

6. 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

7. Pre-­Test #1
• 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

8. 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

9. Pre-­Test #3
• What is the most likely
diagnosis?
a) Acquired Trichorrhexis
Nodosa
b) Monilethrix
c) Congenital Trichorrhexis
Nodosa
d) Androgenetic Alopecia
February 9, 2019 9

10. 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

11. 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
February 9, 2019 11

12. 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

13. 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.

14. 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

15. 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.)
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.).
Khumalo, N. P., et al. "What is normal black African hair? A light and scanning electron-
microscopic study." Journal of theAmerican Academy of Dermatology 43.5 (2000): 814-820.

16. Common Ethnic Hair Practices
February 9, 2019 16

17. Chemical Relaxers

18. 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

19. Chemical Relaxers

20. 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

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

22. 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.

23. 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 (among long term users).
• Suggests an association between relaxers and fibroids, though causality is not
established
February 9, 2019 23

24. Braiding (with extensions)

25. 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

26. Weaves

27. 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

28. Weave Installation

29. Wigs
February 9, 2019 29

30. Lace Front Wig Installation
February 9, 2019 30

31. Thermal Straightening

32. 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

33. Common Hair Disorders In Black Patients

34. Traction Alopecia

35. 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

36. All Extensions Are Not Created Equal
February 9, 2019 36
BAD BAD OKAY

37. Low Risk Braided Extensions
February 9, 2019 37

38. Acquired Trichorrhexis Nodosa

39. 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

40. 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

41. Special Considerations for Treatment of
Common Hair Disorders in Black Patients
• 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
– 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 care practices when recommending minoxidil
– Solution: Better suited for curly hair due to lack of buildup that would normally occur
with infrequent washing. Recommend regular moisturizer to scalp
– Foams-­better for patients who will wash their hair often (at least 2-­3 times per week)

42. The Science of Hair Care
February 9, 2019 42

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
February 9, 2019 43

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

45. Surfactants

46. 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

47. 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

48. 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

49. 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

50. 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

51. 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

52. 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
Anionic Surfactants
The products are the best at removing product
buildup but can be drying. Use sparingly
Benzalkonium Chloride
Cetrimonium Chloride
CocamidopropylBetaine
DecylGlucoside
Lauryl Glucoside
StearamidopropylDimethylamine
Cocamide MEA
Disodium Cocoamphodipropionate
Behentrimonium Methosulfate
Sodium Lauryl Sulfate
Sodium Laureth Sulfate
Sodium Lauroyl Sarcosinate
Ammonium Lauryl Sulfate
Sodium MyrethSulfate
Sodium C14-­16 Olefin Sulfonate
Disodium laureth sulfosuccinate
February 9, 2019 52

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!

54. Post-­Test #1
• 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

55. 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

56. Post Test #3
February 9, 2019 56
• What is the most likely
diagnosis?
a) Acquired Trichorrhexis
Nodosa
b) Monilethrix
c) Congenital Trichorrhexis
Nodosa
d) Androgenetic Alopecia

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

58. 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
February 9, 2019 58

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.
• Wise LA, Palmer JR, Reich D, Cozier YC, Rosenberg L. Hair relaxer use and risk of uterine leiomyomata in African-­American
women. American journal of epidemiology. 2012 Jan 10;;175(5):432-­40.
• Gupta, A. K., and R. Bluhm. "Seborrheic dermatitis." Journal of the European Academy of Dermatology and
Venereology 18.1 (2004): 13-­26.