Hair grooming practices and central centrifugal cicatricial alopecia

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Hair grooming practices and central centrifugal cicatricial alopecia
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  Hair grooming practices and central centrifugal cicatricial alopecia  Raechele Cochran Gathers, MD, Michelle Jankowski, MAS, Melody Eide, MD, MPH, and Henry W. Lim, MD  Detroit, MichiganSee related article on page 660 Background:   The cause of central centrifugal cicatricial alopecia (CCCA) in African American womenremains to be elucidated. Objective:   This study was designed to determine the hair-grooming practices in African American women with and without CCCA and to evaluate possible etiologic factors.  Methods:   Utilizing a novel survey instrument, the Hair Grooming Assessment Survey, we performed aretrospective comparative survey of the hair-grooming practices of two populations of African American women seen and evaluated at the Department of Dermatology, Henry Ford Hospital in Detroit, MI,between 2000 and 2007. The case group were women with clinical and histologic diagnosis of CCCA, andthe control group were those without a history of alopecia. Results:   All 101 surveys that were returned were analyzed (51 from the case group and 50 from the controlgroup).Astrongassociationwasfoundbetweentheuseofbothsewn-inhairweavingandcornroworbraidedhairstyles with artificial hair extensions and CCCA (  P  \ .04,  P  \ .03, respectively). Similarly, women withCCCA were more likely to report a history of ‘‘damage’’, typically defined as uncomfortable pulling andtenderness, from both sewn-in and glued-in weaves, and from cornrow or braided hairstyles with artificialhair extensions (  P  \ .001,  P  \ .02, and  P  \ .03, respectively). In contrast to previous anecdotal beliefs, nocorrelation was found between the use of either hot combing or hair relaxers and the development of CCCA. Limitations:   Results are limited by patient recall of past hair grooming practices. Also, as hair groomingpracticesmayvarybygeographicregion,theseresultsmaynotbegeneralizedtoallwomenofAfricandescent. Conclusion:   There is a clear difference in both quantitative and qualitative hair grooming practices among African American women with CCCA. ( J Am Acad Dermatol 2009;60:574-8.) C linical scarring alopecia in African American women has been recognized for years. 1 Theclassification of this unique form of  alopeciadates back to LoPresti, Papa, and Kligman, 2  who firstdescribed the entity ‘‘hot comb alopecia.’’ They hypothesized that the hot petrolatum applied to thehairduring astraightening procedurecalled pressingcaused a chronic inflammation around the uppersegment of the hair follicle which eventually led tofollicular degeneration and replacement of the folli-cle by scar. Sperling and Sau 3 have described follic-ular degeneration syndrome (FDS) as a replacementfor the term ‘‘hot comb alopecia’’ since a poorcorrelation was noted between the usage of a hotcomb and the onset and progression of the disease. From the Multicultural Dermatology Center, Department of Der-matology, and the Department of Biostatistics and ResearchEpidemiology, Henry Ford Hospital.Supported by funds from the Department of Dermatology, HenryFord Hospital.Conflicts of interest: None declared.This work has been previously presented at the L’Oreal Ethnic Hairand Skin Research Symposium, November 2007, Miami, FL.Accepted for publication October 26, 2008.Reprint requests: Raechele Cochran Gathers, MD, MulticulturalDermatology Center, Henry Ford Hospital. 3031 W Grand Blvd,Suite 800, Detroit, MI 48202. E-mail:$36.00 ª  2008 by the American Academy of Dermatology, Inc.doi:10.1016/j.jaad.2008.10.064  Abbreviations used: CCCA: central centrifugal cicatricial alopeciaCCSA: central centrifugal scarring alopeciaFDS: follicular degeneration syndromeHGAS: Hair Grooming Assessment Survey NAHRS: North American Hair Research Society  574  More recently, FDS has also been described by Sperling, Solomon, and Whiting 4 as a very commonform of central centrifugal scarring alopecia (CCSA),a term that encompasses a group of closely relatedclinical patterns of hair loss that are the most com-mon forms of scarring alopecia in the United Statesand that have the following features in common: (1)hair loss centered on the crown or vertex of the scalp(Fig 1), (2) chronic and progressive disease witheventual ‘‘burnout,’’ (3) roughly symmetrical expan-sion with the most active disease at the periphery,and (4) both clinical and histologic evidence of inflammation in the active peripheral zone. Centralcentrifugal cicatricial alopecia (CCCA) is a relatively new term adopted by the North American HairResearch Society (NAHRS) to encompass the terms‘‘hot comb alopecia,’’ ‘‘follicular degeneration syn-drome,’’ ‘‘pseudopelade’’ in African Americans and‘‘central elliptical pseudopelade’’ in Caucasians. 5  Among African Americans, CCCA is responsiblefor more cases of scarring alopecia than all otherforms combined. The majority of African Americanpatients with CCCA appear to be female. Patients with CCCA present with a chronic and progressivecrown or vertex-centered alopecia that expandsradially in a roughly symmetric fashion. 6 Onset of the condition often occurs between the second andfourth decades. Because a considerable amount of hair has already been lost before the patient noticesthinning, the actual onset of hair loss ma y  actually begin years before the patient takes notice. 3 The hairloss of CCCA presents clinically with a decrease orabsence of follicular openings and a shiny appear-ance of the scalp without overt inflammation.The goal of this project was to determine whathairgrooming practicesare morecommon in African American women with CCCA and to establish corre-lations between certain hair grooming factors andthe development of CCCA. METHODS  We performed a retrospective comparative survey of the hair grooming practices of two populations of  African American women seen and evaluated at theHenry Ford Hospital Department of Dermatology between 2000 and 2007. By using demographic dataand diagnostic codes, a total of 430 patients wereidentifiedasAfricanAmericanwomenwhohadbeentreated intheDepartmentofDermatologyduringthestudy period. All charts were reviewed by theprimary investigator. A total of 118 surveys weresenttowomenwithbothclinicalandhistopathologicdiagnosesofscarring alopecia consistent with CCCA. A total of 312 surveys were sent to women with nodocumented history or physical evidence of alopecia. The Hair Grooming Assessment Survey (HGAS)wasutilizedtosurveythewomen, whowererecruited via US mail. This research was approved by our institutional review board (IRB No. 4439). Study design  Two populations of women were studied: (1) AfricanAmericanfemalesbetweentheagesof18and65 at the time of survey, who had been diagnosedclinically and histopathologically with FDS, ‘‘hotcomb alopecia,’’ pseudopelade, CCSA, CCCA, orscarring alopecia not otherwise specified; (2) a con-trol population of a similarly aged population of  African American females who had not been diag-nosed with a scarring form of alopecia and whoexhibited no clinical signs of CCCA. For study inclu-sion and classification into either case or controlpopulations, each chart was reviewed and analyzedfor demographic information, subjective clinical in-formation, objective physical examination findings,histologicdata,andphysicianassessment.Additionalinclusion criteria included African American, Africanor Caribbean descent. Exclusion criteria included ahistory of lupus, sarcoidosis, syphilis, lichen planus,lichen planopilaris, folliculitis decalvans, dissectingcellulitis, scalp cellulitis, folliculitis keloidalis, alopeciaareata, or clinically significant medical or psychiatricdisease as determined by the primary investigator. Survey instrument  The HGAS is a novel survey instrument designedto elucidate in depth information regarding hairgrooming practices common in women of Africandescent. The survey collects demographic informa-tion, family history, hair grooming history, andduration of common hair grooming practices. Thesurvey also collects information on various symp-tomatologies that may have resulted from thesegrooming practices. The HGAS survey was devel-oped in Scantron format and is 7 pages long. Thereare 20 questions, and the survey is estimated to takeapproximately 15 minutes to complete. Fig 1.  Woman with CCCA. J A  M  A  CAD  D ERMATOL  V  OLUME  60, N UMBER   4 Gathers et al   575  Data analysis The primary analysis was a chi-squared compar-ison of the proportion of women that used each of the styling methods between the case and controlgroups. We also compared the duration and fre-quency of use and any symptoms between the twogroups. The analysis comparing the two groups withthe categorical data was done using a chi-squaretest.The continuous variables were compared using atwo-sample  t   test. Those variables showing statisti-callysignificantdifferences orthosebelievedtobeof clinical relevance were entered into a logistic regres-sion analysis to compute the odds ratio. All  P   values were two sided and a significance level of .05 wasapplied throughout. RESULTS There were 118 surveys mailed to women in theCCCAgroupand312surveysmailedtowomeninthecontrol group. There were 51 surveys collected frompatients with a history of CCCA (response rate, 43%)and 50 surveys collected from control patients(responserate,16%).Onecasesurvey,havingreportedhaving‘‘thickhair,’’wasexcluded.Fourcontrolswereexcluded that reported ‘‘baldness.’’ There were 50final cases and 46 final control surveys. Demographic data   All women surveyed classified themselves as of black/African American or Caribbean American racialgroups. Demographically, there was no statistically significant difference between the two groups. They  were similar in marital status, employment status, andlevel of education. There was no significant agedifference in the women with CCCA (49.1 years) versusthoseinthecontrolgroup(45.0years)(  P  =.08). Onset of disease  Among women with CCCA, 21% had noticedeither thin or bald spots in their hair by the age of 30 years. By age 40, 44% had noticed thin or baldspots (Fig 2). By age 50, 83% of CCCA patients hadnoticed thin or bald spots. Only 72% of patientsnoticed thinning orbaldness themselves. Hairstylists were responsible for alerting 21% of patients abouttheir hair loss. Family history  Compared to the control group, patients withCCCA were not more likely to have a mother, grand-mother, aunt, or cousin with hair loss. However, they  were significantly more likely to have a sister withhair loss. (46% vs. 23%,  P   = 0.03). Positive correlations  Women with CCCAwere more likely to have worncornrowsorbraidswithartificialextensionhairandtohave worn them for more cumulative years as com-pared to control subjects (  P   = .03) (Table I). Women  with CCCA were more likely to have worn sewn-inhair weaves and to have worn them for more cumu-lative years (  P   = .04). With regard to a history of ‘‘damage’’ from certain hairstyling methods (damagedefined as a history of hair falling from the root, hairbreakage, split ends, tender scalp, uncomfortablepulling, or heat burns), CCCA patients reported in-creaseddamagefromcornrowsandbraidswithaddedextension hair (36% vs. 59%;  P   = .03), from sewn-in weaves (13% vs. 60%;  P  \ .001), and from glued-in weaves (24% vs. 47%;  P   = .02). Women with CCCA  were more likely to report having worn a texturizer(  P   = 0.033). With regard to specific types of damage,CCCA patients were more likely to report a history of uncomfortable pulling from cornrow or braidinghairstyles (24% vs. 50%;  P   = .022). They were alsomore likely to report a history of tender scalp fromcornrowed hair or braids with added extension hair(17% vs. 46%;  P   = .009). CCCA patients were morelikely to report tender scalp and uncomfortable pull-ing from sewn-in hair weaves (14% vs. 34%,  P   = .08;10% vs. 30%,  P   = 0.015,respectively). Among wearersof glued-in weaves, CCCA patients were more likely to report tender scalp (0% vs. 30%;  P   = .005). Forevery 10-year increment that a woman wore sewn-in weaves at least once, she was 2.8 times more likely to develop CCCA (95% confidence interval [CI]:1.43-5.63,  P   = .003) (Fig 3). For every 10-year incre-ment during which a woman wore glued-in weaves,she was 2.2 times more likely to develop CCCA (CI:1.11-4.14,  P   = .02). The association of chronicity of cornrow or braiding with added extension hair anddevelopment of CCCA was marginal, with women inthis group being 1.6 times more likely to developCCCA (CI 0.97-2.60,  P   = .06). Of note, the HGAS does Fig 2.  Onset of hair loss by age.  Table I.  Hair grooming practices and CCCA:Pertinent positive associations Cornrows/braids with extension hairSewn-in hair weavesGlued-in hair weaves CCCA , Central centrifugal cicatricial alopecia. J A  M  A  CAD  D ERMATOL  A  PRIL  2009 576  Gathers et al   control for age increments during which alopecia orthinning was first noted, and age increments during which weaving, braiding, cornrowing, and othergrooming techniques were utilized. With regard tosewn-in and glued-in weaves, and cornrow andbraided styles with extensions, these grooming tech-niques were noted to be utilized before alopecia wasnoted by respondents. Negative correlations There was no correlation found between thecumulative usage of hot comb (pressing) andCCCA (  P   = .67) (Table II). There was no associationbetween the usage of hair relaxers (  P   = .99), jhericurls (  P   = .18), rollers (  P   = .41), or curling iron usage(  P   = .52) and CCCA. Similarly, there was no corre-lation between the number of cumulative years women used hair gel (  P   = .55), hair oils (  P   = .29),or hair color (  P   = .67) and CCCA. With regard to useof hair grooming modalities before age 20, there wasno correlation between use of cornrows or braids withorwithoutextensions,sewninweaves,orgluedin weaves before age 20 and CCCA (  P  [  0.05).Similarly, there was no correlation between use of hot combing, relaxing, or jheri curling before age 20and CCCA (  P   >  0.05). Women with CCCA were notmore likely to get hair relaxer applied more fre-quently (P = .10), nor were they more likely to haveexperienced more burns or raw spots after relaxerapplication (  P   = .95). Finally, there was no differencein the frequency of hair washing as a child (  P   = .68)or as an adult (  P   = .20) and CCCA. DISCUSSION The etiology of CCCA is a continued source of debate.Inreviewof44patientsbyMcMichael, 1 more women with scarring alopecia had a history of hair weavingandlong duration ofchemical relaxerusageas compared to those unaffected by scarring alope-cia. Ackerman et al 7 have described what is nowtermed CCC A  as a form of traction alopecia, whereasHeadington 8 has postulated that follicular stem cellsare repeatedly injured by chemical and/or physicaltrauma so that the entire f ollicular structure is ulti-mately destroyed. Nnoruka 9 has implicated the du-ration of hair care practices such as relaxers in thedevelopment of CCCA, and other authors havesimilarly reported scarring alopecia that has beentemporally  or historically related to chemical re-laxers. 10,11 There is an as yet undetermined role of any of these mechanisms, including hair groomingpractices such as hot combing, relaxing, jheri-curl-ing, braiding, extensions, weaving, hair rollers, andglues in the development of CCCA.It is evident from our results that certain hairgrooming practices do appear to be more commoninwomenwhodevelopCCCA;theseincludetheuseof both sewn and glued hair weaves, and the use of cornrow or braided hairstyles with added extensionhair. Furthermore, CCCA patients wearing these 3implicated hairstyles were more likely to report ahistory of hair damage, reflected as a history of tenderscalp or uncomfortable pulling (Table III). Sewn hair weaves are accomplished by cornrowing the naturalhair taut to the scalp. Next, wefts of extension hair are woven into the cornrow braid using a needle andtypically dark-colored thread. Glued weaves may beaccomplished by applying glue directly to natural hairthat has been slicked taut with gel or cornrowed, andthenattachingtheweftofextensionhairtotheglue;oralternatively, by cornrowing the natural hair, coveringthe cornrows with a stocking cap, and then applyingglue and extension hair wefts to the stocking cap.Cornrows and braids are achieved by tightly intermin-gling3ormorepiecesofhair,suchthatthehairliesflatto the scalp, or extends from the scalp, respectively.Because of the inherent mechanical forces of all 3 of theseimplicatedhairstyles,theobviousissuethatarisesis theheavinessandsubsequent traction which wouldresultfromeachofthesemodalities.Tractionasbothacause of folliculitis and alopecia has been suggestedpreviously. 1,7,8,12,13 Our results, at least in part, differfromthefindingsofNnoruka, 9  whohasimplicatedtheuse of relaxers in the development of CCCA. Whetherthis difference is due to the populations studied(Nigerians vs Michiganders) remains to be elucidated.In addition to the lack of correlation betweenCCCAandrelaxerusage, ourfindingsgivesupporttothe concept that the initial description of scarringalopecia in African American women as ‘‘hot comb Fig 3.  Continuous usage of hair grooming habits and CCCA.  Table II.  Hair grooming practices and CCCA:Pertinent negative associations Hair relaxersHot combs/pressing combsHistory of scalp burns or raw spots from hair relaxersHigh frequency of hair relaxer useUse of hair relaxers/hot combs/weaving/cornrows/braidsbefore age 20 CCCA , Central centrifugal cicatricial alopecia. J A  M  A  CAD  D ERMATOL  V  OLUME  60, N UMBER   4 Gathers et al   577  alopecia’’ is a misnomer. In 1992, Sperling and Sau, 3 in a retrospective study of 10 black women, pro-posed that there was a poor correlation between theusage of a hot comb and this particular form of scarring alopecia; they instead suggested the term‘‘follicular degeneration syndrome’’ for what is nowcalled CCCA. Our results, done in a larger number of patients, confirm the findings of Sperling and Sau. With regard to the possibility of some geneticpredisposition to CCCA, we found that while CCCA patients were more likely to report a sister with hairloss, they were not more likely to report a mother,grandmother, aunt, or cousin with hair loss. Thisclearly argues against a genetic predisposition. Wehypothesizethattheassociationseenbetweensistersis likely secondary to similar hair-grooming behav-iors popular among generational peers within thesame household.Interestingly, women who reported that they  wore their hair natural (no chemicals and no heat)before the age of 20 had an 86% decrease in the oddsof developing CCCA. To more clearly delineate therole of ‘‘natural’’ hair styles as a negative risk factorfor CCCA, future studies should likely ask whatpercentage of the time women wore their hairnatural before the age of 20. While traction may well be an explanation for theprevalence of CCCA in women with a history of hair weaving and cornrowing and braiding withextensions, the question also arises regarding thepossibility of irritation from synthetic versus humanhairextensions.Thisstudydidnotdelineatebetweenthe two. Contact dermatitis to hair dyes and theadhesives used in extensions has been reported. 14,15 Similarly,achroniclow-gradedermatitistoextensionhair or the chemicals used in processing it might play a role in the evolution of follicular destruction.Twenty-one percent of patients in our study werefirst alerted of their hair loss by a stylist. Clearly,public education and education of beauty servicesprovidersisparamountintheearlyidentification andtreatment of women with the early signs and symp-tomsofCCCA.Additionally,becausenearlyonefourthof all CCCA patients have experienced evidence of hair loss by age 30, clinical index of suspicion, evenin very young patients, must remain high.In summary, we report the first known retrospec-tive survey study of hair grooming practices associ-ated with CCCA. Larger population-based studies indifferent geographic locales will be necessary tofurther classify the hair grooming practices impli-cated in the development of CCCA. REFERENCES 1. McMichael AJ. Ethnic hair update: past and present. J Am AcadDermatol 2003;48:S127-33.2. LoPresti P, Papa CM, Kligman AM. Hot comb alopecia. ArchDermatol 1968;98:234-8.3. Sperling LC, Sau P. The follicular degeneration syndrome inblack patients. Arch Dermatol 1992;128:68-74.4. Sperling LC, Solomon AR, Whiting DA. A new look at scarringalopecia. Arch Dermatol 2000;136:235-320.5. Olsen EA, Bergfeld WF, Cotsarelis G, Price VH, Shapiro J, Sinclair R,et al. Summary of North American Hair Research Society(NAHRS) sponsored workshop on cicatricial alopecia, February10-11, 2001. Duke University Medical Center, Durham, NC. JAm Acad Dermatol 2003;48:103-10.6. Sperling LC, Cowper SE. The histopathology of primary cica-tricial alopecia. Semin Cutan Med Surg 2006;25:41-50.7. Ackerman AB, Walton NW, Jones RE, Charissi C. Hot combalopecia: ’’Follicular degeneration syndrome’’ in African-Amer-ican women is traction alopecia! Dermatopathol Prac Concept2000;6-21.8. Headington JT. Cicatricial alopecia. Dermatol Clin 1996;14:773-82.9. Nnoruka NE. Hair loss: Is there a relationship with hair carepractices in Nigeria. Int J Dermatol 2005;44(S1):13-7.10. McMichael AJ. Hair and scalp disorders in ethnic populations.Dermatol Clin 2003;21:629-44.11. Bulengo-Ransby SM. Chemical and traumatic alopecia fromthioglycolate in a black woman. Cutis 1992;49:99-103.12. Fox GN, Stausmire JM, Mehregan DR. Traction folliculitis: anunderreported entity. Cutis 2007;79:26-30.13. Slepyan AH. Traction alopecia. AMA Arch Dermatol 1958;78:395-8.14. Wakelin SH. Contact anaphylaxis from natural latex used as anadhesive for hair extensions. Br J Dermatol 2002;146:340-1.15. Cogen FC, Beezhold DH. Hair glue anaphylaxis: a hidden latexallergy. Ann Allergy Asthma Immunol 2002;88:61-3.  Table III.  Hair grooming habits, symptomology,and CCCA Hair grooming habit Symptom reportedOR for CCCA (95% CI) Cornrows or braidswith addedextension hairDamage 2.6 (1.08-6.06)*Tenderness 5.5 (1.84-16.21) y Uncomfortablepulling2.8 (1.20-6.70)*Sewn-in weaves Damage 10.5 (3.46-31.87) z Tenderness 5.6 (1.48-20.93) y Uncomfortablepulling8.1 (2.19-29.73) y Glued-in weaves Damage 2.8 (1.13-7.01)*Tenderness — § Uncomfortablepulling5.5 (1.14-26.63)* CCCA , Central centrifugal cicatricial alopecia;  CI  , confidenceinterval;  OR , odds ratio.* P  \ .05. y P  \ .01. z P  \ .001. § Insignificant association. J A  M  A  CAD  D ERMATOL  A  PRIL  2009 578  Gathers et al 
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