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Hairpin-Induced Alopecia: Case Reports and a Review of the Literature

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Hairpin-Induced Alopecia: Case Reports and a Review of the Literature CONTINUING MEDICAL EDUCATION Hairpin-Induced Alopecia: Case Reports and a Review of the Literature Edidiong Ntuen, MD; Sarah L. Stein, MD RELEASE DATE: May 2010 TERMINATION DATE: May 2011 The estimated time to complete this activity is 1 hour. GOAL To understand hairpin-induced alopecia to better manage patients with the condition LEARNING OBJECTIVES Upon completion of this activity, you will be able to: 1. Describe causes of secondary scarring alopecia. 2. Evaluate and diagnose secondary scarring alopecia. 3. Discuss with patients how to prevent damage to the hair and scalp. INTENDED AUDIENCE CUTIS This CME activity is designed for dermatologists and general practitioners. CME Test and Instructions on page 246. This article has beenDo peer reviewed andNot approved by College Copy of Medicine is accredited by the ACCME to provide MichaelThis article Fisher, has MD, been Professor peer reviewed of Medicine, and Albertapproved Einstein by continuingCollege of Medicinemedical education is accredited for physicians.by the ACCME to provide CollegeMichael ofFisher, Medicine. MD, ProfessorReview date: of Medicine, April 2010. Albert Einstein continuingAlbert Einstein medical College education of Medicine for physicians. designates this edu- CollegeThis activityof Medicine. has beenReview planned date: July and 2009. implemented in cational Albert activityEinstein for College a maximum of Medicine of 1 AMAdesignates PRA Category this edu- 1 accordance This activity with has the beenEssential planned Areas and and implemented Policies of the in CreditcationalTM. activityPhysicians for ashould maximum only claimof 1 AMA credit PRA commensurate Category 1 Accreditationaccordance with Council the Essential for Continuing Areas andMedical Policies Education of the withCredit theTM. extentPhysicians of their should participation only claim in creditthe activity. commensurate throughAccreditation the joint Council sponsorship for Continuing of Albert MedicalEinstein CollegeEducation of withTh theis activity extent ofhas their been participation planned and in the produced activity. in accor- Medicinethrough the and joint Quadrant sponsorship HealthCom, of Albert Inc. Einstein Albert College Einstein of dance This withactivity ACCME has beenEssentials. planned and produced in accor- Medicine and Quadrant HealthCom, Inc. Albert Einstein dance with ACCME Essentials. Drs. Ntuen and Stein report no conflict of interest. The authors report no discussion of off-label use. Dr. Fisher reports no conflict of interest. The staff of CCME of Albert Einstein College of Medicine and Cutis® have no conflicts of interest with commercial Mr. Schwendiman and Drs. Beachkofsky, Wisco, Owens, and Hodson report no conflict of interest. The authors report no dis- interest related directly or indirectly to this educational activity. cussion of off-label use. Dr. Fisher reports no conflict of interest. The staff of CCME of Albert Einstein College of Medicine and Cutis® have no conflicts of interest with commercial interest related directly or indirectly to this educational activity. Traumatic hair loss is a scalp injury that can we describe a preceding ulcerative process. We cause secondary scarring alopecia. It can result describe 3 black adolescent girls with hairpin- from different types of physical and chemi- induced alopecia that started with an ulcer cal injury. Hair loss induced by certain hair- and ended with a scar. We also review the styling techniques has been discussed, but dermatologic literature. Dr. Ntuen was a medical student, Wake Forest University School of Cutis. 2010;85:242-245. Medicine, Winston-Salem, North Carolina, and currently is an intern, Wake Forest University Baptist Medical Center. Dr. Stein is Associate Professor of Medicine, University of Chicago, Illinois, air loss due to physical or chemical trauma is and Attending Physician, Section of Dermatology, University of a cause of scarring alopecia initiated by events Chicago Hospitals. Correspondence: Sarah L. Stein, MD, Section of Dermatology, outside of the follicular unit and has been H 1,2 University of Chicago Hospitals, 5841 S Maryland Ave, MC 5067, termed secondary cicatricial alopecia. Alopecia in Chicago, IL 60637 ([email protected]). black women is common and has been reported as the ® 242 CUTIS Copyright Cutis 2010. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. Hairpin-Induced Alopecia fifth most common dermatosis in black individuals, attached with glue or tight stitches may result in with traumatic alopecia cited as the predominant type.3 traction alopecia, a common form of hair loss in Biochemical and structural differences of hair4 result black individuals. Traction alopecia occurs with loss in hair texture variability among ethnic groups and or thinning of hair in any area of the scalp caused possibly differences in hairstyling preferences. Hairstyl- by tension.12 ing techniques used by black women such as thermal Hairstyling trends in black individuals may occur or chemical hair straightening and hair braiding or because of current and historical models. Conve- weaving may increase the risk for traumatic alopecia.5 nience and time also may dictate style choices.12 Pressure alopecia is another type of alopecia, occurring Sculptured hairstyles are popular and commonly after surgical procedures that require extensive periods involve chemically relaxed or heat-straightened of immobilization.6-11 hair that is molded using styling gels and/or hair Hot-combing is a type of thermal hair straighten- spray. This style is appealing because it usually can ing frequently used by black individuals to tempo- be maintained for 1 to 2 weeks before the hair is rarily straighten hair. With this technique, a metal washed and restyled, but such practices may be comb is heated to high temperatures (668C22608C) harmful to the well-being of the hair and scalp,13 by a heat source such as a small electric warmer, gas causing hair breakage and resulting in dry and brittle burner, or hot flame. An ointment-based lubricant hair.12 Scarring alopecia induced by hairpins has not is used to treat the hair and the hot comb is pulled been formally described. We present a complication through small sections of hair.12 Moderate to severe of sculptured hairstyles requiring multiple hairpins. burns from accidental contact with the hot comb13 Three black adolescent girls experienced ulcerative may result in alopecia, a common scalp problem lesions on the vertex of the scalp where hairpins associated with hot comb use. were used to secure the hairstyles. Chemical hair straightening in black individuals commonly involves the use of hydroxide relaxers that Case Report act by changing the cysteine disulfide bonds in the Patient 1—A 17-year-old black adolescent girl hair12 responsible for kinking or curling.CUTIS Relaxers con- reported a sore on her scalp of 1 month’s duration. taining sodium hydroxide and potassium hydroxide She reported wearing a hairstyle secured with mul- are the strongest and also are the most likely to cause tiple hairpins concentrated at the crown of the scalp. scalp and hair damage.12 A reported complication At this site, a tender pus-filled lesion developed that with these relaxers is fibrosis and inflammation of the healed with a scab. The patient denied any pruritus. Do14 Not Copy scalp associated with alopecia. She had no remarkable medical history, medications, Hair braiding and weaving are popular in the or allergies. Her family history was notable for diabetes black community because these hairstyles may mellitus. On physical examination she had a 233-cm be maintained with relatively little upkeep on a wound with a thick yellow crust and obvious hair daily basis. Additionally, hair thickness and styling loss. Debridement was performed and revealed beefy choices can be augmented. Tight braids or hairpieces red granulation tissue at the base (Figure 1A). The A B Figure 1. Beefy red granulation tissue with exudate at the base of a debrided wound on the vertex of the scalp (A). At 2-week follow-up, reepithelization of the ulcer was demonstrated with surrounding alopecia (B). There was some repigmentation and hair regrowth bordering the ulcer. VOLUME 85, MAY 2010 243 Copyright Cutis 2010. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. Hairpin-Induced Alopecia patient was afebrile and had no lymphadenopathy. by an area of missing hair. On physical examination There were no other remarkable findings. A traumatic the scalp showed a well-healed alopecic, hypopig- ulcer on the vertex of the scalp was diagnosed. The mented, pink plaque with areas of repigmentation patient was prescribed oral cephalexin for secondary and hair growth. There was a small area of beefy bacterial infection and advised to apply a warm water granulation tissue that was in the process of healing compress and antibiotic ointment to the lesion daily. (Figure 2). At 2-week follow-up, the patient and her mother reported that the wound was much improved and Comment there was no longer any drainage. On physical Hair loss may be caused by traction as well as other examination the crown of the scalp showed re- forms of trauma. Traction alopecia can be clinically epithelization of the ulcer with surrounding alopecia. distinguished from other forms of traumatic alope- There was no tenderness. The wound was smaller cia. Local trauma to the scalp can result
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