Update on Hair Loss in African American Women Victoria Barbosa MD, MPH, MBA Mark Allen Everett MD Skin of Color Symposium University of Oklahoma April 23, 2021 Introduction

Associate Professor, University of Chicago Department of Medicine Section of Dermatology

Director of the Hair Loss Program

Email: [email protected] Phone 773-702-5525 FB, IG: @drvickibarbosa Disclosure

Consultant for Ambi Skincare

Will not be discussing any skin care products in this lecture Professional Practice Gap

Most providers are have limited education on hair care and hair loss in African American women

Providers should be comfortable in discussing hair care practices and diagnosing and managing hair loss in African American women Learning Objectives

➢What are the unique properties of Black hair? ➢What are the hair styling and hair care practices that we need to be aware of to be culturally competent and to aid in diagnosis and management of hair loss? ➢What are the common causes of hair loss in African American women? ➢How do I diagnose and manage these diseases? ➢What role do hair care and hair products play in disease in African American women? Black Hair, Hair Styles and Hair Care Black Hair: Curl Pattern Black Hair: Breakage & Growth

BREAKAGE GROWTH

Survival Probability of Different Ethnicities Loussouarn G. African hair growth parameters. Br J Dermatol. 2001 Aug;145(2):294-7 1 0.9 0.8 0.7 0.6 ◦ 256 (+/- 44) vs 396 (+/- 55) micrometers per day 0.5 0.4 for Blacks vs. Caucasians 0.3

SurvivalProbability 0.2 0.1 0 ◦ 3.68” per year vs. 5.74” per year 0 1000 2000 3000 4000 5000 Cycles to Failure

Black Asian Caucasian Latino

The influence of African-American hair's curl pattern on its mechanical properties Crystal E Porter 1, Stephane Diridollou, Victoria Holloway Barbosa Porosity

How easily does hair retain moisture? Hair Grooming: Key Questions Frequency of shampooing Conditioning on wash day and in between Natural vs relaxed ◦ Not all hair that is straight is relaxed ◦ Relaxer, texturizer, hair color Use of Heat Use and frequency of “protective” styling Use of additional synthetic or human hair extensions What Is Natural Hair?

◦ Natural hair is hair that has not been chemically treated ◦ Relaxers are universally considered chemicals and relaxed hair is never considered “natural” ◦ Texturizers are in fact mild relaxers; some people consider themselves to have natural hair even if they use a texturizer because their hair is still curly ◦ Some purists think that if you have hair color then you do not have natural hair; others think that you can have hair color and still be “natural” because hair color does not alter hair texture Loose Hair Styles Wash and go → shrinkage Short natural Twist out Braid out Braided Hair Styles aka “Protective Styles” Hair Weaving: Sew-in or Glued-in Hair Straightening

◦ Use of heat ◦ Hair relaxers ◦ Japanese straightening ◦ Brazilian blowout Hair Care Products

Shampoo: Traditional, co-wash/no-poo Conditioner: Rinse-out, leave-in oils, lotions and creams Hair Color: Permanent, semi-permanent, temporary Relaxers: Lye (sodium hydroxide; pH 12-14) , no-lye (calcium, lithium, potassium or guanidine hydroxide, pH 9-11) Styling: Heat protectors, detanglers, curl enhancers, anti-frizz, shine, oils, gels (hold, twists/locs), etc. What Should I Use on My Hair? Popular Black-Owned Hair Care Brands TGIN Lusters Mielle Organics Design Essentials Girl + Hair Curl Mix Jane Carter Solution Coils By Nature Kinky-Curly Uncle Funky’s Daughter Mixed Chicks Eden Bodyworks Camille Rose Naturals Black Girl Long Hair Miss Jesse’s Rucker Roots Taliah Wajiid Briogeo Curls Hair Rules Other Popular Brands Shea Moisture Cantu Carol’s Daughter ORS Dark & Lovely Soft Sheen Carson African Pride Key Points

Reduced frequency of shampooing based on structure and fragility of hair Increased focus on moisturizing Use of “protective” styles to reduce breakage at the ends but also to decrease time spent of daily care Hair care is time consuming and expensive “I need to examine your scalp…”

Do you feel comfortable to let me examine your scalp? Your hair looks beautiful. Are you wearing any extensions today? How can I best see your scalp? “I need you to come back after you take your weave/braids/crochet down…”

Avoid “Is that your hair?” Traction Alopecia Traction Alopecia

Hair loss due to prolonged or recurrent tension on the hair Initially a non-scarring alopecia, traction may become scarring over time Mostly reported in women of African descent, also seen in AA men, ballerinas, Sikhs, recently reported in Orthodox Jewish woman, TA: Prevalence

SOUTH AFRICAN WOMEN SOUTH AFRICAN GIRLS

Dr Khumalo et al studied 874 adults in Capetown, Dr. Khumalo et al studied 1042 school children in including a survey and physical exam: Capetown, including a survey and physical exam:

◦ TA found in 31.7% of women and 2.2% of men ◦ TA found in 8.6% of girls in their first year of school vs. 21.7% of girls in their last year of high school ◦ TA found in 48% of women with relaxed hair and braided extensions ◦ TA was found in 22.9% of girls with no relaxer and 32.1% of girls with a relaxer

◦ This trend was not statistically significant

Khumalo NP, Jessop S, Gumedze F, Ehrlich R. Hairdressing and the prevalence of scalp disease in African adults. Br J Dermatol. 2007 Khumalo NP, Jessop S, Gumedze F, Ehrlich R. Hairdressing is Nov;157(5):981-8. associated with scalp disease in African schoolchildren. Br J Dermatol. 2007 Jul;157(1):106-10. TA: Associations in African American Girls

Dr. Rucker Wright et al surveyed 201 caregivers of AA girls to evaluate hair care practices and association with disease: ◦ N=98 from derm clinic, n=103 from non-derm clinic ◦ Mean age 9.6 +/- 4.4 ◦ Ponytails worn by 81%, braids worn by 67% and cornrows worn by 49% in the last 12 months ◦ Cornrows were statistically significantly related to TA, OR 5.79

Rucker Wright D, Gathers R, Kapke A, Johnson D, Joseph CL. Hair care practices and their association with scalp and hair disorders in African American girls. J Am Acad Dermatol. 2011 Feb;64(2):253-62. Traction Alopecia: Clinical Presentation Traction Alopecia: Management

Discontinue hair styles that cause the hair to pull Protect the hair from rubbing on hats and wigs Topical or intra-lesional steroids Topical minoxidil Oral antibiotics Hair transplant What’s New?

Frequent braiding contributes to damage to the hair fiber as well as to traction alopecia (IJCS)

Prevalence of TA 7.4% in a study of 428 Nigerian secondary school students (PAMJ)

Report of oral minoxidil use for TA (DT)

Quantifying the impact of braiding and combing on the integrity of natural African hair. Molamodi K, Fajuyigbe D, Sewraj P, Gichuri J, Sijako B, Galliano A, Laurent A. Int J Cosmet Sci. 2021 Feb 19.

Cutaneous disorders of adolescence among Nigerian secondary school students. Oyedepo JT, Katibi OS, Adedoyin OT. Pan Afr Med J. 2020 May 27;36:36.

Case series of oral minoxidil for androgenetic and traction alopecia: Tolerability & the five C's of oral therapy. Beach RA. Dermatol Ther. 2018 Nov;31(6):e12707 Traction: Be Prepared

Traction alopecia is 100% preventable Every interaction with an African American patient is an opportunity for 30 seconds of life changing education Encourage patients to rotate hair styles Have a list of “go to” cosmetologists Keep an open mind to the differential Alopecia Areata Alopecia Areata: Ophiasis Pattern Alopecia Areata: Clinical Presentation Alopecia Areata: Management Topical steroids Systemic Treatments ◦ Prednisone Anthralin .5 - 1% ◦ Azathioprine Intralesional triamcinolone ◦ Methotrexate ◦ ILK 5-10 mg/cc ◦ Cyclosporin Topical Immunotherapy ◦ Sulfasalazine ◦ Squaric acid dibutylester* ◦ Ezetimibe-simvastatin ◦ Diphenylcyclopropenone ◦ JAK Inhibitors (topical, oral) ◦ Dinitrochlorobenzene Adjunctive Treatments ◦ Minoxidil *Penn State Hershey Protocol ◦ PRP Alopecia Areata in African Americans: What’s New?

9340 AA Patients from the NAAR registry identified (JAAD) ◦ African Americans had a higher odds of AA compare to Caucasians (OR 1.77; 95% CI, 1.37-2.2 ◦ Asian Americans had a lower odds of AA compared to Caucasians (OR 0.40; 95% CI, 0.32-0.50

63,960 women from the Nurses' Health Study (NHS) and 88,368 women from the Nurses' Health Study II (NHSII); 418 and 738 cases of AA, respectively (JID) ◦ NHS: OR 2.72 (95% CI 1.61-4.61) amongst black women as compared with white women ◦ NHSII: OR 5.48 (95% CI 4.10-7.32) amongst black as compared with white women. ◦ NHSII Hispanic Women: OR 1.94 (95% CI 1.24-3.02) in Hispanic compared with non-Hispanic white women.

Racial characteristics of alopecia areata in the United States. Lee H, Jung SJ, Patel AB, Thompson JM, Qureshi A, Cho E. J Am Acad Dermatol. 2020 Oct;83(4):1064-1070.

Race and Alopecia Areata amongst US Women. Thompson JM, Park MK, Qureshi AA, Cho E. J Investig Dermatol Symp Proc. 2018 Jan;19(1):S47-S50. Frontal Fibrosing Alopecia Frontal Fibrosing Alopecia

Primary lymphocytic cicatricial alopecia Affects anterior hairline, eyebrows; may have loss of body hair May have facial papules or hyperpigmentation associated First reported in 1994, seeing increase in frequency FFA: Clinical Presentation FFA: Management

Topical ◦ Steroids ◦ Calcineurin inhibitors ◦ Minoxidil Intralesional steroids Systemic treatment ◦ Anti-inflammatory doxycycline or hydroxychloroquine ◦ 5 alpha reductase inhibitors Recalcitrant disease ◦ Retinoids ◦ Immunosuppressive medications FFA: What’s New

Lots of questions! -Why are we seeing an increase in the prevalence of this condition -Sunscreen controversy Central Centrifugal Cicatricial Alopecia CCCA: Etiology & Epidemiology

Limited understanding of the role of genetics, androgens, grooming, sources of inflammation Dlova et al, JAAD 2014 ◦ Studied 14 families with 31 family members; pedigree analysis suggested AD inheritance Suchinwanit et al: IJD 2016 ◦ 38 women with bx proven CCCA ◦ Severity was correlated with duration ◦ Androgen related conditions were prevalent CCCA: Etiology & Epidemiology

Gaithers et al conducted a retrospective survey ◦ 21% had noticed thinning by age 30; 44% by 40 ◦ CCCA patients were more likely to have a sister with hair loss than non-CCCA patients ◦ No correlation with hot combs, relaxer use, h/o burns ◦ CCCA patients more likely to have had cornrows/braids with added hair & weaves, and have worn them for a longer time CCCA: Clinical Presentation Complaint of hair loss, breakage or pruritus Often sent by hair stylist Several years duration May have seen other dermatologists Usually have not used any treatment +/- family history CCCA: Physical Examination

Thinning at the vertex Progression centrifugally Loss of hair follicles No inflammation noted +/- scale Some have itching, burning or tingling Early CCCA End Stage CCCA CCCA: Breakage at the Crown Management Goal #1: Halt Progression Topical or intralesional steroids ◦ High potency topicals used qd or bid ◦ Give patient a choice as to which vehicle, solution, ointment or foam ◦ ILK 5 to 10 mg/cc as tolerated monthly ◦ Depends on amount of scalp involved and patients willingness Oral ◦ Doxycycline 100 mg bid or minocycline 100 mg bid ◦ Plaquenil Management Goal #2: Encourage Regrowth

Topical or oral minoxidil Spironolactone Finasteride Supplements PRP Hair transplantation when stable CCCA: What’s New?

Variant PADI3 in Central Centrifugal Cicatricial Alopecia. Malki L et al. N Engl J Med. 2019 Feb 28;380(9):833-841. Exome sequencing, protein modeling, immunofluorescence staining, etc. 1 splice site and 3 mutations in PADI3 PADI3 encodes peptidyl arginine deiminase, type III This enzyme is involved in post-translational protein modification of proteins involved in hair shaft formation Hair Care and Health Are Relaxers Harmful to Our Health?

No data demonstrating an association between relaxer use and CCCA

One study showing that women diagnosed with fibroids are more likely to have used hair relaxers Hair relaxer use and risk of uterine leiomyomata in African-American women (Wise, et al, American Journal of Epidemiology 2012) BWHS: 23,580 premenopausal women IRR 1.17 (95% CI 1.06-1.30)

Two recent studies demonstrating an association between relaxer use and the development of breast cancer Skin lighteners and hair relaxers as risk factors for breast cancer: results from the Ghana breast health study (Brinton et al, Carcinogenesis 2018) 1131 invasive breast cancer patients and 2106 population controls. OR of 1.58 (95% CI 1.15–2.18) Hair dye and chemical straightener use and breast cancer risk in a large US population of black and white women (Eberle et al, International Journal of Cancer 2020) 46,709 women ages 35-74, 2003 -2009; 2,794 breast cancers identified. Relaxer use was associated with breastcancer risk (OR = 1.18, 95% CI 0.99-1.41 Is Hair Dye Harmful to Our Health? Lymphoma ◦ Conflicting data ◦ Women who started using hair dye before 1980 had a 30% increased risk of developing NHL compared to women who never used hair dye Leukemia ◦ Conflicting data Bladder cancer ◦ Small increase in risk among cosmetologists but not among hair dye users Breast Cancer ◦ Conflicting data ◦ Historically, thought leaned against an association ◦ Recent data suggests an association between hair dye use and African American women Endocrine Disruptors

Natural or man-made chemicals that mimic or interfere Atrazine: weed killer, water contaminant with the body’s hormones Bisphenol A (BPA) : canned foods, plastic bottles

Linked with developmental, reproductive, neurological, Dioxins : forms in industrial processes, found in animal products immunological and other problems. Estrogens: hair growth products

Glycol ethers: found in sunscreen and cosmetics (humectant, emollient)

Parabens: preservative in hair care products

Perchlorate : rocket fuel, water contaminant, produce

Polyfluoroalkyl Substances (PFAS): water contaminant, non-stick pans

Phthalates: plastic containers, “fragrance”

Phytoestrogens: soy

Polybrominated diphenyl ethers (PBDE) : flame retardant

Polychlorinated biphenyls (PCB) : banned coolant, contaminant

Triclosan: antimicrobial soaps Estrogens and Anti-Estrogens in Hair Products Estrogenic and anti-estrogenic activity of off-the-shelf hair and skin care products (Myers et al, Journal of Exposure Science and Environmental Epidemiology 2015) ◦ Evaluated 8 hair and skin care products commonly used by AA women for estrogenic and antiestrogenic activity using a cell proliferation assay ◦ 4/8 products, including a hair oil, demonstrated estrogenic activity ◦ 3/8 products, including a placenta conditioner and a tea tree oil hair conditioner, demonstrated anti-estrogenic activity Endocrine Disruptors in Hair Products Measurement of endocrine disrupting and asthma-associated chemicals in hair products used by Black women (Helm et al, Environmental Research 2018) ◦ Used GC/MS to test 18 hair products in 6 categories used by Black women: hot oil treatment, anti-frizz/polish, leave-in conditioner, root stimulator, hair lotion, and relaxer ◦ Tested for 66 chemicals belonging to 10 chemical classes: ultraviolet (UV) filters, cyclosiloxanes, glycol ethers, fragrances, alkylphenols, ethanolamines, antimicrobials, bisphenol A, phthalates, and parabens ◦ 45 chemicals were found, belonging to all 10 classes ◦ Root stimulators, hair lotions, relaxers, anti-frizz ◦ 84% of ingredients found were not listed on the labels Early Menarche Childhood hair product use and earlier age at menarche in a racially diverse study population: a pilot study (James-Todd et al, Annals of Epidemiology 2011) ◦ 300 AA, African-Caribbean, Hispanic, and white women ages 18-77 years of age. ◦ Data collected retrospectively on hair oil, lotion, leave-in conditioner, perm, and other types of hair products used before age 13. ◦ Women reporting childhood hair oil use had an increased risk for early menarche (RR 1.4, 95% CI 1.1-1.9) ◦ Hair perm users had an increased risk for earlier menarche (ARR 1.4, 95% CI 1.1-1.8) Early Menarche Hair product use, age at menarche and mammographic breast density in multiethnic urban women (McDonald et al, Environmental Health, 2018) ◦ 248 women from 2 cohorts ◦ Examined childhood and adulthood use of hair oils, lotions, leave-in conditioners, root stimulators, perms/relaxers, and hair dyes ◦ Childhood “ever use” of any hair product and specifically use of hair oil were associated with a higher probability of reaching menarche before 11 years of age ◦ Postulates product use may increase risk of breast cancer Conclusion

More information is needed regarding etiology and pathogenesis of these diseases Clarification of the role of grooming practices in disease progression is needed Evidence-based treatment approaches are lacking for many conditions Education of patients, stylists and the general population is key to early diagnosis and treatment compliance More and better treatments are needed