ORIGINAL ARTICLES Central hair loss in African American women: Incidence and potential risk factors EliseA.Olsen,MD,a Valerie Callender, MD,b Amy McMichael, MD,c Leonard Sperling, MD,d KevinJ.Anstrom,PhD,a Jerry Shapiro, MD,e Janet Roberts, MD,f Faith Durden, MD,g David Whiting, MD,h and Wilma Bergfeld, MDi Durham and Winston-Salem, North Carolina; Mitchellville and Bethesda, Maryland; Vancouver, British Columbia, Canada; Portland, Oregon; Dallas, Texas; and Cleveland, Ohio Background: Although central scalp hair loss is a common problem in African American women, data on etiology or incidence are limited. Objective: We sought to determine the frequency of various patterns and degree of central scalp hair loss in African American women and to correlate this with information on hair care practices, family history of hair loss, and medical history. Methods: Five hundred twenty-nine subjects at six different workshops held at four different sites in the central and/or southeast United States participated in this study. The subjects’ patterns and degree of central scalp hair loss were independently assessed by both subject and investigator using a standardized photographic scale. Subjects also completed a detailed questionnaire and had standardized photographs taken. Statistical analysis was performed evaluating answers to the questionnaire relative to pattern of central hair loss. Results: Extensive central scalp hair loss was seen in 5.6% of subjects. There was no obvious association of extensive hair loss with relaxer or hot comb use, history of seborrheic dermatitis or reaction to a hair care product, bacterial infection, or male pattern hair loss in fathers of subjects; however, there was an association with a history of tinea capitis. Limitations: There was no scalp biopsy correlation with clinical pattern of hair loss and further information on specifics of hair care practices is needed. Conclusions: This central scalp photographic scale and questionnaire provide a valid template by which to further explore potential etiologic factors and relationships to central scalp hair loss in African American women. ( J Am Acad Dermatol 2011;64:245-52.) Key words: central centrifugal cicatricial alopecia; central scalp hair loss; hair loss in African American women. high proportion of African American women seeking medical advice on their hair loss Abbreviations used: have central scarring hair loss, a condition CCCA: central centrifugal cicatricial alopecia A FPHL: female pattern hair loss that the North American Hair Research Society has MPHL: male pattern hair loss termed ‘‘central centrifugal cicatricial alopecia’’ (CCCA).1 Hair care products have long been impli- other than the temporal relationship with patchy hair cated as causes of hair loss in this population, but breakage, few data have been generated to prove From the Duke University Medical Center, Durhama; Howard Conflicts of interest: None declared. University, Mitchellvilleb; Wake Forest University, Winston- Accepted for publication November 29, 2009. Salemc; Uniformed Services University of the Health Sciences, Reprints not available from the authors. Bethesdad; University of British Columbia, Vancouvere; North- Correspondence to: Elise A. Olsen, MD, Box 3294 Duke University west Dermatology and Research Center, Portlandf; Western Medical Center, Durham, NC 27710. E-mail: [email protected]. Reserve Dermatology, Clevelandg; Baylor Hair Research and Published online November 15, 2010. Treatment Center, Dallas,h and Cleveland Clinic, Cleveland.i 0190-9622/$36.00 Supported by the North American Hair Research Society and an ª 2010 by the American Academy of Dermatology, Inc. unrestricted educational grant from Procter & Gamble. doi:10.1016/j.jaad.2009.11.693 245 246 Olsen et al JAM ACAD DERMATOL FEBRUARY 2011 this. There are no published data on the incidence/- photographs of the subject’s scalp hair were taken prevalence of either scarring or nonscarring central and both subject and investigator rated this central hair loss in African American women or on poten- scalp hair loss using the aforementioned central tially related medical problems or hereditary factors scalp photographic scale. that may be causative or contributory factors. The first three workshops were held in the south- Moreover, until recently, there have been no stan- eastern United States and the last three workshops in dardized methods to measure the severity of the Cleveland, Ohio. The first three workshops were common central hair loss. designed to address the fre- Nine clinical investigators quency of the various de- with experience in hair dis- CAPSULE SUMMARY grees of central hair loss in orders from various parts of 233 African American d A validated photographic scale of central North America were identi- women in the general popu- hair loss in African American women has fied and first met at Duke lation and to correlate the proven useful to evaluate the frequency University Medical Center in degree of hair loss with an- of the various patterns of hair loss in the Durham, NC, in 2005. From swers to the questionnaire. general population and to assess the this meeting, a 6-point pho- To accomplish this, the work- relatedness of various hair care practices tographic scale using stan- shops were held incidental and associated medical conditions. dardized photographs of to meetings of African the scalp hair of African d Severe central hair loss occurs in 5.6% of American women without American women was re- African American women. previous information on the fined with 0 = no hair loss d hair-related workshops. The 2 Chemical straightening is used by the and 5 = most severe hair loss majority of African American women first workshop was held in (Fig 1). Two subtypes of cen- without development of extensive Mitchellville, Maryland, as tral hair loss were identified central hair loss. part of an annual Health and and designated A (frontal ac- Beauty Symposium for centuation) and B (vertex ac- African American women. centuation). A questionnaire that addresses hair care Of the 825 women who attended the meeting, 150 practices and medical/hereditary factors was also participated in the hair workshop and were evalu- derived and later revised. ated independently by at least two of the four In this article, we report on the results of a investigators (V. C., A. M., E.A.O., and L.S.) in atten- multicenter trial in African American women de- dance. Two other smaller workshops held at general signed to evaluate the incidence and patterns of meetings of women members of two predominantly central hair loss using the aforementioned central African American churches were held in Wake-Forest hair loss photographic scale and the relationship of and Durham, North Carolina. At these latter two hair care practices, family history of hair loss, and meetings, more than 95% of all women (93 total) underlying medical conditions to the degree (if any) attending the meetings participated in the hair-re- of central scalp hair loss. lated workshops, and two investigators (A.M. and E.A.O.) independently evaluated each subject. METHODS Workshops four, five, and six were not part of Consent of subjects other meetings of African American women but were Institutional review board approval for the origi- stand-alone hair-related workshops with previous nal and all revised versions of the protocol and advertising in the African American community for consent form was obtained at the central site (Duke the workshops. One investigator (W.B.), in conjunc- University) and at the other 3 academic sites involved tion with one of her Cleveland Clinic colleagues, in the study. All coinvestigators were approved to evaluated all subjects for their degree of hair loss. partake in the study by one of the 4 institutional The information from the 296 women in attendance review boards. All subjects consented before enroll- at these last three meetings was added to that from ing in the study and before their data were collected. the 233 women who participated in workshops one, two, and three and used in the analysis of factors Overview of study design potentially related to the hair loss but was not used There were 6 study workshops involving a total of for determining the frequency of hair loss in the 529 African American women. At each workshop, general African American female population nor for participants filled out a detailed questionnaire on assessing the interrater variance in determination of their past and current hair care practices, medical the pattern of hair loss. In addition, the questionnaire history, and family history of hair loss. Standardized used in workshop six varied slightly from that used in JAM ACAD DERMATOL Olsen et al 247 VOLUME 64, NUMBER 2 the other workshops, so that answers to all questions in the questionnaire could not be consolidated from all six workshops. Data analysis Subjects. The characteristics of subjects from each workshop were analyzed individually and collectively. The results of the meetings are summa- rized where appropriate. Photographic scale. In our analysis, the sever- ity of the central hair loss patterns as shown in the photographic scale was considered as follows: no hair loss = pattern 0; early hair loss = patterns 1 and 2; and probable CCCA = patterns 3 to 5. Although it is likely that patterns 3 to 5 on the photographic scale may be surrogate markers for CCCA, this study did not include histologic confirmation of CCCA. A clinicohistologic correlation study is underway to address this issue. Investigator