ORIGINAL
ARTICLES
Central hair loss in African American women: Incidence and potential risk factors Elise A. Olsen, MD,a Valerie Callender, MD,b Amy McMichael, MD,c Leonard Sperling, MD,d Kevin J. 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.
A
high proportion of African American women seeking medical advice on their hair loss have central scarring hair loss, a condition that the North American Hair Research Society has termed ‘‘central centrifugal cicatricial alopecia’’ (CCCA).1 Hair care products have long been implicated as causes of hair loss in this population, but
other than the temporal relationship with patchy hair breakage, few data have been generated to prove
From the Duke University Medical Center, Durhama; Howard University, Mitchellvilleb; Wake Forest University, WinstonSalemc; Uniformed Services University of the Health Sciences, Bethesdad; University of British Columbia, Vancouvere; Northwest Dermatology and Research Center, Portlandf; Western Reserve Dermatology, Clevelandg; Baylor Hair Research and Treatment Center, Dallas,h and Cleveland Clinic, Cleveland.i Supported by the North American Hair Research Society and an unrestricted educational grant from Procter & Gamble.
Conflicts of interest: None declared. Accepted for publication November 29, 2009. Reprints not available from the authors. Correspondence to: Elise A. Olsen, MD, Box 3294 Duke University Medical Center, Durham, NC 27710. E-mail:
[email protected]. Published online November 15, 2010. 0190-9622/$36.00 ª 2010 by the American Academy of Dermatology, Inc. doi:10.1016/j.jaad.2009.11.693
Abbreviations used: CCCA: central centrifugal cicatricial alopecia FPHL: female pattern hair loss MPHL: male pattern hair loss
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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 potenscalp 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 southMoreover, until recently, there have been no staneastern 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 freNine clinical investigators quency of the various deCAPSULE SUMMARY with experience in hair disgrees of central hair loss in orders from various parts of 233 African American A validated photographic scale of central North America were identiwomen in the general popuhair 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 anof 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 phoTo accomplish this, the workrelatedness of various hair care practices tographic scale using stanshops were held incidental and associated medical conditions. dardized photographs of to meetings of African the scalp hair of African Severe central hair loss occurs in 5.6% of American women without American women was reAfrican American women. previous information on the fined with 0 = no hair loss hair-related workshops. The Chemical straightening is used by the and 5 = most severe hair loss2 first workshop was held in majority of African American women (Fig 1). Two subtypes of cenMitchellville, Maryland, as without development of extensive tral hair loss were identified part of an annual Health and central hair loss. and designated A (frontal acBeauty Symposium for centuation) and B (vertex acAfrican 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 evaluderived 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 attenmulticenter trial in African American women dedance. 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-reof 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 origistand-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 conjuncUniversity) 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 enrollat 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 potentially related to the hair loss but was not used Overview of study design for determining the frequency of hair loss in the There were 6 study workshops involving a total of general African American female population nor for 529 African American women. At each workshop, assessing the interrater variance in determination of participants filled out a detailed questionnaire on the pattern of hair loss. In addition, the questionnaire their past and current hair care practices, medical used in workshop six varied slightly from that used in history, and family history of hair loss. Standardized d
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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 summarized where appropriate. Photographic scale. In our analysis, the severity 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 versus subject assessments. Investigator assessments of hair loss were analyzed both individually and collectively compared with the subject’s assessment of hair loss. The collective investigator assessment of the subject’s central hair loss (mode score where three or more investigators rated the subjects, lowest score where there was disagreement between two investigators) was used as the determinant of the degree of central hair loss and was correlated with the subject’s answers to the questionnaire. Statistical analysis. To simplify the results and to account for the fact that subjects cannot readily characterize hair loss in their vertex scalp (B subtype) without the concomitant use of mirrors, subtypes A and B on the central photographic scale were merged into one category for analysis purposes. Categorical variables were summarized by percentages. Comparisons of categorical variables were conducted using x 2 tests. Correlations between ordinal factors were computed using Spearman Rho. Comparisons of assessments by the different clinical investigators were conducted using Kappa statistics which correct for agreement caused by chance and offer a measure of agreement between two individuals: poor agreement: \0.20; fair agreement: 0.21-0.40; moderate agreement: 0.41-0.60; substantial agreement: 0.61-0.80; almost perfect agreement: 0.81-1.00. Two-sided P values were considered statistically significant.
RESULTS Five hundred twenty-nine African American women participated in the study. The results for age and central hair loss pattern as determined by the investigators at each meeting/site and collectively
Fig 1. Central scalp alopecia photographic scale in African American women. Reprinted from Olsen et al2 with permission from Wiley-Blackwell.
are given in Table I. The mean age of the 529 subjects was 48.3 years (range, 18-85 years) with 38.5% of subjects over 55 years of age and likely postmenopausal at the time of the survey. There were significant differences in the age of patients across
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Table I. Characteristics of study subjects evaluated in each of the meeting workshops Mitchellville, MD
No. of patients Mean age, y (range) 0 1 2 3 4 5
Wake Forest, NC
Durham, NC
Cleveland #1
Cleveland #2
Cleveland #3
Total
150 60 23 33 103 160 529 45.9 (18-72) 52.1 (22-85) 47.4 (19-70) 42.2 (18-67) 46.4 (18-81) 55.7 (18-83) 48.3 (18-85) Central hair loss pattern as determined by investigator, n (%) 106 (70.7) 33 (55.0) 14 (60.9) 10 (30.3) 33 (32.0) 70 (43.8) 266 27 (18.0) 22 (36.7) 8 (34.8) 19 (57.6) 37 (35.9) 44 (27.5) 157 8 (5.3) 1 (1.7) 1 (4.4) 1 (3.0) 13 (12.6) 21 (13.1) 45 9 (6.0) 2 (3.3) 0 (0.0) 1 (3.0) 9 (8.7) 16 (10.0) 37 0 (0.0) 1 (1.7) 0 (0.0) 2 (6.1) 4 (3.9) 5 (3.1) 12 0 (0.0) 1 (1.7) 0 (0.0) 0 (0.0) 7 (6.8) 4 (2.5) 12
Table II. Comparison of investigator versus subject rating of central hair loss: All sites/subjects Investigator rating of central hair loss pattern Scores
Subject rating
0 1 2 3-5
Total
0 N (%)
180 49 5 12 246
(73) (20) (2) (5) (49.2)
1 N (%)
78 41 7 22 148
(53) (28) (5) (15) (29.8)
2 N (%)
10 13 8 14 45
(22) (29) (18) (31) (9.1)
3-5 N (%)
4 4 14 36 58
(7) (7) (24) (62) (11.7)
Total N
272 107 34 84 497
There are 32 patients without subject rating.
the sites (P \ .0001 with five degrees of freedom). However, the ages of participants in the first three meetings were not statistically significantly different (KruskaleWallis P = .055). By investigator assessment, the majority (65.7%) of subjects in workshops one to three had no hair loss, 28.8% had mild hair loss (patterns 1 and 2), and 5.6% had extensive hair loss (patterns 3-5). In workshops four, five, and six, where subjects with hair loss were overrepresented compared to the general population, 38.1% of subjects had no hair loss, 45.6% had mild hair loss, and 16.2% had extensive hair loss. Across all sites, there was a strong positive correlation between age and degrees of hair loss (Spearman correlation = 0.36, with P \.0001). We previously reported on the good agreement among 4 experienced investigators grading central hair loss at the first of these 3 meetings with an exact match in 72% to 86% of cases (kappa scores 0.460.67) and no investigator more than one grade off from another on any assessment2: this held true for all 3 meetings. Given that two of the investigators (A. M. and E. A. O.) independently rated subjects in all of the first 3 meetings, we compared the agreement between these two investigators at meeting 1 versus meetings 2 and 3 as representative of further experience with the photographic scale in a collaborative trial. There was a kappa statistic of 0.46 (with 72% exact matches) versus kappa statistic of 0.58 (with 75% exact matches) for central hair loss
severity in meeting 1 versus meetings 2 and 3, respectively, revealing both a slight, but not statistically significant, increase in agreement and the reliability of the investigator grading over time. The ability of subjects to discern and to grade their own central scalp hair density/loss with the use of the provided photographic scales was determined by the comparison of their scores to that of the various investigators (Table II). Subjects had only fair agreement with investigators in discerning whether hair loss was present or not (pattern 0-1 vs patterns 25) with kappa statistic of 0.55. Not surprisingly, subjects were poor at determining the degree of hair loss (patterns 0-5; kappa statistic of 0.27) and tended to overestimate their degree of hair loss. We queried women about possible infections that could be related to hair loss: history of infections was not documented by culture or medical records. There was no significant difference in the reporting of bacterial or nonscalp fungal infections between those with patterns 0-2 and those with patterns 3-5 central hair (P = .98). There was, however, a statistically significant association between reports of tinea capitis and patterns 3-5 versus patterns 0-2 (P = .009) although the total number of cases was extremely low (7 in 468 subjects [1.5%] with patterns 0-2 and 4 in 61 subjects [6.5%] with patterns 3-5). We also addressed whether there was an association of a reaction to a hair care product and the development of extensive hair loss: there was no association of a
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Table III. Hair care history (ever used) along with current pattern of hair loss Hair care history (ever used)
Relaxer (P = .61) Hot comb (P = .35) Texturizer (P = .33) Braided with extensions (P = .29) Weaves or tracts (P = .22)
Used (n = 529) N (%)
476 309 61 187
Pattern 0 (n = 266) N (%)
(90) (58) (12) (35)
136 (26)
scalp ‘‘rash’’ after shampoo or relaxer with extensive central hair loss (P = .47 for shampoo and P = .25 for relaxer). There was also no association of seborrheic dermatitis/scaling scalp or eczema with any pattern of central hair loss (P = .80 for seborrheic dermatitis/scaling of scalp and P = .065 for eczema). We were interested in seeing if there was any association of central hair loss with autoimmune or hormonal disorders. We did not find any association of thyroid disease and pattern of central hair loss (P = .31). Type 1 or 2 diabetes mellitus was present in 8.5% of women overall and was less common in those with central hair loss patterns 1 and 2 than those with patterns 3-5 (P = .019). Surprisingly, a history of potential androgen-related disorders was extremely common in subjects but was unrelated to the degree of hair loss: adult acne was reported in 34%, hirsutism (facial hair growth) in 48%, irregular periods in 24%, and difficulty getting pregnant in 9% of the 529 women. Thirty-one percent (77/252) of subjects with hirsutism also complained of irregular periods, thus fulfilling the criteria for polycystic ovarian syndrome.3 However, taking into account the age of subjects and the presence of either facial hair alone or facial hair with at least one other of the above signs/symptoms, there was no relationship between hyperandrogenism and central hair loss pattern. We next looked at whether there was an association of extensive hair loss with pattern hair loss in male and female family members. There was no relationship between central hair pattern 3-5 in subjects and Hamilton Norwood patterns IV-VII (vertex to loss of all central scalp hair) male pattern hair loss (MPHL) in the subjects’ fathers (P = .18). There was also no association of frontal MPHL in the father and patterns 3-5 central scalp hair in the subject (P = .91). We evaluated the reported association of women with polycystic ovarian syndrome (PCOS) and family members with MPHL3 and did not find a statistically significant association in those with both hirsutism and irregular periods (thus fulfilling the criteria for PCOS4) and vertex MPHL in the subjects’ fathers (Spearman correlation P = .06).
237 163 29 97
(89) (61) (12) (38)
63 (25)
Pattern 1 (n = 157) N (%)
143 84 21 57
(91) (54) (12) (34)
45 (27)
Pattern 2 (n = 45) N (%)
39 24 2 10
(87) (53) (4) (22)
8 (17)
Pattern 3-5 (n = 61) N (%)
57 38 9 23
(93) (62) (15) (38)
20 (33)
We then evaluated whether there was a relationship of extensive central hair loss in mothers of subjects with pattern 3-5 loss, realizing that not only hereditary factors but hair care practices might play a role in any similarity. There was a strong, statistically significant association of the severity of central hair loss in the subject and that of her mother (Spearman correlation P = .002). Four hundred seventy-six (90%) of the 529 women had ever used relaxers (Table III). There was no association of relaxer use and extensive central hair loss (P = .61). We asked subjects at what age relaxers were first used and compared the responses of the subjects with no central hair loss (pattern 0), early central hair loss (pattern 1-2), and extensive central hair loss (patterns 3-5) (Table IV). Relaxer use began before 6 years of age in only two (\1%) and between 6 and 15 years of age in 121 (37%) of the 328 subjects who had used relaxers in studies one through five; the questionnaire was modified for study six, and data on the age of first relaxer use were not available for this subset of subjects. There was a statistically significant association with the age of first relaxer use and the current patterns of extensive loss (P = .01 for the Spearman correlation) when comparing patterns 0 versus 3 to 5. However, there was not a statistically significant association comparing patterns 1 and 2 versus 3 to 5 (P = .54 for the Spearman correlation). Of note, for all users of relaxers, regardless of pattern of central hair density, there was much more use of ‘‘no lye’’ versus ‘‘lye’’ relaxers. Three hundred and nine of the 529 women (58%) had ever used hot combs, a much lower percentage than relaxers (Table III). There was no association of use of hot combs ever and extensive hair loss (P = .35) (Table V). In contrast to the use of relaxers, in those women who acknowledged the use of hot combs and for whom we have age of first use, their use began before 6 years of age in 32% to 33% of subjects regardless of whether patterns 0, 1 to 2, or 3 to 5 (Table V) and by age of 15 in 87%. In contrast to those who used relaxers, there was no association of time of onset of use of hot comb use and current
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Table IV. Onset of use of relaxers (1ye or not) in subjects with various patterns of central hair loss Current hair loss pattern in women who have ever used relaxer (328/369*) Age at time of first use, y
0-5 6-15 16-24 25-33 34-43 44-53 $ 54 Total
Pattern 0 (n = 173)
Pattern 1 (n = 104)
Pattern 2 (n = 20)
Pattern 3-5 (n = 31)
n
N (%)
N (%)
N (%)
N (%)
Total
2 121 155 30 14 4 2 328
2 (1) 78 (45) 76 (44) 10 (6) 6 (3) 1 (\1) 0 (0) 173
0 (0) 30 (29) 53 (51) 13 (12) 5 (5) 2 (2) 1 (1) 104
0 (0) 5 (25) 11 (55) 3 (15) 0 (0) 0 (0) 1 (5) 20
0 (0) 8 (26) 15 (48) 4 (13) 3 (10) 1 (3) 0 (0) 31
2 121 155 30 14 4 2 328
*Includes all subjects in workshops one to five; data on age of first relaxer use from workshop six could not be consolidated.
Table V. Onset of hot comb use compared with current hair loss Current hair loss pattern in women who have ever used hot combs (269/369*) Age at time of first use, y
0-5 6-15 16-24 25-33 34-43 44-53 $ 54 Total
Pattern 0 (n = 133)
Pattern 1 (n = 88)
Pattern 2 (n = 18)
n
N (%)
N (%)
N (%)
Pattern 3-5 (n = 30) N (%)
Total
87 147 23 6 3 2 1 269
42 (32) 73 (56) 12 (9) 4 (3) 2 (1) 0 (0) 0 (0) 133
28 (32) 49 (56) 7 (8) 2 (2) 1 (1) 1 (1) 0 (0) 88
7 (39) 10 (56) 0 (0) 0 (0) 0 (0) 0 (0) 1 (5) 18
10 (33) 15 (50) 4 (14) 0 (0) 0 (0) 1 (3) 0 (0) 30
87 147 23 6 3 2 1 269
*This includes all subjects in workshops 1-5; the question was not asked in workshop 6.
extensive hair loss (P = .96 for Spearman correlation comparing central hair loss patterns 0 vs 3 to 5 and P = .87 for comparing 1 and 2 vs 3 to 5). Use of braids with extensions, weaves or tracts, and texturizers were not associated with extensive hair loss (Table III; P = .29 for braids with extensions, P = .22 for weaves or tracts, and P = .33 for texturizers). We attempted to address whether the current central scalp hair loss pattern appeared to select for any particular hair care practice (Table VI). Women with extensive hair loss were less likely to now use relaxers than those without extensive loss (52% for patterns 3-5 vs 67% for those with patterns 1-2), but clearly extensive hair loss did not curtail the use of relaxers. Hot combs continued to be used much less often than relaxerse17%, 19%, and 30% in those with pattern 0, 1, or 2, respectively, and 25% in those with patterns 3 to 5.
DISCUSSION Central centrifugal cicatricial alopecia (CCCA) is the primary reason that African American women seek medical consultation for their hair,5,6 but the incidence and causality are not known. This hair loss
has been called ‘‘hot comb alopecia’’ secondary to its frequent occurrence in those using hot combs to straighten their hair7 or ‘‘follicular degeneration syndrome’’ based on the characteristic histopathologic findings on a representative scalp biopsy.8 That this central scarring hair loss occurs much more commonly in African American than Caucasian women has led to a focus on the hair care practices of African American women as the sole cause of this problem. Our study was initiated to gather data on the type, degree, and frequency of central hair loss in African American women and its relationship to age, family history of hair loss, concurrent medical problems, and hair care practices. The photographic scale developed by the group was found to be a reliable tool for rating the general severity of central hair loss when used by physician investigators and should be able to be used to standardize the assessment of the severity of hair loss in clinical trials. However, subjects that had no previous instructions or training on its use were not reliably able to self-identify their degree of hair loss: whether subjects could more closely mirror investigators with a simplified scale or if the use of the current scale were preceded by a training session
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Table VI. Current hair care practice versus subjects’ current pattern of central hair loss Current pattern of hair loss
Current hair care practices
Relaxer Hot comb Braids with extensions Braids without extensions Weaves Curly perm Jheri curl Twist Texturized
Pattern Pattern Pattern Pattern 3-5 Total 2 1 0 (n = 266) (n = 157) (n = 45) (n = 61) (n = 529) N (%)
N (%)
N (%)
N (%)
N (%)
176 (66) 104 (66) 32 (70) 32 (53) 344 (65) 44 (17) 32 (19) 14 (30) 15 (25) 105 (20) 35 (14) 20 (12) 6 (13) 11 (18) 72 (14) 34 (13) 18 (11) 3 (7) 11 (18) 66 (13) 23 9 15 17 3
(9) (4) (6) (7) (1)
18 3 14 9 7
(11) (2) (8) (5) (4)
7 2 5 2 2
(15) (4) (11) (4) (4)
11 2 5 3 2
(18) (3) (8) (5) (3)
59 16 39 31 14
(11) (3) (7) (6) (3)
needs further evaluation. Taylor et al9 previously reported a similar but less profound disconnect between experienced observers and male subjects in rating their Hamilton-Norwood pattern of MPHL. Because we collapsed the data on the A and B subtypes of central loss in this study, we need further information on both the relative frequency with which the frontal versus vertex predominant patterns are present in African American women with central hair loss and whether there is any particular medical or genetic association with the frontal versus vertex pattern of central hair loss. Overall, 65.7% of the 233 women in workshops one to three, which we felt was indicative of the general population, did not have any central hair loss, a finding similar at all three screenings. In this group, 24.5% of women had pattern 1, 4.3% had pattern 2, and 5.6% had pattern 3 to 5 central scalp hair loss. The use of relaxers per se did not appear to be related to severity of hair loss because it was equally high in women with no or minimal hair loss, (87%-91%) versus those with extensive hair loss (93%). There was obvious difficulty in giving up relaxer use even with extensive hair loss because 53% of women with patterns 3 to 5 continued to use relaxers. Despite the purported potential for hair loss from hot comb use, there was no association with severity of hair loss and use of hot combs. The use of chemical processing of scalp hair by women of African descent is not unique to the US but is also commonly seen in women in African countries: Khumalo et al10 reported that almost 50% of black South African women relax their hair and that CCCA exists in this population as well. Relaxers are a frequent cause of both hair loss and problems that
could lead to hair loss in this country and Africa: 67% of Kenyan women in one study reported relaxerrelated problems, the most common being hair loss (type unspecified) and burns (scalp).11 In our study, there was no association of extensive hair loss and reaction to hair care products, although the type of reactions was not specified. In future studies in the US, we need to go beyond the query of age of onset or current usage of relaxers or other hair care practices to determine if there are differences in the way relaxers or permanent waves are neutralized, the concentrations of active chemicals, the frequency of application, and the severity and number of reactions to the products subjects have had. We also need to consider whether there are other hair care practices, such as the use of heat, hair color, greases, and pomades, being used either concomitantly or sequentially with relaxers or permanent waves that could, in combination, lead to a permanent compromise of normal follicular growth. Extensive hair loss was not found to be related to any history of scalp scaling, seborrheic dermatitis, or eczema. The incidence of tinea capitis (6.5%), however, was high in African American women with central hair loss patterns 3 to 5 and speaks to the need to address early all potentially reversible scalp conditions that could lead to prolonged periods of scalp inflammation. That African American women may be particularly susceptible to tinea capitis was shown in a retrospective study carried out in an academic dermatology practice in which only 60% of the patients were of African descent but all of the culture-documented tinea capitis occurred in African Americans including seven of the nine cases in African American women.12 The incidence of extensive (patterns 3-5) central hair loss at our three meeting sites in the southeastern United States was 5.6%. If central hair loss patterns 3 to 5 can be used as a surrogate marker for CCCA, then although the incidence of this condition is relatively low in African American women, the incidence is far greater than other types of cicatricial alopecia and the total number of affected African American women is high. The overall incidence of CCCA in a group of African women who commonly use relaxers (2.7%)10 is not too dissimilar to our findings. The location of hair loss in African American women with central patterns 1 to 5 mimics that seen in Caucasian women with female pattern hair loss (FPHL) Ludwig patterns 1 to 3, the difference being the less frequent occurrence of extensive hair loss in Caucasian women (;1% incidence of Ludwig pattern 3)13 and the paucity of reports of scarring alopecia in the central scalp in Caucasian compared to African American women. Olsen14 has
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recently reiterated that there can be follicular dropout (confirmed histologically) with extensive FPHL and has hypothesized that CCCA may be a scarring form of female pattern hair loss, perhaps induced by chronic inflammation or infection induced or aggravated by hair care practices. This concept, especially in lieu of the frequency of patterns 1 and 2 in African American women which resembles female pattern hair loss in Caucasian women, needs further exploration including biopsy confirmation. Any hereditary nature of central hair loss in African American women remains unclear: although 27% of women with pattern 3 to 5 hair loss had mothers with pattern 3 to 5 central hair loss, the association could either be genetic or secondary to common hair care practices. The relatively high incidence of clinical signs of hyperandrogenism in African American women with and without hair loss is important to note and should broaden the history taking and evaluation of African American women with hair loss to include a search for signs or laboratory results indicative of hyperandrogenism and its associated conditions. This study has limitations. One limitation is that we used central scalp hair patterns 3 to 5 as a surrogate phenotypic marker for CCCA but do not have biopsy confirmation of the follicular loss and typical inflammatory findings seen histologically with early CCCA. Second, data collected based on memory of distant events are always subject to bias, particularly questions related to when an event occurred. Third, despite asking questions on frequency of hair care treatments, we were not able to determine whether a particular hair care practice, such as relaxers, might be problematic or safe if used in a particular way. Fourth, we did not address whether the type, intensity, and/or frequency of heat or the use of emollients and greases used on the scalp contribute to infection, inflammation, and follicular destruction. Fifth, we do not have enough information to address whether tight braids, weaves, or extensions, if anchored in a particular fashion, could be related to extensive central hair loss. Finally, this was not a populationbased study so no prevalence information can be gleaned from it. Therefore, although this study gives
us a wealth of new data on hair loss in African American women, it is only the starting place in which to evaluate the causality and treatment options for this common condition. The authors thank Melissa H. Piliang, MD, and Angelia Kyie, MD, of the Cleveland Clinic for their role in helping to assess subjects’ hair loss at the Cleveland Clinic workshops. They also thank Andrea Bazakas, BS, and Eric Lai, BS, of Duke University Medical Center for their role in organizing the data for the study analysis. REFERENCES 1. Olsen E, Bergfeld W, Cotsarelis G, Price V, Shapiro J, Sinclair R, et al. Summary of NAHRS-sponsored workshop on cicatricial alopecia, Duke University Medical Center, February 10 and 11, 2001. J Am Acad Dermatol 2003;48:103-10. 2. Olsen EA, Callender V, Sperling L, McMichael A, Anstrom KJ, Bergfeld WD, et al. Central scalp alopecia photographic scale in African American women. Dermatol Ther 2008;21:264-7. 3. Carey AH, Waterworth D, Patel K, White D, Little J, Novelli P, et al. Polycystic ovaries and premature male pattern baldness are associated with one allele of the steroid metabolism gene CYP17. Hum Mol Genet 1994;3:1873-6. 4. Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril 2004;81:19-25. 5. Sperling LC. Scarring alopecia and the dermatopathologist. J Cutan Pathol 2001;28:333-42. 6. Whiting DA, Olsen EA. Central centrifugal cicatricial alopecia. Dermatol Ther 2008;21:268-78. 7. LoPresti P, Papa CM, Kligman AM. Hotcomb alopecia. Arch Dermatol 1968;98:234-8. 8. Sperling LC, Sau P. The follicular degeneration syndrome in black patients: ‘‘hot comb alopecia’’ revisited and revised. Arch Dermatol 1992;128:68-74. 9. Taylor R, Matassa J, Leavy JE, Fritschi L. Validity of self reported male balding patterns in epidemiological studies. BMC Public Health 2004;4:60-4. 10. Khumalo NP, Jessop S, Gumedze F, Ehrlich R. Hairdressing and the prevalence of scalp disease in African adults. Br J Dermatol 2007;157:981-8. 11. Etemesi GA. Impact of hair relaxers in women in Nakuru, Kenya. Int J Dermatol 2007;46(suppl):23-5. 12. Silverberg NB, Weinberg JM, DeLeo VA. Tinea capitis: focus on African American women. J Am Acad Dermatol 2002; 46(Suppl):S120-4. 13. Dinh QQ, Sinclair R. Female pattern hair loss: current treatment concepts. Clin Intervent Aging 2007;2:189-99. 14. Olsen EA. Female pattern hair loss and its relationship to permanent/cicatricial alopecia: a new perspective. J Investig Dermatol Symp Proc 2005;10:217-21.
