Nkanyezi Ferguson, MD, FAAD
University of Iowa Hospital and Clinics
Iowa City, IA
Review common terminology
Discuss different hair care practices in
communities of color
Discuss different hair disorders in skin of
color
Hair appearance and style play an important role
Styling practices are determined by individual
hair characteristics and preferences
Current and historic trends
Ease and convenience of styling
Climate/season, occupation or activities
Health and maintenance of hair
Roseborough IE, et al. Semin Cutan Med Surg. 2009 Jun;28(2):103-8
Kinky hair – Very curly, tangled and difficult to comb hair
Press – Thermal straightening of the hair using a heating device
Permanent/Relaxer – Chemical means of straightening the hair
Hair grease – Protective hair coating agents that contain
mixtures of petrolatum, lanolin, and vegetable, mineral, or
animal oils
Natural – Hair in its native state without chemical processing
Jackson F. ABNF 1998 Sep-Oct;9(5):100-4
Straightening consists of temporary or
permanent breaks in chemical bonds
that maintain structure of keratin
proteins
Keratin fibers have three types of inter-
chain interactions
Disulphide bonds
Hydrogen bonds
Electrostatic interactions
Miranda-Vilela AL, et al. Int J Cosmet Sci. 2014 Feb;36(1):2-11
Thermal manipulation of the hair unit
temporarily disrupts the hydrogen bonds of
keratin
Heating devices: hot comb, hot iron, flat iron,
curling iron
Heating element: stainless steel, ceramic
Reaches temperatures of 150 – 500°C
Quinn CR, et al. Cutis. 2003 Oct;72(4):280-2, 285-9
McMichael AJ. JAAD 2003 Jun;48(6 Suppl):S127-33
Hair is washed and dried (air or blow
dry)
Pomade, oil or cream-based lubricant
is applied to hair
Hair is partitioned into smaller sections
Heating element is passed through the
section of hair from hair root to end
Temporary and reverts back to native
state with water or humidity
McMichael AJ. JAAD. 2003 Jun;48(6 Suppl):S127-33
Pressing method depends on hair texture
Soft press
Medium press
Hard press
Double press
Quinn CR, et al. Cutis. 2003 Oct;72(4):280-2, 285-9
Chemical straightening of the hair unit
permanently alters the disulphide bonds of
keratin
Achieved through alkaline based products:
Lye-based straighteners:
▪ Sodium hydroxide
Non-lye straighteners:
▪ Guanidine hydroxide, Potassium hydroxide, Lithium
hydroxide
Alkaline pH allows penetration of chemical
straightener through the hair cuticle into cortex
de Sá Dias TC, et al. J Cosmet Dermatol. 2007 Mar;6(1):2-5
Disulphide bonds
undergo rearrangement
~35% cystine is converted
to lanthionine
(lanthionization)
▪ Difference between a cystine
and a lanthionine is the loss of
one sulphur atom
dMiranda-Vilela AL, et al. Int J Cosmet Sci. 2014 Feb;36(1):2-11
Stephanie Henderson-Brown, et al. Advanced Hairdressing (Level 3)
The hair is divided into sections
Relaxer is applied to hair
Vaseline used to protect the scalp
Relaxer is left in place for varied
duration of time
Hair is washed with an acidic
‘neutralizing’ shampoo
Hair is then conditioned, dried and
ready for styling
Tanus A, et al. An Bras Dermatol. 2015 Jul-Aug;90(4):450-65
https://www.youtube.com/watch?v=u8LNg4-LPJM
https://www.pinterest.com/pin/319263061054666955/
Braids are composed of three or more
interlacing pieces of hair
Different types of braids:
Plaits, single box braids and microbraids
Braiding can be done with natural/relaxed
hair
Hair extensions can be integrated
Quinn CR, et al. Cutis. 2003 Oct;72(4):280-2, 285-9
Stationary braid that lays flat on
the scalp
The hair is parted and sectioned
Designs can be varied and intricate
Parting of the hair has to be as
accurate as possible
Can be done with natural/relaxed
hair or extensions can be added
http://buzznigeria.com/cornrow-hairstyles/#
Quinn CR, et al. Cutis. 2003 Oct;72(4):280-2, 285-9
Two-strand and Senegalese
twists
Hair is sectioned into two strands
Each individual strand is twisted
Each twisted strand is then
progressively wrapped over the
other with even tension
Ends are secured with
pomades/gels/waxes/bands
Quinn CR, et al. Cutis. 2003 Oct;72(4):280-2, 285-9
Stephanie Henderson-Brown, et al. Advanced Hairdressing (Level 3)
Extensions can be used to vary the thickness and
length of this style
Flat twists
Hair is sectioned into a narrow
channel
The hair is separated into two
strands
Each strand is wrapped around the
other
Hair is kept flat on the scalp and new
hair along the channel is picked up
with a continued twisting motion
Stephanie Henderson-Brown, et al. Advanced Hairdressing (Level 3)
Comb twist/coils
Gel is distributed throughout
dry hair
Hair is sectioned into small
squares
End of a tail comb is used to
grasp the root of the hair
The comb is continuously
rotated downwards resulting in
twisting of the hair
Gel will set and secure twisted
hair in place
https://www.youtube.com/watch?v=-6jbWGVNlBk
Stephanie Henderson-Brown, et al. Advanced Hairdressing (Level 3)
Hair extensions
Human hair
Synthetic hair
Extensions can be
clipped, pinned,
crocheted, cornrowed
or braided into hair for
added length/body
Human or synthetically
manufactured hair
Weave hair section (weft) is
either sewn or glued in place
Application of a weave can
cost anywhere from the low
hundreds dollars to $2,000+
It can take anywhere from 2-
8 hours to complete sewn-in
hair weaves
Hair is cornrowed into horizontal
or vertical patterns
Weave cap may be used
C-shaped weave needle and nylon
thread
The weave is sewn in securing the
weft to the cornrowed hair
Hair bonding and fusion with adhesives
http://www.wikihow.com/Do-a-Quick-Weave
http://www.cchairextensions.co
m/blog/category/hair-weave/
https://www.youtube.com/watch?v=UjhFbDkVnNM
Hair style worn by women,
men and children
Locks form when hair
tangles and mats into
clusters
Once the style matures it is
irreversible
Avoid the term ‘dreadlocks’
Quinn CR, et al. Cutis. 2003 Oct;72(4):280-2, 285-9
Loc styles are based on either a
brick-lay or diamond pattern
Several beginning/starter style
options include:
Free-form
Guided
▪ Palm rolls, comb coils, 2-strand
twists, braids
Requires regular grooming and
twisting of new hair growth
http://ragingrootsstudio.com/brick-lay-pattern/
Quinn CR, et al. Cutis. 2003 Oct;72(4):280-2, 285-9
Stages of locking
Starter, Budding, Teen,
Mature, Rooted
Pre-lock, Budding, Shooting,
Contracting
Baby, Teen, Adult, Elder
Stephanie Henderson-Brown, et al. Advanced Hairdressing (Level 3)
http://blackhair.about.com/od/naturalcare/tp/stagesoflochair.htm
http://curlynugrowth.com/the-4-stages-of-hair-locing/
Molding techniques range from
light hold to freeze hold
Setting lotions/styling gels have
fixatives that contain plasticizers
such as propylene glycol or
glycerin
http://kayewright.com/short-relaxed-hair-
mastering-the-short-hair-mold/
Setting
lotions/styling gels
applied to hair
Comb and/or
fingers are used to
mold or curl the
hair
https://www.youtube.com/watch?v=fJ2wfeBY91g
Refers to hair that has not been chemically
treated
Increasing in popularity over the last decade
Transitioning from chemically treated to
natural hair:
“Big chop” refers to cutting off all chemically
treated hair
Simply growing out chemically treated hair
Protective styling (e.g. braids, weaves,
extensions)
‘Pre-Poo’
Application of oils to the hair
prior to shampooing
Hot oil treatments
Heat oil until warm
Massage oil into damp hair from
roots to ends
Place hair under plastic cap ~20-
30 minutes
Wash and rinse hair thoroughly
Gavazzoni Dias MF. Int J Trichology. 2015 Jan-Mar;7(1):2-15
Hair wrapping
Pin curling
Pineapple
Bosley RE, et al. Cutis. 2015 Feb;95(2):78-80,106
Hair is smoothed against the scalp and wrapped in a
circular motion around the head
Wrap is secured in place with a satin scarf/wrap cap
Hair is partitioned into small sections
Hair is wrapped in the direction of the curl
Hair is gathered, twisted and secured in place
Used to preserve and protect
curls in women with natural hair
styles
Hair is gathered in a high loose
ponytail on the top of the head
Satin scarf is wrapped around the
head
If hair is short a ‘multi-pineapple’
approach can be taken
http://moknowshair.com/pineapplemethod/
Hair styles among communities of color are
varied
Hair style is based on hair characteristics and
individual preferences
Understanding different hair care practices can
help dermatologists have more meaningful and
impactful discussions with patients
Evaluation of hair among
different ethnic groups
demonstrate no
biochemical differences
Structural differences do
however exist
Elliptical cross section
shape
Hair follicle forms tight
curls
http://mathildasanthropo
logyblog
Afro-ethnic hair
Easily forms knots
More likely to break
Develops frayed tips
Lower water content
Lower amounts of sebum
(natural protective oils)
Chronic inflammatory condition
Occurs on the scalp, face, & chest
Can affect infants (cradle cap), children
and adults
Itchy, dry, flaky
Exact cause is unknown
Sebum from sebaceous glands
Malassezia yeast on skin
Genetic susceptibility
Risk factors
Build up of hair products on the scalp can cause irritation
Oils on the scalp can mask the scaling and result in more irritation
Treatment
Cleanse hair every 1 to 2 weeks
Anti-dandruff shampoos (caution as these can dry the hair)
▪ Use only on the scalp and rinse out completely
▪ Follow with regular moisturizing shampoo and conditioner to hair
Use hair oils on the hair shaft only
Prescription oil-based topical steroids
Chronic, progressive scarring alopecia
Centered on the crown or vertex
Gradually expands symmetrically with the
most active disease at the periphery
Usually has no symptoms but some
patients complain of itching or burning
Most commonly seen in women of African
descent
Treatment
Steroids (topical, injection)
Doxycycline/Minocycline
Hydroxychloroquine
Traction alopecia is caused by repeated
pulling on the hair from hairstyling or hair
care
Presentation
Raised bumps around hair
Hair thinning in areas of tension (commonly
frontal hairline)
When identified early, the styling can be
modified and hair will regrow
However, over time, traction alopecia can
lead to scarring and become irreversible
Hairstyles that place traction on the hair
Individual braids
Cornrows
Weaves
Locks
High ponytails
Tips to avoid damage
Avoid styles that put tension/traction on the hair
Make sure braids and cornrows are not too tight
If it hurts while your hair is being styled, ask the stylist to stop and redo
Avoid excessive volume or weight of hair extensions/weaves
Wear light-weight, shoulder length extensions/weaves
Rotate the pattern of braided and twisted hairstyles
Use ‘no damage’ hair hosiery instead of rubber bands or elastic holders
Avoid sleeping in rollers; opt instead to wrap or pin curl the hair at night
Wear weave/extensions for 2-3 months at most
Remove and replace braids every 4-6 weeks
Use a well-trained professional
Acquired trichorrhexis nodosa
Response of the hair shaft to extrinsic or
environmental insults
Results in hair breakage or lack of
growth
Because hair is non-living tissue, total
repair of the hair shaft is not possible
Management of this form of hair loss
involves protecting the hair shaft and
minimizing further damage
Heat treatment/Thermal
straightening
Includes blow drying and pressing
hair (hot comb, flat iron, curling iron)
Hair heated to 150–500
0
F
Heat treatment/Thermal straightening
Heat causes hair damage:
Increases dryness
Bubble formation
Weak points
Split ends
Hair breakage
Tips to avoid damage
Only treat clean (cleansed and conditioned) hair
Consider air drying/wet setting hair instead of blow
drying
Use only on dry hair
Use a heat protecting product before styling
Treat hair no more than 1-2 times/week
Use lowest heat setting possible (use straightening
device with a dial)
Use ceramic combs or irons to press hair
Obtain regular trims (every 8-12 weeks)
Use a well-trained professional
Chemical relaxers
Chemical relaxers cause damage:
Scalp contact irritation
Scalp chemical burns
Loss of tensile strength of the hair shaft
Increased fragility of the hair shaft
Possibly scarring hair loss
Tips to avoid damage
Relaxers should only be applied to the new growth
Never apply relaxer to hair that has already been relaxed
Use non-lye based chemical relaxers
Use a mild relaxer instead of regular or super strength
Space out relaxer application to every 6-12 weeks
Use moisturizing shampoos and conditioners liberally
when hair is washed
Avoid scalp manipulation prior to chemical treatments
Use licensed cosmetologist for chemical treatments
Styling products
Long lasting styling products
e.g. gels, sprays, and spritzes
Products are designed to form a
thick protective coating
Dries out the hair shaft and scalp
Tensile strength of hair shaft is reduced
Increased fragility and breakage
Worsening of seborrheic dermatitis
from lanolin additives
Tips to avoid damage
Decrease combing and grooming once styling product is set
in place
Wash these products out regularly to ensure healthy
sloughing of scalp skin and to minimize drying of the hair
shafts
Try to avoid hairstyles that need these products
Principles of hair cleansing regimen
Proper cleansing of the hair is one of the cornerstones of
any healthy hair care regimen
Although sebum acts as a natural moisturizer, it is also a
potent attractant of dirt, dust and other pollutants
Inadequate cleansing of the hair and scalp can result in
the buildup of styling aids which can lead to scalp irritation
Regular cleansing is necessary to maintain a healthy hair
and scalp
1–4 times per month depending on hair type
Avoid drying shampoos as this can lead to
increased fragility and breakage
Shampoos that contain nonionic surfactants
Gentler and less likely to strip moisture from the
hair shaft
Decyl glucoside, fatty alcohol ethoxylates (cetyl
alcohol, stearyl alcohol, etc.), sorbitan ether
esters
Anionic shampoos have excellent cleansing, but
leaves the hair dry and susceptible to breakage
Lauryl sulfate, laureth sulfates, sarcosines,
sulfosuccinates, sodium myreth sulfate, sodium
stearte
Conditioning is the most important component of a
healthy hair care regimen
Formulated to mimic the action of sebum
Types of conditioners
Rinse-out conditioners
Deep conditioners
Leave-in conditioners
Protein-containing conditioners and protein treatments
Types of conditioners
Rinse-out conditioners
▪ Less effective at repairing hair damage
▪ Use of rinse-out conditioners in place of shampooing (“co-washing”)
Deep conditioners
▪ Typically left on the hair for at least 10 min
▪ Enhance moisturization and are beneficial for severely damaged hair
Leave-in conditioners
▪ Can help prevent damage from routine grooming
Protein-containing conditioners and protein treatments
▪ Contain proteins, which are small enough to penetrate the hair shaft and repair holes and
defects
▪ Use monthly or bi-monthly basis
Some oils (e.g. cocunut oil) when applied to wet hair can
decrease moisture loss and protein loss
Helps to prolong the benefits of shampooing and conditioning
‘Soak and smear’ treatments
▪ 1. Shampoo and/or condition the hair as normal and lightly blot the hair
with a towel
▪ 2. Follow with the application of a water-based leave-in conditioner to
the hair
▪ 3. Immediately apply an oil or thick occlusive moisturizer (e.g. coconut
oil, olive oil, jojoba oil, or mineral oil to the hair)
▪ 4. Allow the hair to air dry and style as desired
African-American women are
least likely to meet
recommended physical
activity guidelines
~40% report avoiding exercise
due to hair style
Consider selecting hair styles
to accommodate exercise:
Ponytail, cornrows, braids or
natural hairstyles
Scarf or hair wrap
