For Black Patients, Hairstyles May Harm the Scalp - Everyday Health

Chesapeake, Virginia native Daree Allen Nieves, 39, has struggled for years with an intensely itchy and irritated scalp. The discomfort began when she started straightening her tightly coiled hair. "I started getting relaxers when I was 13," she explains.

When she was in her late twenties, she began seeing a dermatologist every few months — first a white doctor, then a Black one. Both prescribed a number of different treatments for her dermatitis (the medical term for skin irritation), but nothing helped. Her scalp problems persisted even after she gave her hair what she calls a "big chop" and went natural.

"I've never been given a real cause or solution for my issues," she says.

Allen Nieves' experience is not unique. Tightly coiled Black hair is very delicate and can require a lot of upkeep, but sometimes certain products, treatments, and even so-called "protective" hairstyles can cause more problems than they solve. People may notice continuously flaky scalps, slow or no hair growth, or even progressive hair loss, but have no idea what to do about these conditions.

While a person's first instinct may be to head to a stylist or buy a supplement, thinking that it will finally help hair grow, the real solution should be a visit to a dermatologist — specifically one with experience treating Black scalp issues.

Trying to fix these conditions on your own, ignoring them, or trying to cover them up can make them worse, according to Candrice Heath, MD, a Black dermatology professor at Temple University in Philadelphia. Dermatologists aren't adequately trained to identify issues unique to Black patients, and because the overwhelming majority of dermatologists are white, they don't have personal experience to draw from, either.

Without proper specialized education or firsthand knowledge, dermatologists may be unable to treat Black patients with tightly coiled hair, and might even exacerbate scalp conditions.

When asked at what stage she ends up seeing a Black patient with scalp issues, Dr. Heath's response is, "Often too late."

Given the lack of culturally competent dermatological healthcare, it's especially important for patients to advocate for themselves. This can start with increased awareness of symptoms of several scalp conditions that particularly affect Black people: traction alopecia, trichorrhexis nodosa, and allergic contact and seborrheic dermatitis.

What Is Traction Alopecia?

Traction alopecia is hair loss tied to repeated trauma to the scalp from styling. Not only are Black people at risk of this, but so is anyone who has to wear their hair in a style that causes tension, like women in the military and ballerinas. There is no age restriction, and even children can develop traction alopecia.

"On social media people talk about losing their edges, and what they're really referring to is traction alopecia — hair loss from tension — which most often shows around the front edges of the scalp," Heath explains. For people who wear really tight braids and ponytails, this alopecia usually appears where the hair is most likely to pull.

Unfortunately many people respond to traction alopecia by trying to hide thinning hair with braids and extensions, which can ultimately make the condition worse and get someone stuck in a hair loss cycle.

Treatment for Traction Alopecia

According to Heath, traction alopecia is completely reversible — early on. "If tight hairstyles are changed so that you're wearing more loose hairstyles, you may actually be able to recover your hair," Heath says. The time frame depends on how damaged your hair is and how fast it grows.

Reducing the amount of chemicals and lowering the heat during styling also helps.

A dermatologist may prescribe topical antibiotics or steroids to reduce inflammation, according to the Skin of Color Society (SOCS), a dermatologic nonprofit group. For more advanced traction alopecia, treatment may involve oral antibiotics or steroid injections, or topical minoxidil (Rogaine) to stimulate hair regrowth.

Traction alopecia may be very difficult to treat in some cases, Heath says. "The problem happens when people continue to do really, really tight hairstyles back to back over a number of years, and then you start to have some permanent scarring effects due to the habits not being amended quick enough," she says.

What Is Trichorrhexis Nodosa?

Trichorrhexis nodosa is recurrent hair breakage caused by tight styling, relaxers, overuse of heat tools, dyeing, washing hair too frequently, and even not washing enough. This can make it seem like the hair isn't growing at all, when in reality, it's just breaking faster than it's growing.

Crystal Aguh, MD, the director of the ethnic skin program at Johns Hopkins School of Medicine in Baltimore, explains that while many dermatologists may never treat this condition, she sees at least one case a week.

Trichorrhexis nodosa can look like thinning hair and a visible scalp from prolonged breakage. The scalp may also be itchy, inflamed, or sore. Some sections of the hair may seem like they never grow, especially at the nape of the neck. A patient may also notice small white nodes on individual hair shafts where the hairs are splitting.

Stylists may contribute to these conditions by calling certain hairstyles protective and promoting them for people with natural hair. "The images that we see of natural hair in our society that are embraced have a slightly looser curl pattern," explains Dr. Aguh, "which is more amenable to remaining in a natural state." These styles take more work, she says, increasing the risk of breakage, and may not be as easy to maintain as straight styles — despite the push for natural.

The average person with trichorrhexis nodosa is at least 30 and most likely has 4B or 4C curly hair, and they often cover hair with wigs and don't get trims often enough, says Aguh. They may also have been misdiagnosed with permanent hair loss by a less knowledgeable physician, according to Heath.

Certain hair types, like 4C hair, need more TLC, and a natural hair style doesn't always help. Aguh says that these Black women may be struggling to moisturize their hair enough, which could also lead to breakage.

Treatment for Trichorrhexis Nodosa

Home remedies for trichorrhexis nodosa, according to Aguh, may include washing and conditioning hair more frequently, using a protein treatment, and incorporating oil after applying a leave-in conditioner — all things that may have been neglected by someone throwing a wig over the problem. Ideally, a sulfate-free or gentle-sulfate shampoo and moisturizing conditioner would be used once or twice a week, and after a few months, someone may begin to see new growth.

Limiting the use of heat tools to no more than once a week, and only on clean, dry hair can also help, as well as careful detangling and protecting the hair from extreme cold or drying conditions. It's also better to wait at least two weeks after getting hair relaxed or waved, processes that can weaken hair, before using permanent hair color.

What Are Allergic Contact Dermatitis and Seborrheic Dermatitis?

Several types of dermatitis can affect the scalp, including allergic contact dermatitis and seborrheic dermatitis. Allergic contact dermatitis can be triggered by the ingredients in hair products, including the hair used for braids and extensions. Seborrheic dermatitis, which is caused by an overabundance of oil and yeast on the scalp, can cause dry scaly patches, redness, and dandruff. Both types of dermatitis are marked by an itchy scalp.

Treatment for Allergic Contact Dermatitis and Seborrheic Dermatitis

Heath explains that common treatments for these conditions often aren't a fit for Black people. "Dermatitis affects people of all hair types, and the common knee-jerk reaction would be to say, 'Use an anti-dandruff shampoo five times a week,'" Heath says. "If you give that same advice to someone who has more tightly coiled hair, which is more prone to breakage and dryness, then the outcome is going to be very different" — most likely a dry scalp and dry, brittle hair.

Oftentimes, treatment means changing a problematic hairstyle or using different products. Dermatologists might also prescribe antifungal products like ketoconazole, or even steroids. These are mostly topical products that can be applied to the scalp.

How to Find a Culturally Competent Dermatologist

Unfortunately, healthcare in general, and dermatology in particular, still has quite a ways to go before practitioners reflect the diversity of the population and are better able to address the needs of communities of color.

A big part of the problem when it comes to Black scalp health is that most dermatologists, the majority of whom are white, will recommend what they are familiar with from their own experiences, not necessarily what is right for their patients, says Heath.

To find a dermatologist near you that specializes in scalp care, Heath recommends turning to social channels. "Social media is a valuable tool, and there are websites that list Black dermatologists in your area," including a database maintained by the Skin of Color Society.

She does caution that even Black dermatologists may face a learning curve in their ability to treat Black patients, explaining "It is a reality that a newly minted Black dermatologist may have trained in a program where there were not a lot of patients with skin of color, or with tightly coiled hair."