178 JOURNAL OF COSMETIC SCIENCE SCALP AND HAIR IN THE AFRICAN AMERICAN PATIENT: NORMAL STATE AND IN DISEASE Amy J. McMichael, MD Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC 27157 amcmicha@wfubmc.edu Introduction Hair and scalp disorders in African Americans present interesting dilemmas since all the general disorders seen in the general population are seen in this group as well as those that are traditionally seen primarily in deeply pigmented patients Seborrheic dermatitis, and folliculitis are the most encountered scalp disorders. The next most common disorders include those that are more common in patients of color they are folliculitis decalvans/dissecting cellulitis, acne keloidalis nuchae, and scarring alopecia which may be a result of the above diagnoses or other primary processes to include: discoid lesions of lupus, traction/trauma, and tinea capitis. Seborrheic dermatitis Seborrheic dermatitis is a scaling, inflammatory, often pruritic, eruption that is common on the scalp, oily facial areas, and the mid-chest. Often, pruritus is so persistent that some patients begin to assume it is a natural state. Topical pomades may be used by patients to cover the scaling and alleviate itching. There is no single correct regimen to treat seborrheic dermatitis. Treatments include: anti- dandruff shampoo can be used followed by a moisturizing conditioner. Zinc, tar, and selenium sulfide shampoo, and ketoconazole can be rotated with prescription mid-potency shampoo in an every other week fashion. There are over-the-counter zinc-based conditioners on the market that are formulated specifically for African American patients. Topical steroids may be used in various vehicles for treatment as well. Dissecting cellulitis Perifolliculitis capitis abscedens et suffodiens, also known as dissecting cellulitis, is a chronic inflammatory disorder of the scalp that occurs in both men and women, but is most common in African American men. Large, tender, fluctuant cysts and sinus tracts on the vertex and occipital scalp characterize the disorder. Hair loss can be permanent in this disorder secondary to the severity and chronicity of inflammation of the scalp. The disorder may also eventuate into hypertrophic scarring and keloids on the scalp. Treatment regimens can include oral antibiotics, short courses of oral steroid tapers, intralesional steroids, and incision and drainage of specific fluctuant nodules. oral zinc therapy, oral isotretinoin, and wide local resection of the involved scalp. Acne Keloidalis Nuchae Acne keloidalis is a chronic condition most often seen in African American men, although there are reported cases among African American women. Clinical examination reveals skin-colored to hyperpigrnented follicullarly-based papules on the nape of the neck and occipital scalp. Pustule formation, hypertrophic scarring, and severe keloid formation is often observed. Approach to this disorder is much like that for dissecting cellulitis. First, decrease active inflammation, then attempt maintenance treatment. Topical and oral antibiotics will work well, especially when accompanied by intralesional corticosteroid injections. For severe involvement, local excision and carbon dioxide laser have also been used. Hair removal laser can also be used in the nuchal region. Scarring Alopecia The scarring alopecias are a group of diseases that occur frequently in African Americans, often with no known etiology. These entities include discoid lesions of lupus, lichen planopilaris, idiopathic scarring in African American women, and sequelae to dissecting cellulitis, traction/trauma to the hair follicle, or fo!liculitis.

2007 ANNUAL SCIENTIFIC MEETING 179 Central centrifugal scarring alopecia deserves separate mention since this a fairly new terminology. Once the diagnosis is clearly central centrifugal scarring, the approach to management can proceed with topical agents, intralesional agents. HEAL TH OF THE HAIR SHAFT In African Americans, the curly, flattened hair does not emanate from a straight follicle. Instead, the follicle where the hair is formed is just as curved as the hair itself. Because of the curled nature of the hair, loosening of the curl to allow ease of hair care has been a prominent theme among African Americans, especially women. The flattened nature of the hair shaft predisposes the hair to increased fragility, and the relatively common practice of chemical and heat use compounds this fragility. It is common to see significant scarring alopecia accompanied by significant hair shaft damage from over- processing with heat or chemicals. Once this damage occurs, trichorrhexis nodosa [17] becomes likely and breakage ensues. The hot combing process, also known as pressing the hair, works as a temporary method of straightening kinky or curly hair. In recent times, thermal straightening of the hair has fallen out of favor by many African American women due to the temporary nature of the process. Common problems associated with hot comb use are: moderate to severe burns from accidental contact with the hot comb and overheating of the hair shaft causing weakening and breakage. Long-term use of hot-combing can cause severe damage to the hair shaft if the technique is not performed correctly. To avoid hair shaft damage, a well-trained professional should perform the procedure. In the 1960s, chemical straighteners became more refined and less damaging to the hair and scalp and more women began to utilize these products. Chemical relaxers are now the most common method of hair straightening used by African American women. Most chemical relaxers used on the hair in African- Americans contain sodium, potassium, or guanine hydroxides, sulfites, or thioglycolates. All of these chemicals work to produce a straight appearance by affecting the cysteine disulfide bonds of the hair. Problems that have arisen from the use of chemical straightening agents include: hair shaft dryness, increased fragility of the hair cuticle (over-porosity) and the lesser problem of skin damage. Moisturizing shampoos and conditioners used immediately after chemical treatment can repair some of this over-porosity. In addition to becoming over-porous, the elasticity of the hair can be severely decreased. To combat damage from heat and chemical treatments, African American patients, especially those who have clinical fragility and breakage, must condition the hair regularly after washing. Keeping chemical application to just new growth and only every 6-8 weeks will also help to keep the hair shaft healthy. Regular trims of damaged hair should be recommended every 8-10 weeks since many patients will be hesitant to cut the hair, incorrectly assuming that the damaged hair will grow faster if it is not cut. In summary, the hair and scalp disorders experienced by African American patients include those seen in the population at large, as well as those disorders more common in patients of color. The key is in the approach to clinical history of disease and hair care practices that patients may think is non- contributory to disease. Next, clinical and histologic examination must be performed in standard fashion, followed by therapeutic recommendations that fit both the disorder and the hair type.