Dr. Susan Taylor discusses several tips for diagnosing and treating hair loss in women of African ancestry.
Susan C. Taylor, MD, Professor, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa.
“For women of African ancestry, it’s very important to understand the problem that they are presenting to you with,” said Susan C. Taylor, MD, who presented “Women of African Ancestry with Hair Loss” as part of the Skin of Color Update pre-conference webinar entitled “Hair and Scalp Disorders in Patients with Skin of Color: A Case-Based Conversation with the Experts.”
Dr. Taylor was joined by hair loss expert Crystal Aguh, MD, who presented “Diagnosis, Workup and Treatment of Central Centrifugal Alopecia (CCCA) in Patients with Skin of Color.”
“So often patients will give a nebulous chief complaint, like my hair isn’t growing, or my hair is breaking. And one of my first points is, you have to understand what that patient means,” said Dr. Taylor
In other words, identifying what that problem really is, she said.
“Does it mean that the hair is not growing longer? Does it mean that there’s a loss of density of the hair? Does it mean that they have…visible round bald spots? Does it mean they’re having gradual thinning in certain areas?”
Consider specific regions of the scalp to aid in diagnosis, said Dr. Taylor.
“For example, in the crown area, you have to think about central centrifugal cicatricial alopecia (CCCA); you need to think about female pattern alopecia or lichen planopilaris.”
Importantly, there are a wide range of hair loss diagnoses for patients of African ancestry, she said.
“…it’s critically important to do a good physical examination. And that means asking the patient if you can touch their hair, part their hair, and then looking down to the level of the scalp and then throughout all of the hair, making multiple parts so that you can actually examine the scalp using your dermatoscope with all patients and, if necessary, [performing] a biopsy.
According to Dr. Taylor, dermoscopy plays an important role in all hair loss disorders.
“I perform demoscopy on all of my patients…it allows you to see inflammation and allows you to see scarring, and it allows you to determine, in many cases, if the disorder is active, so I think it’s critically important.”
CCCA Treatment Pearls
In terms of treating CCCA specifically, many patients can benefit from oral and topical antibiotics, steroid injections to the scalp, and anti-inflammatory medications, said Dr. Taylor.
“Dr. Aguh had some pearls about topical metformin that she uses. Oral baricitinib has also been proposed as a treatment. None of these are FDA approved.”
According to Dr. Aguh, her typical treatment algorithm for CCCA begins with tracking and rating symptoms.
“We rate itching, inflammation, tenderness. And if I have a patient with inflammation (so if I see erythema or they are complaining of significant tenderness) that’s the only patient that I will start on an oral tetracycline. Otherwise, if I’m seeing a patient and she says, ‘Hey, I’ve never seen anyone. What type of hair loss do I have?’ that patient is typically going to get intralesional steroids and topical steroids.”
Another consideration is age and the presence of androgenetic alopecia (AGA), said Dr. Aguh.
“So if that patient has signs of androgenic alopecia, if I can appreciate miniaturization, bi-temporal recession, that patient will also get a topical minoxidil.”
All of that said, Dr. Aguh tries not to overload the patient on too many treatments too soon.
“I think it’s so important in the first visit to set expectations. So sometimes I may not want to overload a patient with treatments and especially a treatment that that is meant to regrow [hair] because I really want the patient to understand that our goals of therapy are to stabilize disease and to stabilize their symptoms.”
Therefore, itch might be the focus at first, she said.
“So, I might say, let’s do intralesional steroids and topical steroids first. Let’s make sure you have no itching. And then when you come back if things still look good, then we might add in a topical minoxidil and begin to treat.”
Oral metformin may also be appropriate for patients with a history of insulin resistance or stigmata of PCOS, said Dr. Aguh.
Dr. Taylor said her approach is similar.
“If it’s a patient who’s symptomatic, if it’s a patient who reports progression of their disease, or a patient in whom I see erythema, I will begin oral antibiotics as well as ultrapotent topical steroids, and that is my regimen for six months.”
As symptoms decrease, Dr. Taylor add intralesional triamhinolone.
“I will often add either topical or oral minoxidil if they have AGA or even if they don’t have AGA.”
Dr. Taylor is fairly aggressive with corticosteroid treatment.
“I use ultrapotent steroids. For those patients who are symptomatic, I will ask them to use it daily for a month, every other day for a month, and then a maintenance of twice a week. And that is the regimen that that I am comfortable with.”
Dr. Aguh’s approach is similar.
“If I’m giving, for example, clobetasol alone three to five times a week and if I’m compounding it with, let’s say, metformin, I do daily dosing.”
A Caveat on Doxycycline Dosing
In a recent Delphi Survey1 on treatment of CCCA, 21 nation-wide dermatologist hair experts reached consensus that doxycycline should be dosed at 100 mg twice per day for up to six months.
This is the standard recommended dose and should be taken with meals and no dairy products, said Dr. Taylor.
“…but often patients cannot tolerate that. So I start them with 100 mg once a day. Again, with food, for about two weeks to get them used to it—in the habit of taking it after a meal. Then I tell them to increase it to twice a day. So breakfast and dinner or lunch and dinner. If you give it to the patient twice a day right off the bat and they have some GI distress or nausea and vomiting, you’re not going to get them to stop [and re]start once a day and then increase to twice a day. They’re going to be done.”
For patients who do not respond to oral antibiotics, hydroxychloroquine may be an option, said Dr. Taylor, who also noted that less than 75% of participants in that Delphi Survey agreed that hydroxychloroquine 400 mg a day should be used for patients who do not respond to oral doxycycline.
“I do still try hydroxychloroquine in my patients who do not respond to doxycycline or intralesional triamcinolone acetonide. So I do use hydroxychloroquine in some patients.”
Setting Expectations
Both Drs. Taylor and Aguh recommend setting expectations with hair loss patients from the start, regardless of CCCA stage, with the primary goal being to prevent further hair loss.
“That is really success in and of itself because we know that for many patients with CCCA it’s slow, relenting, continued hair loss. So if we get you to keep your hair, that’s a win, and we will try, although we cannot guarantee, to see if we can regrow some hair,” said Dr. Taylor.
It doesn’t make sense to use injections or systemic antibiotics in asymptomatic CCCA patients, said Dr. Taylor; however, some patients can (and maybe should) sometimes still receive treatment.
“I have seen patients who have regrown 10 hairs or 15 hairs, and it brings joy to them that something has regrown. So that’s why in those patients I do indeed try.”
Aggressive Healthy Hair Practices
Acquired trichorrehexis nodosa and traction alopecia can both be misdiagnosed as CCCA, said Dr. Aguh.
“Many of these patients will come in with a complaint saying their hair does not grow. And in this day and age where most of our patients are natural, sometimes you can see that the breakage is so severe that it breaks down all the way to the scalp.”
Patients at highest risk for hair breakage have curl patterns 6 to 8, she said.
“What I try to tell patients is that from an evolutionary perspective, if you evolved in a Sub-Saharan African climate, the evolutionary advantage is for your hair to break off very easily because no one who’s hunting and gathering in a Sub-Saharan African climate wants hair to their shoulders. Absolutely no one. And you want your hair to be low density so that the scalp pulls easily, and that’s what it’s supposed to do if you do nothing to it. And so, for these patients who have really tightly curled hair, I tell them that if you’re going to be natural, you have to moisturize and condition your hair several times a week.”
According to Dr. Taylor, healthy hair practices in general include trimming, washing, and conditioning. Unfortunately, some women have given up on their hair.
“They just want to avoid all contact with their hair because it’s such a source of frustration and pain. So what I say to them is let’s make sure the hair that you have is healthy. So that involves shampooing once a week maybe once every two weeks, conditioning, let’s cut those dead ends off, and let’s improve the quality of the hair that you have.”
Note:
- Manuscript currently in review by the Journal of the American Academy of Dermatology.