Treating hair loss in Afro-textured hair

Dr Greg Williams, a leading hair transplant surgeon, gives us an overview of what causes hair loss in Afro-textured hair and what treatments are available. Whilst many of the scalp and hair conditions that affect Caucasian and Asian men and women also affect African-Caribbean patients, there are some conditions that are more prevalent in black patients.

Why is Afro-textured hair different?

All hair is made up of the same proteins and layers (medulla, cortex and cuticle). However, Afro-textured hair differs from other hair types in that it has a significant curl both above and below the skin surface, the cross-sectional shape of Afro-textured hair is elliptical compared to the more oval shape of other hair types, and the density of scalp hair in African-Caribbean patients is less than in other races.

What types of hair loss are there in patients with Afro-textured hair?

Whilst Caucasian men are four times more likely than men with Afro-textured hair to bald prematurely, male pattern hair loss (MPHL) is still common in men of African-Caribbean descent and is by far the commonest cause of hair loss in black men

However, women with Afro-textured hair often have their hair loss misdiagnosed. Female pattern hair loss (FPHL) is frequently confused with central centrifugal cicatricial alopecia (CCCA) which is an inflammatory scarring alopecia that starts in the mid-scalp or crown, spreading outwards. Another type of hair loss that can be misdiagnosed in black women is traction alopecia (TA) which is extremely common and results from long-term styling with tight hairstyles and braids. A form of hair loss that is affecting women with an increasing incidence is the immune mediated, scarring condition called frontal fibrosing alopecia (FFA) which targets the hair margin on the front of the scalp. This is thought to perhaps be part of the spectrum of one of the immune mediated forms of alopecia known as lichen planopilaris (LPP). As in female patients with other hair types, hormones and nutritional deficiencies can contribute to hair loss and need to be ruled out.

It is important to note that whilst FPHL and TA are well suited to surgical hair restoration, CCCA, FFA and LPP are not because the inflammation that attacks and destroys the native hair would have a high likelihood of doing the same to any transplanted hair. A biopsy should be done to confirm an inflammatory cause of hair loss.

How is hair transplant surgery carried out?

Donor hair follicles can be harvested in two ways for transplantation:

1. Strip follicular unit transplant (strip FUT) – an elliptical section of scalp is cut from the back and/or sides of the head, leaving a linear scar.
2. Follicular unit excision (FUE) – individual follicular units are incised using either manual punches, motorised drills or robotic devices, and then extracted leaving small round scars.

To adapt both procedures to Afro-textured hair types, there are certain adjustments that should be made to ensure a successful procedure:

• It is usually necessary to use a larger diameter punch in an FUE procedure to reduce transection of the follicles. This is because Afro-textured hair follicles are curlier, and a narrow-diameter punch could cut across the hairs. However, using a larger diameter punch results in larger diameter wounds, longer healing time, and an increased risk of scar hypertrophy.
• In strip FUT, care must be taking when making the skin incisions with a blade not to transect the curly hairs under the surface.
• For both FUE and strip FUT procedures, the recipient site incisions will need to be larger to accommodate the larger diameter follicular unit grafts.
• If shorter hairstyles are preferred after hair restoration, it may be necessary to repeat the surgery to increase hair density since there is a limitation to what can be achieved in each procedure.
• It is also important to discuss with the patient where they would like their hairline to be as there can be different cultural expectations with many black men wanting angular temporal recessions and low, straight hairlines.

What about after a hair transplant surgery procedure?

Women who are considering a hair transplant need to think about how they will style their hair after the transplanted hairs start to grow since tight braids and weaves might cause traction alopecia of transplanted hair and straightening transplanted hair will do the same damage as in non-transplanted native hair.

Men thinking about surgical hair restoration will usually opt for the FUE method because a linear surgical scar will be difficult to hide with short haircuts and sometimes even with longer hair styles.

Are there any alternative treatments available?

If surgery is not something a patient wants to consider for their hair loss, there are other options to consider:

• Medical treatments – using topical minoxidil and oral finasteride in men, and topical minoxidil in women, can be effective for treating both MPHL and FPHL.
• Low-level light therapy (LLLT) – using a portable, home use cap, band or brush devices can stabilise genetic forms of hair loss in some patients.
• Platelet-rich plasma (PRP) – injecting concentrated growth factors may be effective in strengthening existing hair in some patients and treating some dermatological causes of hair loss although it is not yet definitively proven to work for the majority of patients.
• Scalp micropigmentation (SMP) – simulating stubble in balding areas for men with MPHL by injecting small amounts of dark pigment and creating tiny hair coloured dots can be very convincing if the surrounding hair is completely shaved.

FPHL and MPHL are both suitable for hair transplantation, but inflammatory hair loss conditions are not. In terms of how patients should approach their hair loss, prevention is always the best option. For example, whilst there is now increasing awareness of traction alopecia, this remains a very common cause of hair loss in Afro-textured hair because of the preferred methods of styling hair. There are numerous groups now lobbying for black women to wear their hair in a natural style, and avoiding the damaging practices of braiding and chemical relaxants.

Whilst the majority of black patients seen are male, with surgical hair restoration becoming increasingly in demand, women also need to know that hair restoration can be a very successful option for treating traction alopecia and female pattern hair loss.

If you are suffering from hair loss and wish to seek treatment, make an appointment with an expert to discuss your options.