Valerie D. Callender

Medical and surgical therapies for alopecias in black women

ABSTRACT:  Hair loss is a common problem that challenges the patient and clinician with a host of cosmetic, psychological and medical issues. Alopecia occurs in both men and women, and in all racial and ethnic populations, but the etiology varies considerably from group to group. In black women, many forms of alopecia are associated with hair‐care practices (e.g., traction alopecia, trichorrhexis nodosa, and central centrifugal cicatricial alopecia). The use of thermal or chemical hair straightening, and hair braiding or weaving are examples of styling techniques that place African American women at high risk for various “traumatic” alopecias. Although the exact cause of these alopecias is unknown, a multifactorial etiology including both genetic and environmental factors is suspected. A careful history and physical examination, together with an acute sensitivity to the patients perceptions (e.g., self‐esteem and social problems), are critical in determining the best therapy course. Therapeutic options for these patients range from alteration of current hair grooming practices or products, to use of specific medical treatments, to hair replacement surgery. Since early intervention is often a key to preventing irreversible alopecia, the purpose of the present article is to educate the dermatologist on all aspects of therapy for hair loss in black women—including not only a discussion of the main medical and surgical therapies but also an overview of ethnic hair cosmetics, specific suggestions for alterations of hair‐care practices, and recommendations for patient education and compliance.

Acne in ethnic skin: special considerations for therapy

ABSTRACT:  Acne vulgaris occurs in people of all ethnicities and races. Although the pathophysiology and treatment options are similar in all skin phototypes, darker‐skinned patients have higher incidence rates of two sequelae of acne: postinflammatory hyperpigmentation and keloidal scarring. Postinflammatory hyperpigmentation may also be triggered by skin irritation. In choosing therapies for patients of color, therefore, clinicians must find a balance between aggressive early intervention to target inflammatory acne lesions, and gentle treatments to increase tolerability and avoid skin irritation. For most patients, a combination of topical retinoids, and topical or oral antibiotics with hydroquinone (as needed) to control hyperpigmentation will be successful. For patients with sensitive skin, topical agents in lower concentrations and cream vehicles are preferred. If tolerated, the retinoid strength can be titrated upward after four to six weeks. Ethnic patients also need to be counseled on use of noncomedogenic and nonirritating skin and hair‐care products. Individualized care and close monitoring is required.

Postinflammatory hyperpigmentation: etiologic and therapeutic considerations.

Postinflammatory hyperpigmentation (PIH) is a reactive hypermelanosis and sequela of a variety of inflammatory skin conditions. PIH can have a negative impact on a patient’s quality of life, particularly for darker-skinned patients. Studies show that dyschromias, including PIH, are one of the most common presenting complaints of darker-skinned racial ethnic groups when visiting a dermatologist. This is likely due to an increased production or deposition of melanin into the epidermis or dermis by labile melanocytes. A variety of endogenous or exogenous inflammatory conditions can culminate in PIH and typically most epidermal lesions will appear tan, brown, or dark brown while dermal hypermelanosis has a blue-gray discoloration.Depigmenting agents target different steps in the production of melanin, most commonly inhibiting tyrosinase. These agents include hydroquinone, azelaic acid, kojic acid, arbutin, and certain licorice (glycyrrhiza) extracts. Other agents include retinoids, mequinol, ascorbic acid (vitamin C), niacinamide, N-acetyl glucosamine, and soy, and these products depigment by different mechanisms. Certain procedures can also be effective in the treatment of PIH including chemical peeling and laser therapy. It is important to note that these same therapeutic modalities may also play a role in causing PIH. Lastly, those lesions that are not amenable to medical or surgical therapy may experience some improvement with cosmetic camouflage.

Acne in ethnic skin

Acne is the most common disorder observed in ethnic skin. Clinical presentation is different than in white skin. Postinflammatory hyperpigmentation is a common sequelae of acne in darker skin. The management of acne in ethnic skin is based largely on the prevention and treatment of hyperpigmentation.

Central scalp alopecia photographic scale in African American women.

ABSTRACT:  Central centrifugal cicatricial alopecia (CCCA) is a common but poorly understood cause of hair loss in African American women. A photographic scale was developed that captures the pattern and severity of the central hair loss seen with CCCA in order to help identify this problem in the general community and to potentially correlate clinical data with hair loss. The utility and reproducibility of this photographic scale was determined in a group of 150 African American women gathered for a health and beauty day who were evaluated by both four investigators experienced in the diagnosis of hair disorders and by the subjects themselves.

Safety of Nonanimal Stabilized Hyaluronic Acid Dermal Fillers in Patients with Skin of Color: A Randomized, Evaluator‐Blinded Comparative Trial

BACKGROUND Nonanimal stabilized hyaluronic acid (NASHA) dermal fillers have been used in the United States since 2003 for the treatment of moderate to severe facial wrinkles and folds, such as nasolabial folds. Previous trials with NASHA dermal fillers have included small numbers of patients with pigmented skin. OBJECTIVES This randomized, evaluator‐blinded, split‐face trial compared the safety and efficacy of two variable‐particle NASHA fillers in the correction of nasolabial folds in patients with Fitzpatrick skin types IV, V, and VI. METHODS AND MATERIALS One hundred fifty patients (predominantly African American) were enrolled at 10 sites. Patients received one treatment (with an optional touch‐up treatment at week 2) with small‐ and large‐particle NASHA gel randomized to the left or right side of the face. Safety was evaluated through patient diaries for the first 2 weeks and physician assessments at 3 days and 2, 6, 12, and 24 weeks after treatment for adverse events (AEs), skin pigmentation changes, and keloid formation. RESULTS All related AEs were mild or moderate and of limited duration. They included bruising, tenderness, edema, redness, itching, pain, and changes in pigmentation. The incidence of AEs was not different between the 2 preparations, and no patient developed a keloid. There were 3 reported mass formations, 2 of which were infectious in nature. CONCLUSION In patients with skin of color, NASHA dermal fillers are safe for the correction of moderate to severe facial folds and wrinkles, with no immunogenicity or keloid formation and only mild to moderate AEs occurring around the injection site. Medicis Aesthetics Inc. provided Restylane and Perlane and study funding to the authors.

Aesthetic Dermatology for Aging Ethnic Skin

BACKGROUND Dark‐skinned patients manifest the signs of skin aging differently than their fair‐skinned counterparts in that the former exhibit more intrinsic facial aging, whereas the later shows more photodamage. Nevertheless, common cosmetic procedures can be used in skin of color to treat the signs of aging. OBJECTIVE To provide updated clinical information on the use of cosmetic procedures for skin aging in darker phototypes for the safe treatment of this population. METHODS A Medline literature search was performed for publications on the safety and efficacy of botulinum toxin, dermal fillers, chemical peels, laser and light‐based devices, and microdermabrasion for the treatment of skin aging specifically in ethnic populations. RESULTS Similarly to light‐skinned patients, botulinum toxin and dermal fillers provide fast, effective results in skin of color, with fewer complications than with traditional surgery and no downtime. More‐invasive procedures, such as chemical peeling, laser resurfacing, and microdermabrasion, can also be effective, but it is important to exercise caution and remain within certain parameters given the greater risk of dyschromias in this population. CONCLUSION With the proper knowledge of how to treat aging skin of color, these patients can experience the benefits of cosmetic procedures while minimizing the risks. Erica C. Davis, MD, has no conflicts of interests to disclose. Valerie D. Callender, MD, is a consultant and speaker for Allergan, Medicis, Galderma, and Stiefel and a researcher for Medicis, Merz, and Allergan.

Hair Breakage as a Presenting Sign of Early or Occult Central Centrifugal Cicatricial Alopecia: Clinicopathologic Findings in 9 Patients

BACKGROUND Central centrifugal cicatricial alopecia is the most common form of cicatricial alopecia in African American women. Treatment options are limited and mostly aimed at halting further hair loss but rarely result in hair regrowth. Therefore, it is important to recognize early clinical signs, perform a confirmatory biopsy, and begin treatment promptly. We have observed that hair breakage may be a key sign of early central centrifugal cicatricial alopecia, and this association is not clearly described in the literature. OBSERVATIONS Nine patients with hair breakage on the vertex with or without scalp symptoms underwent scalp biopsies as part of their evaluation. Of these, 8 had histologic samples adequate for complete interpretation: 5 specimens (63%) showed histologic changes typical of central centrifugal cicatricial alopecia, with 1 of these showing advanced end-stage changes of cicatricial alopecia. Two (25%) revealed premature desquamation of the inner root sheath as the sole finding suggestive of early central centrifugal cicatricial alopecia and 1 (13%) was normal. CONCLUSIONS Although hair breakage can have multiple causes, early central centrifugal cicatricial alopecia must be considered in the differential diagnosis, particularly in women of African ancestry. Histologic evaluation may reveal early or late findings that can help establish the diagnosis.

A multicenter study of the safety and effectiveness of hyaluronic acid with a cohesive polydensified matrix for treatment of nasolabial folds in subjects with Fitzpatrick skin types IV, V, and VI.

Background: Although the use of the hyaluronic acid with cohesive polydensified matrix hyaluronic acid has been well explored in subjects with lighter skin (i.e., Fitzpatrick skin types I, II, and III), further exploration in subjects with Fitzpatrick skin types IV, V, and IV is warranted. The primary purpose of the study was to assess the safety of a cohesive polydensified matrix hyaluronic acid in the correction of nasolabial folds in subjects with Fitzpatrick skin types IV, V and VI, especially assessment of hyperpigmentation, hypopigmentation, and scarring. Effectiveness was also assessed. Methods: A total of 93 subjects were enrolled in this 24-week investigation at three sites in the United States. All were injected bilaterally for nasolabial fold correction with cohesive polydensified matrix hyaluronic acid. Assessments included the recording of adverse events; injected volumes; wrinkle severity ratings; and global aesthetic improvement by evaluating investigators, treating investigators, and study subjects. Results: Injection of cohesive polydensified matrix hyaluronic acid for the treatment of nasolabial folds in subjects with Fitzpatrick skin types IV, V, and VI showed no evidence of an association with hypopigmentation, hyperpigmentation, or scarring. Adverse events reported were typical of dermal filler injections with respect to type, rate, duration, and severity. Conclusion: Cohesive polydensified matrix hyaluronic acid is a safe and well-tolerated dermal filler for subjects with Fitzpatrick skin types IV, V, and VI.

Hair transplantation in the surgical treatment of central centrifugal cicatricial alopecia.

BACKGROUND Central centrifugal cicatricial alopecia (CCCA) is a progressive primary scarring alopecia that occurs mainly on the vertex of the scalp and expands centrifugally. To date, there is a paucity of published prospective studies reporting successful surgical therapy for CCCA. OBJECTIVE To evaluate the efficacy of hair transplantation using the round (punch) grafting technique in African American women with CCCA. MATERIALS AND METHODS We describe 2 African American female patients with CCCA who had endured nearly 5 to 6 years of progressive hair loss on the crown of the scalp. After a scalp biopsy and hair transplant test session, both patients underwent hair transplantation with the use of round grafts. Digital photographs were obtained before and after hair transplantation to determine the hair growth success and response rates. RESULTS Hair growth was visibly observed at the recipient sites in both patients beginning between 4 to 5 months post-test session. No postoperative scarring in the recipient or donor areas of the scalp were noted in either patient. CONCLUSION Hair transplantation is a safe well-tolerated procedure to improve hair loss in African American women with end-stage CCCA who histologically display a lack of inflammation on scalp biopsy.