A Primer to Natural Hair Care Practices in Black Patients

The phenomenon of natural (nonchemically treated) hair in individuals of African and Afro-Caribbean descent is sweeping across the United States. The ideals of beauty among this patient population have shifted from a relaxed, straightened, noncurly look to a more natural curly and/or kinky appearance. The discussion on natural hair versus straight hair has been brought to the mainstream by films such as Good Hair (2009). Furthermore, major hair care companies have increased their marketing of natural hair products to address the needs of these patients.

Popular traumatic hair care practices such as chemical relaxation and thermal straightening may lead to hair damage. Although the role of hair care practices in various scalp and hair disorders is ambiguous, traumatic practices commonly are performed by patients who are diagnosed with dermatologic conditions such as scarring alopecia.¹ Alopecia is the fourth most common dermatologic diagnosis in black patients.² Central centrifugal cicatricial alopecia is the most common form of scarring alopecia in this patient population³ and has been associated with traumatic hair care practices. As a result, many patients have switched to natural hairstyles that are less traumatic and damaging, often due to recommendations by dermatologists.

As the US population continues to become more diverse, dermatologists will be faced with many questions regarding hair disease and natural hair care in patients with skin of color. A basic understanding of hair care practices among black individuals is important to aid in the diagnosis and treatment of hair shaft and scalp disorders.⁴ When patients switch to natural hairstyles, are dermatologists prepared to answer questions that may arise during this process? This article will familiarize dermatologists with basic hair care terminology and general recommendations they can make to black patients who are transitioning to natural hairstyles.

Characteristics of Hair in the Skin of Color Population

A basic understanding of the structural properties of hair is fundamental. Human hair is categorized into 3 groups: Asian, Caucasian, and African.⁵ African hair typically is curly and, depending on the degree of the curl, is more susceptible to damage due to increased mechanical fragility. It also has a tendency to form knots and fissures along the hair shaft, which causes additional fracturing with simple manipulation. African hair grows more slowly than Asian and Caucasian hair, which can be discouraging to patients. It also has a lower water concentration and does not become coated with sebum as naturally as straightened hair.⁵ A simplified explanation of these characteristics can help patients understand how to proceed in managing and styling their natural hair.

As physicians, it is important for us to treat any underlying conditions related to the hair and scalp in black patients. Common dermatologic conditions such as seborrheic dermatitis, lupus, folliculitis, and alopecia can affect patients’ hair health. In addition to traumatic hair care practices, inflammation secondary to bacterial infections can contribute to the onset of central centrifugal cicatricial alopecia.⁶ Therefore, a detailed history and physical examination are needed to evaluate the etiology of associated symptoms. Treatment of these associated symptoms will aid in the overall care of patients.

Transitioning to Natural Hairstyles

Following evaluation and treatment of any hair or scalp conditions, how can dermatologists help black patients transition to natural hairstyles? The term transition refers to the process of switching from a chemically relaxed or thermally straightened hairstyle to a natural hairstyle. Dermatologists must understand the common terminology used to describe natural hair practices in this patient population.

There are several methods patients can use to transition from chemically treated hairstyles to natural hairstyles. Patients may consider the option of the “big chop,” or cutting off all chemically treated hair. This option typically leaves women with very short hairstyles down to the new growth, or hair that has grown since the last chemical relaxer. Other commonly used methods during the transition phase include protective styling (eg, braids, weaves, extensions) or simply growing out the chemically treated hair.

Protective styling methods such as braids, weaves, and extensions allow hair to be easily styled while the chemically treated hair grows out over time.⁷ Typically, protective styles may be worn for weeks to months, allowing hair growth without hair breakage and shedding. Hair weaving is a practice that incorporates artificial (synthetic) or human hair into one’s natural scalp hair.⁸ There are various techniques to extend hair including clip-in extensions, hair bonding and fusion with adhesives, sewing hair into braided hair, or the application of single strands of hair into a cap made of nylon mesh known as a lace front. Braided styles, weaves, and hair extensions cannot be washed as often as natural hair, but it is important to remind patients to replenish moisture as often as possible. Moisturizing or greasing the exposed scalp and proximal hair shafts can assist with water retention. It is imperative to inform patients that overuse of tight braids and glues for weaves and extensions may further damage the hair and scalp. Some of the natural ingredients commonly used in moisturizers include olive oil, jojoba oil, coconut oil, castor oil, and glycerin. These products can commonly cause pomade acne, which should be recognized and treated by dermatologists. Furthermore, long weaves and extensions can put excess weight on natural hair causing breakage. To prevent breakage, wearing an updo (a hairstyle in which the hair is pulled upward) can reduce the heavy strain on the hair.