Alopecia in Skin of Color: A Discussion of Procedural Treatments

Sotonye Imadojemu, MD, MBE, gave a presentation titled ‘Alopecia in Skin of Color: Procedural Treatments and More’ in which she discussed the management, diagnosis, and treatment of different hair and scalp disorders and the common features of an afro-textured hair care regimen.

Imadojemu is known for her work as an academic medical dermatologist for Brigham and Women’s Hospital, where she serves as Director of the Cutaneous Sarcoidosis and Granulomatous Diseases Clinic as well as the Associate Director of the Dermatology Consult Service.

Her presentation was given at the Society of Dermatology Physician Assistants (SDPA) 2023 Annual Summer Dermatology Conference in Boston.

“I want to start off with a statistic, that less than half African American women believe that their physician understands African American hair,” Imadojemu explained. “And you can substitute dermatologists in there. So our first step is really gaining trust.”

She began her presentation on this important topic by delving into some definitions.

“What does it mean when I say ‘afro-textured’ hair, this is just my term of choice,” Imadojemu noted. “Synonyms can be coily or kinky hair texture, it’s hair that is helical, coiled, or spirals, and in cross section, the hair has a flattened appearance…It's associated with people of African ancestry. But you can also see this hair texture and people who have oceanic and Southeast Asian ancestry.”

Imadojemu also explored some of the common hairstyles she states are known to be associated with afro-textured hair, also noting common cleaning strategies and importance of understanding for those who have this hair type.

She then went into some of the elements dermatologists should search for when examining the scalp of someone with this hair texture.

“So you're looking for the presence or absence of follicular orifices, tufting of follicles sort of grouping together, or textural change of the hair or scalp,” Imadojemu said. “You're looking for perifollicular erythema, scaling, crusting, pustules, pigmentation, atrophy, and all this stuff can help you narrow in on your diagnosis on how to classify the pattern of alopecia.”

She added that clinicians will also want to examine the hair shaft, as opposed to only the scalp. This is because it may be hair breakage, which can happen mid-shaft.
“In the alopecia category, we have inflammatory versus non-inflammatory, scarring versus non scarring,” she stated. “In the hair breakage categories, they can be traumatic, nutritional, endocrinologic, or perhaps genetic. Sometimes in the course of your evaluation you will decide that a biopsy is necessary.”

Imadojemu also explained that a punch biopsy may be needed to evaluate alopecia, adding that she recommends at least 4 millimeters.

“The HoVert technique I believe to be best if your pathologist is comfortable reading the specimen section in that way,” she said. “Essentially what the HoVert technique is is that the superficial aspects of the punch, and that includes the epidermis, is sectioned horizontally like we normally section skin biopsy in other parts.”

Imadojemu noted that this technique can be the best of both worlds, before then going into other steps to take.

“With your biopsy, you have to make sure that hair follicles are present,” she stated. “So you don't want to actually go after the area and choose your biopsy site in the area that is most severely affected, because there's not going to be hair follicles there to evaluate.”

She explained that one will need to biopsy the hair area adjacent to the alopecia and probably a bit further into the hair-bearing area than one might think is necessary, given that the more follicles there, the better information can be uncovered in the biopsy.

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The quotes contained in this description were edited for clarity.