Acute ‘relaxer’-associated scarring alopecia: a report of five cases

Abstract

We have some issues with the study design and feel the results are distant from everyday practice. Based on the results of several multicentre trials a medical decision tree was designed to compare standard therapy for AK and BCC with MAL-PDT. To achieve this, in the case of BCC the authors have made a combination of the outcome results of two multicentre trials. However, the data in both studies differ largely, not only in type of BCC (superficial vs. nodular) but also in treatment pathway (initial single treatment vs. two PDT cycles) and treatment mode (comparison with surgery in one publication, cryosurgery in the other). Subsequently, the authors have added the conclusions for a virtual second-line treatment of the nonresponders for the AK and BCC group, respectively, based on the expert opinion of 12 Belgian dermatologists who participated in a tworound written questionnaire by mail.The interviews at most only reflect the possibly biased opinions of these 12 dermatologists and not the current consensus or the evidence-based best therapies. Secondly, in order to calculate the cost-benefit ratios 'full responders' were used. If after one session of cryotherapy any AK remained or if the cosmetic result was not excellent it was considered a therapeutic failure and second-line therapies were considered. However, in the case of cryosurgery, cosmetic outcome and response are heavily influenced by the duration and number of freeze-thaw cycles. For instance, in a prospective randomized study comparing MAL-PDT with cryosurgery, 2 two long freeze cycles (24 s) were used, which should influence the cosmetic outcome dramatically. In the randomized study 3 used in this publication by Caekelbergh et al., only one freeze cycle is used which resulted in a response of only 68% for cryosurgery compared with 91% for MAL-PDT. With respect to cosmetic outcome of AK after cryosurgery, in our combined experience of more than 30 years as dermatologists we have never had to refer patients. Moreover, even the suggestion that reconstructive surgery for AK is an option is in our view preposterous and perhaps only reflects the opinion of a plastic surgeon.Thirdly, we found that the results presented in their Tables 1 and 2 diametrically oppose our experience and probably that of many other dermatologists. The authors state that the cosmetic result after successful AK treatment is excellent in only 51% of cases. In the case of BCC, the authors report that this percentage is only 7% after a surgical removal of the tumour. However, in the study of Rhodes et al. 4 which was used for this publication, the cosmetic outcome of surgery was defined as excellent by 75% of the patients (and 41% by a panel). We fear that the figures in the study by Caekelbergh et al. have been mixed because in our opinion too, the majority of patients treated with cryosurgery for AK and surgical excision for BCC are satisfied with the cosmetic result. For MAL-PDT also the cosmetic outcome results should be higher than presented in Tables 1 and 2. Our personal opinio...

‘Relaxers’ damage hair: Evidence from amino acid analysis

“…22 Thus, the reduction in arginine and citrulline in asymptomatic relaxed hair, which was most dramatic proximally without further worsening distally, may indicate damage from relaxer-induced inflammation of adjacent skin (ie, affecting hair closest to the scalp). Scalp inflammation and scarring alopecia have been anecdotally reported with both lye and no-lye relaxers, 23 despite the fact that the latter are often advertised as safer. In this study it was not possible to analyze relaxer types separately; the claimed relative safety of no-lye relaxers needs elucidation with chemical processing done under controlled conditions.…”

Hair care practices and their association with scalp and hair disorders in African American girls

“…16,17 Permanent chemical relaxers (straighteners), waves, and dyes may cause contact allergic or irritant dermatitis, chemical burns, scarring alopecia, and increased hair breakage. 9,[11][12][13][14] Sewn-in weaves and artificial hair extensions have been associated with central centrifugal cicatricial alopecia. 15 For other hair and scalp dermatoses, such as tinea capitis (TC), which has a high prevalence in African American children, 18,19 the role of hair care and styling practices is unclear.…”

“…Several of these practices have been implicated as risk factors for scalp and hair dermatoses. 3,4,[7][8][9][10][11][12][13][14][15] Prolonged tension on the hair root by certain hairstyles lead to TA, which can over time result in irreversible scarring alopecia. 16,17 Permanent chemical relaxers (straighteners), waves, and dyes may cause contact allergic or irritant dermatitis, chemical burns, scarring alopecia, and increased hair breakage.…”

Nonscarring Alopecias

“…Severe irritant dermatitis can result in blisters and/or erosions. There have been care reports of scarring alopecia following relaxer application, but this is not a common occurrence [ 7,8 ] . Some studies have demonstrated that relaxer use is prevalent among patients with central centrifugal cicatricial alopecia, a condition that predominantly affects African American women [ 9,10 ] .…”