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A Systematic Review

Nonhlanhla P. Khumalo, MBChB, FCDerm; Susan Jessop, MBChB, FCDerm; Rodney Ehrlich, MBChB, PhD

Arch Dermatol. 2006;142:377-383.

ABSTRACT
Objective  To identify studies of the prevalence of cutaneous complications of hairdressing in (1) hairdressers and the general population and (2) those more common in people of African ancestry.

Data Sources  Three versions of MEDLINE were searched from January 1966 through December 2004 and with a repeated search in August 2005 using 2 groups of search terms: group 1, terms used for hair care and specific study designs: survey, cross-sectional study, and cohort study; group 2, the terms African hair, Afro-Caribbean hair, African American hair, central centrifugal cicatricial alopecia, acne keloidalis nuchae, traction alopecia, and synonyms for each.

Study Selection and Data Extraction  All identified cross-sectional and cohort studies of cutaneous adverse effects were included and their quality assessed using criteria developed by Radulescu et al.

Data Synthesis  Four studies used either questionnaires or patch testing to estimate the prevalence of cutaneous adverse effects of hair chemicals in the general population and found a prevalence of contact dermatitis, secondary to use of hair dye, of 5.3% and of allergy to paraphenylenediamine of 0.1% to 2.3%. Working as a hairdresser is associated with a prevalence of contact dermatitis ranging from 16.4% in larger cohort studies that included a clinical examination to 80% in the smaller, questionnaire-based studies. Three studies of people of African ancestry found a prevalence of acne keloidalis nuchae ranging from 1.3% to 13.7% and of traction alopecia of 1%. None of these were in the general population.

Conclusions  Working as a hairdresser is associated with an increased risk of contact allergy and/or hand dermatitis. Studies of skin disorders of individuals of African ancestry are needed to quantify the health burden and clarify causal variables of these disorders. It is not clear how much the unique shape of the African hair follicle contributes to the development of these conditions.

INTRODUCTION

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Chemical or mechanical hair treatments may affect hairdressers and their clients. Studies of the systemic adverse effects of hairdressing have concentrated on the association of hair dyes with some malignancies, which seems likely from initial systematic reviews,^1-2 but a recent large meta-analysis failed to confirm the association with most cancers.³ Respiratory symptoms, suspected to be associated with exposure to chemicals and aerosol sprays used in hairdressing, have been reported^4-5 with crude incidences of asthma⁶ and prevalence of chronic bronchitis reported to be higher in hairdressers than controls.⁷ Female hairdressers have been found to have a higher adjusted mortality rate from asthma than people in other occupations, if smoking is taken out of the equation.⁸ No association between hair dyes and systemic lupus erythematosus has been confirmed.⁹

Cutaneous adverse effects of chemical hair products are commonly reported and mainly involve contact dermatitis, which can occur either as a result of an irritant or as an allergic reaction, and commonly affects the hands and face. In a retrospective study¹⁰ of 261 patients with contact dermatitis who were hairdressers' clients, 49 were patch tested and showed 1 (27 patients) or more (22 patients) positive reactions to hairdressing chemicals, and 19 (7.3%) tested positive for allergy to paraphenylenediamine (PPD), which is the most frequently used hair dye. A large collaborative retrospective European study¹¹ comparing data from 9 patch test centers found that hairdressers had a higher frequency of positive patch test results for most allergens in the hairdressing series than their clients. The exception in this study was PPD; 15.0% of hairdressers and 19.2% of clients tested positive for PPD allergy.¹¹ More recent studies (such as that by Uter et al¹²) have shown more PPD allergy in hairdressers (18.7%) than in their clients (15.4%). It is important to note that the study by Uter et al¹² was of a highly selected group of patients who were already suspected of having contact allergies to hairdressing chemicals and who were grouped during analysis by whether they were or were not hairdressers. The figures are lower for patients who had more general patch tests (95% confidence interval [CI], 4.8% [4.6%-5.1%]).¹³ Another study of 42 839 patients with contact dermatitis found that hairdressing was 1 of the 5 occupations that collectively accounted for up to 60% of the cases.¹⁴

Mechanical adverse effects of hairdressing are primarily burns and traction alopecia. An American retrospective survey,¹⁵ based on data from the National Electronic Injury Surveillance System report for 1991, found that heated hair curlers and curling irons caused about 2% of consumer product–related eye injuries treated in hospital emergency departments. In another study,¹⁶ 78% of hair care product–related injuries in a 5-year period involved burns from curling irons.

People of African ancestry seem to have a higher prevalence of specific scalp disorders, which are suspected to have an association with hairdressing. The phenotype of hair in Africa varies from very tightly coiled in the south to very straight in the northern part of the continent. For the purposes of this article, African hair refers to the former group. Hair grooming is generally different between the sexes; for example, more women than men use chemical relaxers and wear braids, and short haircuts are more popular with men. The extent to which the curved African hair follicle contributes to the pathogenesis of central centrifugal cicatricial alopecia (CCCA), acne keloidalis nuchae (AKN), and traction alopecia (TA) remains uncertain.

Initially, CCCA was referred to as hot comb alopecia and later as follicular degeneration syndrome.¹⁷ The heat associated with the use of the hot comb for straightening hair was first suspected to be the cause. However, cases in patients who had never used a hot comb were described, and premature degeneration of the inner root sheath of the hair follicle was identified in biopsy findings from persons with affected scalps. These findings were inconsistent, and the name CCCA is now preferred.¹⁸ It occurs almost exclusively in women of African ancestry, who tend to have specific hair grooming practices, and is rarely reported in men.¹⁹ This condition may occur as a result of hairdressing procedures, such as the use of chemicals,²⁰ but traction may also play a role.

Acne keloidalis nuchae is a scarring alopecia predominantly affecting men of African ancestry with a predilection for the nuchal scalp. Lesions start as papules and pustules and heal with small or large confluent keloids. The pathogenesis of AKN is unclear, but there is suspicion that hair grooming, particularly shaving very close to the skin, and friction, may play a part in susceptible individuals. The role of bacteria is still unclear.²¹

Traction alopecia has been described in ballerinas, Sikh men,^22-23 nurses,²⁴ and Japanese²⁵ and Iraqi individuals.²⁶ As the name implies, TA is associated with traction caused by styling hair in ponytails or braids, for example. Women of African ancestry, including children,^27-28 seem to have a high prevalence of TA. (It was found in 30 [37%] of 80 women who visited a primary care health center in Cape Town; unpublished pilot study by N.P.K.)

The first aim of this systematic review was to measure the frequency of cutaneous adverse effects of chemical and mechanical hairdressing treatments by identifying epidemiologic studies, performed in the general population and among hairdressers, that investigated the prevalence or incidence of cutaneous complications of hairdressing, including those resulting from contact with or the use of hairdressing products or implements. The second aim was to establish the prevalence or incidence of 3 specific hair and scalp disorders that are suspected to be associated with grooming and are thought to be more common in persons of African ancestry: CCCA, AKN, and TA.

METHODS

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SEARCH STRATEGY

We performed literature searches of 3 versions of MEDLINE (Silver Platter, Ovid, and PubMed) from January 1966 through December 2004, with a repeated search in August 2005. The references of relevant manuscripts were also examined. Two distinct searches were performed, as follows.

1. The first used the following search terms: hair care OR hair style OR hair dye OR hair straightener OR permanent wave OR hair perm OR hair tint OR hair bleach OR hair peroxide OR hair highlights OR hair dress OR hair product OR hair chemical OR shampoo OR hair gel OR hair conditioner OR hair oil OR hair strengthener OR hair stimulant OR scalp treatment OR hair spray OR hair mousse OR hair color OR hair dryer OR hair brush OR hair comb OR curling tong OR curling iron OR hair roller OR hair clip OR hair extension OR hair adhesive OR hair attachment AND survey OR cross-sectional study OR prevalence study OR cohort study OR incidence study OR population study.
   
2. A second search was performed, using the following search terms: African hair OR African American hair OR Afro-Caribbean hair OR traction alopecia OR trauma alopecia OR hot comb alopecia OR follicular degeneration OR central centrifugal alopecia OR acne keloid OR acne keloidalis OR folliculitis keloidalis OR dermatitis papillaris capillitii AND survey OR cross-sectional study OR prevalence study OR cohort study OR incidence study OR population study.
   

RESULTS

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The first search yielded 1925 abstracts, and most (>1800) of these were either clearly unrelated to hair or were from toxicology (drug testing on hair) and audiometry (involving hair in the inner ear) publications. Of the remaining 100 studies, most were either case reports or studies that reported cutaneous and systemic (cancer, systemic lupus, and respiratory) adverse effects of hair dyes. A total of 12 studies satisfied the inclusion criteria.^30-41

The second search identified 121 articles of which only 3 studies fulfilled the inclusion criterion.^42-44 Because of the small number of studies identified, we performed an additional search that excluded combining the search terms with the study designs. This last search identified 520 references, but no additional studies fulfilled the inclusion criteria.

QUALITY OF INCLUDED STUDIES

Of the first 7 criteria for quality assessment, only 4 studies satisfied 5 criteria,^{30, 37, 40, 44} 3 studies satisfied 4 criteria,^35-36,39 3 studies satisfied 3 criteria,^31-32,42 and 2 studies satisfied 2 criteria.^{34, 43} Three studies satisfied only 1 of the first 7 criteria.^{33, 38, 41} All the studies were cross-sectional in design with only 1 cohort study, which although large had a high dropout rate (>40% by the end of the study).³⁹ The details of all the studies, including their quality assessments, are summarized in the Table and are grouped as studies of contact dermatitis in the general public and in hairdressers and studies of skin conditions specific to persons of African ancestry.

View this table: [in this window] [in a new window] [as a PowerPoint slide]   Table. Details of Included Studies

HAND ECZEMA AND CONTACT ALLERGY

General Public

A cross-sectional Danish study³¹ of the general population, the objectives of which were to assess changes in the prevalence of self-reported hand eczema and to evaluate the association between contact allergy and hand eczema before and after regulation of nickel exposure in Denmark, was performed twice with an 8-year interval. The study found that the prevalence of positive patch test reactions to PPD increased from 0.1% to 1.0%. A cross-sectional study⁴¹ of 593 healthy Italian army cadets who were patch tested with various allergens found that 0.5% of them had results that were positive for allergy to PPD. In a German study,⁴⁰ 1537 participants were recruited from a random general population sample of 2539 (60.5% participation rate). With 1141 interpretable patch tests, PPD allergy was present in 1.5% of the subjects (2% of women and 1% of men). The most recent patch test study,³² published as an abstract, was performed in unselected nonclinical populations of 2545 volunteers in Bangkok, Thailand. The study used 7 common allergens, and the tests were read at 48 hours after the patches were applied. The authors found that 2.3% of the participants had positive test results for allergy to PPD. Finally, an estimate of the use of hair dyes was obtained from a large (sample of 4000 participants) questionnaire-based population study³⁰ in Holland, which found that 18.4% of men and 74.9% of women had ever used hair dyes. Of these, 5.3% had a history of adverse skin reactions consistent with allergic reactions to hair dyes. This study also found no association between temporary tattoos and adverse reactions to hair dyes.

Hairdressers

Small cross-sectional studies showed a prevalence of hand dermatoses among hairdressers ranging from 16.9%³⁴ to 38.2%,³⁵ with 1 study³⁶ showing a very high prevalence of irritant contact dermatitis (83%) and allergic dermatitis (44%) (patch test results positive for presence of PPD, 3%) among hairdressers. This study also found a prevalence of 32% of scars caused by scissors. Contact dermatitis seems to occur as early as within 6 weeks after starting work as a hairdresser's apprentice (the rate of contact dermatitis increased from 0% at the beginning of the study to 36% after 6 weeks).³⁷ The rate increased in prevalence with the duration of time spent in the hairdressing profession (51% of hairdressers after an 8-year follow-up).³⁸ A clinical study by Rivett and Merrick³³ reported a significantly higher prevalence of hand dermatoses in trainee hairdressers (74%) than in stylists (30%), possibly because trainees have more exposure to water and chemicals. A 3-year cohort study³⁹ showed a less dramatic point prevalence of irritant hand dermatitis than the study by Rivett and Merrick,³³ from 35.4% at initial examination, 47.5% at the intermediate examination, and 55.1% at the final examination after 3 years. These values fall to 12.9%, 23.5%, and 23.9%, respectively, if a more conservative (stricter) definition of hand dermatitis is used.

Skin Conditions Specific to Persons of African Ancestry

Only 3 studies could be found that examined 2 of the 3 skin conditions found in persons of African ancestry that may be associated with hair styling. A prevalence of AKN in patients in a Nigerian skin clinic was 1.3%.⁴⁴ Interestingly, this study found that bacteria, especially Staphylococcus pyogenes, was found in skin cultures from 95% of affected patients.⁴⁴ Nuchal acne mechanica, which is thought to be induced by friction from football helmets, was more prevalent in high school athletes (15.5%) than in older, professional athletes (1.2%). Among the older athletes, there was a prevalence of AKN of 13.6% vs 0% in persons of African ancestry and white individuals, respectively.⁴² Among adult males of African ancestry treated at a London, England, skin clinic, the prevalence of AKN, which included scalp folliculitis, was 13.7%. There was a prevalence of TA of 1% among adult patients.⁴³ No studies estimating the frequency of CCCA were identified.

COMMENT

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Four studies used either patch tests^31-32,40 or questionnaires³⁰ to estimate the prevalence of cutaneous adverse effects of hair chemicals in the general population. These population studies report patch test results showing positive allergy reaction to PPD ranging from 0.1% to 2.3% and a questionnaire-based clinical diagnoses of contact dermatitis of 5.3%. Seven studies looked at the association between contact dermatitis and an occupation as a hairdresser, and of these, the only patch test study found positive reactions to PPD in 3% of study participants. This is significantly lower than the highly selected, patient-based data mentioned at the beginning of this article (positive test results in 18.7% of hairdressers and in 15.4% of clients),¹² but it is consistent with recently published adjusted prevalence data¹³ that show lower percentages of allergy to PPD in the general population (1.2% prevalence; 95% CI, 0.9%-1.6%) than in clinic-based studies (4.8% prevalence; 95% CI, 4.6% -5.1%). Hairdressers could be expected to have a higher prevalence of PPD allergy than the general public. Definition of contact dermatitis disease is crucial, as demonstrated by the change in point prevalence figures depending on the diagnostic criteria used.³⁹ These studies varied in quality from small cross-sectional studies to 1 large prospective cohort study (Table).

This review was concerned with how common cutaneous adverse effects of hairdressing are; it was not a review of contact dermatitis. Studies of interest therefore either addressed specific questions about symptoms directly related to hairdressing procedures or compared the prevalence of skin disorders in hairdressers with those in the general public. Our review excluded all studies performed on patients in the clinical setting because this tends to be a highly selected, well-studied, and well-reported group. Data collected from specialist clinics¹² or multicenter surveillance groups are very useful for monitoring trends with the passage of time and between countries.^{11, 45-46} Although these data can be used to calculate various national rates of disease occurrence for comparative studies, random samples are best for estimating disease occurrence in the general (or specific) population partly because not everyone who has the disease will be seen for treatment in specialist clinics. This may explain unexpected results such as the higher prevalence of PPD-positive patch test results in clients than in hairdressers.¹¹

Limitations of this review are the restriction of the literature search to MEDLINE and the inclusion of observational studies. Searches of other electronic databases, publication in other languages, and hand searches from journals and industry sources could have identified more studies, although the last are more likely to be case reports. Observational studies are prone to bias such as in the choice of the sampling frame and selection bias, which is influenced by the diagnostic criteria. Loss to follow-up is more likely in cohort studies of long duration.

This study has 6 important findings.

1. The prevalence of cutaneous adverse effects of hairdressing products in the general population is significantly less than in hairdressers.
   
2. Small prevalence studies³⁶ may suggest higher prevalence figures, whereas larger studies³⁹ or cohort studies give more reliable estimates.
   
3. The diagnostic criteria (disease definition) profoundly influence the measure of disease frequency.³⁹
   
4. The prevalence of contact dermatitis is much higher with questionnaires compared with clinical examination–based assessments in the same group of participants.³⁶
   
5. Mechanical injuries from scissors, burns from hair dryers, and so forth, have not been reported from population studies. Data are available from surveillance and casualty units.^15-16
   
6. Although case reports suggest that AKN, TA, and CCCA are more common in persons of African ancestry than in other groups, only 3 prevalence studies^42-44 have been performed, and none have been in the general population. No studies looking at CCCA in any population have been identified. An association of these conditions with hairdressing preferences between men and women seems likely, although it is still not clear how much the curved African hair follicle contributes to their pathogenesis.⁴⁷
   

AUTHOR INFORMATION

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Correspondence: Nonhlanhla P. Khumalo, MBChB, FCDerm, Division of Dermatology, Ward G23, Groote Schuur Hospital and the University of Cape Town, Observatory 7925, Cape Town, South Africa.

Accepted for Publication: October 7, 2005.

Author Contributions: Study concept and design: Khumalo, Jessop, and Ehrlich. Acquisition of data: Khumalo. Drafting of the manuscript: Khumalo. Critical revision of the manuscript for important intellectual content: Jessop and Ehrlich. Study supervision: Jessop and Ehrlich.

Financial Disclosure: None.

Acknowledgment: We thank Gail Todd, PhD, MBChB, for suggesting some of the search terms used, and W. Uter, MD, for helping to clarify data from previously published studies.

Author Affiliations: Division of Dermatology (Drs Khumalo and Jessop) and School of Public Health and Family Medicine (Dr Ehrlich), Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa.

REFERENCES

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