Page 1 of 9
Afro-textured hair
This leaflet explains more about afro-textured hair, common causes of hair loss
amongst people with afro-textured hair and some recommendations for hair care.
Afro-textured hair is the term used to describe curly, kinky, coiled hair that generally grows
upwards (as opposed to curly hair that grows downwards). It is generally thought of as the
hair that is naturally seen in people of African descent, although this is not the rule.
Afro-textured hair can be styled in many ways, making it versatile and adaptable.
Due to the nature of the curl pattern and differences in the hair shaft, research has shown
that Afro-textured hair is more fragile when compared to Caucasian or Asian hair.
Afro-textured hair also grows more slowly; more hairs are found in the telogen (resting)
phase of the hair cycle and the number of anagen (growing) hairs is reduced on
comparison. The curly nature also makes Afro-textured hair much more prone to knots and
dryness.
Importantly, many people with Afro-textured hair partake in hair styling practices which can
be damaging. All these factors can contribute to problems with hair growth and
maintenance. This guide aims to discuss some of these practices and provide
recommendations for healthy hair. Three common causes of hair loss or breakage caused
by damaging hair practices are traction alopecia, acquired trichorrexis nodosa and central
centrifugal cicatricial alopecia.
Traction alopecia (TA)
TA is where prolonged or repeated pulling forces put strain on the hair follicles, causing
the hair to be prematurely uprooted. Pain, redness, dimpling of the scalp and small pus
filled lumps (pustules) soon after installing a particular hairstyle are early signs. TA is
commonly seen at the periphery of the hairline (commonly known as a person’s “edges”)
but can occur anywhere on the scalp where the hair is being pulled. Whilst traction
alopecia is preventable and can be reversed with care, it can lead to scarring, causing
permanent hair loss in later stages.
Many different hair practices have been implicated in TA and are well documented,
however many women find it difficult to know how to minimise the risk whilst maintaining
their hair in manageable hairstyles that they like.
Acquired trichorrhexis nodosa (ATN)
ATN is dry, brittle hair characterised by breaking of hair shafts. It is a common form of hair
breakage, caused by extrinsic insults, such as heat or chemical agents. Although ATN is
seen in all ethnicities, structural differences in Afro hair make it more prone to ATN, and
styling practices such as chemical relaxers, hair dyes, thermal straighteners and even
combing can all contribute to ATN. The damage is additive; harmful styling practices
cause gradual weathering of the hair shaft, although the cause is almost always
Page 2 of 9
multifactorial. Small white nodules are often seen throughout the hair, which correspond to
loss of the hair cuticle. This condition can take two to four years to completely resolve, but
optimising hair care and stopping damaging practices are crucial to hair regrowth
Central centrifugal cicatricial alopecia (CCCA)
Central centrifugal cicatricial alopecia is a form of scarring (permanent) hair loss and is the
most common cause of hair loss in women of African descent. The hair loss starts in the
centre of the scalp and spreads outwards, hence its name. The disease is characterised
by inflammation around the hair follicles, which leads to follicle destruction and scarring.
CCCA was previously known as “hot comb alopecia”, as it was thought that hair care
practices were the most important factor in the disease process. Currently, the cause is
not completely understood, but it is most likely due to a combination of multiple factors,
including genetics and a predisposition to autoimmunity and fibrosis.
Cultural significance
Hair has an important position in the black community, particularly amongst women.
The significance of hair within black history is well documented; indeed, hairstyles were
historically used to indicate a person’s tribe and even their place in society in many African
cultures. The slave trade carried millions of Africans across the Atlantic and Afro-textured
hair was frowned upon by slave masters and society as a whole, causing many slaves to
develop a negative relationship with their hair. Following emancipation, straighter hair
became more fashionable, as many African Americans sought to adhere to European
beauty standards. Furthermore, straighter hair was marketed as more manageable and
versatile and many African Americans began using chemical relaxers and heat tools.
Indeed, America’s first black female millionaire, Madam CJ Walker made her fortune
selling such products post-emancipation.
The Afro became popular during the 1960s civil rights movement, often serving as a
political statement. The 2000s ushered a new natural hair movement, with many black
women choosing to wear their hair in its natural state, many after years of relaxing their
hair. The term “big chop” is used to describe cutting off a woman’s relaxed hair so that she
can grow new, naturally curly and kinky hair again. Natural hair influencers on social
media, YouTube and personal blogs have undoubtedly played an important role in this
movement, empowering many women to familiarise themselves with their natural hair,
should they choose to do so.
Today, there are numerous hairstyles that are popular amongst people of African descent.
For some, hairstyles are chosen based on ease of maintenance, while for others,
hairstyles can be chosen to reflect a religious or social position, such as dreadlocks
amongst the Rastafarian community. It’s important to remember that many women will
cycle through several different hairstyles as per their personal preference and no hairstyle
is superior to another, although certain habits and methods of styling increase the risk of
hair damage and loss.
Page 3 of 9
Many women have had their chosen hairstyle deemed as unprofessional in the workplace
or have been ridiculed for the way they choose to style their hair. Apart from this, many
black women spend significant amounts of time and money on their hair and hair loss can
sometimes impact not only a woman’s self-esteem but their mental health and
professional and personal relationships. It’s important for clinicians to consider the
significance each woman’s hair holds for them personally and to remain sensitive.
Below is a non-exhaustive description of some common hairstyles seen within the black
community and some important considerations.
Natural hair
Afro-textured hair can broadly be divided into two types – natural
and relaxed.
Natural hair is hair that has not been treated with chemical
relaxers and is generally considered to be stronger than
chemically processed hair, as it can withstand greater stress from
traction and grooming. Natural hair is however much more prone
to tangling given its coarse and kinky texture.
General recommendations for people with Afro-textured hair
• A basic maintenance routine for Afro-textured hair should include washing the hair
every one-two weeks, applying a deep wash-out conditioner, gently towel drying
and applying a leave in conditioner.
• Afro-textured hair needs more moisture than Caucasian or Asian hair. A lack of
moisture causes stress along the hair shaft, which can lead to breakage even at low
levels of tension. Women should find a regime for keeping their hair moisturised
that works for them. This may include lotions, creams, and/or oils.
• Excessive manipulation of the hair increases the risk of damage.
• Hair should be combed using a soft brush with widely spaced bristles and coated
tips or a wooden comb with wide teeth.
• Tight ponytails and buns are deemed high risk for traction alopecia.
• At bedtime, hair should be put into loose plaits or twists and covered with a satin or
silk cap or scarf. Alternatively, sleeping on a satin or silk pillowcase will achieve the
same goal of minimising friction.
Page 4 of 9
Relaxed hair
A relaxer is an alkaline cream used to chemically straighten
curly, “natural” hair. The cream is applied to hair strands, left
in for some time and washed out using a neutralising
shampoo, which returns the hair to its original pH. Chemical
relaxers work by breaking hydrogen and disulphide bonds,
which permanently straightens the hair. This causes loss of
tensile strength, which leads to an increased risk of hair
breakage. As the hair grows, relaxer will need to be reapplied
to the new natural hair so that its texture matches the relaxed
hair.
There are two main types of chemical relaxer: lye and no-lye.
The main active ingredient in lye-based relaxers is sodium
hydroxide and they may be preferred by professional hair stylists because they are believed
to straighten the hair more effectively and cause less damage to the hair itself. However,
they are more alkaline and therefore can potentially increase the risk of burns and scalp
irritation. Low-lye relaxers exist, which have a lower concentration of the active ingredient.
No-lye relaxers are found in over the counter, relax at home kits. They contain potassium
hydroxide, calcium guanidine or lithium hydroxide. These are less alkaline and are less likely
to cause scalp irritation. However, no-lye relaxers are thought to be more likely to cause dry,
brittle hair as the chemicals produce minerals which can build up on the scalp.
Recommendations
•
For touch-ups, relaxer should only be applied to new growth and never to hair that has
already been straightened. This can make the hair irreparably fragile, leading to hair
breakage.
•
Relaxers should not be used more frequently than every 6-10 weeks and taking
breaks from relaxers for some months can be helpful to give the hair a rest.
•
The relaxer should never be allowed to burn the scalp. There is no benefit to leaving a
relaxer on longer than specified on the instructions and burns can lead to scarring
alopecia.
•
A protectant such as Vaseline should be applied along the hairline and around the
ears to prevent damage to the skin. When relaxers come into contact with skin, they
can cause irritant or allergic contact dermatitis, which is a type of eczema caused by
contact with a particular product. This manifests as an irritable, dry, itchy rash.
•
If the relaxer comes with a neutralising shampoo, this must be used.
•
Dying the hair soon after using a relaxer will cause cumulative damage, as will using
excessive heat on the hair. A two-week interval between relaxing and dyeing or
thermal straightening is recommended.
•
Relaxers strip the hair shaft of proteins and so protein containing products can help to
restore the hair and reduce breakage.
Page 5 of 9
Braids
Braids come in various forms (box braids, knotless braids,
cornrows etc). The hair is divided into sections and braided
with or without additional extensions in three-strand plaits or
two-strand twists. Cornrows (American pronunciation) or
canerows (British pronunciation) are braids where the strands
are interlocked flat to the scalp in stationary rows.
Braids can be a helpful hairstyle as whilst the hair is in braids,
they are protected from manipulation. However, the process of
installation is a time when damage can occur if braids are
installed too tightly. The edges are particularly susceptible to
traction alopecia.
Many children have their hair styled into plaits or cornrows, commonly without additional
extensions. Alternatively, a small amount of extra hair is sometimes added to achieve a
certain style or to add length.
Recommendations
• Hair should be braided by an experienced hair stylist, who does not braid the hair too
tightly.
• If the scalp is painful after installation, it’s probably too tight and will increase the risk
of traction alopecia. It should never be necessary to take painkillers after the hair is
done.
• Consider leaving the edges out of the braids to avoid putting tension on the delicate
hairs there.
• More manipulation = more damage. Braiding the hair soon after a relaxer can
increase the risk of breakage.
• Braiding with extensions adds weight to the hair follicle. Long extensions, with the
addition of decorative ornaments like beads equals more weight, and therefore a
higher risk of damage.
• Braids with larger sections are overall considered to place less stress on the hair and
are lower risk but the risk will be increased if
heavy extensions are used.
• Whilst the hair is in braids, the scalp should be
cleansed with a damp sponge and mild shampoo
to reduce scalp build up.
• Braids should not be left in for longer than six
weeks.
• Tying braids into tight ponytails or buns
increases the risk of damage and should be
avoided.
Page 6 of 9
• Ideally, braids should be installed in alternate directions to avoid repeated stress in
one direction.
Wigs, weaves and extensions
Wigs and weaves offer versatile hair styling and can also be
protective, as often the natural hair is braided into cornrows
or twists and tucked away underneath the wig, protected
from manipulation. Exogenous hair can be bought in the
form of tracks, which are hairs stitched together onto wefts in
a long line. These tracks can be bought in a variety of
lengths, colours and textures. A weave is used to describe
the style where individual hair tracks are sown onto the
braided cornrows, until all the cornrows are covered by the
attached hair. Alternatively, the tracks can be attached to the
scalp using hair adhesives such as bonding glue. A ‘closure’
(usually a square piece of lace with hair arranged to create
an artificial parting) may be used at the top of the scalp to cover the tracks there, or some of
the woman’s native hair is left unbraided to comb over the tracks at the top of the scalp.
Wigs may be simply worn over the native hair (either braided into cornrows/twists or left
unbraided if short enough) or some women choose to wear a wig cap underneath the wig.
Alternatively, the peripheries of the wig can be sewn onto the braided hair underneath or
hair adhesives/gels, clips or small combs can be used to secure the wig in place.
Lastly, a variable number of tracks of hair extensions can be added to a woman’s natural or
relaxed hair to add volume and length. These are often glued or clipped in.
Recommendations
• It’s important to ensure that the hair is being cleansed and moisturised whilst it is
under the wig/weave and isn’t braided too tightly underneath.
• If the wig or weave is being sewn in, it should not be sewn in too tightly.
• Adhesives used to secure wigs or weave tracks have been associated with irritant or
contact dermatitis of the scalp.
• If some of the native hair is left out to cover the tracks of the weave or wig, that hair
needs to be taken care of and kept moisturised. It’s common for women to use heat
to straighten the hair that is left out to match the texture of the weave and this can
cause long term damage if done excessively.
• It’s important to ensure that the edges are protected from damage caused by the wig
itself rubbing on the hairline and causing friction. If a wig cap is worn, one made of
satin is less likely to cause frictional damage than cotton or nylon, and satin is less
likely to absorb moisture from the hair, reducing the risk of dryness. Furthermore,
hair glue and gels used to secure the wig/weave can rip out the delicate hair at the
edges when removed.
Page 7 of 9
• Weaves should be removed after eight weeks or sooner.
Locs
Locs, or dreadlocks are traditionally strands of hair that have
been joined and matted into rope-like fibres. They became
popular in mainstream media in the 1960s, during the rise of the
Rastafari movement but dreadlocks date back centuries and
have an important place in cultures and religions all over the
world, including India and Ancient Greece.
Contemporarily, “locs” is considered to be the more culturally
sensitive term, due to negative connotations with the term
“dreadlocks”. Others are not of this viewpoint and may continue
to prefer to use the term “dreadlocks” or “dreads”. Locs most
commonly are not achieved by just leaving the hair to grow but
are carefully sectioned and twisted into locs by professional
hairstylists, sometimes known as locticians. There are several different types of locs,
including sisterlocs, interlocs and freeform locs.
Some may have religious, social or political motivation for choosing to lock their hair but
some may just choose the hairstyle because that’s what they like. Some women may install
‘faux locs’ which are temporary, artificial locs attached to the native hair. It’s important not to
make assumptions and for both the patient and clinician to communicate effectively to allow
the best management plans to be made.
Recommendations
• Hair can grow very long in locs and many mistake that as being a measure of
healthy hair. This is not necessarily the case, as long locs can become heavy and
place tension on the hair strands, increasing the risk of traction alopecia and hair
loss. The risk is particularly high with this hairstyle as the locs are usually worn for
several years, causing continuous strain on the scalp.
• Excessive tension at the root of the scalp caused by twisting the locs too tightly
should be avoided.
• Individuals with locs will need to develop a routine for cleansing their scalp and locs
that works for them. For example, people who exercise frequently are likely to need
to wash their locs more frequently.
• It’s important for locs to be dried thoroughly after washing, otherwise mould and
mildew can build up.
Page 8 of 9
Natural twists
Twists are a popular hairstyle amongst women with natural
hair and are generally regarded as one of the safest
maintenance styles.
To achieve this hairstyle, the hair is detangled and divided
into sections. Each section is divided into two or three
strands and twisted around each other. This is usually done
loosely and without hair extensions, placing very little strain
on the hair.
Recommendations
• Hair should be well detangled prior to twisting,
otherwise the twists can become matted, leading to
hair breakage when they are taken down.
• Natural hair requires frequent moisturisation, which should still be done whilst the
hair is in twists.
• It’s recommended that twists are redone every four weeks or sooner
Best practice tips for hair styling
• Taking breaks with protective styles can be beneficial, e.g., take a 6-12 month break
from relaxers, twist or braid the hair loosely without extensions or loosely cornrow
the hair under a wig.
• The highest risk of traction alopecia, acquired trichorrhexis nodosa and CCCA, is
amongst women who combine hair practices, such as relaxing the hair, straightening
it with heat and installing braids, for example.
• Any hair that’s already been lost will not grow back overnight and growing your hair
will require patience and consistency. In cases of traction alopecia, hair regrowth
may start after three months of stopping damaging hair practices but can be
permanent.
Page 9 of 9
Hairstyles according to risk of causing traction alopecia (Haskin A, Aguh C,
2016)
Unmanipulated natural hair
Wigs with hair under a satin wig cap
Hair tied back loosely
Loose braids/cornrows/dreadlocks
Braided natural hair
Weave installed on natural hair
Wigs with hair under a cotton or nylon wig cap
Hair extensions applied to natural hair
Hair frequently tied back tightly
Tight braids/cornrows/dreadlocks
Braided relaxed hair
Weave installed on relaxed hair
Hair extensions applied to relaxed hair
Any hairstyle causing symptoms of pain, stinging, crusting, tenting
or dimpling
Additional services
Patient Advice and Liaison Service (PALS)
PALS can offer you on-the-spot advice and information when you have comments or
concerns about our services or the care you have received. You can visit the PALS office
between 9.30am and 4.30pm, Monday to Friday in the main corridor between Grosvenor
and Lanesborough wings (near the lift foyer).
Tel: 020 8725 2453 Email: [email protected]
NHS Choices
NHS Choices provides online information and guidance on all aspects of health and
healthcare, to help you make decisions about your health. Web: www.nhs.uk
NHS 111
You can call 111 when you need medical help fast but it’s not a 999 emergency. NHS 111
is available 24 hours a day, 365 days a year. Calls are free from landlines and mobile
phones. Tel: 111
AccessAble
You can download accessibility guides for all our services by searching ‘St George’s
Hospital’ on the AccessAble website (www.accessable.co.uk). The guides are designed to
ensure everyone – including those with accessibility needs – can
access our hospital and community sites with confidence.
Reference: DER_ATH_01 Published: February 2022 Review date: February 2024