Beyond male pattern baldness: The overlooked signs of scarring alopecia in male patients of colour
In men with SoC, scarring hair loss is frequently mislabeled as androgenetic alopecia—delaying treatment and risking permanent damage (Issue #522, 1,600 words, 8 minutes)
Inflammatory and scarring hair loss in male patients with skin of colour is frequently mistaken for androgenetic hair loss, leading to delays in diagnosis and treatment. Signs of inflammation, such as pruritus, tenderness, or erythema around hair follicles, should prompt dermatologists to investigate further.
This message was part of a discussion with dermatologist Dr. Kayla Taylor, presented by the Skin of Colour Society.
Dr. Taylor practices at Atrium Health Dermatology in Charlotte, N.C.
“I have been to several different meetings and attended a lot of lectures where we have discussed scarring and non-scarring forms of hair loss,” Dr. Taylor said in the video. “What I found is that in a majority of these talks, the specific focus on men was kind of lost.”
Dr. Taylor (pictured above) said she suspects part of this oversight stems from hair loss being “expected” in men. Men who experience hair loss often do not seek dermatologic care because they have observed hair loss among family members and friends and have normalized it. They may also self-treat with products purchased online rather than seeking a prescription through a medical specialist.
She noted that scarring disorders such as lichen planopilaris and central centrifugal cicatricial alopecia can often mimic androgenetic alopecia but require a more focused diagnostic and therapeutic approach. In particular, managing these conditions involves anti-inflammatory therapies, which are not usually necessary for androgenetic alopecia.
“These are [conditions] to consider highly when you’re looking at a patient who has new hair loss, especially if they’re experiencing symptoms such as itch or tenderness,” she said. Additionally, if a physician examines a patient and observes erythema or scaling around the hair follicles, they may consider performing a biopsy or conducting dermoscopy on additional areas of the scalp to confirm the diagnosis.
Other forms of scarring hair loss, such as folliculitis decalvans and dissecting cellulitis, often present at a more advanced stage, said Dr. Taylor, noting that male patients with skin of colour usually experience significant delays in diagnosis for these conditions.
“Knowing the early signs can help to make the diagnosis early, and result in a decrease in the loss of hair. Which is really what we’re trying to do.”
Dr. Taylor said that the treatment of inflammatory and scarring hair loss in male patients is the same as in female patients. She noted that she prescribes minoxidil and finasteride not only for androgenetic alopecia but also for inflammatory forms of hair loss. For inflammatory hair loss, she prescribes topical and intralesional steroids, and other options include oral antibiotics such as doxycycline.
Many male patients seeking care for hair loss are expecting minoxidil or finasteride, Dr. Taylor said. As a result, she finds there is a significant need to educate these patients during consultations about why they are being prescribed anti-inflammatory treatment and what the outcomes will be if they do not follow through with the prescriptions.
Bottom line: Male patients with skin of colour are often overlooked in discussions of inflammatory or scarring hair loss. The perception of hair loss as “normal” among men can delay seeking professional care and treatment. Physicians should have a higher degree of suspicion when patients report itch or tenderness, or when erythema is present.
From the literature on hair and scalp dermatology in skin of colour
Trichoscopic features of scalp psoriasis: Their association with disease severity and quality of life in a Hispanic population
Researchers characterized the trichoscopic findings of scalp psoriasis in a Hispanic cohort and evaluated their association with clinical severity and quality-of-life (QoL) measures.
A total of 81 participants (mean age 40±13.65 years; 50.6% female) were included in the study. All participants underwent a comprehensive clinical assessment, involving the Psoriasis Scalp Severity Index (PSSI), the Dermatology Life Quality Index (DLQI), and the Scalp-Specific Dermatology Life Quality Index (SCALPDEX). Researchers captured standardized trichoscopic images from five scalp regions and analyzed them for characteristic vascular patterns. The authors used multiple linear regression analyses to identify associations between trichoscopic findings and clinical outcomes.
They found that twisted red loops were the most frequent vascular pattern (64-84% across regions) and were significantly correlated with elevated PSSI, Videodermoscopy Scalp Psoriasis Severity Index (VSCAPSI), and DLQI scores (p<0.05). Hemorrhagic dots in the parietal regions were associated with higher QoL impairment (DLQI: +5 points; SCALPDEX: +17.1 points, p < 0.01). Female participants reported greater scalp-specific symptom burden despite lower objective severity scores.
Pathogenic variants affecting peptidyl arginine deiminase 3 and its major substrates underlie central centrifugal cicatricial alopecia
The authors note that although genetic susceptibility has been implicated in the pathogenesis of central centrifugal cicatricial alopecia (CCCA), only one gene (PADI3, encoding peptidyl arginine deiminase 3) has thus far been associated with CCCA. This study was conducted to broaden the understanding of the genetic basis of CCCA by analyzing whole-exome sequences from 75 patients with clinically and histologically confirmed CCCA.
Researchers identified nine pathogenic heterozygous variants in PADI3, including four that they report as previously unreported missense variants, all predicted to disrupt protein function. Functional analyses revealed reduced expression, abnormal intracellular localization, and diminished enzymatic activity in cells transfected with constructs expressing the PADI3 variants.
Investigators also identified pathogenic variants in two additional genes, S100A3 and TCHH, which encode the primary substrates of PADI3, S100 calcium-binding protein A3 and trichohyalin. Both proteins play critical roles in hair shaft integrity. They found that the S100A3 variant reduced PADI3-mediated citrullination, whereas TCHH variants altered intracellular localization and led to significantly reduced protein expression.
The authors conclude their findings provide further insights into disease mechanisms and may inform future strategies for genetic testing and targeted therapies.
Racial and ethnic disparities in persistent chemotherapy-induced alopecia among women with breast cancer
Investigators evaluated racial and ethnic disparities in the incidence of persistent chemotherapy-induced alopecia (PCIA) and alopecia-related psychological distress among women with breast cancer from baseline to 12 months after completion of chemotherapy.
A total of 304 women were recruited from two tertiary cancer centres in the U.S. and South Korea. All women were 18 years of age or older, with stage I to III breast cancer and had received chemotherapy. Of the participants, 52.3% (159) were Asian, 6.6% (20) were Black, 5.6% (17) were Hispanic or Latino, and 35.5% (108) were White. Their mean age was 50.3 years (SD 10.6).
The primary outcome was PCIA incidence, which the authors defined as hair thickness or density at 12 months after completion of chemotherapy that fell more than two standard deviations (SDs) below the level measured before chemotherapy. Secondary outcomes included changes in hair density, hair shaft thickness, and alopecia-related distress, calculated using the Chemotherapy-Induced Alopecia Distress Scale (CADS).
At baseline, Asian women had the thickest hair shafts (mean [SD], 83.2 [13.4] µm) but the lowest follicular density (mean [SD], 136.2 [27.6] hairs/34.34 mm2 at ×50 magnification; p<0.001). At 12 months, PCIA incidence was highest in Asian women (59 [42.1%]), followed by White (24 [22.2%]), Black (2 [10.0%]), and Hispanic or Latino (1 [5.1%]) women (p=0.001). Asian women also had the most significant increases in CADS scores compared with White women, particularly in the emotional (adjusted mean difference, 1.88 [95% CI, 0.92-2.95]) and activity-related (1.55 [95% CI, 0.58-2.52]) domains.
VIDEO: Black hair loss: Understanding CCCA, traction alopecia, and scalp health
Hair transplant surgeon Dr. Ross Kopelman (New York) and trichologist Tamarrian Myrick (Austell, Ga.) discuss hair loss in the Black community, highlighting conditions that are frequently misunderstood, underdiagnosed, or dismissed.
At the intersection of skin and society
Indigenous leaders in Manitoba are calling it a significant step forward after a federal court ruling confirmed Canada has a legal duty to provide adequate housing on First Nations communities, reports CityNews.
According to the news outlet, the ruling affirms Canada's obligation to ensure adequate on-reserve housing. It stems from a class action brought by St. Theresa Point and Sandy Lake First Nation, both of which have dealt with decades of chronic housing shortages.
Evidence presented indicated that one in four homes in St. Theresa Point are uninhabitable, and more than half of the homes in Sandy Lake require significant repairs.
Manitoba Chiefs say this ruling confirms that safe housing is a Treaty and constitutional obligation, and that it validates a fight stretching back to the 1909 Adhesion to Treaty 5—years of underfunding that left Nations without control over their housing systems.
Chief Emeritus Elvin Flett of St. Theresa Point Anisininew Nation is quoted, saying: “Homes without heat, children without safety, families without hope. This isn’t an accident, this is policy.”
“All we know is that our band-based capital was capped nearly three decades ago, and we are not given the resources to respond and to plan with adequate housing for our community members,” said St. Theresa Point Anisininew Nation Chief Raymond Flett.
Chiefs say overcrowding, mould, sewage issues and unsafe electrical systems have contributed to tragedies, including deadly house fires involving children.
Kyra Wilson, Grand Chief of the Assembly of Manitoba Chiefs, said, “We need clear timelines, dedicated funding and recognizing First Nations must lead the design and delivery of housing solutions in their own communities.”
The federal government may appeal; if not, the lawsuit will proceed, with First Nations seeking damages and long-term solutions.
This week
January is Tamil Heritage Month in Canada
January is World Health Esteem Month
January is International Quality of Life Month
Something to think about in the week ahead . . .
—Rainer Maria Rilke (1875-1926), German poet
Next week
In a presentation at the 2025 Skin Spectrum Summit in Toronto, Montreal’s Dr. Danielle Marcoux reviews dermatology in pediatric patients with skin of colour, including genetic variations of atopic dermatitis in Asian patients.
If you enjoy Skin Spectrum Weekly, why not check out the Chronicle’s other publications, podcasts, and portals?
Established in 1995, The Chronicle of Skin & Allergy is a scientific newspaper providing news and information on practical therapeutics and clinical progress in dermatologic medicine. The latest issue features:
Dermatologist Dr. Cathryn Sibbald (Toronto) discusses the current state of management for alopecia areata.
Drs. Jen Lipson (Ottawa), Sam Hanna (Toronto), Lauren Lam (Calgary), and Catherine Zip (Calgary) review current and investigational acne therapies.
Dr. Sheila Au (Vancouver) provides insight into the risk of skin cancer in patients receiving organ transplants and the need for dermatologists to collaborate with their patients’ transplant teams to improve outcomes.
Plus regular features, including the popular column “Vender on Psoriasis” by dermatologist Dr. Ron Vender.
You can read a recent digital edition of The Chronicle of Skin & Allergy here. To apply for a complimentary subscription or to request a sample copy, please email health@chronicle.org with your contact information.
The Women in Dermatology e-newsletter updates readers with new findings concerning dermatologic issues affecting women and the female dermatologists who care for them. Read the current issue here.
Season three of the Vender on Psoriasis podcast, featuring Dr. Ron Vender, has begun. Listen to the new season here. In episode five, Dr. Vender discusses whether vitamin D influences the severity of psoriasis, sex differences in psoriatic inflammation and itch, and the risk of psychiatric disorders associated with acitretin.
And if you’re looking for a web destination for all things derm, visit derm.city, “Where Dermatology Lives.” Please like, rate, review, and share it with your colleagues.