Professional Documents
Culture Documents
P
atients presenting with hair and scalp disorders
are more frequently encountered in medical prac-
tice than the average medical student might
imagine. Such encounters encompass a number of con-
ditions that, while they are not life threatening, never-
theless may be of significant concern to the patient or
the patient’s parent. The management of these condi-
tions is frequently an intellectual challenge, not neces-
sarily in diagnosis, but in patient management. A range
of near-physiological to pathological problems—neona-
tal “cradle cap”—to severe and dysmorphic hair loss
are well treated in the literature. Allied to these and as
a separate area for consideration are cosmetic hair is-
sues. In this arena, it is perhaps inappropriate to imply
triviality. Physicians will be required to manage com-
plex and difficult cases of hair disorder wherein patient
expectations of daily hair-care regimen advice is as high
as hopes of a cure (Fig 1).
To advise patients on the “proper” frequency of hair
washing, appropriate use of the myriad of conditioners
now available, and the suitability of styling and fixing
products, the physician might perhaps be familiar with
the cosmetic technology and product trends. Figure 1. Home coloring and cut by “desperate” patient with
chronic telogen effluvium after chemotherapy.
It should be remembered that the normal daily hair
care regimen of an individual may be influenced by
age, sex, culture, and economic circumstance as well as Coloring and bleaching
fundamental hair type. In the care of patients with Perming or relaxing
disorders of hair growth, the daily routines of hair care
and the types of products used at home or in the salon Increasing consumer demands have led industry to
should at least be recognizable. This section reviews the developing ranges of hair care products to meet specific
range of retail and professional hair care products that cosmetic needs—“damage,” “dryness,” “body,” “vol-
are now widely available and offers suggestions on hair ume”—to achieve maximum overall “end benefit” for
care regimens that may be part of patient management. the individual.
Expert help in this area may improve compliance to To develop “global” products to meet these needs is
less acceptable therapies or create a more optimistic no easy task. Fine “Nordic” hair and African hair, for
attitude to the probable outcome. example, have very specific grooming needs and cos-
metic problems. The frequency of washing and variabil-
Hair Care Products ity of water hardness (and supply) even before succinct
usage information in multiple languages are all chal-
The general categories of hair care products are: lenges to be met (Fig 2a and 2b).
Cleansing
Conditioning and “treatment”
Cleansing Products
Fixing—Style control Human hair may be left totally unwashed, as it proba-
bly was for many generations of Homo sapiens. Even-
tually, a static or stable state of sebum distribution
From the Procter & Gamble Technical Centres, Twickenham, England, appears to be reached: the interim is not necessarily
United Kingdom.
Address correspondence to John Gray, Lovett House, Procter & Gamble conducive to modern living.
Technical Centres, Lovett Road, Staines, Middlesex TW 18 3A2, England, UK. The frequency of hair washing may be influenced by
© 2001 by Elsevier Science Inc. All rights reserved. 0738-081X/01/$–see front matter
655 Avenue of the Americas, New York, NY 10010 PII S0738-081X(00)00133-4
228 GRAY Clinics in Dermatology Y 2001;19:227–236
Figure 2. Fine “nordic” hair (a) and tightly coiled “African” hair (b) have very different grooming needs.
length of hair, culture, sex, social pressures, and eco- that confer properties of increased mildness, condition-
nomics, as well as individual preference. Modern, well- ing benefits, anti-dandruff activity, volume enhance-
formulated shampoos effectively remove detritus, se- ment, and even improved moisturization (Fig 4).
bum, and such deposited cosmetics as hair spray. The Shampoo ingredients include the following:
surfactant systems are now sufficiently mild to allow at
Cleansing agents—surfactants;
least daily washing without evidence of accumulating
cuticular damage. Lather boosters;
Conditioning agents;
ADVICE POINT: Q. How frequently can hair be safely
washed? A. There is no upper limit of frequency; how- Functional additives—adjust pH and viscosity;
ever, regular conditioning is important Preservatives—from the point of view of microbial con-
tamination, a shampoo is a particularly promising
Shampoos
environment, having a water content of, on average,
For many years, shampoos were nothing less than 80%, a pH range of 5–7, and no antagonistic ingre-
soaps. Although potent cleansers, they had poor lath- dients; and
ering capabilities in hard water and led to dulling dep- Aesthetic agents—fragrance, colorants, and pearlescing
osition of insoluble calcium-magnesium salts (sterarate) agents.
on the hair. In some cultures, bar soaps are curiously
still preferred. Soaps are, strictly speaking, surfactants, but the term
In dermatological practice 30 years ago, shampoos is usually reserved for synthetic ingredients. Surfac-
with harsh surfactants were used to remove messy tants used in shampoos are syndets (synthetic deter-
treatments applied to the scalp. Retail shampoos were gents) and usually contain fatty acid chains with
originally simple products comprising aqueous solu-
tions of surfactants designed to clean the hair by emul-
sifying oils and dispersing solid material. Lemon juice
was, where available, used to remove the resultant hard
deposits.
Such was the irritation potential of these products
that bath night and, specifically, hair-washing night
could be a torment for both child and parent. Fortu-
nately, the introduction of modern mild synthetic sur-
factant systems allow hair washing to be, not infre-
quently, a pleasure (Fig 3).
ADVICE POINT: Shampoos are formulated for normal,
greasy, dry, permed, and damaged hair.
In the twenty-first century, the consumer (and the
physician) are now faced with a plethora of sophisti-
cated shampoo products (Fig. 4) designed for a range of Figure 3. Modern shampoos for children include very mild
hair types and conditions with additional ingredients synthetic surfactant systems to reduce eye irritation.
Clinics in Dermatology Y 2001;19:227–236 HAIR CARE 229
Conditioner Use
Regular conditioners are applied immediately after
each shampoo and are rinsed out immediately. Ver-
sions may include “frequent” or “dry/damaged.” In-
tensive conditioners are often cream formulations that
are applied once or twice weekly and left in for several
hours. These are useful for dry or weathered hair. Se-
rum or spray conditioners are portable and may be
used as “quick fix” for weathered hair. Conditioners
may include UV filters for color protection.
Combined Shampoos/Conditioners
As stated, conditioning ingredients are nowadays often
included in shampoos. Procter & Gamble introduced “2
in 1” shampoos/conditioners in 1987 using silicone
(dimethicone) droplets suspended in a surfactant mix- Figure 8. Severely weathered hair after repeated bleaching with
ture. It had been previously argued (and occasionally hydrogen peroxide. The patient was unaware of the cause of her
still is) that this is not feasible. The technology has been appalling hair condition. She declined to cut it, but prolonged
reviewed and approved by a panel of eminent derma- conditioning treatment eventually bore fruit.
tologists.1
Stage 2: Shampoo with appropriate variant “dry/dam-
aged/permed.”
Weathered Hair Stage 3: Regularly condition with appropriate formu-
The causes of weathered hair are legion—many self lation (see above).
inflicted.3 Today a plethora of conditioning and “treat- Stage 4: Use intensive conditioning (cream) once or
ment products” confront the consumer to deal with this twice weekly.
issue. Aqueous sprays to temporarily improve the ap- Stage 5: Minimize further damage from blow drying/
pearance of “split ends;” deep conditioning “masks” bleaching.
weathered hair; and the inclusion of UV filters prevents
photo-degradation, particularly for those with colored Fixing-Styling Products
hair. Women, and to a lesser extent men, use fixing or styling
“Deep conditioners” in cream formulations can be products to create temporary changes to their hair to
left on for prolonged periods, and some are now avail-
able that do not need to be rinsed out.
Advice offered to those with hair shaft and hair
growth disorders on maintaining the hair shafts in op-
timum condition depends on avoidance of excessive
physical and chemical treatments, and regular condi-
tioning. The basic morphology of the hair shaft and the
type and degree of damage must be assessed before
advice is considered. Over-conditioning may alarm and
discourage the patient as it may result in heavy and
unmanageable style.
Weathered Hair—Advice
Weathered hair is most frequently self-induced by pro-
longed physical and chemical damage. Consider under-
lying hair shaft abnormality (Fig 8).
EMG-1—conditioners tend to deposit at areas of increased
Stage 1: Recommend a good cut from an expert. weathering.
232 GRAY Clinics in Dermatology Y 2001;19:227–236
2. Metallic dyes, and the color required, the weaker the strength (or lower the
3. Para dyes. volume) of hydrogen peroxide.
As a general rule, 30 vol. (9%) hydrogen peroxide is
NATURAL VEGETABLE DYES Originally, coloring materials the highest strength that can be safely used on the scalp,
for the hair were obtained from plants, henna being the and 40 vol. (12%) hydrogen peroxide is the highest
best known. Henna, also known as Lawsone, is produced strength that can be safely used on the hair. Sixty vol.
from the crushed, dried leaves of the Egyptian privet (18%) hydrogen peroxide should only be used with spe-
plant, which grows in Iran, Egypt, and along the Medi- cially designed tints, and the manufacturer’s instructions
terranean coast. It imparts red pigment to the hair, and the should be strictly followed. Repeated applications at
shades vary slightly according to existing levels of pig- high concentrations can lead to gross weathering.
mentation and hair condition. The depth of red depends
on the length of time that it is left in contact with the hair. Bleaching
METALLIC DYES These deposit metal salts both in the Bleaching lightens the shade of the hair by oxidation of
cortex and on the cuticle, which may dull the hair, can pigments in the hair shaft, eumelanin and pheomelanin
color the skin, and potentially react with hydrogen in the hair cortex. Bleaching is permanent, and serial
peroxide. They are not now widely used. bleaching of black hair will result in the following:
Black ⬃ Brown—Red ⬃ Orange—Yellow—Pale yellow—
PARA DYES (OXIDATION DYES) Modern permanent dyes White
are synthetic organic dyes consisting of solutions of para-
phenylenediamine (PPD), or similar “para” compounds, The main oxidizing agent used in bleaches is hydro-
together with other substances, such as conditioners and gen peroxide (H2O2), which can release oxygen. It is a
antioxidants to prolong shelf-life. PPDs are derivatives of highly effective bleaching agent, which releases oxygen
coal tar and are synthetic aniline dyes. Para dyes are and can then bind to the hair pigments and lighten their
known sensitizers and may induce and elicit contact color. This ability to act as an oxidizing agent is also
allergic dermatitis. Skin testing for a reaction before used in ‘fixing’ perms and developing oxidation tints.
each application of a para dye is recommended. Hydrogen peroxide is colorless and odorless.
These dyes are widely used in retail a professional Uses of bleaching:
hair color products. They are able to cover white, gray,
1. To lighten previously unbleached hair.
or most natural hair colors, and have a vast color range. It
2. To pre-lighten prior to tinting.
is possible to obtain almost any shade, from natural right
3. To lighten or remove tint from hair.
through to exotic greens, reds, blues or purples (Fig 10). 4. To lift the cuticle scales slightly and make the hair
Para dyes are manufactured in three forms: cream, more porous; therefore, resistant hair becomes more
liquid and gel. All forms must be mixed with hydrogen susceptible to tinting as it can penetrate into the
peroxide before application, without which they are cortex more easily.
ineffective. These dyes are water soluble and have com- 5. To break down any resistant patches before a tint is
paratively small molecules (at this point it is often applied.
colorless), which will penetrate the cuticle and enter the 6. To give highlights and streaks to the hair.
cortex. When mixed with hydrogen peroxide, the oxy- 7. In conjunction with tint, to produce extra hair color-
gen released enables colorless molecules to join to form ing techniques.
larger, colored, insoluble molecules, which are then
RESULTS OF FREQUENT OR EXCESSIVE BLEACHING One of the
trapped in the cortex. They are too large to pass through
commonest cosmetic conditions seen by physicians is
the cuticle and therefore do not wash out easily. For an
the result of excessive bleaching (occasionally com-
efficient tint, 20 vol. (6%) hydrogen peroxide is used, bined with perming): increased porosity and reduced
unless tints lighter than the natural shade are required, tensile strength result in weathering, occasionally
in which case, 30 vol. (9%) is used. grossly so. Bleached hair is less elastic and more porous
Lightening dyes consist of tinting the base shade of than untreated hair; therefore, it will require far more
the hair lighter than the original color. Covering dyes attention when conditioning, perming, or tinting.
consist of tinting the hair darker or a similar shade to
the natural base color, or matching white hair to the
natural base color. Conclusions
The base color of the hair determines the volume The care of the hair is almost certainly part of the
strength of the hydrogen peroxide to be used. The physician’s own personal and professional life. It is
lighter the color required, the stronger the strength (or important to keep abreast of the enormous increase in
higher the volume) of hydrogen peroxide. The darker sophisticated products available in retail and profes-
236 GRAY Clinics in Dermatology Y 2001;19:227–236