SKIN July 2018 Volume 2 Issue 4 Copyright 2018 The National Society for Cutaneous Medicine 214 ORIGINAL RESEARCH Scarring Alopecia: The Attitudes, Knowledge, and Referral Patterns of Hair Stylists and Barbers Julia Accetta BS a , Aderonke Obayomi BS a , Rachel Evers-Meltzer MD b , Virginia Alldredge MD a , Andrea Murina MD a a Department of Dermatology,Tulane University School of Medicine b Department of Dermatology, Boston Medical Center The most common hair complaints seen by dermatologists include progressive thinning and excessive shedding of the scalp hair. Complaints may include decrease in hair coverage, inability to maintain hairstyle, or extreme thinning of ponytail size. 1 The delayed detection and diagnosis of alopecia may be detrimental for scarring alopecias such as central centrifugal cicatricial alopecia (CCCA) and lichen planopilaris because hair regrowth can rarely occur if treated very early. 2 Hair loss is often a significant source of psychological distress and therefore emphasis should be placed on early detection and referral for counseling. 3 Research has shown that using beauty salons as a setting for implementing health promotion programs capitalizes on the relationships hairdressers have with their clients. Stylists are in a unique position to detect scalp anomalies because they routinely assess this area during a client appointment. Interventions targeting the education, detection and physician referral ABSTRACT Disorders of hair loss are commonly encountered by hair stylists, who are in a unique position to identify early signs and symptoms. The goals of this study were to assess hair stylists’ knowledge of and propensity to refer patients with scarring alopecias. One-hundred- eighteen stylists completed surveys to this effect. The majority of respondents (66.1%) stated that they had been asked by clients to evaluate for hair loss, whereas approximately half reported routinely referring clients with hair loss to a dermatologist. Although knowledge of alopecia varied, the vast majority indicated they would be willing to undergo further training in identifying hair loss disorders and would be willing to discuss this information with clients. These results demonstrate that hairdressers frequently interact with patients suffering from hair loss and that many are receptive to receiving additional training to ensure proper identification and prompt referral. INTRODUCTION SKIN July 2018 Volume 2 Issue 4 Copyright 2018 The National Society for Cutaneous Medicine 215 of melanoma, hypertension, breast cancer, and prostate cancer have successfully utilized hairdressers. 4-7 This study was approved for exempt review by the Tulane University Institutional Review Board. Cross-sectional data were obtained via questionnaire administered to certified hairdressers at 51 salons in the New Orleans Metropolitan area. The majority of salons, with the exception of four barbershops, serviced both men and women. Blank surveys were given to all employees at each establishment and were collected forty eight hours later. Surveys were received from 118 respondents. Response rate is unknown. Our findings indicate that many hairdressers already examine their clients for hair loss and about half of the time they will refer their client to a dermatologist. Table 1 provides hairdressers’ hair loss detection and referral practices. Table 2 provides hair stylist beliefs of permanent versus non-permanent alopecia. Most hairdressers (66.1%) responded that they have been asked by clients to examine them for hair loss. When hairdressers notice hair loss, almost half of the respondents (49.2%) refer their client to a dermatologist. Most respondents (68.6%) received some form of hair loss training while in beauty school, though most were largely unfamiliar with the most common types of alopecia. The majority (79.7%) of hairdressers were willing to learn more about the different types of hair loss and a larger portion of respondents (90.7%) indicated that they would be willing to discuss hair loss with their clients if they were trained to identify the different types of hair loss. Of the five education modes surveyed, respondents preferred attending a continuing education seminar or using the Internet to receive further information. Overall, the majority of stylists responded that they believe a scalp exam by a hairdresser is helpful for finding the cause of hair loss and some even reported having a client return with a medical diagnosis. The study identified key knowledge deficits in detecting specific hair loss patterns among hair stylists and barbers. While most stylists received some form of hair loss training in beauty school, the majority of respondents were generally unfamiliar with the eleven listed alopecia subtypes despite reporting confidence in their ability to recognize permanent versus nonpermanent hair loss. The types of hair loss most familiar to the stylists included alopecia areata and androgenic alopecia. While this study provided a generalized descriptive overview of hairstylist knowledge of alopecia, further investigation is required and may include investigating the type of hair loss education provided by beauty schools. Further research is also warranted to explore these trends in salons with predominantly African American clientele. METHODS RESULTS DISCUSSION SKIN July 2018 Volume 2 Issue 4 Copyright 2018 The National Society for Cutaneous Medicine 216 Table 1. Hairdressers’ hair loss detection and referral patterns, N=118 Variable N % Received training in beauty school about hair loss No 37 31.4 Yes 81 68.7 Know about the different types of hair loss (referred to in Table 2) No 42 35.6 Yes 76 64.4 Frequency that clients ask stylists to examine them for hair loss Never 40 33.9 Yearly 15 12.7 Monthly 41 34.7 Weekly 16 13.6 Daily 6 5.1 Frequency that stylists have noticed permanent hair loss regardless of client asking Never 23 19.5 Yearly 31 26.3 Monthly 42 35.5 Weekly 16 13.6 Daily 6 5.1 Frequency stylist refers client to a doctor after noticing unusual hair loss Never noticed 8 6.8 Rarely 31 26.3 About half the time 20 16.9 Most or every time 59 50 Client came back with medical diagnosis after doctor referral Never made a referral 17 14.4 No 68 57.6 Yes 33 28.0 Confidence in ability to identify permanent vs nonpermanent hair loss Not at all confident 41 34.7 Somewhat confident 59 50 Very confident 18 15.3 Believe scalp exam by a hairdresser is effective in hair loss detection Not at all helpful 21 17.8 Somewhat helpful 67 56.8 Very helpful 30 25.4 Interest in learning more about hair loss No 24 20.3 Yes 94 79.7 Willingness to educate clients on hair loss No 11 9.3 Yes 107 90.7 Preferred source for learning about hair loss Internet 45 38.1 Lecture 19 16.1 Pamphlet 11 9.3 Video 24 20.3 Continuing education 56 47.5 SKIN July 2018 Volume 2 Issue 4 Copyright 2018 The National Society for Cutaneous Medicine 217 Table 2. Hair stylist beliefs of permanent versus non-permanent alopecia, N=118 Permanent (%) Not Permanent (%) Not familiar (%) Telogen effluvium 2.54 12.7 84.7 Anagen effluvium 0.85 16.1 83.1 Central centrifugal cicatricial alopecia* 21.2 15.2 63.6 Alopecia areata 36.4 29.6 33.9 Discoid lupus erythematosus* 14.4 6.77 78.8 Frontal fibrosing alopecia 21.2 17.8 61 Male pattern baldness (androgenic alopecia) 65.3 8.47 26.2 Lichen planopilaris* 2.54 9.32 88.1 Folliculitis decalvans* 6.78 7.62 85.6 Traction alopecia 16.1 25.4 58.5 *hair loss pattern associated with permanent, scarring alopecia Because certain types of scarring alopecia, such as CCCA, are more predominant in African Americans, the knowledge and attitudes of the hairstylists serving this population would be particularly valuable when developing new training programs. Lastly, including images and descriptions in addition to names of the various alopecias may be better understood by hair stylists unfamiliar with medical terminology. In summary, hairdressers frequently interact with patients suffering from hair loss and many provide product recommendations and physician referrals. These results provide evidence that most stylists are engaged in alopecia screening and education and that most are receptive to additional training to expand this role. This suggests that training hairdressers in alopecia screening and patient education may be a worthwhile and promising opportunity for early detection of irreversible hair loss and prompts further investigation. Conflict of Interest Disclosures: None Funding: None Corresponding Author: Rachel Evers-Meltzer, MD, MPH Department of Dermatology Boston University School of Medicine Boston Medical Center 609 Albany Street Boston, MA 02118 617-638-5500 (Office) 617-638-7289 (Fax) Rachel.EversMeltzer@bmc.org References: 1. Mubki T, Rudnicka L, Olszewska M, Shapiro J. Evaluation and diagnosis of the hair loss patient: part I. History and clinical examination. J Am Acad Dermatol. 2014;71(3):415.e1-15. 2. Hamilton T, Otberg N, Wu WY, Martinka M, Shapiro J. Successful hair re-growth with multimodal treatment of early cicatricial alopecia in discoid lupus erythematosus. Acta Derm Venereol 2009;89:417-8. CONCLUSIONS SKIN July 2018 Volume 2 Issue 4 Copyright 2018 The National Society for Cutaneous Medicine 218 3. Hadshiew IM, Foitzik K, Arck PC, Paus R. Burden of hair loss: stress and the underestimated psychosocial impact of telogen effluvium and androgenetic alopecia. J Invest Dermatol 2004;123:455-7. 4. Roosta N, Wong MK, Woodley DT. Utilizing hairdressers for early detection of head and neck melanoma: an untapped resource. J Am Acad Dermatol. 2012;66(4):687-8. 5. Victor RG, Ravenell JE, Freeman A, Leonard D, et al. Effectiveness of a barber-based intervention for improving hypertension control in black men. Arch Intern Med. 2011;171(4):342-50. 6. Wilson TE, Fraser-White M, Feldman J, et al. Hair salon stylists as breast cancer prevention lay health advisors for African American and Afro- Caribbean women. J Health Care Poor Underserved. 2008;19(1):216-26. 7. Luque JS, Rivers BM, Kambon M, Brookins R, et al. Barbers against prostate cancer: a feasibility study for training barbers to deliver prostate cancer education in an urban African American community. J Cancer Educ. 2010;25:96-100.