Hair Care and Dyeing: Zoe Diana Draelos

Ioannides D, Tosti A (eds): Alopecias – Practical Evaluation and Management.
Curr Probl Dermatol. Basel, Karger, 2015, vol 47, pp 121–127 (DOI: 10.1159/000369412)
Hair Care and Dyeing

Zoe Diana Draelos
Department of Dermatology, Duke University School of Medicine, Durham, N.C., USA
Abstract crease the cosmetic value of the hair. It may be

Alopecia can be effectively camouflaged or worsened challenging to convince patients and their beauti-
through the use of hair care techniques and dyeing. Prop- cians of this fact. There is a social and personal
er hair care, involving hair styling and the use of mild need to do something as the hair is thinning to
shampoos and body-building conditioners, can amplify somehow regain control over the process. This
thinning scalp hair; however, chemical processing, in- chapter examines both how cosmetic procedures
cluding hair dyeing, permanent waving, and hair straight- can be used to camouflage alopecia while mini-
ening, can encourage further hair loss through breakage. mizing hair damage and the use of hair care prod-
Many patients suffering from alopecia attempt to im- ucts and hair dyeing in the patient with hair loss.
prove their hair through extensive manipulation, which
only increases problems. Frequent haircuts to minimize
split ends, accompanied by gentle handling of the fragile Hair Care Techniques in the Alopecia Patient
fibers, is best. This chapter offers the dermatologist in- (Table 1)
sight into hair care recommendations for the alopecia
patient. © 2015 S. Karger AG, Basel Hair Styling
Probably the most basic hair care practice is hair-
cutting. While hair is nothing more than a nonliv-
Introduction ing human fiber, humans spend a great deal of
time cutting their hair to perfection. When fewer
Hair care can be challenging in the setting of alo- hair shafts are present, the tendency is to allow the
pecia. There is a tendency to manipulate the hair remaining hair to grow longer. While this does
more as hair loss progresses to try to improve the increase the amount of hair present on the head,
appearance of the remaining hair. It is important it only magnifies the presence of alopecia. Short-
to remember that there is no chemical procedure er, rather than longer, hair is better in the alopecia
that will enhance the hair shaft. All hair dyes de- patient. The weight of the longer hair lies against
Siriraj Medical Library, Mahidol University
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Table 1. Hair styling tips for alopecia patients easily fractures, causing hair loss. If the hair of the
alopecia patient has extensive split ends, the best
1. Cut hair frequently to remove hair damaged by
grooming, environmental exposure, shampooing,
way to decrease this type of hair loss is to get a
chemical processing, etc. haircut.
2. Handle the hair as little as possible. Hair is healthiest
when not manipulated Hair Grooming
Alopecia patients may develop an obsession with
3. Do not pull, yank, or stretch wet hair. Wet hair is
more elastic than dry hair and can be easily their hair appearance, resulting in excessive
stretched to the breaking point combing and brushing. Hair combing and brush-
4. Comb hair gently with a wide-toothed comb
ing are necessary to arrange the hair as desired
possessing smooth teeth that easily glide over but actually damage the hair shaft by encouraging
the hair removal of the cuticle. Hair is shiny and appears
5. Brush hair as little as possible selecting a brush with healthy when the cuticle is intact. In other words,
smooth, ball-tipped, coarse, bendable bristles great-looking hair possesses an intact cuticle and
6. Remember that less is more when it comes to hair nothing more. Thus, the best way to achieve great
grooming for alopecia patients hair is to leave the cuticle in place and not encour-
age removal. Frequent combing and brushing
greatly accelerate cuticle loss; however, a few
grooming tips can minimize cuticle trauma.
the scalp and can easily cause separation, expos- Hair should only be combed when dry, if pos-
ing the balding scalp. However, the hair should sible. Wet hair is more elastic than dry hair, mean-
not be so short that the areas of hair loss are more ing that vigorous combing of the moist fibers can
visible. I usually recommend chin-length hair in stretch the shaft to the point of fracture. The ideal
women for best results. These recommendations comb should be made of a flexible plastic and pos-
do not pertain to men since a bald, shaved head is sess smooth, rounded, coarse teeth to easily slip
considered socially acceptable in males. through the hair. If the comb does not glide
Some female patients with alopecia are con- through the hair, pulling and tugging will result
cerned that cutting their hair may result in de- in cuticle removal and hair breakage. Styling
creased hair growth. It is important for the der- products are available that can decrease hair shaft
matologist to emphasize that the growing hair friction by temporarily smoothing the cuticle.
follicle deep in the scalp is oblivious to hair length. These products are discussed more thoroughly
There is no relationship between new hair growth, later in the chapter.
hair loss, and hair length. This is a myth that Extensive hair brushing should also be avoid-
should be dispelled. ed while hair is wet. A good brush should have
With time, the hair undergoes weathering. smooth, ball-tipped, coarse, bendable bristles.
Weathering is due to the trauma that the hair sus- Any brush that feels rough when stroked over the
tains from combing, brushing, shampooing, wind hand will also damage the hair with use. Aggres-
friction, UV exposure, etc. All of these events sive bristles will encourage cuticle loss and pro-
cause the cuticular scale to loosen and shed from mote breakage. While brushing the hair is often
the hair shaft. As the cuticle is lost, the weak cor- viewed as beneficial, brushing should be avoided
tex is exposed, which also frays with time, pro- in the alopecia patient. Older teachings that the
ducing a phenomenon medically known as hair should be brushed 100 strokes a day and the
trichoptilosis and commonly known as a split scalp vigorously massaged with the brush are not
end. The split end has no structural strength and appropriate for the alopecia patient.
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122 Draelos
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Heat and Hair Damage
One of the most common forms of hair damage is
caused by excessive heat. Heat may be used to
both dry and style the hair. High heat from a blow
dryer, accompanied by pulling, can be used to
straighten curly hair. Conversely, heated man-
drels, such as hot rollers, or a heated rod, such as
a curling iron, can be used to make straight hair
curly. This is possible because hair contains wa-
ter-deformable bonds that will maintain the hair
in whatever conformation desired at the moment
that the hair goes from being wet to being com-
pletely dry. While this quality of the hair fiber is Fig. 1. Bubble hair occurs when the water in the hair shaft
the basis for the majority of hair styling tech- is converted to steam after exposure to high tempera-
niques, heat can be very damaging to the hair. tures from heated styling appliances or hair dryers.
Hair is made out of protein, which can be de-
natured when exposed to high heat. Since hair is
nonliving, the protein denaturation is permanent Table 2. Damaging effects of heat on hair
and can only be treated by cutting away the dam- 1. Heat denatures the keratin protein structure of the
aged hair. Heat damage can be observed under the hair shaft
electron microscope as small bubbles; thus, the
2. Heat turns the water in the hair shaft, which allows
condition is known as bubble hair [1]. Since the the hair to function as an elastic material, into steam
hair contains water, as mentioned previously, the
3. The highly energetic steam escapes from the hair
water in the hair shaft can be converted to steam shaft, physically removing the cuticular scale
when very briefly exposed to high temperatures
4. The removed cuticular scale exposes the underlying
(fig. 1). The steam, which is water in the gas phase, cortex, which has less structural strength than the
is highly energetic and escapes from the hair shaft cuticle
by popping off the cuticular scale, creating what
5. Hair that is heat damaged easily fractures and
appears to be a bubble [2]. This damage weakens appears frizzy at the ends
the hair shaft by removing water that functions as
6. Heat-damaged hair is known as bubble hair and
a plasticizer, allowing the hair to bend easily with- cannot be repaired
out fracturing. The damaging effects of heat on
the hair shaft are summarized in table 2.
the hair. There are several types. Instant condi-

Hair Styling Products tioners are applied after shampooing and rinsed
out in the bath, while leave-in conditioners are
Hair styling products can improve the appear- applied to towel-dried hair and left in until re-
ance of the hair in the alopecia patient. These are moved at the next shampooing. Instant condi-
products that put a coating on the hair shaft to tioners place a thin coating of dimethicone or a
smooth the cuticle or increase the ability of the quaternary ammonium compound over the hair
hair to stay in a desired position. Products that shaft to temporarily glue down loosened cuticular
smooth the cuticle are known as ‘conditioners’ scales. This reduces combing friction, improves
because they intend to improve the ‘condition’ of hair shine, increases hair softness, and minimizes
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Dimethicone’s effect on hair
Knot w/smooth cuticle Knot w/uplifted cuticle
Fig. 2. Hair conditioners can

improve hair flexibility, minimizing
Conditioner smoothes cuticle Non-conditioned hair
breakage and improving the and protects hair from damage
cosmetic value of the hair fiber.
static electricity, all of which reduce the coarse, Table 3. Scalp camouflage tips for the alopecia patient
frizzy appearance of damaged hair. A thicker
1. Curling the hair will allow less hair to cover more
coating can be achieved by adding a second layer
scalp
via a leave-in conditioner. The thicker coating en-
hances the positive effects noted earlier and can 2. Crayons can be rubbed on the scalp to minimize the
color contrast between the lighter balding scalp and
also improve hair flexibility (fig. 2). darker hair
The only problem with hair conditioners is
3. Wool fibers in the form of a powder or spray will
that the coating can make the hair appear limp. If adhere to remaining hair shafts to thicken the
the hair is fine, as may be the case in the alopecia appearance of the hair and camouflage the
patient, the conditioner may increase the weight underlying scalp temporarily
of the hair, encouraging it to lie on the scalp rath- 4. Avoid pulling the hair with braids or ponytails that
er than to hold a curl. Selecting a conditioner for are tight against the scalp
fine hair can minimize this problem. Condition- 5. Use hair spray to style hair over areas of hair thinning
ers are valuable in the alopecia patient for protect-
6. Avoid a distinct part, which can expose areas of hair
ing the remaining hair while increasing its cos- thinning. Select a hair style that does not require a
metic value. distinct part
7. Use leave-in hair conditioners that are applied to
towel-dried hair and not rinsed to place a film over
Scalp Camouflage Techniques for the the remaining hair, physically thickening the hair
Alopecia Patient shaft temporarily until the next shampoo
Optimizing the hair that is present on the head is

most important in alopecia patients, but aids to
assist in camouflaging hair loss may be necessary to color the scalp and pigmented fibers that ad-
(table 3). There are a variety of products that cre- here to the existing hair. The crayons are made of
ate the impression of fuller, thicker hair by dimin- a soft wax encased in wood, much like crayon lip-
ishing the contrast between the color of the hair sticks and eye shadows, and are stroked over the
and the color of the scalp skin. These scalp-cam- balding scalp to pigment the scalp. The waxes are
ouflaging techniques consist of crayons designed available in shades of brown and black and are
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removed with regular shampooing. The crayons Table 4. Hair dyeing tips for the alopecia patient
can be purchased at beauty supply stores.
1. Dye hair as infrequently as possible. All hair dyes are
The pigmented fibers are more effective at damaging to the hair shaft
camouflaging the underlying scalp afflicted with
2. Dye hair within your natural color group, perhaps
alopecia, as they provide better coverage and
selecting shades that are no more than 2 shades
more natural-appearing camouflage. The fibers lighter or 2 shades darker. This will minimize hair
are derived from wool fabric threads that have shaft damage
been dyed to match the 8 basic hair shades. The 3. Dye hair darker rather than lighter, if possible.
fibers are mixed with a polymer adhesive and Bleaching is more damaging to the hair shaft
charged with static electricity to better adhere to 4. Avoid highlighting hair or selectively bleaching
the natural hair fibers. These fibers are sprayed certain hair strands. This promotes hair breakage in
from a can or sprinkled from a jar over the area the h
ighlighted hair strands
of thinning. They are removed with shampoo- 5. Always permanently wave or straighten hair first,
ing and must be reapplied whenever water con- waiting at least 2 weeks before undergoing a hair
tact occurs. These products can be purchased in dye p rocedure. If possible, avoid permanent waving
a regular drug store and are sold to camouflage or straightening
the balding vertex in men but can be used safe- 6. Do not wash hair for at least 4–5 days after hair
ly by male and female alopecia patients for cam- dyeing
ouflaging any area of scalp hair loss. 7. Use a shampoo for chemically processed hair to
extend the life of the hair dye
8. Protect dyed hair from UV exposure as the UV will
Hair Dyeing for the Alopecia Patient undesirably lighten the hair color
Many alopecia patients may wish to dye their hair.

This is understandable, as gray, thinning hair is
not cosmetically attractive. There are a variety of salts are deposited on the hair shaft in the form of
hair dyeing processes that have been developed, oxides, suboxides, and sulfides [3, 4]. Hair color
and these will be briefly summarized in the setting lightening is not possible, and other chemical hair
of the alopecia patient. Table 4 summarizes help- procedures, such as permanent hair waving and
ful tips for hair dyeing in the alopecia patient. chemical relaxing, cannot be combined with
gradual hair dyes. These dyes make the hair stiff
and brittle and are not recommended in the alo-
Gradual Hair Dyes pecia patient.
Gradual hair dyes are some of the easiest to use

because they can be purchased and used at home, Temporary Hair Dyes
without any special skill. This category of hair dye
is termed a gradual hair dye because the color of Temporary hair dyes are used to add slight tint or
the hair darkens slowly over time with repeated to brighten a natural shade [5]. They are the only
application of the metal-containing solution. hair dyes that do not damage the hair because
Gradual hair dyes are also known as metallic or their particle size is too large to penetrate through
progressive hair dyes. This type of dye changes the cuticle. This not only minimizes damage but
the hair color from gray to yellow-brown to black also accounts for their temporary nature, as they
over a period of weeks as the water-soluble metal are removed in one shampooing [6]. Persons who
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are allergic to paraphenylenediamine may use dyes, but rather colorless dye precursors that
them. The alopecia patient may use temporary chemically react with hydrogen peroxide inside
hair dyes, if desired. the hair shaft to produce colored molecules [12].
The process entails the use of primary intermedi-
ates (p-phenylenediamines, p-toluenediamine,
Semipermanent Hair Dyes and p-aminophenols) that undergo oxidation
with hydrogen peroxide. These reactive interme-
Semipermanent hair dyes are longer lasting than diates are then exposed to couplers (resorcinol,
temporary hair dyes. They last through 6–10 epi- 1-naphthol, m-aminophenol, etc.) to result in a
sodes of shampooing, as the dyes are retained in wide variety of indo dyes. These indo dyes can
the hair shaft by weak polar and Van der Waals produce shades from blonde to brown to black,
attractive forces [7]. These dyes are designed for with highlights of gold to red to orange. Varia-
use on natural, unbleached hair to cover gray, add tions in the concentration of hydrogen peroxide
highlights, or rid hair of unwanted tones [8]. Usu- and the chemicals selected as the primary inter-
ally, 10–12 dyes are mixed to obtain the desired mediates and couplers produce this color selec-
shade [9]. Semipermanent dyes can be used by the tion [13].
alopecia patient and are best suited to patients Permanent dyeing allows shades both lighter
with less than 30% gray hair who want to restore and darker than the patient’s original hair color to
their natural color [10]. It is not possible either to be attained. Higher concentrations of hydrogen
lighten hair with semipermanent dyes since they peroxide can bleach melanin; thus, the oxidizing
do not contain hydrogen peroxide or to darken step functions both in color production and in
hair more than three shades beyond the patient’s bleaching. Due to the use of hydrogen peroxide in
natural hair color. the formation of the new color molecules, hair
A newer form of hair coloring that is longer dyes must be adjusted so that hair lightening is
lasting than semipermanent dyes is known as not produced with routine dyeing [14]. However,
demipermanent hair coloring. Demipermanent hydrogen peroxide alone cannot remove suffi-
dyes are longer lasting, usually remaining through cient melanin to lighten dark brown or black hair
10–12 episodes of shampooing, and have the ad- to form blonde hair. Boosters, such as ammoni-
vantage of longevity without sharp color contrast um persulfate or potassium sulfate, must be add-
with new growth, a characteristic of permanent ed to achieve greater degrees of color lightening.
hair dyes. The boosters must be left in contact with the hair
for 1–2 hours for an optimal result. These boost-
ers and hydrogen peroxide are very damaging to
Permanent Hair Dyes the hair shaft and should be avoided in the alope-
cia patient. Dyeing the hair the same color as the
Permanent hair dyes not only are the most popu- natural hair is best to minimize damage and cov-
lar in the marketplace but also cause the most hair er gray hair.
shaft damage. Alopecia patients can use them, but
the best results are obtained in the hands of a
skilled beautician. Permanent hair dyes are so Summary
named because the dyestuff penetrates the hair
shaft to the cortex and forms large color mole- Hair loss can be socially and emotionally disabling
cules that cannot be removed by shampooing in the alopecia patient. While wearing a wig is an
[11]. This type of hair coloring does not contain alternative, most patients prefer to optimize their
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126 Draelos
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existing hair for as long as possible. If the alopecia as repair is not possible. While a wide variety of
is minimal, creative hair grooming can camou- procedures and products exist for beautifying the
flage the hair loss until treatment encourages hair hair, virgin hair that is newly grown is the health-
regrowth. This chapter has provided tips on hair iest hair. Anything else that is placed on the hair
grooming, hair dyeing, and methods to avoid un- shaft or done to the hair shaft will diminish its cos-
necessary hair damage to share with the alopecia metic value. These effects are more pronounced in
patient. Since hair is a nonliving fiber, it is impor- the alopecia patient, in whom hair growth is
tant to minimize damage because it is permanent, slowed and hair loss increased.
References
1 Ruetsch S, Kamath Y: Effects of thermal 6 Corbett JF: Hair coloring. Clin Dermatol 11 Tucker HH: Formulation of oxidation
treatments with a curling iron on hair 1988;6:93–101. hair dyes. Am J Perfum Cosmet 1968;83:
fiber. J Cosmet Sci 2004;55:13–27. 7 Corbett JF: Hair coloring processes. Cos- 69.
2 Detwiler SP, Carson JL, Woosley JT, et met Toilet 1991;106:53–57. 12 Corbett JF, Menkart J: Hair coloring.
al: Bubble hair. J Am Acad Dermatol 8 Spoor HJ: Semi-permanent hair color. Cutis 1973;12:190.
1994;30:54–60. Cutis 1976;18:506–508. 13 Zviak C: Oxidation coloring; in Zviak C
3 Pohl S: The chemistry of hair dyes. Cos- 9 Robbin CR: Chemical and Physical Be- (ed): The Science of Hair Care. New
met Toilet 1988;103:57–66. havior of Human Hair, ed 2. New York, York, Marcel Dekker, Inc., 1986, pp
4 Spoor HJ: Part II: metals. Cutis 1977;19: Springer-Verlag, 1988, pp 185–188. 263–286.
37–40. 10 Zviak C: Hair coloring, nonoxidation 14 Corbett JF: Chemistry of hair colorant
5 Spoor HJ: Hair dyes: temporary color- coloring; in Zviak C (ed): The Science of processes – science as an aid to formula-
ings. Cutis 1976;18:341–344. Hair Care. New York, Marcel Dekker, tion and development. J Soc Cosmet
Inc., 1986, pp 235–261. Chem 1984;35:297–310.
Zoe Diana Draelos, MD

2444 North Main Street
High Point, NC 27262 (USA)
E-Mail [email protected]
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Ioannides D, Tosti A (eds): Alopecias – Practical Evaluation and Management.