Acute ‘relaxer’-associated scarring alopecia: a report of five cases

Conflicts of interest: none declared. Sir, Relaxers, the chemicals used to straighten African hair, are usually divided into two groups: ‘lye’ (mostly sodium hydroxide) and ‘no lye’ (usually guanidine hydroxide).1 Both groups act by breaking down disulphide bonds present in hair keratins. Disulphide bonds are responsible not only for the inherent strength of hair but also for its tight curls. Relaxers are applied to hair for about 10–20 min, only to new growth in the case of repeat applications. After copious rinsing, a neutralizer is applied to reverse the chemical reaction. Disulphide bonds then reform across keratins arranged in the new, straight, shape. Adverse effects include convincing cases of contact dermatitis2 and alopecia due to incorrect formulations,3 and a large less‐defined group with or without evidence of suspected abuse (hair breakage, scarring alopecia).4, 5 We report a series of five patients who presented to our hair clinic over a 3‐year period with a history of discomfort which started during or within minutes of a salon hair relaxation procedure. In all patients the discomfort lasted for at least a few days and healed with patches of hair loss that have persisted. Two patients presented within 2 weeks. Patient 1 presented with papules and nodules, but no pus, in a background of erythema which healed with scarring (Fig. 1a). Patient 4 presented with significant erythema on the vertex somewhat suggestive of contact dermatitis; her standard battery patch test was negative and histology of the epidermis did not show evidence of spongiosis. Although seen late, and a few years older than the others, patient 5 is a medical practitioner and gave a convincing history of symptom onset and disease progression. Although the vertex of the scalp was involved and healed with scarring in all subjects, the lesions extended beyond the vertex in two subjects (patients 2 and 5). The trade names of the products used were substituted with the groups into which they fall, i.e. ‘lye’ or ‘no lye’. The characteristics of the patients are summarized in Table 1.