- Email: [email protected]
Hair care practices and their association with scalp and hair disorders in African American girls
LETTERS NOTES
& COMMENTS
Effective use of teledermatology: Defining expectations and limitations as we move forward To the Editor: The American Academy of Dermatology’s recent support of teledermatology is an important step toward incorporation of a novel technology that possesses the potential to improve patient care and lead to early detection of skin cancers and other cutaneous disease.1 This evolution in innovation will undoubtedly spread at a rapid pace and become an integrative component of the dermatology consultation process. Before we jump on the ‘‘teledermatology bandwagon,’’ it is important to proceed with caution. Our recent study found that a very large percentage of skin cancers within our health care system were diagnosed at sites remote from the lesion of concern prompting referral.2 Of the 149 skin cancers found by dermatologists, 61 (41%) were found at other areas that presumably might not have been included in a teledermatology consult. Although in our study we did not review teledermatology per se, we believe that these findings are provocative and warrant further study. Clearly, in areas of the world that are either remote or underserved, we agree that teledermatology may play an important role in allowing patients increased access to dermatologists. However, as physicians integrate teledermatology into their health care systems globally, both expectations and limitations must be defined to maximize effective use. If teledermatology is going to play an important role in our armamentarium to detect skin cancer, nondermatologists should have a lower threshold to include images of all lesions that represent potential concern after a total body skin examination. Assessment solely of one specific lesion of concern as may occur with teledermatology may be associated with underdiagnosis of clinically significant lesions that are not appreciated by the referring physician, and therefore must not be used as a substitute for a total body skin examination when skin cancer is suspected. Kate V. Viola, MD, MHS,a and Daniel G. Federman, MD, FACPb Department of Dermatology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New Yorka; and Yale University School of J AM ACAD DERMATOL
Medicine, Department of Veterans Affairs Connecticut Healthcare System, West Haven, Connecticutb Funding sources: None. Conflicts of interest: None declared. Correspondence to: Kate V. Viola, MD, MHS, Department of Dermatology, Albert Einstein College of Medicine, Montefiore Medical Center, 111 E 210 St, Bronx, NY 10467 E-mail: [email protected] REFERENCES 1. Ault A. AAD backed telemedicine project helps more patients access care. Available from: URL: http://www.skinandallergy news.com/newsletter/the-skinny/singleview40680/aad-backedtelemedicine-project-helps-more-patients-access-care/5906d16 e1e.html. Accessed May 13, 2011. 2. Viola KV, Tolpinrud WL, Gross CP, Kirsner RS, Imaeda S, Federman DG. Outcomes of referral to dermatology for ‘‘suspicious lesions’’: implications for teledermatology. Arch Dermatol 2011;147:556-60. doi:10.1016/j.jaad.2011.07.035
Hair care practices and their association with scalp and hair disorders in African American girls To the Editor: We read with great interest the article by Wright et al1 on the association of certain hair care practices with hair and scalp disorders in African American girls in the February 2011 issue of the Journal. The authors have made a meaningful contribution to the understanding of these conditions in an understudied demographic. We disagree, however, with some of the conclusions they come to regarding what these data suggest about seborrheic dermatitis in this population. First, the authors state that seborrheic dermatitis is described on the survey as ‘‘dandruff.’’ In the minds of many laypeople, dandruff describes loose flakes in the hair. Seborrheic dermatitis commonly present as a scaly plaque on the scalp. Patients surveyed may have considered this a different condition than dandruff. Also, in this population, flakes in the hair and on the scalp may be described as ‘‘dry scalp,’’ something thought to be distinct from ‘‘dandruff.’’ We also take issue with the finding that ‘‘use of hair oil/grease less often than daily’’ was significantly associated with seborrheic dermatitis. As mentioned JANUARY 2012 157
J AM ACAD DERMATOL
158 Letters
JANUARY 2012
above, the participants in the survey may have considered their symptoms ‘‘dry scalp’’ rather than dandruff or seborrheic dermatitis. Frequent application of hair oil/grease is commonly done in response to what is thought to be ‘‘dryness’’ and may in fact indicate that the participant is attempting to mask the signs and symptoms of seborrheic dermatitis. Many hair oil/grease products aimed at African Americans, in fact, contain sulfur (eg, Sulfur8 products), which is a treatment for seborrheic dermatitis. It follows that, in fact, with further investigation it would be found that the frequent application of these hair oil/grease products would correlate positively with the incidence of seborrheic dermatitis. Given the broad ranges taken regarding the frequency of hair washing and seborrheic dermatitis (once weekly or more vs 2 to 4 weeks), we should be conservative in concluding that frequency is irrelevant. We also cannot conclude that hair extensions are causal. The presence of the extensions may result in different grooming practices, product use, or may unmask the symptoms of seborrheic dermatitis, not cause the condition. It would be of interest to see the data regarding the frequency of hair washing, extensions, and seborrheic dermatitis that was not shown. These authors do an excellent job of uncovering the complexity of understanding hair and scalp disorders in African American girls. Although we should be conservative regarding some of the conclusions drawn from these data, this article certainly builds a foundation for further investigation. Dina D. Strachan, MD,a and Uchenna Okerekeb Columbia University College of Physicians and Surgeons, New York University Medical Center,a New York, New York, and Meharry Medical College,b Nashville, Tennessee (medical student) Funding sources: None. Disclosure: Dr Strachan is a consultant for Alberto Culver and a speaker for Allergan and Medicis. Ms Okereke has no conflicts of interest to disclose. Correspondence and reprint requests to: Dina D. Strachan, MD, Aglow Dermatology, 853 Broadway, Suite 701, New York, NY 10003. E-mail: [email protected] REFERENCE 1. Wright RD, Gathers R, Kapke A, Johnson D, Joseph D, Joseph CLJ. Hair care practices and their association with scalp and hair disorders in African American girls. J Am Acad Dermatol 2011;64:253-62. doi:10.1016/j.jaad.2011.05.054
Reply To the Editor: I would like to thank Dr. Strachan and Ms Okereke for their interest in our original research article, ‘‘Hair care practices and their association with scalp and hair disorders among African American girls.’’1 In their letter to the Editor, one of the concerns was the study survey’s use of the layman’s term ‘‘dandruff’’ to describe seborrheic dermatitis, which they argue could have been misunderstood by participants. Non-infantile scalp seborrheic dermatitis (SD) can clinically present with ill-defined erythematous patches associated with fine scaling or with non-inflammatory fine white diffuse scale. Dandruff is a form of mild SD.2 On the survey; the actual medical term ‘‘seborrheic dermatitis’’ was used alongside the layman’s term ‘‘dandruff’’ in parentheses. Participants were asked if their ‘‘daughter ever experienced or was ever diagnosed/treated by a health care provider for this condition.’’ If, according to Dr Strachan and Ms Okereke, participants believed that their daughter’s ‘‘dry scalp’’ is not considered seborrheic dermatitis or dandruff, then that would mean our results underrepresented the actual number of girls having seborrheic dermatitis, that is, more participants selected ‘‘no’’ to ever having or being diagnosed/treated with SD. If participants who believed they had dry scalp actually answered ‘‘yes’’ to the question about dandruff, our odds ratio would have been even higher, meaning our associations would have been even stronger. We acknowledged in our article’s discussion section the limitation of self-report and possibility for misinterpretation of questions, which is inherent in any self-report survey. Nonetheless, the associations concluded in the study via statistical analysis based on a number of responses to the questions are still valid. With regard to Dr Strachan and Ms Okereke’s second issue, the design of this study does not prove causality but a significant association between reporting having seborrheic dermatitis (dandruff) and reporting the use of hair oils/grease every 2 weeks, with an odds ratio of 3.69 (95% CI, 1.07-12.7; P ¼ .039). In other words, infrequent application of hair oil was significantly associated with seborrheic dermatitis. Based on survey data, daily application of oil is not associated with SD. As discussed in our article, the type of hair oil/grease was not specified; moreover, data on the use of sulfur-based products on African-American girls’ hair is not actually known. In regards to the frequency of shampooing, the choices on the actual survey were: once a week or
& COMMENTS
Effective use of teledermatology: Defining expectations and limitations as we move forward To the Editor: The American Academy of Dermatology’s recent support of teledermatology is an important step toward incorporation of a novel technology that possesses the potential to improve patient care and lead to early detection of skin cancers and other cutaneous disease.1 This evolution in innovation will undoubtedly spread at a rapid pace and become an integrative component of the dermatology consultation process. Before we jump on the ‘‘teledermatology bandwagon,’’ it is important to proceed with caution. Our recent study found that a very large percentage of skin cancers within our health care system were diagnosed at sites remote from the lesion of concern prompting referral.2 Of the 149 skin cancers found by dermatologists, 61 (41%) were found at other areas that presumably might not have been included in a teledermatology consult. Although in our study we did not review teledermatology per se, we believe that these findings are provocative and warrant further study. Clearly, in areas of the world that are either remote or underserved, we agree that teledermatology may play an important role in allowing patients increased access to dermatologists. However, as physicians integrate teledermatology into their health care systems globally, both expectations and limitations must be defined to maximize effective use. If teledermatology is going to play an important role in our armamentarium to detect skin cancer, nondermatologists should have a lower threshold to include images of all lesions that represent potential concern after a total body skin examination. Assessment solely of one specific lesion of concern as may occur with teledermatology may be associated with underdiagnosis of clinically significant lesions that are not appreciated by the referring physician, and therefore must not be used as a substitute for a total body skin examination when skin cancer is suspected. Kate V. Viola, MD, MHS,a and Daniel G. Federman, MD, FACPb Department of Dermatology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New Yorka; and Yale University School of J AM ACAD DERMATOL
Medicine, Department of Veterans Affairs Connecticut Healthcare System, West Haven, Connecticutb Funding sources: None. Conflicts of interest: None declared. Correspondence to: Kate V. Viola, MD, MHS, Department of Dermatology, Albert Einstein College of Medicine, Montefiore Medical Center, 111 E 210 St, Bronx, NY 10467 E-mail: [email protected] REFERENCES 1. Ault A. AAD backed telemedicine project helps more patients access care. Available from: URL: http://www.skinandallergy news.com/newsletter/the-skinny/singleview40680/aad-backedtelemedicine-project-helps-more-patients-access-care/5906d16 e1e.html. Accessed May 13, 2011. 2. Viola KV, Tolpinrud WL, Gross CP, Kirsner RS, Imaeda S, Federman DG. Outcomes of referral to dermatology for ‘‘suspicious lesions’’: implications for teledermatology. Arch Dermatol 2011;147:556-60. doi:10.1016/j.jaad.2011.07.035
Hair care practices and their association with scalp and hair disorders in African American girls To the Editor: We read with great interest the article by Wright et al1 on the association of certain hair care practices with hair and scalp disorders in African American girls in the February 2011 issue of the Journal. The authors have made a meaningful contribution to the understanding of these conditions in an understudied demographic. We disagree, however, with some of the conclusions they come to regarding what these data suggest about seborrheic dermatitis in this population. First, the authors state that seborrheic dermatitis is described on the survey as ‘‘dandruff.’’ In the minds of many laypeople, dandruff describes loose flakes in the hair. Seborrheic dermatitis commonly present as a scaly plaque on the scalp. Patients surveyed may have considered this a different condition than dandruff. Also, in this population, flakes in the hair and on the scalp may be described as ‘‘dry scalp,’’ something thought to be distinct from ‘‘dandruff.’’ We also take issue with the finding that ‘‘use of hair oil/grease less often than daily’’ was significantly associated with seborrheic dermatitis. As mentioned JANUARY 2012 157
J AM ACAD DERMATOL
158 Letters
JANUARY 2012
above, the participants in the survey may have considered their symptoms ‘‘dry scalp’’ rather than dandruff or seborrheic dermatitis. Frequent application of hair oil/grease is commonly done in response to what is thought to be ‘‘dryness’’ and may in fact indicate that the participant is attempting to mask the signs and symptoms of seborrheic dermatitis. Many hair oil/grease products aimed at African Americans, in fact, contain sulfur (eg, Sulfur8 products), which is a treatment for seborrheic dermatitis. It follows that, in fact, with further investigation it would be found that the frequent application of these hair oil/grease products would correlate positively with the incidence of seborrheic dermatitis. Given the broad ranges taken regarding the frequency of hair washing and seborrheic dermatitis (once weekly or more vs 2 to 4 weeks), we should be conservative in concluding that frequency is irrelevant. We also cannot conclude that hair extensions are causal. The presence of the extensions may result in different grooming practices, product use, or may unmask the symptoms of seborrheic dermatitis, not cause the condition. It would be of interest to see the data regarding the frequency of hair washing, extensions, and seborrheic dermatitis that was not shown. These authors do an excellent job of uncovering the complexity of understanding hair and scalp disorders in African American girls. Although we should be conservative regarding some of the conclusions drawn from these data, this article certainly builds a foundation for further investigation. Dina D. Strachan, MD,a and Uchenna Okerekeb Columbia University College of Physicians and Surgeons, New York University Medical Center,a New York, New York, and Meharry Medical College,b Nashville, Tennessee (medical student) Funding sources: None. Disclosure: Dr Strachan is a consultant for Alberto Culver and a speaker for Allergan and Medicis. Ms Okereke has no conflicts of interest to disclose. Correspondence and reprint requests to: Dina D. Strachan, MD, Aglow Dermatology, 853 Broadway, Suite 701, New York, NY 10003. E-mail: [email protected] REFERENCE 1. Wright RD, Gathers R, Kapke A, Johnson D, Joseph D, Joseph CLJ. Hair care practices and their association with scalp and hair disorders in African American girls. J Am Acad Dermatol 2011;64:253-62. doi:10.1016/j.jaad.2011.05.054
Reply To the Editor: I would like to thank Dr. Strachan and Ms Okereke for their interest in our original research article, ‘‘Hair care practices and their association with scalp and hair disorders among African American girls.’’1 In their letter to the Editor, one of the concerns was the study survey’s use of the layman’s term ‘‘dandruff’’ to describe seborrheic dermatitis, which they argue could have been misunderstood by participants. Non-infantile scalp seborrheic dermatitis (SD) can clinically present with ill-defined erythematous patches associated with fine scaling or with non-inflammatory fine white diffuse scale. Dandruff is a form of mild SD.2 On the survey; the actual medical term ‘‘seborrheic dermatitis’’ was used alongside the layman’s term ‘‘dandruff’’ in parentheses. Participants were asked if their ‘‘daughter ever experienced or was ever diagnosed/treated by a health care provider for this condition.’’ If, according to Dr Strachan and Ms Okereke, participants believed that their daughter’s ‘‘dry scalp’’ is not considered seborrheic dermatitis or dandruff, then that would mean our results underrepresented the actual number of girls having seborrheic dermatitis, that is, more participants selected ‘‘no’’ to ever having or being diagnosed/treated with SD. If participants who believed they had dry scalp actually answered ‘‘yes’’ to the question about dandruff, our odds ratio would have been even higher, meaning our associations would have been even stronger. We acknowledged in our article’s discussion section the limitation of self-report and possibility for misinterpretation of questions, which is inherent in any self-report survey. Nonetheless, the associations concluded in the study via statistical analysis based on a number of responses to the questions are still valid. With regard to Dr Strachan and Ms Okereke’s second issue, the design of this study does not prove causality but a significant association between reporting having seborrheic dermatitis (dandruff) and reporting the use of hair oils/grease every 2 weeks, with an odds ratio of 3.69 (95% CI, 1.07-12.7; P ¼ .039). In other words, infrequent application of hair oil was significantly associated with seborrheic dermatitis. Based on survey data, daily application of oil is not associated with SD. As discussed in our article, the type of hair oil/grease was not specified; moreover, data on the use of sulfur-based products on African-American girls’ hair is not actually known. In regards to the frequency of shampooing, the choices on the actual survey were: once a week or