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Dermatopathology: Practical & Conceptual October - December 2000
Quandary Resolved!: “Hot Comb Alopecia”/“Follicular Degeneration Syndrome” in African-American Women Is Traction Alopecia!
A. Bernard Ackerman, M.D.
Norman W. Walton, III, M.D.
Robert E. Jones, M.D.
Christine Charissi, M.D.
Synonymy of “Follicular Degeneration Syndrome” and “Hot Comb Alopecia”
Importance of Knowledge of Histology and the Follicular Cycle
Crtitique of the Notion of “Follicular Degeneration”
Histopathologic Findings in Chronological Sequence
“Hot Comb Alopecia”/“Follicular Degeneration Syndrome” is Traction Alopecia
The "follicular degeneration syndrome," described by Sperling and Spau in 1992 and elaborated on by Sperling
in 1994, is said by them to represent a "clinically and histologically distinct form of scarring alopecia" that was "formerly called hot comb alopecia" by LoPresti, Papa, and Kligman who, in 1968, had given that latter name to irreversible, partial, scarring alopecia of the crown of the scalp of African-American women. Those three authors claimed that the alopecia was distinctive clinically and histopathologically. As the appellation "hot comb alopecia" implies, the loss of hair was thought by them to be a consequence of the effects of heated combs that African-American women employed commonly in the past, and even nowadays, to straighten their hair. The procedure consists of passing a hot comb through hair that already had been stretched and covered with petrolatum. Sections of tissue of biopsy specimens taken from the alopecia that results from the procedure were said by LoPresti and coworkers to be characterized by a "chronic inflammatory reaction around the upper portion of the follicle" that led to "degeneration of the upper segment of the external root sheath" and eventually to destruction of the entire follicle, which was replaced by a band of fibrous tissue. Furthermore, the epidermis was said to become altered and to display thin, elongated rete ridges, thin suprapapillary plates, hypogranulosis, and a normal cornified layer.
LoPresti and coauthors implied that a burn from the hot petrolatum was responsible for the alopecia, but the histopathologic findings in hot comb alopecia, as described by LoPresti
and presented in their photomicrographs are not those of scarring secondary to a burn; the fibrosis is not diffuse across at least the upper part of the dermis, altered bundles of collagen are not oriented parallel to the skin surface, and venules are not disposed perpendicular to the surface. Fibrosis in hot comb alopecia was purported to occur only at discrete sites where follicles were affected individually. An alopecia caused by a burn from hot petrolatum should involve all follicles diffusely, not individual ones randomly.
After the seminal presentation of hot-comb alopecia by Lo Presti and collaborators, the histopathologic findings in that particular condition do not seem to have been the subject of any other article in any journal for more than two decades. During that period, the popularity of hot combs for straightening hair began to decline slowly, but steadily, as chemical products for that purpose became available. The condition, nonetheless, continues to be common in black women. In 1992, Sperling and Sau proposed both a new term for hot comb alopecia, namely,
syndrome, and a new hypothesis for it, to wit, degeneration of follicles as the cause. The designation "degeneration" for a follicle is itself perplexing, considering that a follicle is made up entirely of epithelium and in classic pathology only non-epithelial elements undergo degeneration, for example, "fatty," "mucinous," and "hyaline" types.
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