Journal of Dermatological Treatment

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Breaking the cycle of hair breakage: pearls for the

management of acquired trichorrhexis nodosa

Alessandra Haskin, Shawn G. Kwatra & Crystal Aguh

To cite this article: Alessandra Haskin, Shawn G. Kwatra & Crystal Aguh (2017) Breaking the
cycle of hair breakage: pearls for the management of acquired trichorrhexis nodosa, Journal of
Dermatological Treatment, 28:4, 322-326, DOI: 10.1080/09546634.2016.1246704

To link to this article: http://dx.doi.org/10.1080/09546634.2016.1246704

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Oct 2016.
Published online: 28 Oct 2016.

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 JOURNAL OF DERMATOLOGICAL TREATMENT, 2017
VOL. 28, NO. 4, 322–326
http://dx.doi.org/10.1080/09546634.2016.1246704

REVIEW ARTICLE

Breaking the cycle of hair breakage: pearls for the management of acquired
trichorrhexis nodosa
Alessandra Haskina, Shawn G. Kwatrab and Crystal Aguhb
a
Howard University College of Medicine, Washington, DC, USA; bDepartment of Dermatology, Johns Hopkins School of Medicine, Baltimore,
MD, USA

ABSTRACT ARTICLE HISTORY

Acquired trichorrhexis nodosa (TN) is a common cause of hair loss for patients of all ethnicities. It is espe- Received 7 August 2016
cially prevalent in black patients with tightly curled hair types and can present unique diagnostic and Revised 24 September 2016
therapeutic challenges due to structural differences in these hair types and the combination of various Accepted 24 September 2016
Downloaded by [Australian Catholic University] at 08:28 22 September 2017

hair care and styling practices that contribute to hair damage. While scalp biopsies can help rule out other Published online 28 October
2016
etiologies of hair loss, there is a paucity of histologic findings in acquired TN, making this primarily a clin-
ical diagnosis. Instead of more traditional prescription based therapies, the management of this form of KEYWORDS
hair loss emphasizes protecting the hair shaft and minimizing further damage through the development Acquired trichorrhexis
of a healthy hair care regimen. This involves appropriate selection and use of cleansing products and con- nodosa; ethnic hair; ethnic
ditioning agents that help protect the hair from the insults of daily grooming. This paper will review the skin; hair loss; hair
current literature on acquired TN and will provide guidelines and recommendations for management by breakage
reviewing the different types of cleansing and conditioning products that can be used to prevent and/or
halt the progression of hair breakage.

Introduction
Acquired trichorrhexis nodosa (TN) is a common cause of hair loss
best defined as a distinctive response of the hair shaft to extrinsic
or environmental insults, resulting in hair breakage or lack of
growth (1). It can present unique diagnostic and therapeutic chal-
lenges in patients of color, as tightly curled hair types are more
susceptible to breakage and the combination of various hair care
and styling practices commonly used by these patients can be
extensive and complicated (2). This form of hair loss can occur in
patients of all ethnic groups and most commonly occurs second-
ary to the additive effects of deleterious styling practices that lead
to weathering of the hair shaft, fragility and ultimately hair
breakage.
For patients with significant hair loss as a result of acquired TN,
scalp biopsy is of low yield as histology is devoid of findings such
as inflammation or scarring. Instead of more traditional medical
therapies, the management of this form of hair loss emphasizes
protecting the hair shaft and minimizing further damage through
the development of a healthy hair care regimen. Over time, imple-
mentation of healthy hair care practices can lead to a cessation or
complete reversal of hair loss due to acquired TN (Figure 1(a,b))
(3). This paper will review the current literature on TN and provide
a practical guide to the management of acquired TN with an
emphasis on ethnic patients with tightly curled hair types.
Risk factors for the development of acquired
trichorrhexis nodosa
In patients with African hair, characterized as the tightly coiled
hair types in people of African, African-American and Afro-
Caribbean descent, there is an elevated risk for acquired TN due
to structural differences within the hair shaft. African hair fibers
have an asymmetric shape and curvature, which forms points of
geometric weakness in the hair shaft, resulting in lower resistance
to common mechanical stressors such as combing and brushing
(4,5). These differences are believed to contribute to the higher
incidence of structural damages such as full and partial breaks,
knotting and longitudinal fissures observed in African hair, com-
pared to other ethnic groups (6).
These damages may also relate to differences in the hydration
properties of curly hair types. Sebum, the product of the scalp’s
sebaceous glands, is a natural moisturizer that protects the hair
from damage and aids in moisture retention (7). While there are
conflicting reports as to the possibility of racial differences in
sebum production (8), the kinky, curly shape of African hair
impairs the normal distribution of sebum along the entire length
of the hair shaft (5,9). As a result, African hair is drier and even
more susceptible to weathering from styling.
Thermal styling tools such as flat irons and blow dryers and
chemical processing such as permanent dyeing and chemical
straightening, damage the protective cuticular scale and alter the
hair’s protein structure (10–14). These insults disrupt cuticular cells
causing exposed cortical fibers to fray, resulting in weak points
called “nodes” where breakage occurs (1,15). Acquired TN can be
further classified into distal or proximal types, depending on the
location of pathology along the hair shaft (1).
Presentation and differential diagnosis of acquired
trichorrhexis nodosa
Acquired TN can present in a variety of forms and is
typically noticed by the patient long before they seek medical

CONTACT Crystal Aguh, MD cagi1@jhmi.edu Johns Hopkins Bayview Medical Center, Mason F. Lord Bldg Center Tower, Suite 2500, 5200 Eastern Ave,
Baltimore, MD 21224, USA
ß 2016 Informa UK Limited, trading as Taylor & Francis Group
 JOURNAL OF DERMATOLOGICAL TREATMENT 323

Figure 1. (a) Acquired trichorrhexis nodosa. This patient presented with recurrent hair breakage in the scalp vertex and occipital scalp. Histology was unremarkable
and the patient was started on a healthy hair care regimen consisting of regular conditioning and avoidance of harsh shampoos. (b) Six weeks following initiation of
therapy the patient noted complete cessation of breakage, hair growth and improved scalp coverage.
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Table 1. Shampoo surfactants.

Surfactant type Characteristics Common identifiers
Anionic  Provide excellent cleansing, but can leave the hair harsh, dry Lauryl sulfates, laureth sulfates, sarcosines, sulfosuccinates, sodium
and susceptible to breakage (11,27). myreth sulfate, sodium stearte (11,21).
 Should be used sparingly in curly or damaged hair.
Cationic  Smooth the cuticle, reduce frizz, neutralize static electricity, Quaternary ammonium compounds such as stearalkonium chloride
impart softens and manageability (11,21,27). and benzalkonium chloride (19).
 Poor cleansing and lathering ability (11).
Nonionic  Mild cleansing ability, increase manageability and Decyl glucoside, fatty alcohol ethoxylates (cetyl alcohol, stearyl alco-
softness (11,27). hol, etc.) and sorbitan ether esters (7,11,22).
Amphoteric  Mild cleansing ability, nonirritating to eyes, increase manage Betaines, sultaines, imidazolinium derivatives (11).
ability (11,27).

evaluation (2). This form of hair loss can be identified on physical
examination by the presence of broken blunt-ended shortened
hairs of uneven lengths that may present in specific locations
such as the scalp vertex or occipital scalp (Figure 1(a)) (12). Hair
fragility can be demonstrated by gently tugging the distal ends of
a section of hairs (tug test), resulting in the breakage of small hair
fragments (12). Microscopic examination of these broken hair
fibers may demonstrate nodes, which appear as uneven breakages
that resemble broom stick-like projections of cuticular material (2).
On dermoscopy, the hair shafts show multiple areas that corres-
pond to the sites of swelling and future fracturing (16). At higher
magnification, the areas of breakage resemble thrust paintbrushes,
as they appear as the ends of brushes aligned in opposition (16).
Diagnostic testing and telltale clinical signs should be carefully
examined to distinguish this type of hair loss from other etiolo-
gies. Hair breakage or weathering along the occipital scalp can
often be misdiagnosed as tinea capitis and should therefore be
confirmed with a potassium hydroxide test (2). Absent or dimin-
ished follicular ostia should direct the clinician toward a diagnosis
of cicatricial alopecia. Isolated areas of decreased hair density
along the temporal and frontal hairline may support a diagnosis
of traction alopecia (17). It is important that the diagnosis of
acquired TN be considered when assessing hair loss patients to
prevent unnecessary exposure to inappropriate treatments. If sus-
picion is still high, a scalp biopsy should be obtained to rule out
other causes.
Management of acquired trichorrhexis nodosa
Because hair is non-living tissue, total repair of the hair shaft is
not possible; therefore, the only way to minimize further damage
is through proper hair care practices (18). Clinicians should coun-
sel patients on the damaging effects of chemical and thermal styl-
ing and provide safer alternatives to the patient’s current
hairstyling routine. Although these modifications are likely to
lessen the degree of hair breakage associated with these practices,
it is of utmost importance that patients improve the quality of
hair cleansing and conditioning, which are the foundations of a
healthy hair care routine.
Principles of hair cleansing regimen
Proper cleansing of the hair is one of the cornerstones of any
healthy hair care regimen. Although sebum acts as a natural mois-
turizer, it is also a potent attractant of dirt, dust and other envir-
onmental pollutants (7,19). Inadequate cleansing of the hair and
scalp can result in the buildup of styling aids, which can exacer-
bate problems such as seborrheic dermatitis or irritant dermatitis
from product residue (14,20). Therefore, regular cleansing is neces-
sary to maintain a healthy hair and scalp.
The active ingredients in most shampoo formulations are sur-
factants, which consist of a lipophilic structure that binds sebum
and a hydrophilic structure that binds water (11). There are several
different types of shampoos, which are classified according to
their hydrophilic structure (7,19). This variation in chemical surfac-
tants results in differences in hair cleansing abilities and esthetic
properties of the hair. Table 1 outlines common identifiers and
characteristics of each class of surfactants.
Shampoo selection
Anionic surfactants are the most commonly used cleansing ingre-
dients and are typically best suited for those with oily hair (19,21).
These surfactants are quite efficient at removing sebum from the
hair shaft due to their ability to bind to dirt. Although anionic sur-
factants are effective at cleansing the hair, they can often leave
the hair dry and more prone to breakage (11,19). For those with
very curly hair, over-cleansing can be particularly damaging due
 324 A. HASKIN ET AL.
to the decreased sebum content along the length of the hair
shaft.
Instead, cleansing should be limited to the use of shampoos
that contain nonionic or amphoteric surfactants, which are gentler
and are less likely to strip moisture from the hair shaft (20).
Amphoteric surfactants contain both anionic and cationic chemical
structures, resulting in a neutrally charged surfactant with moder-
ate cleansing capabilities (11). These surfactants can improve man-
ageability and are different from cationic surfactants in that they
can be combined with anionic surfactants to increase the efficacy
of cleansing.
Nonionic surfactants are the mildest class of surfactants and
are also effective at improving hair maneagability (19). They are
often combined with cationic or anionic surfactants but can be
used alone in shampoo formulations that are designed to be gen-
tle to the hair (7,22). These ingredients are especially popular in
shampoos formulated for natural black hair but can be used in all
hair types, particularly in individuals who have dry, damaged or
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color-treated hair.
Cationic surfactants are positively charged surfactants and thus
have the greatest ability to impart softness to the hair, but have
poor cleansing ability (19). For this reason, they are rarely found
in shampoos.
Shampoo frequency
Many patients will inquire about the ideal frequency of washing;
however, this varies based on the individual, age, ethnic origin,
country and the initial condition of the hair. Tightly curled hair
types may benefit from less frequent shampooing as this practice
is inherently damaging due to the removal of protective sebum,
subjecting the hair shaft to increased dryness (13). As a result,
shampooing should only be performed when there is excess prod-
uct buildup or undesired oiliness. For those with straight hair, this
may mean daily shampooing, while those with dry, damaged or
curly hair should limit shampooing to not more than once per
week and ideally only a couple of times a month.
Hair conditioning
Conditioning is arguably the most important component of a
healthy hair care regimen for those experiencing hair breakage.
Conditioners are formulated to mimic the action of sebum, the
ideal hair conditioner, but have the added benefit of being easily
applied to the entire length of the hair shaft. They increase hair
manageability by reducing friction between neighboring hair
fibers and increase the hair’s resistance to mechanical insults
induced by daily grooming (21,23). Conditioners also help elimin-
ate static electricity by depositing positively charged ions on the
hair shaft, which counteract negative charges caused by combing
or brushing (23). One of the most beneficial effects of conditioners
is the ability to temporarily mend hair shaft damages such as tri-
choptilosis, by re-aligning the cortex and medulla to halt the pro-
gression of breakage (19). As previously stated, routine grooming
of tightly curled hair is more likely to result in mechanical dam-
age; therefore, prevention of breakage through the use of condi-
tioners is especially important for these patients (6). Conditioners
are available in many different formulations depending on the
desired effect.
Rinse-out conditioners
Rinse-out conditioners are formulated to be applied immediately
after shampooing and then rinsed out of the hair with water.
Many of them contain quaternary ammonium compounds which
are positively charged cationic surfactants that balance out the
anionic charge of shampoos (21). This helps combat the drying
effect of shampooing and increases manageability. These condi-
tioners also enhance shine by increasing the adherence of the
cuticular scales to the hair shaft and can aid in detangling by
reducing friction (11). However, these conditioners are less effect-
ive at repairing hair damage than other types of conditioners due
to their short contact time with the hair (19).
The use of rinse-out conditioners in place of shampooing, com-
monly referred to as conditioner-only washing or “co-washing”,
has recently gained popularity among those with naturally curly
hair as a gentle technique for hair cleansing. This is useful for
those with very dry hair as regular use of conditioners can help
reduce hair loss. However, over time, conditioner use can lead to
the accumulation of residue due to inadequate cleansing; there-
fore, traditional shampoos should still be used at least monthly in
those who choose to co-wash regularly.
Deep conditioners
Unlike rinse-out conditioners, deep conditioners are typically left
on the hair for at least 10 min and may include the additional
application of heat from a hair dryer or warm towel. The added
heat helps lift the cuticular scales and causes hair shaft swelling,
allowing for deeper penetration of the conditioning agents (23).
Deep conditioners usually contain more concentrated ingredients
and are formulated as thick creams, which enhance moisturization
and are particularly beneficial for severely damaged hair (7,19).
Leave-in conditioners
Leave-in conditioners are designed to be applied after the use of
shampoo and conditioner and are not rinsed out. These products
typically contain conditioning agents such as silicones and humec-
tants. Many leave-in conditioners also contain film-forming agents
such as polyvinylpyrrolidone (PVP), which are lightweight poly-
mers that are designed to coat the hair, fill-in hair shaft defects
and reduce static electricity (19). These products can be applied
daily before and after using a hair dryer (at low temperature) and
are ideal for preventing damage from routine grooming.
Protein-containing conditioners
Protein-containing conditioners and protein treatments are consid-
ered an essential component of the hair care regimen for patients
with dry and/or damaged hair. Chemical and thermal styling often
results in damaged hair that contains holes within the cortex (24).
Most of these products contain hydrolyzed proteins, which are
small enough to penetrate the hair shaft and repair holes and
defects, thereby increasing the strength of the hair by up to 10%
(11). However, this benefit is temporary as excess proteins are
removed from the hair with subsequent shampooing. Protein-con-
taining conditioners can be formulated as rinse-out, deep or
leave-in conditioners; however, they are most effective with pro-
longed contact on the hair (11). It is recommended that protein-
containing conditioners and protein treatments be applied on a
monthly or bi-monthly basis as many consumers will report dry-
ness and brittleness with over use.
The repurposed soak and smear
The “soak and smear” is a popular technique used by dermatol-
ogists to treat severe eczema, as it serves to trap moisture
 JOURNAL OF DERMATOLOGICAL TREATMENT 325

Table 2. Recommendations for hair care product selection.

Product Ttype Most Iimportant characteristic
Shampoo Free of anionic surfactants if using
regularly.
Rinse-out conditioner Formulated for dry or damaged hair.
Deep conditioner Formulated for dry or damaged hair.
Coconut oil Should be solid at room temperature,
liquid when warmed.
Styler (hair lotion, Can be applied after oils when using
cream, butter or gel) with soak and smear technique.
Additional characteristics to consider Frequency of use
Formulated for color-treated or damaged 1–4 times per month depending on hair
hair if applicable. type. Less often if hair is dry.
Formulated for color-treated or damaged 1–3 times per week; more often if hair is
hair if applicable. dry.
Formulated for color-treated or damaged 2–4 times per month. More often if hair is
hair if applicable. damaged or dry.
None Before and after every wash.
None Preferences depend on hair type. Thick but-
ters preferred for thick, dense hair;
lotions/milks preferable for fine, thin hair.

within the skin while also facilitating deeper penetration of top- Disclosure statement
ical medications. A similar process can be applied to the hair to
The authors have no conflicts of interest to declare.
aid in moisture retention. Dry hair is more prone to breakage
and is less resistant to the insults of routine styling (6,19).
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Increasing the quality of moisture retention enhances hair elasti- References

city, resulting in fewer tangles and increased protection from
damage (19). When applied to wet hair, some oils, such as
coconut oil, have been shown to decrease moisture and protein
loss, which help to prolong the benefits of shampooing and
conditioning (25,26).
The repurposed soak and smear method for hair care is as
follows:
1. Shampoo and/or condition the hair as normal and lightly blot
the hair with a towel.
2. Follow with the application of a water-based leave-in condi-
tioner to the hair.
3. Immediately apply an oil or thick occlusive moisturizer such
as coconut oil, olive oil, jojoba oil, petrolatum or mineral oil
to the hair.
4. Allow the hair to air dry and style as desired.
The repurposed soak and smear method can be executed as
often as needed throughout the week. For those not wishing to
shampoo/condition the hair prior to applying occlusive oils, water
can be sprayed directly onto the hair shaft until damp to create a
similar result. This layering technique of hair shaft conditioners is
especially beneficial for patients with tightly coiled hair types as it
can help reduce dryness associated with over-processing from
heat and/or chemical applications (14).
Conclusion
Complaints of hair fragility and recurrent breakage in the form of
acquired TN are common in patients with tightly curled hair types
and are usually secondary to a combination of structural and styl-
ing factors unique to this patient population. However, successful
resolution of acquired TN can often be achieved by simply adjust-
ing the patient’s hair care routine. Table 2 provides practical
guidelines for product use and selection that can be used to help
build a healthy hair care regimen in patients with hair damage.
Although chemical and thermal processing are often significant
contributors to hair breakage, implementation of proper cleansing
and conditioning techniques in addition to appropriate product
selection, can improve the overall health of the hair, making it
more resilient to trauma induced by these practices. The recom-
mendations provided here are effective for people of all ethnic
backgrounds who are experiencing excess hair breakage.
Dermatologists should feel comfortable discussing proper hair
care practices with acquired TN patients, as this is one of the few
types of hair loss that responds quickly when addressed
appropriately.
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