Hair Breakage - Acquired Trichorrhexis Nodosa
Hair Breakage/ Acquired Trichorrhexsis Nodosa
Clinical Presentation
Acquired trichorrhexsis nodosa (ATN) is a disorder of the hair shaft in response to repeated environmental insults resulting in hair breakage or lack of growth. ATN presents as hair that is fragile and breaks or fractures easily upon minimal manipulation (1, 2). The hair appears lusterless and dry, and individuals may complain of “whitish spots” or nodes along the shaft (2).
Who: It can occur in any person although it is prevalent in women of African descent. Hair breakage can occur in up to 18% of African American women using a hot comb (3, 4)
Causes (1, 2, 6)
ATN is likely caused by loss of the hair cuticle cells resulting from physical or chemical insults to the hair (see below). These insults may expose the cortical hair cells to further damage significantly weakening the hair.
Environmental insults: Chemical and/ or heat straightening, excessive brushing/ manipulation
Women of color: ATN may be increased in this population due to the inherent properties of tightly coiled hair and common hair grooming practices.
Diagnosis (1, 3, 6)
Diagnosed via history, clinical hair exam (“tug test”), hair mount, dermoscopic/ microscopic examination
Clinical exam / “tug test”: Significant number of hairs to break off mid-shaft
Microscopic exam of broken hairs (5): fraying of the hair cortical fibers leads to the appearance of paint brushes crushed against each other- “paintbrush fracture” on microscopic exam
Clinical Imitators (Differential Diagnosis) (1)
Tinea Capitis (scalp fungus), traction alopecia, scarring alopecia
Treatment Options
Hair grooming:
Prevention: Avoid potentially damaging hair care practices such as traction/ tension hairstyles (weaves, wigs, braids, extensions, ponytails, etc.), chemical relaxers, excessive heat, hair bleaching, and hardening gels and sprays. The practices mentioned above may further compromise an already fragile hair and increase breakage. Follow-up with a haircare professional who is knowledgeable about safe hair care practices.
Management (1, 3, 6): Cut/ trim damaged hair regularly, adopt a more "natural", non-tension, loose, low manipulation hairstyle (routine grooming can result in hair breakage in tightly coiled hair), maintain proper protein-moisture balance, heat style no more than once per week and temperature should not exceed 350 °F (or low/medium setting), increase intervals between use of chemical relaxers, watchful waiting for new hair growth, choosing proper hair grooming products for ethnic hair types (1, 6)
Shampoo (1, 6): Choose shampoos that have a milder cleansing ability and increase manageability of the hair. Shampoo frequency varies based on hair type and scalp needs (ranges from 3-7 days/week) for oilier straighter hair types with excess scalp buildup to 2-4 times per month for dryer curlier or more damaged hair types.
Conditioner (1, 6):
Rinse out: May be used immediately after washing and is rinsed out. Helps to combat dryness from shampoos and increase manageability. Sometimes used as “co-washing” (hair cleaning technique popularized in the naturally curly hair community to help those with very dry hair) agent. Regular use of “co-washing” may lead to the inadequate cleansing of the hair (recommended to use traditional shampoo 1-4 times a week)
Deep: May be applied after washing or use of a rinse out conditioner. Typically left on the hair for a minimum of 10 minutes with or without heat for enhanced penetration.
Leave-in: Are left on after shampooing and conditioning the hair. Contain products that form a film, coat the hair and fill in defects on the hair shaft.
Protein: Contain small protein fragments (hydrolyzed) that temporarily penetrate the hair shaft and repair holes
“Soak and smear” (1, 6): Aids in moisture retention. Shampoo and condition and lightly blot hair —> then apply water-based leave-in conditioner —> then apply oil or occlusive moisturizer (jojoba oil, olive oil, etc.)
Consider hair steamer once to twice a month.
Docs4Hair also recommends a general holistic approach to hair loss.