Afro-textured hair care: a narrative review and recommendations for dermatologists

Abstract

Background:

Afro-textured hair has unique structural and biochemical properties that influence hair behavior and clinical outcomes. Persistent disparities in the characterization, diagnosis, and management of conditions affecting individuals with Afro-textured hair highlight gaps in clinician training and cultural competence.

Objective:

To synthesize current literature on Afro-textured hair into clinically relevant domains.

Methods:

We performed a narrative review of PubMed, Scopus, and Web of Science (2010–2024) using terms including “Afro-textured hair,” “curly hair care,” and “ethnic dermatology.” Peer-reviewed English-language articles relevant to dermatologic care were included. Recommendations were derived from recurring themes.

Results:

Afro-textured hair is defined as a spectrum of fibers consistent with established characteristics of African hair, irrespective of georacial origin. Six domains were identified: patient–physician relationships, classification and terminology, hereditary and acquired conditions, biochemical structure and behavior, diagnostic approaches, and hair products and styling practices. Practical recommendations are provided to advance inclusivity and cultural humility in dermatologic care.

Limitations:

As a narrative review, this work inherently lacks a systematic search strategy and formal quality appraisal and is subject to potential selection bias.

Conclusion:

Organizing the literature into 6 domains offers actionable guidance to improve education, diagnosis, and management of hair and scalp conditions affecting patients with Afro-textured hair.

What is known about this subject in regard to women and their families?

• There is often a disconnect between curly/Afro-texture hair research conclusions and how they are relevant to day-to-day curly hair care regimens.

What is new from this article as messages for women and their families?

• Dermatologists bear significant responsibility for accurately interpreting and communicating current curly hair research to optimize treatment recommendations for common scalp conditions affecting individuals with Afro-textured hair, particularly those influenced by distinct intrinsic and extrinsic factors.

Introduction

Afro-textured hair types are characterized by their unique biochemical and morphological structures. These distinctions have critical implications for diagnosing and managing scalp and hair conditions predominantly affecting patients of African descent. For example, persistent gaps in dermatology—including limited training in skin of color and the shortage of race-concordant dermatologists—continue to compromise both patient trust and the quality of medical education.^1–3 Therefore, clinicians should mindfully consider these racial differences when employing diagnostic methods, selecting treatments, and partnering with patients to optimize their hair care regimen. Herein, we present a review of the current literature on Afro-textured hair classification, morphology, care practices, and styling techniques to accomplish the following objectives: further discouraging monolithic, geo-racial generalizations of Afro-textured hair, summarizing recent findings in curly hair research and natural hair care practices, and offering clinical recommendations to guide dermatologists in caring for patients with different hair types. Clinical domains and corresponding recommendations are summarized in Table 1 and Figure 1.

Table 1.

Afro-textured hair clinical domains and recommendations

Domain	Recommendations
1. Therapeutic relationship	Understand that the quality of therapeutic relationships between dermatologists and patients with Afro-textured hair is multidimensional. Clinicians should be aware of these factors when consulting patients with this hair type
	Be aware of common concerns and misconceptions about the toxicity and effects of common hair care products used by patients with Afro-textured hair
	Actively seek to fill knowledge gaps, understanding that a lack of cultural concordance or incompetence may serve as a barrier to adequate care
	Engage in active reflection to eliminate biases that may preclude sufficient care of patients with Afro-textured hair
2. Classification and terminology	Understand limitations of curly hair research and associated classification systems
	Avoid basing clinical decisions on outdated and inaccurate classifications of hair fibers, as these may result in improper diagnosis and treatment of hair and scalp conditions
	Use a hair typing system that optimizes patient communication and best represents their particular hair/scalp characteristics, pathologies, and hair care practices
3. Biochemical structure and behavior	Understand the implications of these distinct biochemical properties when devising treatment plans and offering advice to patients about their hair care regimen
	Understand how a patient’s hair and scalp concerns in persons with Afro-textured hair may be related to their unique hair properties
4. Hereditary and acquired conditions	Understand the genetic variances implicated in common conditions affecting Black and non-Black persons with Afro-textured hair
5. Hair products and styling practices	Understand the styling practices implicated in hair damage in Black and non-Black patients with Afro-textured hair
	Become familiarized with the ingredients of hair care products commonly used by patients with Afro-textured hair effects on hair and scalp health to advise patients on which will optimize their hair
	Become familiarized with common hair care and styling practices of Black and non-Black patients with Afro-textured hair and their possible effects on hair and scalp health
	In cases of extreme chemical damage or hair loss, advise patients to use appropriate products formulated to optimize moisture and strength in Afro-textured hair
	Counsel patients on product selection and hair care practices for the optimization of their hair care regimen
	Understand and integrate the role of the hair stylist in the treatment of hair and scalp conditions in patients with Afro-textured hair. Hairstylists are often the first point of contact for individuals with Afro-textured hair and play a pivotal role in identifying early hair and scalp conditions. Their insights can bridge the gap between clinical knowledge and lived hair care practices. Dermatologists should consider collaborating with hairstylists to enhance the practical applicability of clinical guidance and improve outcomes
6. Diagnostication	Acknowledge the importance of diagnostic accuracy in treating hair and scalp conditions in patients with Afro-textured hair
	Understand the utility of current diagnostic methods when diagnosing 1 or multiple hair and scalp conditions in patients with Afro-textured hair
	Remain mindful of dermoscopic features of healthy hair in patients with darker hair and scalp pigmentation and/or Afro-textured hair
	Recognize dermoscopic findings for common hair and scalp conditions in patients with different hair and scalp pigmentation and hair fiber types

Fig. 1.

Six domains of Afro-textured hair care in the current literature: visual summary.

Quality of patient-physician interaction and cultural concordance

The quality of the therapeutic relationship heavily impacts the diagnosis and treatment of Afro-textured hair conditions. Current Afro-texture hair studies indicate a prominent gap between clinician knowledge and the lived experience of patients with Afro-textured hair and associated conditions. Additionally, social attitudes toward Afro-textured hair may also contribute to the discomfort of race-discordant providers with recommending specialized treatments.^1,4,5 Although a lack of patient-clinician concordance is often implicated, patients also emphasized the importance of dermatologist interaction style, in addition to cultural competence.^2–4

A solid therapeutic relationship provides a firm foundation upon which the dermatologist may consider other clinical aspects of treating Afro-textured hair and scalp conditions.⁶ Dermatologists’ understanding of the cultural overtones, misinformation, and knowledge gaps that affect Afro-textured hair care is essential to care.² This process begins with clinicians actively engaging in reflection to eliminate bias and discomfort that may hinder the adequate care of patients with Afro-textured hair.^1,6 Next, it is important to validate and address patient resistance to certain interventions or recommendations, creating an open forum for clarification and reassurance when appropriate. This is further discussed in Section 5⁷ see Table 1, Sections 1 and 5.

Classification and terminology

The clinical perspective of curly hair is derived from anthropological studies of human and wool hair fibers. As a result, early literature established 3 broad hair fiber categories: African, Caucasian (synonymous with “European”), and Asian.⁸ This categorization yielded subsequent tripartite studies identifying curly hair as synonymous with “African hair,” characterized by coiled, elliptical fibers emerging from ovoid, retro-curved (as opposed to straight, perpendicular) follicles with asymmetric cellular and protein organization. This configuration is thought to cause fiber bending and impair the distribution and absorption of sebum along the hair shaft, leading to increased breakage points, a tendency to form simple knots, and slower growth rates compared to Asian and Caucasian hair types.⁸ Other early studies broadly characterize hair as “straight,” “wavy,” “curly,” and “kinky.”

Upon the appraisal of current methods for researching curly hair fibers, newer studies have rendered the broad generalization of “African” hair antiquated, as they do not accurately represent race- and regional- independent nuances of the natural curly hair spectrum.^8–12 Clinicians should be aware of the appropriate application of antiquated and recent research findings when classifying Afro-textured hair. Dermatologists treating hair and scalp conditions should understand and correctly apply curly hair classification systems established in the literature that optimize patient communication and best represent their hair/scalp characteristics, pathologies, and hair care practices.^7,13,14 See Table 1, Section 2.

Henceforth, in this review, we will collectively use the term “Afro-textured” hair to encompass a range of hair fibers that align with the described characteristics of “African” hair, regardless of georacial background. We acknowledge that prevailing research biases have resulted in an oversimplification of curly hair types, leading to a restricted exploration of conditions impacting Black and non-Black individuals with Afro-textured hair. However, when addressing hair conditions primarily affecting Black patients, we will exclusively employ this term to denote hair fibers of African descent. See Table 1, Section 2.

Biochemical and physiological structure of Afro-textured hair

Afro-textured hair has a unique structure characterized by an elliptically shaped hair shaft, which generally distinguishes it from other hair types, as highlighted in Figure 1, Section 4. Appreciating these structural differences is essential for accurate clinical assessment and effective treatment planning. The inherent morphology of Afro-textured hair predisposes its fibers to intertwining, ultimately leading to increased susceptibility to tangling, knotting, and uneven oil distribution.^15,16 Additionally, trends between diameter, cross-section, lipid permeability, and biomechanical strength have been observed in African fibers with varying degrees of curliness.^10,17,18 This variability impacts moisture and shine, which are critical metrics for patients, medical providers, and hair stylists. Though chemical and protein differences are not fully understood or applied as a basis for hair classification, appreciating these nuanced differences may aid in optimizing hair health.

Therefore, dermatologists treating hair and scalp conditions in patients with Afro-textured hair should understand the implications of these distinct biochemical properties when devising treatment plans and offering advice to patients about their hair care regimens. See Table 1, Sections 3 and 5.

Tensile strength of Afro-textured hair

It is commonly accepted that Afro-textured hair exhibits lower tensile strength compared to other hair types. Traditionally, the elastic region is the factor used when assessing tensile strength. Cloete et al.⁸ suggest that the tensile strength of hair fibers is influenced by 2 main components: 1 from a viscous “toe-region” and 1 from the elastic region. When subjected to stress, curly hair fibers show a distinct lag in the “toe-region” before transitioning into elastic deformation, suggesting a more prominent viscous response compared to straight hair fibers. Thus, traditional methods for assessing tensile strength may not fully capture the complex response of curly hair fibers and should be used judiciously when treating curly hair conditions.⁸ Khumalo et al.¹⁷ challenges the notion of inherent Afro-textured hair fragility, instead attributing it to mechanical trauma. Notwithstanding, clinicians should carefully select hair care products, treatments, and styles to mitigate the risk of mechanical damage during manipulation. This will be further discussed in Section 5.

Genetic and hereditary conditions affecting persons with Afro-textured hair

In addition to the unique intrinsic properties of Afro-textured hair, clinicians should be aware of implicated genetic variances that may predispose persons with this hair type to certain conditions. Central centrifugal cicatricial alopecia (CCCA) is an inflammatory scarring alopecia commonly observed among women with Afro-textured hair. Recent studies have identified partially penetrant autosomal dominant mutations in the PADI3 gene, which encodes proteins for hair shaft development, as being implicated in CCCA.¹⁹

Moreover, research has revealed connections between CCCA and fibroproliferative disorders such as keloids, atherosclerosis, and fibroids. Common features between CCCA and fibroproliferative disorders, including low-grade inflammation and irritation, which culminate in the development of end-stage fibrosis, prompted exploration of potential shared genetic pathways.²⁰ Recent studies demonstrating the association between CCCA and other fibroproliferative conditions suggest that clinicians should be well-equipped to adequately screen for and refer patients to the appropriate disciplines. These findings also shed light on potential therapies for CCCA, suggesting that antifibrotic therapies could be beneficial in its treatment and management and should therefore be considered. Furthermore, clinicians should also have a high clinical index of suspicion for female pattern hair loss, trichorrhexis nodosa, and hereditary syndromes in patients with Afro-textured hair.^21–23 See Table 1, Section 4; Figure 1, Section 3.

Afro-textured hair products, care practices, and styling practices

While biochemical, morphological, and genetic factors may increase the susceptibility of Afro-textured hair to breakage, it’s important to recognize that everyday hair styling and care practices play a significant role in maintaining overall hair and scalp health.⁹ These practices, often distinctive in the Black and Latin-x communities, can contribute to better hair health and facilitate the diagnosis and treatment of common hair and scalp issues in patients with Afro-textured hair. Clinician competence in this domain can be helpful when working with the patient to adapt their current Afro-textured hair care regimen to a more beneficial alternative. See Table 1, Section 6; Figure 1, Section 6.

Afro-textured hair products

The most common concerns for patients with Afro-textured hair are hair dryness and breakage.²⁴ Despite this, many hair products commonly used by those with Afro-textured hair contain ingredients that worsen these issues by increasing tension, stripping of lubricating sebum, and promoting product buildup.⁷ These ingredients include sulfates, parabens, silicones, mineral oils, and cationic surfactants and polymers. Although we will not discuss the biochemical effects of each here at length, they are well-documented in the literature as potential contributors to poor hair care hygiene.^24–27 Clinicians should know that numerous popular products still contain trace amounts of these ingredients, often without proper regulatory disclosure.⁷ Studies on the utility of alternative natural and organic products (Chebe powder, flaxseed, egg yolk, mayonnaise, aloe vera, etc) in Afro-textured hair care are limited and therefore should be endorsed with discretion.

Therefore, it is critical that clinicians are aware of the common hair care products used in patient groups with Afro-textured hair suffering from common hair and scalp conditions, as some products may worsen existing damage. Moreover, selecting hair shampoos, conditioners, moisturizers, oils, and protein treatments compatible with the patient’s unique hair properties—especially following prolonged periods of mechanical or chemical stress—can aid in hair repair.^7,28,29

Afro-texture hair care practices: cleansing, maintenance, and nocturnal care

Although many doctors currently feel uncomfortable discussing natural hair care routines with patients, addressing cleansing and nighttime care practices is critical for the appropriate treatment of hair and scalp conditions in patients with Afro-textured hair.⁶ Ethnic hair care studies emphasize the significant benefits of weekly, gentle cleansing and the use of silk head scarves and pillowcases during sleep.^24,27,30 However, a common belief that frequent shampoo use leads to dryness and breakage has fostered a cultural adoption of bi-monthly and monthly hair washing, along with prolonged protective styling methods in adults. This practice increases the risk of developing seborrheic dermatitis and in some cases, traction alopecia (TA).^30,31 However, recent studies suggest that weekly washing of Afro-textured hair with appropriate products regulates the scalp microenvironment and reduces product buildup, both which counter hair breakage.^7,30,32 Perceived clinician cultural incompetence and a lack of knowledge regarding curly hair often lead patients to seek guidance from the community and online forums.^2,33 Clinicians should inquire about daily hair maintenance techniques, nighttime protective methods, and cleansing frequency.³

Afro-textured hair styling: mechanical, protective, thermal, and chemical styling

Mechanical and protective styling

In addition to proper hair hygiene, hair styling practices directly influence the health and quality of Afro-textured hair. Many patients with Afro-textured hair frequent the salons of trained and untrained Afro-textured hair stylists and specialists.³³ Irrespective of stylist experience, persons with Afro-textured hair generally attribute increased hair growth with what is termed as “protective styling,” due to its facilitation of long periods of low hair manipulation.

Clinicians should be aware of these cultural nuances when evaluating a patient with Afro-textured hair. Popular protective hair styles—including single/knotless braids, cornrows (“fulani braids”), 2-strand twists, and French twists—minimize interstrand friction, retain hair moisture, and ease hair management. Other popular hairstyles include ponytails, wigs, sew-in weaves, and locks (“dreadlocks”). See Figure 2.

Fig. 2.

Common Afro-textured hair styles. (A) Afro or afro-puff. (B) “Single” box braids with hair extensions. (C) Micro or “sister” locs. (D) Dread locks (larger size). (E) Cornrows. (F) Style achieved with thermal or chemical straightening.

Notwithstanding the benefits of protective styling, some methods and styling maintenance practices are implicated in common hair and scalp conditions in patients with Afro-textured hair, such as TA, CCCA, and acquired trichorrhexis nodosa.^27,33–36 Additionally, recurrent use of hard-bristle brushes, hair rollers, hair clips, and other hair accessories may also contribute to damage of the hair shaft. When evaluating patients with Afro-textured hair, clinicians should engage in conversations about these styles and how they may affect hair and scalp health.^3,6

While patients may vary in their capacity to accurately assessing the tension their hairstyles place on the scalp, clinicians should still inquire about the type of frequency of these styling practices. This information is likely to enhance the diagnosis and treatment of related hair and scalp conditions and may enable dermatologists to better identify high-risk hairstyles and provide safer alternatives.^25,32

Thermal styling

Likewise, common thermal styling practices—flat ironing, hot combing, and blow drying—damage Afro-textured hair strands. The literature generally agrees that thermal styling practices temporarily disrupt hydrogen bonds in hair, resulting in irreversible bond weakness, grossly observed as “loosening of curl pattern.”³⁵ Clinicians and patients should also understand that Afro-textured hair strand response to heat is often rate-limited, regional (with most damage occurring at the peripheral hairline), and may vary between patients with similar hair textures.

Chemical styling

There is similar agreement in the literature regarding chemical straightening practices. Lye and non-lye-based chemical straighteners permanently disrupt hydrogen and disulfide bonds. These should be applied and retouched by a hairstylist with appropriate licensure and experience with treating natural hair care. If patients lack access to a professional stylist, chemical straighteners should be used as directed. Alternatively, patients may be advised to cut off straight ends, another sign of damage, to prevent the development of split ends along overly processed areas or to maintain coil consistency along the hair shaft.²⁷

Clinicians should understand that some conditions may result from a combination of the above styling practices. For example, acquired trichorrhexis nodosa is often caused by both mechanical and chemical trauma. Therefore, patients with Afro-textured hair, especially those with increased thermal, mechanical, or chemical damage, should be advised to abstain from damaging practices for prolonged periods—allowing their natural curl pattern to “grow out”— or regularly trim visibly damaged areas.²⁷

Access to Afro-textured hair care specialists

Although many popular and convenient hair styling practices are implicated in causing common hair and scalp conditions in patients with Afro-textured hair, clinicians should be aware that cultural identity and affordability of changing hair care regimens or styling practices may prevent patients from adopting alternative methods of Afro-textured hair care³⁵ Also, many patients defer to the advice of natural hair specialists, who may be better acquainted with their hair type or unique hair characteristics.^3,33However, hair stylists are not required to obtain specialized training in natural hair, limiting the standardization of their education on the impact of certain styling practices on the development or slow treatment of hair and scalp conditions.

Nevertheless, with proper education, stylists may be able to refer patients to clinicians before conditions worsen or develop.^27,33 Therefore, the clinician should standardize partnership with each patient—and their hairstylist, if possible—to individualize care and recommend appropriate alternative products and regimens.

For a summary of recommendations regarding hairstyling cleansing practices, please see Table 1, Section 5.

Diagnostic methods in afro-textured hair and scalp conditions

Recognizing the genetic and cultural distinctions inherent in scalp and hair conditions, as well as unique hair care practices in Black and Brown patients, has prompted the refinement of specialized diagnostic tools and methodologies tailored for the Afro-textured hair and scalp. Clinicians treating patients with Afro-textured hair should be aware of these methods and their applications.

Given the prevalence of marginal and centrifugal TA in Black patients, the diagnostic utility of the hair-pull test has been investigated. While McDonald and colleagues initially employed classical broad categories to compare hair-pull test results among “Afro-textured,” “Asian,” and “all participants,” their findings were further stratified to accommodate different texture subgroups: “curly,” “wavy,” and “straight.”³⁷ Their results strongly indicate that a normal hair-pull test result range of less than 2 hairs is sufficient to predict low hair loss risk across all hair textures and may be incorporated in the clinical assessment.

Although there is limited diagnostic utility in the histopathological evaluation of sebaceous gland volume, dermatologists may consider this method to differentiate between early and late-stage fibrosis in marginal traction alopecia.³⁶ Dermoscopy (also “dermatoscopy” and “trichoscopy”) may also be used to diagnose various conditions with Black predominance. Quaresma et al.³⁸ identified normative characteristics in patients of African descent, noting marked breakage points with associated nodular swelling following minimal handling of “virgin,” or non-chemically-processed, Afro-textured hair fibers. A subsequent study by this group observed distinct dermatoscopic findings in similar patients with trichorrhexis nodosa.¹⁵ As discussed previously, their observations may assist the clinician in informing patients about the selection of natural hair care products to optimize hair and scalp pathologies.

Clinicians should utilize diagnostic methods that minimize unnecessary manipulation and biopsy procedures on Afro-textured hair.³⁹ Dermoscopy may be helpful in efficiently assessing patients with Afro-textured hair, who frequently present with multiple concurrent disorders.⁴⁰ Although there is limited evidence that validates improved outcomes of Afro-textured-hair-specific dermatoscopy methods, all studies suggest that increased diagnostic accuracy and efficiency may result in therapeutic benefit for Black and non-Black patients with Afro-textured hair.

For a summary of recommendations regarding diagnostication, please see Table 1, Section 6.

Conclusion

Despite the breadth of Afro-textured hair care literature, a knowledge gap remains as to how dermatologists should apply this information. Therefore, we distilled current curly hair literature into 6 domains that generate actionable guidance for managing hair and scalp conditions primarily impacting individuals with Afro-textured hair. Although yet to be validated, these recommendations help optimize patient and provider education and aid in diagnosing, preventing, and treating hair and scalp conditions. Future studies may be aimed at validating applications of each domain in clinical practice.

Conflicts of interest

None.

Funding

None.

Study approval

N/A.

Author contributions

JGH and MJH: Writing – original draft, writing review and editing. KMC and LET: Writing – writing review and editing. JL: Writing – original draft, writing review and editing, supervision, and project administration.