3.3 Hair and Scalp Disorders, Diseases & Contraindications

Clinical Trichology & Cosmetologist Scope of Practice

Cosmetologists are licensed to care for and cosmetically treat healthy hair and scalp tissue. While cosmetologists are trained to recognize a wide variety of hair and scalp disorders, cosmetologists are legally prohibited from diagnosing medical conditions or prescribing medical treatments.

When a client presents with an active, infectious, inflamed, or contagious scalp condition, the cosmetologist must immediately and tactfully refuse service, sanitize all contaminated equipment, and advise the client to consult a licensed physician or dermatologist. Understanding trichological pathology is vital for protecting client safety, maintaining salon sanitation, and passing the Pennsylvania Cosmetology State Board Exam.

Types of Hair Loss (Alopecia)

Alopecia is the clinical term for abnormal hair loss, thinning, or baldness. While daily shedding of 50 to 100 hairs is normal, excessive loss indicates an underlying genetic, hormonal, autoimmune, or mechanical disorder:

+------------------------------------------------------------------------------------------+
|                                 MAJOR TYPES OF ALOPECIA                                  |
+-----------------------+------------------------------------------------------------------+
| Condition             | Etiology & Clinical Presentation                                 |
+-----------------------+------------------------------------------------------------------+
| Androgenetic Alopecia | - Hereditary progressive thinning & miniaturization of follicles |
|                       | - Triggered by DHT (dihydrotestosterone) & 5-alpha reductase     |
|                       | - Men: receding hairline & crown baldness (Norwood scale)        |
|                       | - Women: diffuse crown thinning with intact front line (Ludwig)  |
+-----------------------+------------------------------------------------------------------+
| Alopecia Areata       | - Autoimmune disorder; immune system attacks hair follicles      |
|                       | - Sudden, round or oval smooth bald patches without inflammation |
|                       | - Alopecia Totalis: complete loss of all scalp hair              |
|                       | - Alopecia Universalis: complete loss of all body/facial hair    |
+-----------------------+------------------------------------------------------------------+
| Postpartum Alopecia   | - Temporary diffuse shedding occurring 2 to 4 months postpartum   |
|                       | - Caused by sudden drop in pregnancy estrogen shifting anagen    |
|                       |   follicles rapidly into telogen; resolves in 9 to 12 months     |
+-----------------------+------------------------------------------------------------------+
| Telogen Effluvium     | - Premature generalized shedding of 30% to 50% of scalp hair     |
|                       | - Triggered by severe shock, high fever, major surgery, rapid    |
|                       |   crash dieting, severe illness, or extreme emotional trauma     |
+-----------------------+------------------------------------------------------------------+
| Traction Alopecia     | - Mechanical hair loss caused by chronic, excessive tension      |
|                       | - Common from tight braids, cornrows, weaves, or tight ponytails |
|                       | - Reversible early; leads to permanent scarring if sustained     |
+-----------------------+------------------------------------------------------------------+

FDA-Approved Treatments for Androgenetic Alopecia

There are only two treatments clinically proven and approved by the FDA to stimulate hair growth in androgenetic alopecia:

1. Minoxidil: A topical over-the-counter liquid or foam medication (2% or 5% strength) applied twice daily to the scalp. Safe for both men and women.
2. Finasteride: An oral prescription medication for men only that inhibits the 5-alpha reductase enzyme from converting testosterone to follicle-miniaturizing DHT. (Contraindicated for women of childbearing potential due to birth defect risks).

Disorders of the Hair Shaft

Hair shaft disorders involve structural defects, genetic anomalies, or mechanical damage occurring along the length of the keratinized fiber:

• Canities: The technical term for gray or unpigmented hair, resulting from the loss or reduction of natural melanin pigment in the hair cortex.
  • Congenital Canities: Exists at or before birth; occurs in albinism and piebaldism.
  • Acquired Canities: Develops with age, genetic predisposition, or prolonged severe stress.
• Ringed Hair: A rare genetic condition characterized by alternating bands of pigmented and gray/white hair throughout the length of the hair strand.
• Hypertrichosis (Hirsutism): Abnormal, excessive terminal hair growth in areas of the body that normally produce only fine vellus hair (such as the face, chest, or back in women).
• Trichoptilosis: The technical term for split ends. Characterized by longitudinal splitting of the hair shaft cuticle and cortex fibers. Caused by mechanical trauma, heat, or harsh chemicals. The only permanent cure is physically trimming the split ends off.
• Trichorrhexis Nodosa: The technical term for knotted hair. Characterized by extreme brittleness and the formation of nodular swellings along the hair shaft. At the node, the cortex fibers fracture, fray, and spread apart, resembling two paintbrushes pushed together. Caused by severe chemical over-processing, aggressive thermal heat, or physical trauma.
• Monilethrix: The technical term for beaded hair. A genetic disorder in which the hair shaft develops periodic bead-like nodes along its length separated by narrow, fragile constrictions. The hair easily breaks off between the beads.
• Fragilitas Crinium: The technical term for brittle hair. The hair strands are fragile, split, or snap spontaneously along any point of the shaft.

Scalp Disorders: Pityriasis (Dandruff)

Pityriasis is the technical medical term for dandruff, characterized by the excessive production and shedding of accumulated epidermal scalp skin cells. Dandruff is not caused by dry skin; modern dermatological science proves that dandruff is caused by the overgrowth of a naturally occurring, microscopic, lipophilic fungus/yeast called Malassezia (formerly Pityrosporum ovale).

                  PITYRIASIS (DANDRUFF) CLASSIFICATIONS
                  
  [ PITYRIASIS CAPITIS SIMPLEX ]          [ PITYRIASIS STEATOIDES ]
  - Classic dry dandruff                  - Severe greasy / waxy dandruff
  - Small, thin, white scales             - Thick, yellowish, oily crusts
  - Flakes fall freely on shoulders       - Scales stick tightly to scalp
  - Accompanied by mild itching           - Mixed with sebum; foul odor
  - Treatable with OTC anti-dandruff      - If inflamed/oozing, refer to MD

Salon Care for Dandruff

Pityriasis Capitis Simplex is treatable in the salon using specialized anti-dandruff shampoos containing active anti-fungal agents such as zinc pyrithione, selenium sulfide, or ketoconazole, accompanied by gentle scalp manipulations. However, if the scalp shows severe inflammation, bleeding, or oozing crusts (severe Pityriasis Steatoides or seborrheic dermatitis), all chemical services must be discontinued and the client referred to a physician.

Contagious Scalp Infections & Strict Contraindications

Cosmetologists must immediately recognize contagious fungal, parasitic, and bacterial infections. Under Pennsylvania State Board regulations, all contagious conditions are strict contraindications for any salon service.

1. Fungal Infections (Tinea / Ringworm)

Tinea is the medical term for ringworm, a contagious fungal infection caused by dermatophytes that feed on keratin protein. Characterized by itchy, red, circular lesions with elevated borders:

• Tinea Capitis: Ringworm of the scalp. Begins with small red papules at the follicle openings that spread outward. Hair becomes brittle, lusterless, and breaks off at or near the scalp surface, leaving bald-looking patches with stubble. CONTAGIOUS — DO NOT SERVICE.
• Tinea Favosa (Favus): Characterized by dry, sulfur-yellow, cup-like crusts on the scalp called scutula. Scutula have a distinct, pungent, musty/mousy odor. As the crusts heal, they leave shiny pink or white bald scars resulting in permanent hair loss. CONTAGIOUS — DO NOT SERVICE.

2. Parasitic Infestations

• Pediculosis Capitis: Infestation of the scalp and hair with head lice (Pediculus humanus capitis). Lice feed on human blood from the scalp, causing intense itching. Female lice lay microscopic, oval, translucent/whitish eggs called nits that are firmly glued to the hair shafts near the scalp. Unlike dandruff flakes, nits cannot be brushed, blown, or shaken off. Transmission occurs through direct head-to-head contact or shared fomites (brushes, combs, towels, hats). STRICT CONTRAINDICATION — IMMEDIATELY REFUSE SERVICE, DISINFECT WORKSPACE, REFER TO PHYSICIAN / OTC PEDICULICIDE.
• Scabies: A highly contagious skin disease caused by the microscopic itch mite (Sarcoptes scabiei), which burrows beneath the skin to lay eggs, producing intense nocturnal itching and red pustular vesicles. CONTAGIOUS — DO NOT SERVICE.

3. Bacterial Infections (Staphylococcal Infections)

Bacterial infections of the scalp are primarily caused by Staphylococcus bacteria invading the hair follicle:

• Folliculitis: A superficial or deep bacterial infection of the hair follicles, producing small, red, pustular elevations surrounding the hair shaft (common in the beard area as folliculitis barbae or sycosis barbae).
• Furuncle (Boil): An acute, localized bacterial infection of a single hair follicle that produces constant, throbbing pain, deep localized swelling, erythema, and a central core of pus.
• Carbuncle: A larger, deeper, and more severe inflammation than a furuncle, formed by a cluster of interconnected hair follicles infected by Staphylococcus. Produces multiple drainage sinuses, fever, and severe pain.

[!CAUTION] Critical Contraindication Rule: Never touch, squeeze, drain, or perform any salon service on a client with a furuncle, carbuncle, folliculitis, or any open lesion. Doing so risks spreading severe staph infections (including MRSA) across the client's scalp or to yourself and other salon patrons.

Salon Treatable Conditions vs. Medical Referral Contraindications

The following table summarizes what a licensed cosmetologist may treat versus what must be refused and referred to a medical doctor: