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To the Editor: I would like to thank Dr Khumalo for her comments on our original article, “Hair care practices and associations with scalp and hair dermatoses among African-American girls.”1Rucker Wright D. Gathers R. Kapke A. Johnson D. Joseph C.L.M. Hair care practices and their association with scalp and hair disorders in African American girls.J Am Acad Dermatol. 2011; 64 (Epub 2010 Aug 21): 253-262Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar Dr Khumalo’s main concern is the use of self-report in our analyses. We did not have clinical examination as part of this exploratory and hypothesis-generating study. The authors acknowledge the limitation of self-report, which may lead to misclassification and biased results. However, there are other factors that can add credence to our observed associations in accordance with the Bradford-Hill criteria,2Hill A.B. The environment and disease: association or causation?.Proc R Soc Med. 1965; 58: 295-300PubMed Google Scholar such as the strength of the association, the biological plausibility of our study’s associations (which we detail in the Discussion section of our article), the consistency of the observed associations in different study samples, coherence with current theories on the pathogenesis of certain hair disorders, and the report of other associations between similar factors and diseases, such as braids and traction alopecia. Finally, to minimize misclassification, the questionnaire used in our study listed both medical and layman terminology for the conditions of interest, for example, ringworm (tinea capitis), dandruff (seborrheic dermatitis), and hair thinning around hairline/ponytail (traction alopecia). We also note that many national studies in the United States rely on self-report, including the Centers for Disease Control and Prevention National Health Interview Survey3Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System. Available at: http://www.cdc.gov/brfss/. Accessed November 20, 2010.Google Scholar and the Behavioral Risk Factor Surveillance System.4Centers for Disease Control and Prevention. National Health Interview Survey. Available at: http://www.cdc.gov/nchs/nhis.htm. Accessed November 20, 2010.Google Scholar Interestingly, a study by Jagou et al5Jagou M. Bastuji-Garin S. Bourdon-Lanoy E. Penso-Assathiany D. Roujeau J.C. Poor agreement between self-reported and dermatologists’ diagnoses for five common dermatoses.Br J Dermatol. 2006; 155: 1006-1012Crossref PubMed Scopus (37) Google Scholar evaluated the agreement between self-report and dermatologists’ diagnosis of 5 common dermatoses in 4622 adults and discovered that the self-reported prevalence was significantly lower than the actual prevalence for most diseases, including seborrheic dermatitis. I have observed this in my clinical practice where patients tend to under-recognize their symptoms of seborrhea, tinea capitis, folliculitis, and hair loss until they become severe. With regard to Dr Khumalo’s second point on distinguishing between cornrows and braids, we agree that the terms “braids” and “cornrows” may be used interchangeably by some people. Our results suggest that respondents were able to make some distinction, as evidenced by the difference in odds ratios representing the association of these practices with traction alopecia: OR (95% confidence interval) = 1.0 (0.4-2.3), P = .96 and 2.4 (1.1-5.3), P = .03 for braids and for cornrows, respectively. Patients should be educated about the greater risk for traction alopecia with certain styles in order to avoid styles that may be associated with increased risk of certain hair or scalp disorders. We agree that more U.S. studies are needed on the hair and scalp disorders that may be associated with certain cultural hair care practices and that these studies preferably be conducted with larger sample sizes. We hope our results, and the results of previous investigators, will encourage more research in this area. Hair care practices and scalp/hair disease in African American girlsJournal of the American Academy of DermatologyVol. 64Issue 6PreviewTo the Editor: The recent study by Rucker Wright et al1 is to be commended for being the first to investigate grooming practices in a clinic population of African American girls. This knowledge is crucial if we are to make strides in understanding scalp disease in patients with Afro-textured hair. However, the study does warrant a few comments regarding its stated aims, methods, results and their interpretation. Full-Text PDF