The development of non-scarring alopecia in women who wear the hijab

Little is known about hair loss associated with wearing the hijab, a religious head covering worn by Muslim women. We performed a single-center analysis to investigate the association between various forms of non-scarring alopecia and wearing the hijab. This study included 125 patients who wore the hijab and 40 race/ethnicity-matched women who did not wear the hijab. Among the 165 total patients diagnosed between January 2015 and March 2022, 71 had telogen effluvium, 78 had female pattern hair loss, and 16 had traction alopecia. We found patients who wore the hijab had a younger mean age of alopecia onset than patients who did not wear the hijab (31.5 vs. 37.3 years; P = 0.02). Our study suggests that vitamin D deficiency (OR 4.1; 95% CI 1.2–14.1; P = 0.02) and seborrheic dermatitis (OR 2.9; 95% CI 1.1–8.1; P = 0.03) may significantly impact the development of telogen effluvium in patients who wear the hijab. Targeting these risk factors among patients who wear the hijab may be considered to prevent hair loss.


Introduction
Interest is growing in understanding the link between wearing the hijab, a religious head covering worn by Muslim women, and hair loss, but few studies have explored this phenomenon [3,4].Our goal was to investigate whether wearing the hijab was associated with various forms of nonscarring alopecia in women of Middle Eastern and South Asian race/ethnicity.

Methods
We retrospectively reviewed medical records of female adult patients with Middle Eastern or South Asian (Indian and Bangladeshi) race/ethnicity diagnosed with telogen effluvium (TE), female pattern hair loss (FPHL), or traction alopecia (TA) between January 2015 and March 2022 at our institution.Patients were grouped based on hijab preference.Alopecia diagnoses and potentially contributing disorders (seborrheic dermatitis and vitamin D deficiency [VDD]) were gathered.Chi-square and Fisher exact tests were conducted in SAS 9.4.

Discussion
Our results suggest that hijab-associated hair loss may be linked to TE with underlying VDD or seborrheic dermatitis.Previous studies indicate that women who wear a hijab might have lower vitamin D levels because of extensive body coverage outdoors [1,2].Also, the occlusive nature of hijab fabrics may alter the scalp microbiome and contribute to seborrheic dermatitis [5].For this population, we recommend early VDD screening with counseling on routine hair washing and use of breathable hijab fabrics to prevent seborrheic dermatitis [3].
Limitations of this study include a small sample size.Our population was gathered from race/ethnicity, rather than religion, due to electronic health record limitations, which may affect generalizability to the Muslim population.Some patients had multiple forms of alopecia; the primary diagnosis was selected in these cases.Larger prospective studies should address potential confounding factors to provide comprehensive insights into hair loss prevention strategies within this population.

Conclusion
Hair loss in Muslim women who wear the hijab may be influenced by VDD and seborrheic dermatitis, highlighting the need for strategies to address this unique dermatological challenge.
Table 1 Frequencies of telogen effluvium, female pattern hair loss, and traction alopecia diagnoses for Middle Eastern and South Asian women who do or do not wear the hijab a Row percentages are shown.Some patients had concurrent diagnoses of seborrheic dermatitis and vitamin D deficiency; therefore, the number of patients diagnosed with telogen effluvium or female pattern hair loss and concurrent disorder is larger than the total number of patients diagnosed with telogen effluvium or female pattern hair loss b P values were calculated using chi-square test for equal proportions, except for traction alopecia, which was analyzed with Fisher exact test for small sample sizes