Effects of chemical straighteners on the hair shaft and scalp

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The first, in general, results from the use of acidic straighteners, have variable durability, and can present a cumulative effect with consecutive applications. The definitive ones, on the other hand, are permanent in the area of treatment and, as a rule, make use of alkaline substances.Several compounds are used by the population to obtain chemical straightening, regardless of their approval by legislation. In Brazil, the technique called “progressive brushing” has spread with the use of acidic straighteners, such as formaldehyde and glutaraldehyde. The procedure has been disseminated worldwide as a Brazilian keratin treatment, among other names. Formaldehyde is classified as a colorless, highly toxic substance that, at room temperature, is a flammable gas.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> The terms methanal, methyl aldehyde, methylene oxide, formalin, oxymethylene, formic aldehyde, methylene glycol, paraformaldehyde, and oxymethane are listed as synonyms.<a class="elsevierStyleCrossRefs" href="#bib0025">5,6</a> According to the National Health Surveillance Agency (ANVISA, Agência Nacional de Vigilância Sanitária), formaldehyde and glutaraldehyde are not listed as straighteners.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> Recently, substances that release formaldehyde only during the heating process have been used, such as methylene glycol, glyoxylic acid, timonacic acid.<a class="elsevierStyleCrossRefs" href="#bib0025">5,8</a> The so-called “safe keratin treatments” use glyoxylic acid associated with carbocysteine or amino acids, silicone derivatives and fatty acids.<a class="elsevierStyleCrossRef" href="#bib0045">9</a>The ANVISA Normative Instruction -NI - number 64 of 07/27/2020 established, under the terms of the Resolution of the Collegiate Board (RDC, Resolução de Diretoria Colegiada) N. 409, its “List of allowed active principles in cosmetic products to straighten or curl hair”, which includes: thioglycolic acid and its salts, thioglycolic acid esters, sodium or potassium hydroxide, lithium hydroxide, calcium hydroxide associated with guanidine salt, sulfites, and inorganic bisulfites.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> These are the traditional hair straighteners, commonly referred to as relaxers. Although there are divergences, in general, this name is used to designate alkaline straighteners. They can be classified as lye (sodium hydroxide based), no-lye, ammonium thioglycolate, and bisulfites.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> Hydroxides are divided into lye and no-lye. Some authors categorize thioglycolate in the no-lye group.<a class="elsevierStyleCrossRef" href="#bib0055">11</a>This article aims to identify the alterations in the hair shaft and scalp caused by the use of chemical straighteners.MethodsA search was carried out in the Pubmed, Lilacs and Scielo databases using the terms hair straightening, Brazilian hair treatment, Brazilian blowout, hair relaxer, formaldehyde hair, glyoxylic acid hair, thioglycolic hair, sodium hydroxide hair, calcium hydroxide hair, guanidine hair, potassium hydroxide hair, lithium hydroxide hair, alisamento cabelo, escova progressiva, relaxamento cabelo, formaldeído cabelo, ácido glioxílico cabelo, tioglicolato cabelo, hidróxido de sódio cabelo, hidróxido de cálcio cabelo, guanidina cabelo, hidróxido de potássio cabelo, hidróxido de lítio cabelo. Publications between January 2000 and May 2020 were included. The search period for the research was from 03/16/2020 to 05/20/2020. A total of 703 results were obtained.The criteria for article inclusion was the topic of hair straighteners and their effects on the scalp and hair shaft. All results unrelated to hair straighteners were excluded by reading the article titles. Review articles, letters to the editor and doctoral theses were excluded after reading the abstracts of these articles, (but articles resulting from doctoral theses published in scientific journals were included). Articles on the term “permanent” were also excluded because, although the substances overlap with chemical straighteners, the technique consists of different steps. Articles related to occupational exposure to chemical substances in straighteners and publications that analyzed the formulations without investigating their effects on hair shafts or scalp were excluded.Studies related to other hair techniques were not excluded when the information was mixed with that of straighteners (for example, the association of techniques) or when straightening was one of the studied subjects (in this case, the review only included information about straighteners). When the article jointly addressed the researched effects and systemic side effects, the latter were not detailed in the review.Therefore, after applying the inclusion and exclusion criteria, 649 articles were excluded. The search resulted in 33 articles, after removing the duplicates, which were selected for reading and review. The methods are depicted in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>ResultsAcid straighteners: formaldehyde, other aldehydes and formaldehyde derivativesFormaldehyde can cause allergic contact dermatitis with progressive severity after each re-exposure, with the clinical presentation of eczema on the scalp and adjacent regions and swelling on the face.<a class="elsevierStyleCrossRef" href="#bib0060">12</a>Cases of psoriasiform eczema on the scalp, face, neck, and upper trunk, occasionally with pustules, have been reported after treatment with a Brazilian keratin brushing. Dermoscopy revealed erythema and interfollicular and perifollicular desquamation, and histopathology showed psoriasiform and spongiotic patterns. The possibility has been raised that formaldehyde does not only causes lesions by allergic contact dermatitis or as a primary irritant, but it may induce reactions through other mechanisms.<a class="elsevierStyleCrossRef" href="#bib0065">13</a>As for changes in the hair shaft, a comparative analysis of the mechanical properties of the hairs after treatment with formaldehyde and glyoxylic acid showed, in both, a reduction in hair breakage resistance, water uptake and retention, and mass. The hair treated with formaldehyde showed an increase in cuticle irregularity, enhanced by the use of heat. Glyoxylic acid showed even greater damage. These would be evidence of the harmful effects of the products on the hair shaft, despite findings of increased denaturation temperature, absence of increased oxidative damage, and presence of shine observed after treatments.<a class="elsevierStyleCrossRef" href="#bib0070">14</a>Sanad et al. observed a better macroscopic appearance, correlated with the histopathological finding of reduced cuticle damage after the use of keratin straightener containing methylene glycol, in curly hair. On electron microscopy, two samples showed an increase in the density of intermacrofibrillar matrix in the cortex. Hair bleaching also occurred in some individuals, and hair loss was reported in 13.3%.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> In an evaluation of yak fibers and human hair by Boga et al., the sample treated with glyoxylic acid showed regular cuticles, whereas the sample treated with the basic solution and straightening iron showed more irregularities.<a class="elsevierStyleCrossRef" href="#bib0080">16</a>Goshiyama et al., when studying formulas with glyoxyloyl-carbocysteine and glyoxyloyl-amino acids of keratin, showed better straightening effect and more damage with more acidic solutions. Some of the side effects were changes in the strength, color, enthalpy and amount of tryptophan in the hairs. On electron microscopy, a film was observed on the treated hair, with a tighter cuticle, but which was partially removed after five washes.<a class="elsevierStyleCrossRef" href="#bib0085">17</a> The results are shown in <a class="elsevierStyleCrossRefs" href="#tbl0005">Table 1 and 2</a>.<a class="elsevierStyleCrossRefs" href="#bib0060">12–17</a><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Hair relaxersThe effects observed after more than one hair straightening with chemical relaxers include increased frizz, scalp desquamation, hair loss, thinning or weakening of the hair, hair dyschromia, trichoptilosis.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> In Kenya, 67% of women with Afro hair reported systemic and local effects after using different brands of hair relaxers. Among the dermatological manifestations, the following were mentioned: pain and/or desquamation on the scalp, allergic reactions, skin atrophy, weakening and/or change in hair color. The two most frequently mentioned effects were burns and hair loss. Despite the side effects, 55% chose to maintain some type of hair straightening method.<a class="elsevierStyleCrossRef" href="#bib0095">19</a>The impacts of a Brazilian brand straightener, which had two products labeled as “chemical-free” and whose average tested pH was between 1.39 and 2.82, included serious effects such as hair breakage or loss in 95%, loss of more than 40% of hair in 56%, absence of repilation in 9%, in addition to other hair and scalp alterations.<a class="elsevierStyleCrossRef" href="#bib0100">20</a> The pH of these products diverged from the alkaline standard of hair relaxers.<a class="elsevierStyleCrossRef" href="#bib0100">20</a>In addition to the chronic effects on the scalp, secondary acute alterations have been reported, as in the case of a diabetic patient who, after using calcium hydroxide, developed a burning sensation on the skin with contact dermatitis, which progressed to infection with multiple abscesses.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> Also, patients who had acute irritative symptoms on the scalp during the relaxing process subsequently developed areas of cicatricial alopecia, especially in the vertex of the scalp, with histological findings suggestive of central centrifugal cicatricial alopecia (CCCA).<a class="elsevierStyleCrossRef" href="#bib0110">22</a>Factors related to histopathologically confirmed CCCA were investigated by Shah & Alexis, and the use of hair relaxers was the most commonly reported element in patients with available data. However, due to the absence of a control group, it was not possible to establish an association.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> Gathers et al. and Olsen et al. found no relationship of relaxer use with the development of CCCA.<a class="elsevierStyleCrossRefs" href="#bib0120">24,25</a> However, Olsen et al. found a statistically significant association between age at the first hair relaxing and the presence of alopecia when comparing the pattern without alopecia with the patterns of more advanced alopecia (probable CCCA). Hair loss does not prevent the use of relaxers, although it does decrease as the severity increases.<a class="elsevierStyleCrossRef" href="#bib0125">25</a>Other types of alopecia are also a concern. In African-American girls, in which the prevalence of use of chemical relaxers was 42%, the previous use of relaxers doubled the risk of traction alopecia, and when associated with cornrow braids made 12 months before, the odds ratio exceeded five. Therefore, there is a risk in pulling relaxed hair into tight hairstyles.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> Some individuals may have structural changes related to major hair loss. In an atopic Nigerian woman, generalized proximal trichorrhexis nodosa was diagnosed after three episodes of universal hair loss related to relaxing procedures.<a class="elsevierStyleCrossRef" href="#bib0135">27</a>Studies have explored the difference in the response of hair from different ethnicities to straightening. When evaluating cuticle damage after the process of shaking the hairs in water, in samples treated with thiol straightener, there was greater susceptibility to damage in the treated hair, proportionally higher in Chinese hair than in Caucasian hair. Cuticle damage was demonstrated on electron microscopy.<a class="elsevierStyleCrossRef" href="#bib0140">28</a> Several procedures (including straightening), either associated or not, in natural black hair of different textures, did not result in a visible difference in clinical examination, on dermoscopy or optical microscopy. However on eléctron microscopy there was a significant difference between the groups, with more damage in those submitted to procedures compared to the control group, but not in relation to the type of hair or the specific treatment.<a class="elsevierStyleCrossRef" href="#bib0145">29</a>The behavior of Caucasian and Afro hair submitted to straightening with thioglycolate diverged. The demand in Joules for the combing of Afro hair decreased, but there were no drastic differences in the other hair types. In the evaluation of color, there was a greater variation in dark brown and Afro-ethnic hair. Treatment-virgin hair showed greater tensile strength than straightened hair in all hair types, and the use of thioglycolate did not result in additional loss of protein or tryptophan, except in Afro hair. On electron microscopy, dark brown wavy, curly, and Afro hair showed mild opening of the hair scales, fissures, and breakage.<a class="elsevierStyleCrossRef" href="#bib0150">30</a> Conversely, a study showed that Afro hair was more resistant to combined chemical stress. When straightening was combined with a commercial dye, the Afro cuticle and cortex were more resistant when compared to other ethnic groups. This was not expected, and perhaps hair mechanics themselves have been altered.<a class="elsevierStyleCrossRef" href="#bib0155">31</a>Straightened hair is more vulnerable to other hair techniques added to straighteners. Areas of permanent alopecia were found where an artificial hair implant of Italian-knot type had been associated with hair straightening.<a class="elsevierStyleCrossRef" href="#bib0160">32</a> The effects of the combination between hair dye and straighteners were studied in Caucasian dark brown and curly hair: the dye chosen by the researchers and straighteners increased, in relation to virgin hair, the loss of protein during washing. When the two were combined, there was no significant additional increase in these values, except for sodium hydroxide.<a class="elsevierStyleCrossRef" href="#bib0055">11</a>Alterations were also demonstrated at the molecular level. Straight hair samples exposed to sodium hydroxide showed increased oxidative alterations, increased dehydroalanine formation, side-chain dehydration, and cysteine damage, which likely corresponds to structural damage.<a class="elsevierStyleCrossRef" href="#bib0165">33</a> Protein integrity, represented by the level of tryptophan and other degradation products, was studied in response to damage after straightening with lye relaxing cream. Fluorescence for tryptophan decreased, but there was no difference in kynurenines (one of the metabolites of tryptophan), which may mean that both tryptophan and its metabolites are chemically degraded.<a class="elsevierStyleCrossRef" href="#bib0170">34</a>Afro and Caucasian white hairs were submitted to straightening with ammonia thioglycolate or triple treatment with the same straightener associated with discoloration with ammonia and hydrogen peroxide and also to the straightening iron use. After the treatments, important bonds were changed, with small differences between ethnicities. Straightening showed greater action on the band belonging to cysteic acid and resulted in lesions to the hairs, with cuticle irregularities and detachment and small undulations along them. The triple treatment showed hair shafts with irregular contours, cuticle detachment and deformation, as well as possible cortical damage.<a class="elsevierStyleCrossRef" href="#bib0175">35</a>When comparing product A (lye) with product B (no-lye, with guanidine hydroxide), Mamabolo et al. showed a decrease in cystine in the hairs after treatment with both products, with a greater loss with the use of product B. The reduction in cystine was accompanied by greater straightening activity.<a class="elsevierStyleCrossRef" href="#bib0180">36</a> There was no significant difference in the tolerability of the two products on the scalp.<a class="elsevierStyleCrossRef" href="#bib0180">36</a>Khumalo et al. found a difference in the amount of four amino acids (cystine, citrulline, arginine and glutamine) between the groups with and without straightening. Cystine levels in treated hair were similar to those found in trichothiodystrophy.<a class="elsevierStyleCrossRef" href="#bib0185">37</a>Focusing on inflammatory changes, Beach et al. collected some cytokines from the sebum of the scalp of women who underwent procedures with relaxers or remained with their natural hair. At sufficient levels for interpretation, IL-1α (pro-inflammatory) and IL-1ra (anti-inflammatory) were detected, and although cytokine differences between the vertex and crown may reflect a distinct predisposition of scalp sites to inflammation, it was not possible to demonstrate changes in specific inflammatory cytokines after use of relaxers.<a class="elsevierStyleCrossRef" href="#bib0190">38</a> Tackey et al., using a three-dimensional epidermis model, compared lye and no-lye straighteners paired with untreated controls in relation to cytokines involved in the modulation of irritation after hair straightening. IL-1α reached higher levels at 24 and 48 hours after the use of a no-lye straightener. Both straighteners resulted in higher prostaglandin E2 (PGE2) levels than controls at all assessed periods, and the cytokine could account for sensory differences between different types of products.<a class="elsevierStyleCrossRef" href="#bib0195">39</a>Conditioning and protective agents can minimize damage caused by straighteners, and their interference with straightening effectiveness is controversial.<a class="elsevierStyleCrossRefs" href="#bib0200">40–42</a> Findings are summarized in <a class="elsevierStyleCrossRefs" href="#tbl0015">Tables 3–7</a>.<a class="elsevierStyleCrossRefs" href="#bib0055">11,18–43</a><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><elsevierMultimedia ident="tbl0035"></elsevierMultimedia>Straighteners in generalRegarding exposure to straighteners, Marks et al. compared patients with cicatricial alopecia and patients with non-cicatricial alopecia (control group). There was a significant difference in the groups regarding prior history of chemical straightening (25% in the scarring alopecia group and 13% in the non-scarring group), mainly due to patients with lichen planopilaris (LPP) and frontal fibrosing alopecia (FFA).<a class="elsevierStyleCrossRef" href="#bib0215">43</a> This study does not specify which straighteners were used by the subjects; however, it mentions sodium hydroxide and glutaraldehyde as examples.<a class="elsevierStyleCrossRef" href="#bib0215">43</a> The summary of results is shown in <a class="elsevierStyleCrossRef" href="#tbl0040">Table 8</a>.<a class="elsevierStyleCrossRef" href="#bib0215">43</a><elsevierMultimedia ident="tbl0040"></elsevierMultimedia>DiscussionStraighteners based on formaldehyde or derivatives consist, in general, of aldehyde and proteins such as hydrolyzed keratin: after exposure to heat, the aldehyde would promote a cross-link between the keratins in the product and those in the hair.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> Supposedly, straightening occurs by diffusing keratin into the cortex, filling in the defects, and restructuring the hairs; however, there is no evidence of this effect.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> The use of formaldehyde and glutaraldehyde as hair straighteners is not legal in Brazil.<a class="elsevierStyleCrossRef" href="#bib0035">7</a>Products with glyoxylic acid are mentioned on the ANVISA website as glyoxyloyl-carbocysteine and glyoxyloyl keratin amino acids in the section “recommendations on straighteners - what should I find on the label of these products”, with the consideration that they must warn the consumer about the risk of hair loss or change in hair color.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> However, the substance does not appear in the NI n. 64 of the organization.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> Carbocisteine is not a straightener when used alone, but it is usually combined with glyoxylic acid.<a class="elsevierStyleCrossRef" href="#bib0040">8</a>Acid straighteners remain a constant in straightening products. Locally, formaldehyde can cause dermatitis, including allergic eczema and psoriasiform eczema.<a class="elsevierStyleCrossRefs" href="#bib0060">12,13</a> The medical literature reports of scalp reactions may be underestimated, as irritant contact dermatitis following formaldehyde use is often considered to be a normal effect by users. In the hair shaft, formaldehyde and glyoxylic acid, despite the macroscopic appearance of hair shine, worsened cuticle irregularity on electron microscopy and decreased resistance to breakage.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> However, other studies have not shown the same damage.<a class="elsevierStyleCrossRefs" href="#bib0075">15,16</a> Although there are changes in strength, hair color, and other evidence of damage to the shaft, the Work for the combing the hair decreases with acidic straighteners, as shown in a study with glyoxylic acid.<a class="elsevierStyleCrossRef" href="#bib0085">17</a>As for the straighteners permitted by law in Brazil, they comprise those listed in NI n. 64 of ANVISA.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> The hydroxides act due to their high pH, opening the cuticles and allowing the action of the alkaline reducing agent in the cortex, where the disulfide bonds are broken. The hair is then mechanically straightened with the restructuring of the bonds between the keratins. Then, the hair is exposed to the acidic substance to terminate the process and close the cuticles (neutralization process).<a class="elsevierStyleCrossRefs" href="#bib0005">1,8,44</a> Alkalis react with cystine and produce lanthionine, a process called lanthionization. This process replaces one-third of the cystine with lanthionine.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> There is no need for heat or external traction.8 In contrast, thioglycolate does not act by lanthionization, but through a selective reduction of cystine bonds without changing the entire protein, being neutralized with hydrogen peroxide or sodium bromate, and the bonds are rearranged.<a class="elsevierStyleCrossRefs" href="#bib0040">8,44</a> Heat should be applied for the heat treatment step.<a class="elsevierStyleCrossRefs" href="#bib0040">8,44</a> Its use is commonly referred to as the “Japanese brushing”.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> It maintains 90% of the cystine content, and 10% becomes cysteic acid.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> There is also ammonium bisulfite, which is less aggressive, less effective, and more commonly used in household products.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>Relaxer-type straighteners are not free of side effects. Allergies, hair shaft frizz, dry hair, thinning and weakening of hairs, trichoptilosis, and hair color change have been reported.<a class="elsevierStyleCrossRefs" href="#bib0090">18–20,30</a> On the scalp, desquamation, pain, atrophy, even burns, and potentially severe cases of contact eczema with secondary infection have been reported.<a class="elsevierStyleCrossRefs" href="#bib0090">18–21</a>The long-term consequences of acute inflammation are not known, but they are even thought to be related to central centrifugal cicatricial alopecia.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> One hypothesis would be that cytokine changes caused by straighteners might play a role in the inflammatory process.<a class="elsevierStyleCrossRef" href="#bib0190">38</a> The role of cytokines, including their relationship to the sensory diferences among several types of products, has been studied.<a class="elsevierStyleCrossRef" href="#bib0195">39</a>Hair loss has also been described , including irreversible alopecia.<a class="elsevierStyleCrossRefs" href="#bib0090">18–20</a> Data regarding the association with CCCA diverge.<a class="elsevierStyleCrossRefs" href="#bib0115">23–25,43</a> There is an increased risk of traction alopecia with relaxers, especially if associated with cornrow braids, and generalized proximal trichorrhexis nodosa was associated with hair straightening.<a class="elsevierStyleCrossRefs" href="#bib0130">26,27</a>The hair shaft, with the use of relaxers, show an increase in the inter-scale distance, the opening of the scales, irregularity of their edges, fissures, severe lifting of the cuticle with exposure of the cortex, damage to the fiber, increase in particles extracted from them.<a class="elsevierStyleCrossRefs" href="#bib0140">28–30,35</a>The use of straighteners concomitantly with other hair techniques seems to increase the vulnerability to damage. Hair relaxing in addition to the use of artificial hair implants has been related to areas of permanent alopecia.<a class="elsevierStyleCrossRef" href="#bib0160">32</a> Hair relaxers resulted in a greater propensity for protein loss, and when combined with hair dye, sodium hydroxide was even more aggressive.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> The summation of ammonium thioglycolate straightening, discoloration, and straightening iron resulted in hairs with irregular contours, cuticle detachment and deformation, and possible cortical damage.<a class="elsevierStyleCrossRef" href="#bib0175">35</a>Regarding lye and no-lye straighteners, a difference was found in the number of amino acids of treated hair compared to virgin hair. The decrease in cystine, present in the disulfide bonds that give hair strength, is evident.<a class="elsevierStyleCrossRef" href="#bib0185">37</a> Cysteine deterioration was observed at the molecular level in European straight hair exposed to sodium hydroxide<a class="elsevierStyleCrossRef" href="#bib0165">33</a> and straightening with lye relaxer degraded tryptophan;<a class="elsevierStyleCrossRef" href="#bib0170">34</a> however, the use of thioglycolate did not result in additional loss of protein or tryptophan.<a class="elsevierStyleCrossRef" href="#bib0150">30</a> Comparing lye and no-lye straighteners, there was a reduction in cystine after the use of both, with a greater loss with no-lye straighteners.<a class="elsevierStyleCrossRef" href="#bib0180">36</a>Hairs of different ethnicities seem to diverge regarding their susceptibility to straightening, with mixed findings in the literature.<a class="elsevierStyleCrossRefs" href="#bib0155">31,35</a> Structural damage can be minimized by using conditioning agents, some ceramides, and waxes.<a class="elsevierStyleCrossRefs" href="#bib0200">40–42</a> Despite the side effects, many women choose to straightening their hair.<a class="elsevierStyleCrossRefs" href="#bib0095">19,25</a>The study limitations were: the search was restricted to three databases only; the search was carried out in two languages only; there is a scarcity of research, resulting in low scientific rigor for article inclusion; accepting different study designs.ConclusionThe review of data related to the last 20 years, despite limitations, discloses the significant occurrence of alterations in the hair shaft and scalp secondary to hair straightening. Clinical and subclinical inflammation of the scalp, damage to hair, hair loss due to breakage were evident. The long-term effects are still unknown.Health professionals, especially dermatologists, as well as beauty salon professionals and their clients, need to know about the risks and benefits of these chemical treatments.ANVISA’s recent norm limits the registration of straighteners; however, it does not clarify the new “acid straighteners”, such as glyoxylic acid.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> The effects of acidic straighteners are a matter for research, especially because of the Brazilian multicenter study that hypothesized the association of frontal fibrosing alopecia with formalin-straightening procedures.<a class="elsevierStyleCrossRef" href="#bib0225">45</a>Studies carried out with scientific rigor are necessary to better understand the responses of hair structures to chemical agents, especially their relationship with the development of alopecia.This research did not receive any specific funding from public, private or nonprofit funding agencies.Financial supportNone declared.Authors’ contributionsJoane Nathache Hatsbach de Paula: Design and planning of the study; collection, analysis, and interpretation of data; critical review of the literature; drafting and editing of the manuscript.Flávia Machado Alves Basílio: Design and planning of the study; effective participation in research orientation; critical review of the manuscript; approval of the final version of the manuscript.Fabiane Andrade Mulinari-Brenner: Effective participation in research orientation; critical review of the manuscript; approval of the final version of the manuscript.Conflicts of interestNone declared." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1688458" "titulo" => "Abstract" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Study limitations" ] 5 => array:2 [ "identificador" => "abst0030" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1497316" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 3 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 4 => array:3 [ "identificador" => "sec0015" "titulo" => "Results" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Acid straighteners: formaldehyde, other aldehydes and formaldehyde derivatives" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Hair relaxers" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Straighteners in general" ] ] ] 5 => array:2 [ "identificador" => "sec0035" "titulo" => "Discussion" ] 6 => array:2 [ "identificador" => "sec0040" "titulo" => "Conclusion" ] 7 => array:2 [ "identificador" => "sec0045" "titulo" => "Financial support" ] 8 => array:2 [ "identificador" => "sec0050" "titulo" => "Authors’ contributions" ] 9 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-10-06" "fechaAceptado" => "2021-02-01" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1497316" "palabras" => array:5 [ 0 => "Alopecia" 1 => "Hair" 2 => "Hair diseases" 3 => "Hair preparations" 4 => "Keratins, hair-specific" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "BackgroundThe effects of chemical straighteners on the scalp and hair shaft are not fully known, although such substances are widely used. Hair straightening became popular in Brazil with the use of formaldehyde and its derivatives, despite the prohibition by the current legislation. ObjectiveTo identify changes in hair shaft and scalp caused by the use of chemical straighteners. MethodsA search was performed using keywords in three databases from 03/16/2020 to 05/20/2020, with publications between the years 2000 to 2020. After applying the inclusion and exclusion criteria, 33 articles were selected for review. ResultsIn some studies, hair relaxers were associated with eczema, desquamation, pain, burns, and inflammation in the scalp. Hair loss, damage to the shaft, alteration in the color of the hairs and in the composition of their amino acids were observed. Findings are variable across the studies. Study limitationsThe search was restricted to three databases, in two languages, different study designs were accepted. ConclusionsStraightening techniques can have side effects, including scalp inflammation, damage to the shaft, and hair loss. Its long-term effects remain unknown and further studies are necessary." "secciones" => array:6 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Study limitations" ] 5 => array:2 [ "identificador" => "abst0030" "titulo" => "Conclusions" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "⋆" "nota" => "Study conducted at the Department of Dermatology, Complexo Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil." ] ] "multimedia" => array:9 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1336 "Ancho" => 2675 "Tamanyo" => 207219 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Article selection methodology." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table 1" "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "n, Number of patients; F, Female; M, Male." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Author \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Study type \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Population \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Hair straightener \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Scalp alterations \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Van Lerberghe & Baeck.,<a class="elsevierStyleCrossRef" href="#bib0060">12</a> 2014. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Case report \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n = 1 (F:1, M:0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Formaldehyde \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Allergic contact dermatitis. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Gavazzoni-Dias et al.,<a class="elsevierStyleCrossRef" href="#bib0065">13</a> 2016.</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Case series</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n = 7</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Brazilian keratin treatment</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Psoriasiform eczema. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Biopsies (n = 4) compatible with psoriasiform dermatitis and psoriasiform spongiotic dermatitis. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2872324.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Studies on the effects of acid hair straighteners on the scalp." ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table 1" "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "n, Number of patients; F, Female; M, Male." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Author \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Study type \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Population \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Hair straightener \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Hair shaft alteration \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Leite & Maia Campos.,<a class="elsevierStyleCrossRef" href="#bib0070">14</a> 2017.</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical trial</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Curly hair samples</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Glyoxylic acid and formaldehyde</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reduced resistance to hair breakage and diminished hair mass, less water uptake and retention, increased cuticle irregularity. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Increased denaturation temperature, stable oxidative damage. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="6" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sanad et al.,<a class="elsevierStyleCrossRef" href="#bib0075">15</a> 2019.</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="6" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical trial</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="6" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n = 30 (F:30 M:0)</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="6" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Methylene glycol</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Increased softness and shine at macroscopic examination. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No changes in trichoptilosis or in cross-sectional fissures. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reduction of cuticle damage on histopathology, but no cuticle repair on electron microscopy. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Increased density of intermacrofibrillar matrix in the cortex (n = 2). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Shaft bleaching (n = 9). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hair loss (n = 4). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Boga et al.,<a class="elsevierStyleCrossRef" href="#bib0080">16</a> 2014. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical trial \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yak fibers and human hair \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Glyoxylic acid \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Persistence of cuticular regularity under electron microscopy. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Goshiyama et al.,<a class="elsevierStyleCrossRef" href="#bib0085">17</a> 2020</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical trial</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dark brown curly hair samples</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Glyoxyloyl-carbocysteine and glyoxyloyl -Amino keratin acids</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reduction in combing Work: 59.4% (pH 1.0), 33.3% (pH 2.0). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reduction of strand strength by: 15.7% (pH 1.0), 8.7% (pH 2.0). No statistical significance. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Color changes and reduction in hair shaft enthalpy in both pHs. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2872326.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Studies on the effects of acidic straighteners on the hair shaft." ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "n, Number of patients; F, Female; M, Male." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Author \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Study type \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Population \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Hair straightener agent \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Alterations in hairs and scalp \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Shetty et al.,<a class="elsevierStyleCrossRef" href="#bib0090">18</a> 2013.</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cross-sectional (questionnaire)</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n = 90 (F:90, M:0)</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chemical relaxers</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Increased frizz (67% of cases), thinning or weakening of the hair (40%), dyschromia (greying) of the hair (22%), trichoptilosis (17%). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Scalp desquamation (61%) and hair loss (47%). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Etemesi BA.,<a class="elsevierStyleCrossRef" href="#bib0095">19</a> 2007.</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cross-sectional (questionnaire)</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">242 (F:242, M:0)</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chemical relaxers</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Weakening and/or changing of hair color. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Scalp pain and/or desquamation, allergic reactions, thinning of the skin, burns and hair loss. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Kaur et al.,<a class="elsevierStyleCrossRef" href="#bib0105">21</a> 2002. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Case report \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n = 1 (F:1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Calcium hydroxide \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Contact eczema and secondary staphylococcal infection. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2872329.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Studies that evaluated signs and symptoms from hair straighteners." ] ] 4 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "n, Number of patients; F, Female; M, Male." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Author \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Study type \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Population \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Hair straightener agent \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Alterations in hairs and scalp \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Swee et al.,<a class="elsevierStyleCrossRef" href="#bib0100">20</a> 2000.</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cross-sectional (questionnaire)</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n = 464 (F:457, M:5, non- identified: 2)</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Acid straightener (non-traditional) with metallic salts</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hair breakage or loss (95% of cases), dry or coarse hair (70%), hair discoloration (28%). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dry scalp (53%), burning pain in the scalp (25%). \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2872325.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Study that evaluated signs and symptoms of a hair straightener (non-traditional acid straightener)." ] ] 5 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "n, Number of patients; F, Female; M, Male." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Author \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Study type \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Population \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Hair straightener \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Scalp alterations \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Khumalo et al.,<a class="elsevierStyleCrossRef" href="#bib0110">22</a> 2007. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Case series \t\t\t\t\t\t\n \t\t\t\t</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n = 5 (F:5, M:0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sodium hydroxide (n = 3) and Guanidine hydroxide (n = 2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Irritative symptoms and development of areas of cicatricial alopecia. Histological findings of perifollicular lymphocytic infiltrate, follicular fibrosis, and premature desquamation of the inner root sheath. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Shah & Alexis,<a class="elsevierStyleCrossRef" href="#bib0115">23</a> 2010. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Case series \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n = 69 (F:67, M:2) (64: data on hair care) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chemical relaxers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Straighteners were the most common traumatic practice in patients with CCCA. It was not possible to establish an association due to the absence of a control group. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Gathers et al.,<a class="elsevierStyleCrossRef" href="#bib0120">24</a> 2009.</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Case-control study</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n = 101 (F:101, M:0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chemical relaxers</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">There is no relationship between the use of relaxers, their frequency of application or complications from their use with the development of CCCA.</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CCCA Group (n = 51). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Group without cicatricial alopecia (n = 50). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Olsen et al.,<a class="elsevierStyleCrossRef" href="#bib0125">25</a> 2011</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Case-control study</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n = 529 (F:529, M:0)</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chemical relaxers</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No association was observed between the use of straighteners or reaction to their use with extensive central hair loss. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Association between age at first hair straightening and hair loss pattern when comparing pattern 0 (no loss) vs. patterns 3 and 5 (probable CCCA). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rucker et al.,<a class="elsevierStyleCrossRef" href="#bib0130">26</a> 2011. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cross-sectional (questionnaire) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n = 201 (F:201, M:0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chemical relaxers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hair straightening was a risk factor for traction alopecia (OR = 2.2; (95%CI 1.1–4.5; p = 0.03). Straightening associated with cornrow braids: OR = 5.27 (95% CI 1.5–18.32; p = 0.009). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ogunbiyi et al.,<a class="elsevierStyleCrossRef" href="#bib0135">27</a> 2014. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Case report \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n = 1 (F:1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chemical relaxers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hair loss associated to generalized proximal trichorrhexis nodosa, with atopy as the baseline condition. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Amorim et al.,<a class="elsevierStyleCrossRef" href="#bib0160">32</a> 2017. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cross-sectional \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n = 30 (F:30, M:0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sodium hydroxide or guanidine hydroxide. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Areas of permanent alopecia were found where an artificial hair implant of Italian-knot type had been associated with hair straightening. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2872328.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Studies that evaluated the association of hair straighteners with alopecia." ] ] 6 => array:8 [ "identificador" => "tbl0030" "etiqueta" => "Table 6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0035" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "n, Number of patients; F, Female; M, Male." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Author \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Study type \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Population \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Hair straightener \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Alterations in hair strand and scalp \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Galliano et al.,<a class="elsevierStyleCrossRef" href="#bib0140">28</a> 2010.</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical trial</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n = 12 (6 Chinese hair samples and 6 Caucasian hair samples)</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Thiol straightener</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Increased inter-scale distance, scale inclination and edge irregularity. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Average size of particles extracted from hair after stirring in water for 30 minutes: different between ethnicities and proportionally greater increase in Chinese hair. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Kaliyadan et al.,<a class="elsevierStyleCrossRef" href="#bib0145">29</a> 2016.</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cross-sectional</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n = 25 (F:25) (19 subjects and 6 controls)</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chemical relaxers</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In straightening only (n = 2): curly hair had grade 2 damage (severe cuticle lift, fissures or gaps with exposed cortex) and wavy hair had grade 0 (intact cuticle). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In straightening associated with hair dye (n = 7): damage degrees from 1 (irregular cuticle without fissures or gaps) to 2. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In the association of straightening, discoloration and hair dye (n = 1): grade 3 damage (partially exposed cortex). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In the control group (wavy or straight hair): damage degree from 0 to 1. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bloch et al.,<a class="elsevierStyleCrossRef" href="#bib0150">30</a> 2019.</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical trial</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Samples of Caucasian hair (straight dark brown; straight blond; wavy dark brown; and curly dark brown) and Afro hair.</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ammonia thioglycolate</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">71% reduction in Work (in Joules) for the combing of Afro hair. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Greater color variation in dark brown and Afro-ethnic hair. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Decreased tensile strength in all hair types. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No additional loss of protein or tryptophan (except in Afro hair). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Afro, curly and wavy dark brown hair: discreet opening of the scales, fissures and breakage. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lee et al.,<a class="elsevierStyleCrossRef" href="#bib0155">31</a> 2014.</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical trial</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Asian, Caucasian, European and African American hair samples.</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ammonia thioglycolate</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In straightening: Asian hair cuticles were the most resistant. The damage to the cortex was similar in the three groups. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In straightening combined with commercial dye: the African American cuticle and cortex were the most resistant. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The three groups showed similar patterns of cell membrane damage after straightening or straightening combined with dye. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">França-Stefoni et al.,<a class="elsevierStyleCrossRef" href="#bib0055">11</a> 2015.</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical trial</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dark brown curly Caucasian hair.</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ammonia thioglycolate, guanidine hydroxide, sodium hydroxide</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Additional protein loss in washing: dye (48%), ammonia thioglycolate (159%); guanidine hydroxide (188%); sodium hydroxide (276%). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">When combined with dye, ammonia thioglycolate and guanidine hydroxide did not cause a significant additional increase in protein loss. Sodium hydroxide did. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dyer et al.,<a class="elsevierStyleCrossRef" href="#bib0165">33</a> 2013. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical trial \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">European straight hair samples \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sodium hydroxide \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Increased oxidative alterations, alkali-associated damage, increased dehydroalanine formation and side chain dehydration, and cysteine damage. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">McMullen et al.,<a class="elsevierStyleCrossRef" href="#bib0170">34</a> 2011. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical trial \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Samples of dark brown European hair and Piedmont hair \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sodium hydroxide \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Degradation of tryptophan and its metabolites. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dos Santos et al.,<a class="elsevierStyleCrossRef" href="#bib0175">35</a> 2019.</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical trial</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Afro and Caucasian white hair samples</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ammonia thioglycolate</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fiber lesions, with irregularities and cuticle detachment, and small undulations along its extension. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Association of straightening with discoloration and straightening iron: irregular-contour hairs, cuticle detachment and deformation, and possible cortical damage. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mamabolo et al.,<a class="elsevierStyleCrossRef" href="#bib0180">36</a> 2013.</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical trial</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">N: 5 (F:5, M:0)</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sodium hydroxide and guanidine hydroxide</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Guanidine hydroxide: greater softness, smooth appearance, shine, and less dry appearance. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The two products were similar regarding damage. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The no-lye straightener showed fewer split ends. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cystine content is reduced with lye straightener and more intensely with no-lye straightener. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lysine decreased in relation to virgin hair for the two straighteners; however, with no statistical difference between them. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Khumalo et al.,<a class="elsevierStyleCrossRef" href="#bib0185">37</a> 2010. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Historical cohort \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n = 30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chemical relaxers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cystine, citrulline (not always with statistical significance) and arginine decreased and glutamine increased in straightened hair. Cystine levels were lower in treated hair than in virgin hair, with levels similar to those found in trichothiodystrophy. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Beach et al.,<a class="elsevierStyleCrossRef" href="#bib0190">38</a> 2012.</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical trial</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n = 36 (F:30, M:0)</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Guanidine hydroxide, sodium hydroxide, ammonium thioglycolate</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">IL-1α and IL-1ra were detected on the scalp. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">After the straightening, the levels of IL-1α and IL-1ra on the crown and vertex were lower, but with no difference compared to the group that did not straighten the hair. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">It was not possible to demonstrate changes in specific inflammatory cytokines after use of straighteners. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tackey et al.,<a class="elsevierStyleCrossRef" href="#bib0195">39</a> 2013.</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical trial</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Three-dimensional epidermis model</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sodium hydroxide, guanidine hydroxide</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">IL-1α: at 4h of application there was no significant difference between the groups of straighteners, and at 24h and 48h the no-lye straightener reached higher levels. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">IL-1ra: always higher with no-lye. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Both types had similar IL-1ra/IL-1α ratios in the early phases(suggestive of lack of relationship with immediate discomfort after application) and late phases; however the no-lye straightener had a higher ratio at 24h. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PGE2 levels were higher than in controls at all phases. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2872323.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Studies on hair straighteners with morphological and physiological assessments." ] ] 7 => array:8 [ "identificador" => "tbl0035" "etiqueta" => "Table 7" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0040" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Author \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Study type \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Population \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Hair straightener \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Effects on hairs \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">De Sá Dias et al.,<a class="elsevierStyleCrossRef" href="#bib0200">40</a> 2008. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical trial \t\t\t\t\t\t\n \t\t\t\t</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Afro hair samples \t\t\t\t\t\t\n \t\t\t\t</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ammonia thioglycolate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Conditioning agents added to the straightener resulted in less protein loss, in fiber protection and in increased strength to breakage. However, it may reduce the effectiveness of straightening. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bernard et al.,<a class="elsevierStyleCrossRef" href="#bib0205">41</a> 2002. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical trial \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">African-American hair samples \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Guanidine hydroxide or sodium hydroxide \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The use of ceramides (in this case, C18-dhCer) prevented damage to straightened hair. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vermeulen et al.,<a class="elsevierStyleCrossRef" href="#bib0210">42</a> 2004. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical trial \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hair samples \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sodium hydroxide, lithium hydroxide \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Addition of polymethylene waxes to a straightening formula resulted in a better appearance compared to commercial formulas, without minimizing performance. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2872330.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Studies about prevention of structural damage during the use of hair straighteners." ] ] 8 => array:8 [ "identificador" => "tbl0040" "etiqueta" => "Table 8" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0045" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "n, Number of patients; F, Female; M, Male." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Author \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Study type \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Population \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Straightener agent \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Alterations \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Marks et al.,<a class="elsevierStyleCrossRef" href="#bib0215">43</a> 2019.</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Case-control</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n = 286 (n = 43 patients with cicatricial alopecia), (143 patients with non-cicatricial alopecia: control group)</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chemical straightener</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Higher frequency of hair straightening in the cicatricial alopecia group (25%) compared to the control group (13%). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prior history of straightening in 21% in LPP/FFA group and in 10% of paired controls. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CCCA: more cumulative exposure to straighteners. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2872327.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Studies on the effects of acid straighteners and traditional straighteners (hair relaxers)." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:45 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hair care products: waving, straightening, conditioning, and coloring" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C. 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Effects of chemical straighteners on the hair shaft and scalp

Joane Nathache Hatsbach de Paula

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joanedermatologista@gmail.com

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, Flávia Machado Alves Basílio, Fabiane Andrade Mulinari-Brenner

Department of Dermatology, Complexo Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil

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    "titulo" => "Effects of chemical straighteners on the hair shaft and scalp"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Article selection methodology&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The hair shaft consists of three layers with keratin in its composition&#58; medulla&#44; cortex and cuticle&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> Keratins are proteins rich in cysteine &#8203;&#8203;residues&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> Adjacent keratin chains join through tightly bonded disulfide bridges and other bonds such as Van der Waals&#44; hydrogen bonds&#44; and salt bonds&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The hair shaft can be changed in shape by progressive or permanent chemical straightening&#46; The first&#44; in general&#44; results from the use of acidic straighteners&#44; have variable durability&#44; and can present a cumulative effect with consecutive applications&#46; The definitive ones&#44; on the other hand&#44; are permanent in the area of treatment and&#44; as a rule&#44; make use of alkaline substances&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Several compounds are used by the population to obtain chemical straightening&#44; regardless of their approval by legislation&#46; In Brazil&#44; the technique called &#8220;progressive brushing&#8221; has spread with the use of acidic straighteners&#44; such as formaldehyde and glutaraldehyde&#46; The procedure has been disseminated worldwide as a Brazilian keratin treatment&#44; among other names&#46; Formaldehyde is classified as a colorless&#44; highly toxic substance that&#44; at room temperature&#44; is a flammable gas&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The terms methanal&#44; methyl aldehyde&#44; methylene oxide&#44; formalin&#44; oxymethylene&#44; formic aldehyde&#44; methylene glycol&#44; paraformaldehyde&#44; and oxymethane are listed as synonyms&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> According to the National Health Surveillance Agency &#40;ANVISA&#44; <span class="elsevierStyleItalic">Ag&#234;ncia Nacional de Vigil&#226;ncia Sanit&#225;ria</span>&#41;&#44; formaldehyde and glutaraldehyde are not listed as straighteners&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Recently&#44; substances that release formaldehyde only during the heating process have been used&#44; such as methylene glycol&#44; glyoxylic acid&#44; timonacic acid&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;8</span></a> The so-called &#8220;safe keratin treatments&#8221; use glyoxylic acid associated with carbocysteine &#8203;&#8203;or amino acids&#44; silicone derivatives and fatty acids&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The ANVISA Normative Instruction -NI - number 64 of 07&#47;27&#47;2020 established&#44; under the terms of the Resolution of the Collegiate Board &#40;RDC&#44; <span class="elsevierStyleItalic">Resolu&#231;&#227;o de Diretoria Colegiada</span>&#41; N&#46; 409&#44; its &#8220;List of allowed active principles in cosmetic products to straighten or curl hair&#8221;&#44; which includes&#58; thioglycolic acid and its salts&#44; thioglycolic acid esters&#44; sodium or potassium hydroxide&#44; lithium hydroxide&#44; calcium hydroxide associated with guanidine salt&#44; sulfites&#44; and inorganic bisulfites&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> These are the traditional hair straighteners&#44; commonly referred to as relaxers&#46; Although there are divergences&#44; in general&#44; this name is used to designate alkaline straighteners&#46; They can be classified as lye &#40;sodium hydroxide based&#41;&#44; no-lye&#44; ammonium thioglycolate&#44; and bisulfites&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Hydroxides are divided into lye and no-lye&#46; Some authors categorize thioglycolate in the no-lye group&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">This article aims to identify the alterations in the hair shaft and scalp caused by the use of chemical straighteners&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">A search was carried out in the Pubmed&#44; Lilacs and Scielo databases using the terms hair straightening&#44; Brazilian hair treatment&#44; Brazilian blowout&#44; hair relaxer&#44; formaldehyde hair&#44; glyoxylic acid hair&#44; thioglycolic hair&#44; sodium hydroxide hair&#44; calcium hydroxide hair&#44; guanidine hair&#44; potassium hydroxide hair&#44; lithium hydroxide hair<span class="elsevierStyleItalic">&#44; alisamento cabelo&#44; escova progressiva&#44; relaxamento cabelo&#44; formalde&#237;do cabelo&#44; &#225;cido gliox&#237;lico cabelo&#44; tioglicolato cabelo&#44; hidr&#243;xido de s&#243;dio cabelo&#44; hidr&#243;xido de c&#225;lcio cabelo&#44; guanidina cabelo&#44; hidr&#243;xido de pot&#225;ssio cabelo&#44; hidr&#243;xido de l&#237;tio cabelo</span>&#46; Publications between January 2000 and May 2020 were included&#46; The search period for the research was from 03&#47;16&#47;2020 to 05&#47;20&#47;2020&#46; A total of 703 results were obtained&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The criteria for article inclusion was the topic of hair straighteners and their effects on the scalp and hair shaft&#46; All results unrelated to hair straighteners were excluded by reading the article titles&#46; Review articles&#44; letters to the editor and doctoral theses were excluded after reading the abstracts of these articles&#44; &#40;but articles resulting from doctoral theses published in scientific journals were included&#41;&#46; Articles on the term &#8220;permanent&#8221; were also excluded because&#44; although the substances overlap with chemical straighteners&#44; the technique consists of different steps&#46; Articles related to occupational exposure to chemical substances in straighteners and publications that analyzed the formulations without investigating their effects on hair shafts or scalp were excluded&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Studies related to other hair techniques were not excluded when the information was mixed with that of straighteners &#40;for example&#44; the association of techniques&#41; or when straightening was one of the studied subjects &#40;in this case&#44; the review only included information about straighteners&#41;&#46; When the article jointly addressed the researched effects and systemic side effects&#44; the latter were not detailed in the review&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Therefore&#44; after applying the inclusion and exclusion criteria&#44; 649 articles were excluded&#46; The search resulted in 33 articles&#44; after removing the duplicates&#44; which were selected for reading and review&#46; The methods are depicted in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Results</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Acid straighteners&#58; formaldehyde&#44; other aldehydes and formaldehyde derivatives</span><p id="par0050" class="elsevierStylePara elsevierViewall">Formaldehyde can cause allergic contact dermatitis with progressive severity after each re-exposure&#44; with the clinical presentation of eczema on the scalp and adjacent regions and swelling on the face&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Cases of psoriasiform eczema on the scalp&#44; face&#44; neck&#44; and upper trunk&#44; occasionally with pustules&#44; have been reported after treatment with a Brazilian keratin brushing&#46; Dermoscopy revealed erythema and interfollicular and perifollicular desquamation&#44; and histopathology showed psoriasiform and spongiotic patterns&#46; The possibility has been raised that formaldehyde does not only causes lesions by allergic contact dermatitis or as a primary irritant&#44; but it may induce reactions through other mechanisms&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">As for changes in the hair shaft&#44; a comparative analysis of the mechanical properties of the hairs after treatment with formaldehyde and glyoxylic acid showed&#44; in both&#44; a reduction in hair breakage resistance&#44; water uptake and retention&#44; and mass&#46; The hair treated with formaldehyde showed an increase in cuticle irregularity&#44; enhanced by the use of heat&#46; Glyoxylic acid showed even greater damage&#46; These would be evidence of the harmful effects of the products on the hair shaft&#44; despite findings of increased denaturation temperature&#44; absence of increased oxidative damage&#44; and presence of shine observed after treatments&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Sanad et al&#46; observed a better macroscopic appearance&#44; correlated with the histopathological finding of reduced cuticle damage after the use of keratin straightener containing methylene glycol&#44; in curly hair&#46; On electron microscopy&#44; two samples showed an increase in the density of intermacrofibrillar matrix in the cortex&#46; Hair bleaching also occurred in some individuals&#44; and hair loss was reported in 13&#46;3&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> In an evaluation of yak fibers and human hair by Boga et al&#46;&#44; the sample treated with glyoxylic acid showed regular cuticles&#44; whereas the sample treated with the basic solution and straightening iron showed more irregularities&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Goshiyama et al&#46;&#44; when studying formulas with glyoxyloyl-carbocysteine &#8203;&#8203;and glyoxyloyl-amino acids of keratin&#44; showed better straightening effect and more damage with more acidic solutions&#46; Some of the side effects were changes in the strength&#44; color&#44; enthalpy and amount of tryptophan in the hairs&#46; On electron microscopy&#44; a film was observed on the treated hair&#44; with a tighter cuticle&#44; but which was partially removed after five washes&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> The results are shown in <a class="elsevierStyleCrossRefs" href="#tbl0005">Table 1 and 2</a>&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;17</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Hair relaxers</span><p id="par0075" class="elsevierStylePara elsevierViewall">The effects observed after more than one hair straightening with chemical relaxers include increased frizz&#44; scalp desquamation&#44; hair loss&#44; thinning or weakening of the hair&#44; hair dyschromia&#44; trichoptilosis&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> In Kenya&#44; 67&#37; of women with Afro hair reported systemic and local effects after using different brands of hair relaxers&#46; Among the dermatological manifestations&#44; the following were mentioned&#58; pain and&#47;or desquamation on the scalp&#44; allergic reactions&#44; skin atrophy&#44; weakening and&#47;or change in hair color&#46; The two most frequently mentioned effects were burns and hair loss&#46; Despite the side effects&#44; 55&#37; chose to maintain some type of hair straightening method&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The impacts of a Brazilian brand straightener&#44; which had two products labeled as &#8220;chemical-free&#8221; and whose average tested pH was between 1&#46;39 and 2&#46;82&#44; included serious effects such as hair breakage or loss in 95&#37;&#44; loss of more than 40&#37; of hair in 56&#37;&#44; absence of repilation in 9&#37;&#44; in addition to other hair and scalp alterations&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> The pH of these products diverged from the alkaline standard of hair relaxers&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">In addition to the chronic effects on the scalp&#44; secondary acute alterations have been reported&#44; as in the case of a diabetic patient who&#44; after using calcium hydroxide&#44; developed a burning sensation on the skin with contact dermatitis&#44; which progressed to infection with multiple abscesses&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Also&#44; patients who had acute irritative symptoms on the scalp during the relaxing process subsequently developed areas of cicatricial alopecia&#44; especially in the vertex of the scalp&#44; with histological findings suggestive of central centrifugal cicatricial alopecia &#40;CCCA&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Factors related to histopathologically confirmed CCCA were investigated by Shah &#38; Alexis&#44; and the use of hair relaxers was the most commonly reported element in patients with available data&#46; However&#44; due to the absence of a control group&#44; it was not possible to establish an association&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Gathers et al&#46; and Olsen et al&#46; found no relationship of relaxer use with the development of CCCA&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;25</span></a> However&#44; Olsen et al&#46; found a statistically significant association between age at the first hair relaxing and the presence of alopecia when comparing the pattern without alopecia with the patterns of more advanced alopecia &#40;probable CCCA&#41;&#46; Hair loss does not prevent the use of relaxers&#44; although it does decrease as the severity increases&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Other types of alopecia are also a concern&#46; In African-American girls&#44; in which the prevalence of use of chemical relaxers was 42&#37;&#44; the previous use of relaxers doubled the risk of traction alopecia&#44; and when associated with cornrow braids made 12 months before&#44; the odds ratio exceeded five&#46; Therefore&#44; there is a risk in pulling relaxed hair into tight hairstyles&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Some individuals may have structural changes related to major hair loss&#46; In an atopic Nigerian woman&#44; generalized proximal trichorrhexis nodosa was diagnosed after three episodes of universal hair loss related to relaxing procedures&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Studies have explored the difference in the response of hair from different ethnicities to straightening&#46; When evaluating cuticle damage after the process of shaking the hairs in water&#44; in samples treated with thiol straightener&#44; there was greater susceptibility to damage in the treated hair&#44; proportionally higher in Chinese hair than in Caucasian hair&#46; Cuticle damage was demonstrated on electron microscopy&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> Several procedures &#40;including straightening&#41;&#44; either associated or not&#44; in natural black hair of different textures&#44; did not result in a visible difference in clinical examination&#44; on dermoscopy or optical microscopy&#46; However on el&#233;ctron microscopy there was a significant difference between the groups&#44; with more damage in those submitted to procedures compared to the control group&#44; but not in relation to the type of hair or the specific treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The behavior of Caucasian and Afro hair submitted to straightening with thioglycolate diverged&#46; The demand in Joules for the combing of Afro hair decreased&#44; but there were no drastic differences in the other hair types&#46; In the evaluation of color&#44; there was a greater variation in dark brown and Afro-ethnic hair&#46; Treatment-virgin hair showed greater tensile strength than straightened hair in all hair types&#44; and the use of thioglycolate did not result in additional loss of protein or tryptophan&#44; except in Afro hair&#46; On electron microscopy&#44; dark brown wavy&#44; curly&#44; and Afro hair showed mild opening of the hair scales&#44; fissures&#44; and breakage&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> Conversely&#44; a study showed that Afro hair was more resistant to combined chemical stress&#46; When straightening was combined with a commercial dye&#44; the Afro cuticle and cortex were more resistant when compared to other ethnic groups&#46; This was not expected&#44; and perhaps hair mechanics themselves have been altered&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Straightened hair is more vulnerable to other hair techniques added to straighteners&#46; Areas of permanent alopecia were found where an artificial hair implant of Italian-knot type had been associated with hair straightening&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> The effects of the combination between hair dye and straighteners were studied in Caucasian dark brown and curly hair&#58; the dye chosen by the researchers and straighteners increased&#44; in relation to virgin hair&#44; the loss of protein during washing&#46; When the two were combined&#44; there was no significant additional increase in these values&#44; except for sodium hydroxide&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Alterations were also demonstrated at the molecular level&#46; Straight hair samples exposed to sodium hydroxide showed increased oxidative alterations&#44; increased dehydroalanine formation&#44; side-chain dehydration&#44; and cysteine &#8203;&#8203;damage&#44; which likely corresponds to structural damage&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> Protein integrity&#44; represented by the level of tryptophan and other degradation products&#44; was studied in response to damage after straightening with lye relaxing cream&#46; Fluorescence for tryptophan decreased&#44; but there was no difference in kynurenines &#40;one of the metabolites of tryptophan&#41;&#44; which may mean that both tryptophan and its metabolites are chemically degraded&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Afro and Caucasian white hairs were submitted to straightening with ammonia thioglycolate or triple treatment with the same straightener associated with discoloration with ammonia and hydrogen peroxide and also to the straightening iron use&#46; After the treatments&#44; important bonds were changed&#44; with small differences between ethnicities&#46; Straightening showed greater action on the band belonging to cysteic acid and resulted in lesions to the hairs&#44; with cuticle irregularities and detachment and small undulations along them&#46; The triple treatment showed hair shafts with irregular contours&#44; cuticle detachment and deformation&#44; as well as possible cortical damage&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">When comparing product A &#40;lye&#41; with product B &#40;no-lye&#44; with guanidine hydroxide&#41;&#44; Mamabolo et al&#46; showed a decrease in cystine in the hairs after treatment with both products&#44; with a greater loss with the use of product B&#46; The reduction in cystine was accompanied by greater straightening activity&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> There was no significant difference in the tolerability of the two products on the scalp&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Khumalo et al&#46; found a difference in the amount of four amino acids &#40;cystine&#44; citrulline&#44; arginine and glutamine&#41; between the groups with and without straightening&#46; Cystine levels in treated hair were similar to those found in trichothiodystrophy&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Focusing on inflammatory changes&#44; Beach et al&#46; collected some cytokines from the sebum of the scalp of women who underwent procedures with relaxers or remained with their natural hair&#46; At sufficient levels for interpretation&#44; IL-1&#945; &#40;pro-inflammatory&#41; and IL-1ra &#40;anti-inflammatory&#41; were detected&#44; and although cytokine differences between the vertex and crown may reflect a distinct predisposition of scalp sites to inflammation&#44; it was not possible to demonstrate changes in specific inflammatory cytokines after use of relaxers&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> Tackey et al&#46;&#44; using a three-dimensional epidermis model&#44; compared lye and no-lye straighteners paired with untreated controls in relation to cytokines involved in the modulation of irritation after hair straightening&#46; IL-1&#945; reached higher levels at 24 and 48&#160;hours after the use of a no-lye straightener&#46; Both straighteners resulted in higher prostaglandin E2 &#40;PGE2&#41; levels than controls at all assessed periods&#44; and the cytokine could account for sensory differences between different types of products&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Conditioning and protective agents can minimize damage caused by straighteners&#44; and their interference with straightening effectiveness is controversial&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">40&#8211;42</span></a> Findings are summarized in <a class="elsevierStyleCrossRefs" href="#tbl0015">Tables 3&#8211;7</a>&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;18&#8211;43</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><elsevierMultimedia ident="tbl0035"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Straighteners in general</span><p id="par0145" class="elsevierStylePara elsevierViewall">Regarding exposure to straighteners&#44; Marks et al&#46; compared patients with cicatricial alopecia and patients with non-cicatricial alopecia &#40;control group&#41;&#46; There was a significant difference in the groups regarding prior history of chemical straightening &#40;25&#37; in the scarring alopecia group and 13&#37; in the non-scarring group&#41;&#44; mainly due to patients with lichen planopilaris &#40;LPP&#41; and frontal fibrosing alopecia &#40;FFA&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> This study does not specify which straighteners were used by the subjects&#59; however&#44; it mentions sodium hydroxide and glutaraldehyde as examples&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> The summary of results is shown in <a class="elsevierStyleCrossRef" href="#tbl0040">Table 8</a>&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a></p><elsevierMultimedia ident="tbl0040"></elsevierMultimedia></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Discussion</span><p id="par0150" class="elsevierStylePara elsevierViewall">Straighteners based on formaldehyde or derivatives consist&#44; in general&#44; of aldehyde and proteins such as hydrolyzed keratin&#58; after exposure to heat&#44; the aldehyde would promote a cross-link between the keratins in the product and those in the hair&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Supposedly&#44; straightening occurs by diffusing keratin into the cortex&#44; filling in the defects&#44; and restructuring the hairs&#59; however&#44; there is no evidence of this effect&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The use of formaldehyde and glutaraldehyde as hair straighteners is not legal in Brazil&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Products with glyoxylic acid are mentioned on the ANVISA website as glyoxyloyl-carbocysteine &#8203;&#8203;and glyoxyloyl keratin amino acids in the section &#8220;recommendations on straighteners - what should I find on the label of these products&#8221;&#44; with the consideration that they must warn the consumer about the risk of hair loss or change in hair color&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> However&#44; the substance does not appear in the NI n&#46; 64 of the organization&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Carbocisteine &#8203;&#8203;is not a straightener when used alone&#44; but it is usually combined with glyoxylic acid&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Acid straighteners remain a constant in straightening products&#46; Locally&#44; formaldehyde can cause dermatitis&#44; including allergic eczema and psoriasiform eczema&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a> The medical literature reports of scalp reactions may be underestimated&#44; as irritant contact dermatitis following formaldehyde use is often considered to be a normal effect by users&#46; In the hair shaft&#44; formaldehyde and glyoxylic acid&#44; despite the macroscopic appearance of hair shine&#44; worsened cuticle irregularity on electron microscopy and decreased resistance to breakage&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> However&#44; other studies have not shown the same damage&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;16</span></a> Although there are changes in strength&#44; hair color&#44; and other evidence of damage to the shaft&#44; the Work for the combing the hair decreases with acidic straighteners&#44; as shown in a study with glyoxylic acid&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">As for the straighteners permitted by law in Brazil&#44; they comprise those listed in NI n&#46; 64 of ANVISA&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The hydroxides act due to their high pH&#44; &#8203;&#8203;opening the cuticles and allowing the action of the alkaline reducing agent in the cortex&#44; where the disulfide bonds are broken&#46; The hair is then mechanically straightened with the restructuring of the bonds between the keratins&#46; Then&#44; the hair is exposed to the acidic substance to terminate the process and close the cuticles &#40;neutralization process&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;8&#44;44</span></a> Alkalis react with cystine and produce lanthionine&#44; a process called lanthionization&#46; This process replaces one-third of the cystine with lanthionine&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> There is no need for heat or external traction&#46;<span class="elsevierStyleSup">8</span> In contrast&#44; thioglycolate does not act by lanthionization&#44; but through a selective reduction of cystine bonds without changing the entire protein&#44; being neutralized with hydrogen peroxide or sodium bromate&#44; and the bonds are rearranged&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;44</span></a> Heat should be applied for the heat treatment step&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;44</span></a> Its use is commonly referred to as the &#8220;Japanese brushing&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> It maintains 90&#37; of the cystine content&#44; and 10&#37; becomes cysteic acid&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> There is also ammonium bisulfite&#44; which is less aggressive&#44; less effective&#44; and more commonly used in household products&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Relaxer-type straighteners are not free of side effects&#46; Allergies&#44; hair shaft frizz&#44; dry hair&#44; thinning and weakening of hairs&#44; trichoptilosis&#44; and hair color change have been reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#8211;20&#44;30</span></a> On the scalp&#44; desquamation&#44; pain&#44; atrophy&#44; even burns&#44; and potentially severe cases of contact eczema with secondary infection have been reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#8211;21</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">The long-term consequences of acute inflammation are not known&#44; but they are even thought to be related to central centrifugal cicatricial alopecia&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> One hypothesis would be that cytokine changes caused by straighteners might play a role in the inflammatory process&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> The role of cytokines&#44; including their relationship to the sensory diferences among several types of products&#44; has been studied&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Hair loss has also been described &#44; including irreversible alopecia&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#8211;20</span></a> Data regarding the association with CCCA diverge&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#8211;25&#44;43</span></a> There is an increased risk of traction alopecia with relaxers&#44; especially if associated with cornrow braids&#44; and generalized proximal trichorrhexis nodosa was associated with hair straightening&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;27</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">The hair shaft&#44; with the use of relaxers&#44; show an increase in the inter-scale distance&#44; the opening of the scales&#44; irregularity of their edges&#44; fissures&#44; severe lifting of the cuticle with exposure of the cortex&#44; damage to the fiber&#44; increase in particles extracted from them&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28&#8211;30&#44;35</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">The use of straighteners concomitantly with other hair techniques seems to increase the vulnerability to damage&#46; Hair relaxing in addition to the use of artificial hair implants has been related to areas of permanent alopecia&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> Hair relaxers resulted in a greater propensity for protein loss&#44; and when combined with hair dye&#44; sodium hydroxide was even more aggressive&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The summation of ammonium thioglycolate straightening&#44; discoloration&#44; and straightening iron resulted in hairs with irregular contours&#44; cuticle detachment and deformation&#44; and possible cortical damage&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">Regarding lye and no-lye straighteners&#44; a difference was found in the number of amino acids of treated hair compared to virgin hair&#46; The decrease in cystine&#44; present in the disulfide bonds that give hair strength&#44; is evident&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> Cysteine deterioration was observed at the molecular level in European straight hair exposed to sodium hydroxide<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> and straightening with lye relaxer degraded tryptophan&#59;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> however&#44; the use of thioglycolate did not result in additional loss of protein or tryptophan&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> Comparing lye and no-lye straighteners&#44; there was a reduction in cystine after the use of both&#44; with a greater loss with no-lye straighteners&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">Hairs of different ethnicities seem to diverge regarding their susceptibility to straightening&#44; with mixed findings in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31&#44;35</span></a> Structural damage can be minimized by using conditioning agents&#44; some ceramides&#44; and waxes&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">40&#8211;42</span></a> Despite the side effects&#44; many women choose to straightening their hair&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;25</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">The study limitations were&#58; the search was restricted to three databases only&#59; the search was carried out in two languages only&#59; there is a scarcity of research&#44; resulting in low scientific rigor for article inclusion&#59; accepting different study designs&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusion</span><p id="par0210" class="elsevierStylePara elsevierViewall">The review of data related to the last 20 years&#44; despite limitations&#44; discloses the significant occurrence of alterations in the hair shaft and scalp secondary to hair straightening&#46; Clinical and subclinical inflammation of the scalp&#44; damage to hair&#44; hair loss due to breakage were evident&#46; The long-term effects are still unknown&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Health professionals&#44; especially dermatologists&#44; as well as beauty salon professionals and their clients&#44; need to know about the risks and benefits of these chemical treatments&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">ANVISA&#8217;s recent norm limits the registration of straighteners&#59; however&#44; it does not clarify the new &#8220;acid straighteners&#8221;&#44; such as glyoxylic acid&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The effects of acidic straighteners are a matter for research&#44; especially because of the Brazilian multicenter study that hypothesized the association of frontal fibrosing alopecia with formalin-straightening procedures&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">Studies carried out with scientific rigor are necessary to better understand the responses of hair structures to chemical agents&#44; especially their relationship with the development of alopecia&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">This research did not receive any specific funding from public&#44; private or nonprofit funding agencies&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Financial support</span><p id="par0235" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Authors&#8217; contributions</span><p id="par0240" class="elsevierStylePara elsevierViewall">Joane Nathache Hatsbach de Paula&#58; Design and planning of the study&#59; collection&#44; analysis&#44; and interpretation of data&#59; critical review of the literature&#59; drafting and editing of the manuscript&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">Fl&#225;via Machado Alves Bas&#237;lio&#58; Design and planning of the study&#59; effective participation in research orientation&#59; critical review of the manuscript&#59; approval of the final version of the manuscript&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">Fabiane Andrade Mulinari-Brenner&#58; Effective participation in research orientation&#59; critical review of the manuscript&#59; approval of the final version of the manuscript&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicts of interest</span><p id="par0255" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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              "identificador" => "sec0020"
              "titulo" => "Acid straighteners&#58; formaldehyde&#44; other aldehydes and formaldehyde derivatives"
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            1 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Hair relaxers"
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            2 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Straighteners in general"
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          "titulo" => "Discussion"
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          "titulo" => "References"
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    "fechaRecibido" => "2020-10-06"
    "fechaAceptado" => "2021-02-01"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1497316"
          "palabras" => array:5 [
            0 => "Alopecia"
            1 => "Hair"
            2 => "Hair diseases"
            3 => "Hair preparations"
            4 => "Keratins&#44; hair-specific"
          ]
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      ]
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    "resumen" => array:1 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">The effects of chemical straighteners on the scalp and hair shaft are not fully known&#44; although such substances are widely used&#46; Hair straightening became popular in Brazil with the use of formaldehyde and its derivatives&#44; despite the prohibition by the current legislation&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">To identify changes in hair shaft and scalp caused by the use of chemical straighteners&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">A search was performed using keywords in three databases from 03&#47;16&#47;2020 to 05&#47;20&#47;2020&#44; with publications between the years 2000 to 2020&#46; After applying the inclusion and exclusion criteria&#44; 33 articles were selected for review&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">In some studies&#44; hair relaxers were associated with eczema&#44; desquamation&#44; pain&#44; burns&#44; and inflammation in the scalp&#46; Hair loss&#44; damage to the shaft&#44; alteration in the color of the hairs and in the composition of their amino acids were observed&#46; Findings are variable across the studies&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Study limitations</span><p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">The search was restricted to three databases&#44; in two languages&#44; different study designs were accepted&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conclusions</span><p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">Straightening techniques can have side effects&#44; including scalp inflammation&#44; damage to the shaft&#44; and hair loss&#46; Its long-term effects remain unknown and further studies are necessary&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Study conducted at the Department of Dermatology&#44; Complexo Hospital de Cl&#237;nicas&#44; Universidade Federal do Paran&#225;&#44; Curitiba&#44; PR&#44; Brazil&#46;</p>"
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          "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">n&#44; Number of patients&#59; F&#44; Female&#59; M&#44; Male&#46;</p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Author&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Study type&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Hair straightener&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Scalp alterations&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Van Lerberghe &#38; Baeck&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> 2014&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Case report&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">n&#160;&#61;&#160;1 &#40;F&#58;1&#44; M&#58;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Formaldehyde&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Allergic contact dermatitis&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Gavazzoni-Dias et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> 2016&#46;</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Case series</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">n&#160;&#61;&#160;7</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Brazilian keratin treatment</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Psoriasiform eczema&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Biopsies &#40;n&#160;&#61;&#160;4&#41; compatible with psoriasiform dermatitis and psoriasiform spongiotic dermatitis&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Studies on the effects of acid hair straighteners on the scalp&#46;</p>"
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      ]
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        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0015"
            "detalle" => "Table 1"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">n&#44; Number of patients&#59; F&#44; Female&#59; M&#44; Male&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Author&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Study type&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Population&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Hair straightener&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Hair shaft alteration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Leite &#38; Maia Campos&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> 2017&#46;</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clinical trial</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Curly hair samples</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Glyoxylic acid and formaldehyde</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Reduced resistance to hair breakage and diminished hair mass&#44; less water uptake and retention&#44; increased cuticle irregularity&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Increased denaturation temperature&#44; stable oxidative damage&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sanad et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> 2019&#46;</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clinical trial</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">n&#160;&#61;&#160;30 &#40;F&#58;30 M&#58;0&#41;</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Methylene glycol</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Increased softness and shine at macroscopic examination&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No changes in trichoptilosis or in cross-sectional fissures&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Reduction of cuticle damage on histopathology&#44; but no cuticle repair on electron microscopy&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Increased density of intermacrofibrillar matrix in the cortex &#40;n&#160;&#61;&#160;2&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Shaft bleaching &#40;n&#160;&#61;&#160;9&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hair loss &#40;n&#160;&#61;&#160;4&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Boga et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> 2014&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clinical trial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yak fibers and human hair&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Glyoxylic acid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Persistence of cuticular regularity under electron microscopy&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Goshiyama et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> 2020</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clinical trial</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dark brown curly hair samples</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Glyoxyloyl-carbocysteine and glyoxyloyl -Amino keratin acids</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Reduction in combing Work&#58; 59&#46;4&#37; &#40;pH 1&#46;0&#41;&#44; 33&#46;3&#37; &#40;pH 2&#46;0&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Reduction of strand strength by&#58; 15&#46;7&#37; &#40;pH 1&#46;0&#41;&#44; 8&#46;7&#37; &#40;pH 2&#46;0&#41;&#46; No statistical significance&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Color changes and reduction in hair shaft enthalpy in both pHs&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Studies on the effects of acidic straighteners on the hair shaft&#46;</p>"
        ]
      ]
      3 => array:8 [
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        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0020"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">n&#44; Number of patients&#59; F&#44; Female&#59; M&#44; Male&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Author&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Study type&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Population&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Hair straightener agent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Alterations in hairs and scalp&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Shetty et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> 2013&#46;</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cross-sectional &#40;questionnaire&#41;</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">n&#160;&#61;&#160;90 &#40;F&#58;90&#44; M&#58;0&#41;</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chemical relaxers</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Increased frizz &#40;67&#37; of cases&#41;&#44; thinning or weakening of the hair &#40;40&#37;&#41;&#44; dyschromia &#40;greying&#41; of the hair &#40;22&#37;&#41;&#44; trichoptilosis &#40;17&#37;&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Scalp desquamation &#40;61&#37;&#41; and hair loss &#40;47&#37;&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Etemesi BA&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> 2007&#46;</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cross-sectional &#40;questionnaire&#41;</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">242 &#40;F&#58;242&#44; M&#58;0&#41;</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chemical relaxers</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Weakening and&#47;or changing of hair color&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Scalp pain and&#47;or desquamation&#44; allergic reactions&#44; thinning of the skin&#44; burns and hair loss&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Kaur et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> 2002&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Case report&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">n&#160;&#61;&#160;1 &#40;F&#58;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Calcium hydroxide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Contact eczema and secondary staphylococcal infection&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab2872329.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Studies that evaluated signs and symptoms from hair straighteners&#46;</p>"
        ]
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      4 => array:8 [
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        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0025"
            "detalle" => "Table "
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">n&#44; Number of patients&#59; F&#44; Female&#59; M&#44; Male&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Author&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Study type&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Population&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Hair straightener agent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Alterations in hairs and scalp&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Swee et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> 2000&#46;</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cross-sectional &#40;questionnaire&#41;</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">n&#160;&#61;&#160;464 &#40;F&#58;457&#44; M&#58;5&#44; non- identified&#58; 2&#41;</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Acid straightener &#40;non-traditional&#41; with metallic salts</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hair breakage or loss &#40;95&#37; of cases&#41;&#44; dry or coarse hair &#40;70&#37;&#41;&#44; hair discoloration &#40;28&#37;&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dry scalp &#40;53&#37;&#41;&#44; burning pain in the scalp &#40;25&#37;&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab2872325.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Study that evaluated signs and symptoms of a hair straightener &#40;non-traditional acid straightener&#41;&#46;</p>"
        ]
      ]
      5 => array:8 [
        "identificador" => "tbl0025"
        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0030"
            "detalle" => "Table "
            "rol" => "short"
          ]
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">n&#44; Number of patients&#59; F&#44; Female&#59; M&#44; Male&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Author&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Study type&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Population&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Hair straightener&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Scalp alterations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Khumalo et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> 2007&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Case series&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">n&#160;&#61;&#160;5 &#40;F&#58;5&#44; M&#58;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sodium hydroxide &#40;n&#160;&#61;&#160;3&#41; and Guanidine hydroxide &#40;n&#160;&#61;&#160;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Irritative symptoms and development of areas of cicatricial alopecia&#46; Histological findings of perifollicular lymphocytic infiltrate&#44; follicular fibrosis&#44; and premature desquamation of the inner root sheath&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Shah &#38; Alexis&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> 2010&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Case series&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">n&#160;&#61;&#160;69 &#40;F&#58;67&#44; M&#58;2&#41; &#40;64&#58; data on hair care&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chemical relaxers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Straighteners were the most common traumatic practice in patients with CCCA&#46; It was not possible to establish an association due to the absence of a control group&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Gathers et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> 2009&#46;</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Case-control study</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">n&#160;&#61;&#160;101 &#40;F&#58;101&#44; M&#58;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chemical relaxers</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">There is no relationship between the use of relaxers&#44; their frequency of application or complications from their use with the development of CCCA&#46;</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CCCA Group &#40;n&#160;&#61;&#160;51&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Group without cicatricial alopecia &#40;n&#160;&#61;&#160;50&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Olsen et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> 2011</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Case-control study</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">n&#160;&#61;&#160;529 &#40;F&#58;529&#44; M&#58;0&#41;</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chemical relaxers</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No association was observed between the use of straighteners or reaction to their use with extensive central hair loss&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Association between age at first hair straightening and hair loss pattern when comparing pattern 0 &#40;no loss&#41; vs&#46; patterns 3 and 5 &#40;probable CCCA&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Rucker et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> 2011&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cross-sectional &#40;questionnaire&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">n&#160;&#61;&#160;201 &#40;F&#58;201&#44; M&#58;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chemical relaxers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hair straightening was a risk factor for traction alopecia &#40;OR&#160;&#61;&#160;2&#46;2&#59; &#40;95&#37;CI 1&#46;1&#8211;4&#46;5&#59; p&#160;&#61;&#160;0&#46;03&#41;&#46; Straightening associated with cornrow braids&#58; OR&#160;&#61;&#160;5&#46;27 &#40;95&#37; CI 1&#46;5&#8211;18&#46;32&#59; p&#160;&#61;&#160;0&#46;009&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ogunbiyi et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> 2014&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Case report&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">n&#160;&#61;&#160;1 &#40;F&#58;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chemical relaxers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hair loss associated to generalized proximal trichorrhexis nodosa&#44; with atopy as the baseline condition&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Amorim et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> 2017&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cross-sectional&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">n&#160;&#61;&#160;30 &#40;F&#58;30&#44; M&#58;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sodium hydroxide or guanidine hydroxide&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Areas of permanent alopecia were found where an artificial hair implant of Italian-knot type had been associated with hair straightening&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Studies that evaluated the association of hair straighteners with alopecia&#46;</p>"
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        "etiqueta" => "Table 6"
        "tipo" => "MULTIMEDIATABLA"
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          0 => array:3 [
            "identificador" => "at0035"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">n&#44; Number of patients&#59; F&#44; Female&#59; M&#44; Male&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Author&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Study type&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Population&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Hair straightener&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Alterations in hair strand and scalp&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Galliano et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> 2010&#46;</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clinical trial</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">n&#160;&#61;&#160;12 &#40;6 Chinese hair samples and 6 Caucasian hair samples&#41;</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Thiol straightener</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Increased inter-scale distance&#44; scale inclination and edge irregularity&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Average size of particles extracted from hair after stirring in water for 30 minutes&#58; different between ethnicities and proportionally greater increase in Chinese hair&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Kaliyadan et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> 2016&#46;</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cross-sectional</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">n&#160;&#61;&#160;25 &#40;F&#58;25&#41; &#40;19 subjects and 6 controls&#41;</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chemical relaxers</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">In straightening only &#40;n&#160;&#61;&#160;2&#41;&#58; curly hair had grade 2 damage &#40;severe cuticle lift&#44; fissures or gaps with exposed cortex&#41; and wavy hair had grade 0 &#40;intact cuticle&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">In straightening associated with hair dye &#40;n&#160;&#61;&#160;7&#41;&#58; damage degrees from 1 &#40;irregular cuticle without fissures or gaps&#41; to 2&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">In the association of straightening&#44; discoloration and hair dye &#40;n&#160;&#61;&#160;1&#41;&#58; grade 3 damage &#40;partially exposed cortex&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">In the control group &#40;wavy or straight hair&#41;&#58; damage degree from 0 to 1&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bloch et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> 2019&#46;</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clinical trial</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Samples of Caucasian hair &#40;straight dark brown&#59; straight blond&#59; wavy dark brown&#59; and curly dark brown&#41; and Afro hair&#46;</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ammonia thioglycolate</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">71&#37; reduction in Work &#40;in Joules&#41; for the combing of Afro hair&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Greater color variation in dark brown and Afro-ethnic hair&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Decreased tensile strength in all hair types&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No additional loss of protein or tryptophan &#40;except in Afro hair&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Afro&#44; curly and wavy dark brown hair&#58; discreet opening of the scales&#44; fissures and breakage&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lee et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> 2014&#46;</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clinical trial</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Asian&#44; Caucasian&#44; European and African American hair samples&#46;</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ammonia thioglycolate</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">In straightening&#58; Asian hair cuticles were the most resistant&#46; The damage to the cortex was similar in the three groups&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">In straightening combined with commercial dye&#58; the African American cuticle and cortex were the most resistant&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The three groups showed similar patterns of cell membrane damage after straightening or straightening combined with dye&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fran&#231;a-Stefoni et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> 2015&#46;</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clinical trial</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dark brown curly Caucasian hair&#46;</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ammonia thioglycolate&#44; guanidine hydroxide&#44; sodium hydroxide</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Additional protein loss in washing&#58; dye &#40;48&#37;&#41;&#44; ammonia thioglycolate &#40;159&#37;&#41;&#59; guanidine hydroxide &#40;188&#37;&#41;&#59; sodium hydroxide &#40;276&#37;&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">When combined with dye&#44; ammonia thioglycolate and guanidine hydroxide did not cause a significant additional increase in protein loss&#46; Sodium hydroxide did&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dyer et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> 2013&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clinical trial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">European straight hair samples&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sodium hydroxide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Increased oxidative alterations&#44; alkali-associated damage&#44; increased dehydroalanine formation and side chain dehydration&#44; and cysteine damage&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">McMullen et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> 2011&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clinical trial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Samples of dark brown European hair and Piedmont hair&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sodium hydroxide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Degradation of tryptophan and its metabolites&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dos Santos et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> 2019&#46;</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clinical trial</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Afro and Caucasian white hair samples</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ammonia thioglycolate</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fiber lesions&#44; with irregularities and cuticle detachment&#44; and small undulations along its extension&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Association of straightening with discoloration and straightening iron&#58; irregular-contour hairs&#44; cuticle detachment and deformation&#44; and possible cortical damage&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mamabolo et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> 2013&#46;</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clinical trial</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">N&#58; 5 &#40;F&#58;5&#44; M&#58;0&#41;</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sodium hydroxide and guanidine hydroxide</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Guanidine hydroxide&#58; greater softness&#44; smooth appearance&#44; shine&#44; and less dry appearance&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The two products were similar regarding damage&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The no-lye straightener showed fewer split ends&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cystine content is reduced with lye straightener and more intensely with no-lye straightener&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lysine decreased in relation to virgin hair for the two straighteners&#59; however&#44; with no statistical difference between them&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Khumalo et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> 2010&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Historical cohort&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">n&#160;&#61;&#160;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chemical relaxers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cystine&#44; citrulline &#40;not always with statistical significance&#41; and arginine decreased and glutamine increased in straightened hair&#46; Cystine levels were lower in treated hair than in virgin hair&#44; with levels similar to those found in trichothiodystrophy&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Beach et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> 2012&#46;</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clinical trial</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">n&#160;&#61;&#160;36 &#40;F&#58;30&#44; M&#58;0&#41;</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Guanidine hydroxide&#44; sodium hydroxide&#44; ammonium thioglycolate</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IL-1&#945; and IL-1ra were detected on the scalp&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">After the straightening&#44; the levels of IL-1&#945; and IL-1ra on the crown and vertex were lower&#44; but with no difference compared to the group that did not straighten the hair&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">It was not possible to demonstrate changes in specific inflammatory cytokines after use of straighteners&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tackey et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> 2013&#46;</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clinical trial</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Three-dimensional epidermis model</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sodium hydroxide&#44; guanidine hydroxide</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IL-1&#945;&#58; at 4h of application there was no significant difference between the groups of straighteners&#44; and at 24h and 48h the no-lye straightener reached higher levels&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IL-1ra&#58; always higher with no-lye&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Both types had similar IL-1ra&#47;IL-1&#945; ratios in the early phases&#40;suggestive of lack of relationship with immediate discomfort after application&#41; and late phases&#59; however the no-lye straightener had a higher ratio at 24h&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PGE2 levels were higher than in controls at all phases&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2872323.png"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Studies on hair straighteners with morphological and physiological assessments&#46;</p>"
        ]
      ]
      7 => array:8 [
        "identificador" => "tbl0035"
        "etiqueta" => "Table 7"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0040"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Author&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Study type&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Population&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Hair straightener&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Effects on hairs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">De S&#225; Dias et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> 2008&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clinical trial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Afro hair samples&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ammonia thioglycolate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Conditioning agents added to the straightener resulted in less protein loss&#44; in fiber protection and in increased strength to breakage&#46; However&#44; it may reduce the effectiveness of straightening&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bernard et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> 2002&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clinical trial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">African-American hair samples&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Guanidine hydroxide or sodium hydroxide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The use of ceramides &#40;in this case&#44; C18-dhCer&#41; prevented damage to straightened hair&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vermeulen et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> 2004&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clinical trial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hair samples&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sodium hydroxide&#44; lithium hydroxide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Addition of polymethylene waxes to a straightening formula resulted in a better appearance compared to commercial formulas&#44; without minimizing performance&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2872330.png"
              ]
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Studies about prevention of structural damage during the use of hair straighteners&#46;</p>"
        ]
      ]
      8 => array:8 [
        "identificador" => "tbl0040"
        "etiqueta" => "Table 8"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0045"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">n&#44; Number of patients&#59; F&#44; Female&#59; M&#44; Male&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Author&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Study type&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Population&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Straightener agent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Alterations&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="3" align="left" valign="\n
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                  \t\t\t\t">Marks et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> 2019&#46;</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Case-control</td><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="3" align="left" valign="\n
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                  \t\t\t\t">n&#160;&#61;&#160;286 &#40;n&#160;&#61;&#160;43 patients with cicatricial alopecia&#41;&#44; &#40;143 patients with non-cicatricial alopecia&#58; control group&#41;</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="3" align="left" valign="\n
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                  \t\t\t\t">Chemical straightener</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Higher frequency of hair straightening in the cicatricial alopecia group &#40;25&#37;&#41; compared to the control group &#40;13&#37;&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">Prior history of straightening in 21&#37; in LPP&#47;FFA group and in 10&#37; of paired controls&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CCCA&#58; more cumulative exposure to straighteners&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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Article information

ISSN: 03650596
Original language: English

DOI:10.1016/j.abd.2021.02.010

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