Shampoos, Conditioners, and

C a m o u f l a g e Tec h n i q u e s
Zoe Diana Draelos, MD

KEYWORDS
 Scalp hair  Scalp-hair cleansers  Dimethicone  Hair loss

KEY POINTS
 Shampoos are used to cleanse the scalp and beautify the hair. These activities must occur
simultaneously.
 Conditioning shampoos are valuable for patients with hair loss in maintaining adequate hygiene
while smoothing the cuticle to maintain hair shine and manageability.
 Dimethicone is a valuable conditioner in the hair-loss patient because it does not make thinning hair
limp, while providing decreased static electricity and improved hair styling.

INTRODUCTION hair. This method was somewhat unsatisfactory

because hard water in combination with bar
Scalp-hair appearance assumes great importance soap left behind a scum that dulled the hair
in both men and women. Hair can be cut, shaved, appearance. Early shampoo formulations were
styled, combed, brushed, braided, twisted, glued, liquid coconut-oil soaps that lathered and rinsed
shampooed, conditioned, dyed, curled, straight- better than bar soap. Surfactant shampoos were
ened, and teased. Why are there so many tech- introduced in the late 1930s and represented
niques to modify human scalp hair? The answer a significant advance because they performed
lies in human behavior patterns whereby such well even with the hardest water.2 These new
services and products are purchased to support surfactants have allowed the hair-care formulator
the hair-care industry. The amount of money spent to develop shampoos that meet a variety of hair
on beautifying scalp hair signifies the preoccupa- and scalp needs, including those of the patient
tion humans have with their hair. This preoccupa- with hair loss.
tion is even more challenging in persons who are The act of shampooing involves the following
experiencing hair loss. This article examines hair steps: (1) hair and scalp are wetted and the liquid
care in persons with hair loss. The use of sham- shampoo distributed; (2) shampoo is foamed and
poos, conditioners, and hair styling products to massaged into the scalp; (3) shampoo foam is
camouflage hair loss is discussed. distributed throughout the hair; (4) water is used
to thoroughly rinse the hair and scalp; (5) hair is
SHAMPOOS towel dried to absorb excess water; (6) wet hair
is combed. Shampooing is actually a very complex
Shampoos are designed to primarily clean the procedure because the average woman has 4 to
scalp and secondarily clean the hair, even though 8 m of hair surface area to clean.3 It is easy to
most consumers believe otherwise.1 In fact, formulate a shampoo that will remove all of the
shampoo is a relatively modern invention. Until sebum from the hair and scalp, but this will leave
the mid-1930s bar soap was used to cleanse the the hair frizzy, dry, and unattractive. The challenge
derm.theclinics.com

No conflicts of interest pertain to this article.

Department of Dermatology, Duke University School of Medicine, Durham, 2444 North Main Street, High
Point, NC 27262, USA
E-mail address: [email protected]

Dermatol Clin 31 (2013) 173–178

http://dx.doi.org/10.1016/j.det.2012.08.004
0733-8635/13/$ – see front matter Ó 2013 Elsevier Inc. All rights reserved.
174 Draelos

is to remove just enough sebum to allow the hair to permanently waved or dyed hair, mild detergents
appear clean and leave behind enough condi- are selected to reduce sebum removal. Persons
tioning agents, actually representing synthetic with hair loss typically want to maximize hair
sebum, to beautify the clean hair. The basic formu- cleansing, because sebum makes the hair appear
lation for shampoo is listed in Box 1.4 flat, and then beautify the hair to make it shiny,
The cleansing ingredient found in shampoos is smooth, and easy to untangle. This action is best
known as a detergent or surfactant. These agents accomplished with a product known as a 2-in-1
are soap-free synthetic substances that possess shampoo. Two-in-1 shampoos are so named
both lipophilic and hydrophilic structures. The lipo- because they clean and condition, performing 2
philic end binds to the sebum and the hydrophilic functions, in 1 product. The detergents that can
end allows the sebum to rinse away with water be combined to achieve these results and their
down the drain. Chemical moieties that possess attributes are listed in Table 1.7
this chemical structure are amphiphilic.5 The
most commonly used detergents in shampoos
Shampoos for Hair Loss
are listed in Box 2.6
The art of shampoo formulation is mixing A shampoo for hair loss should remove adequate
together detergents to achieve the desired balance sebum, but not overdry the hair to make it harsh,
between cleansing and hair beautification. Typi- rough, subject to static electricity, dull, and difficult
cally several detergents are combined together to to untangle. Sodium lauryl sulfate is a strong
achieve the desired end result. For example, if the surfactant while sodium laureth sulfate is slightly
shampoo is intended for oily hair, detergents with milder. Most shampoos for hair loss use sodium
strong sebum removal qualities are selected; laureth sulfate as the primary surfactant and then
conversely, if the shampoo is intended for combine a secondary surfactant that is milder.

Box 1
Basic shampoo ingredient formulation and function

1. Detergents
Function to remove environment dirt, styling products, sebum, and skin scale from the hair and scalp
2. Foaming agents
Allow the shampoo to form suds, because consumers equate cleansing with foaming even though
the two are unrelated
3. Conditioners
Leave the hair soft and smooth after sebum removal by the detergent
4. Thickeners
Thicken the shampoo, because consumers believe that a thick shampoo works better than a thin
shampoo
5. Opacifiers
Added to make a shampoo opaque as opposed to translucent for aesthetic purposes unrelated to
cleansing
6. Sequestering agents
Function to prevent soap scum from forming on the hair and scalp in the presence of hard water: the
basic difference between a liquid shampoo and a bar cleanser
7. Fragrances
Added to give the shampoo a consumer acceptable smell
8. Preservatives
Prevent microbial and fungal contamination of the shampoo before and after opening
9. Specialty additives
Treatment ingredients or marketing aids added to impart other benefits to the shampoo besides hair
and scalp cleansing
 Shampoos, Conditioners, and Camouflage Techniques 175

Box 2 unique in that they contain both an anionic and

Common shampoo detergents a cationic group, which allows them to behave
as cationic detergents at lower pH values and as
1. Sodium laureth sulfate anionic detergents at higher pH values. The
2. Sodium lauryl sulfate amphoteric detergent category includes the beta-
ines, sultaines, and imidazolinium derivatives.
3. Triethanolamine lauryl sulfate
Amphoteric detergents, such as cocamidopropyl
4. Ammonium laureth sulfate betaine and sodium lauraminopropionate, are
5. Ammonium lauryl sulfate used in shampoos for hair loss because they
6. Diethanolamine lauryl sulfate foam moderately well, leaving the hair manageable
and soft.
7. Sodium olefin sulfonate
Conditioning Shampoos
The best shampoos for hair loss combine the
The detergent listed first is the primary cleanser in cleansers previously discussed with a conditioning
highest concentration and the detergent listed agent. The conditioner in the shampoo functions
second is the secondary cleanser designed to to impart manageability, gloss, and antistatic pro-
complement the shortcomings of the primary perties to the hair.9,10 Substances that per-
detergent. form this function are usually fatty alcohols, fatty
Sodium laureth sulfate is an anionic detergent esters, vegetable oils, mineral oils, or humectants.
representing only one category of surfactants. Commonly used conditioning substances in sham-
Anionic detergents are named for their negatively poos include hydrolyzed animal protein, glycerin,
charged polar group. A second detergent group, dimethicone, simethicone, polyvinylpyrrolidone,
known as cationic detergents, possesses a posi- propylene glycol, and stearalkonium chloride.11,12
tively charged polar group. Cationic detergents Protein-derived substances are popular in
have limited ability to remove sebum and do not conditioning shampoos because they can tempo-
produce much lather, but are excellent at impart- rarily mend split ends, medically known as trichop-
ing softness and manageability to damaged tilosis. Split ends arise when the protective cuticle
hair.3 A third detergent category is the nonionics, has been lost from the distal hair shaft and the
which have no polar group. Nonionic detergents exposed cortex splits. Protein is attracted to the
are the mildest of all surfactants and are used in keratin, a property known as substantivity, and
combination with ionic surfactants as a secondary the protein adheres the cortex fragments together
cleanser.8 Examples of commonly used nonionic until the next shampooing occurs.13 However, the
detergents include polyoxyethylene fatty alcohols, effectiveness of proteins in shampoos is not great
polyoxyethylene sorbitol esters, and alkanola- because the contact time between the shampoo
mides. The final and fourth group of detergents is protein and the hair is minimal. Conditioners that
the amphoterics, named for the fact that they remain on the hair for a longer period have
possess both a negatively charged and a positively a more profound effect on beautifying hair in the
charged polar group. Amphoteric detergents are hair-loss patient.

Table 1
Shampoo detergent characteristics

Surfactant Type Chemical Class Characteristics

Anionics Lauryl sulfates, laureth sulfates, Deep cleansing, may leave hair harsh
sarcosines, sulfosuccinates
Cationics Long-chain amino esters, Poor cleansing, poor lather,
ammonioesters impart softness and manageability
Nonionics Polyoxyethylene fatty alcohols, Mildest cleansing, impart manageability
polyoxyethylene sorbitol esters,
alkanolamides
Amphoterics Betaines, sultaines, imidazolinium Nonirritating to eyes, mild cleansing,
derivatives impart manageability
Natural surfactants Sarsaparilla, soapwort, soap bark, Poor cleansing, excellent lather
ivy, agave
176 Draelos

pH and Shampoos the subsequent shampoo. Although the concept

of hair thickening may be misleading, these condi-
Another key shampoo consideration in hair-loss
tioners do lead to hair with a better cosmetic ap-
patients is shampoo pH. Hair shampoos contain
pearance in the hair-loss patient, thus accounting
pH adjusters to minimize hair damage from alkalin-
for their continued marketing success.
ization. Most shampoo detergents have an alkaline
Occasionally it is necessary to impart more
pH, which causes hair-shaft swelling. This swelling
conditioning benefits to thinning hair than an
loosens the protective cuticle predisposing the
instant conditioner can deliver; this is especially
hair shaft to damage. Hair-shaft swelling can be
the case in hair that has underdone chemical pro-
prevented by “pH-balanced” shampoos formu-
cessing, such as permanent dyeing, bleaching,
lated with the addition of an acidic substance,
permanent waving, or chemical straightening.
such as glycolic acid. Shampoos formulated at
These procedures all intentionally disrupt the cu-
a neutral pH are most important for chemically
ticular scale to reach the cortex and medulla of
treated hair from either permanent dyeing or
the hair shaft to induce a change in color or config-
permanent waving.
uration. Once the cuticle has been disrupted with
chemical processing, it can never be fully restored.
CONDITIONERS FOR HAIR LOSS Thus, there is a trade-off for the hair-loss patient
between the cosmetic value of chemically treating
Additional beautification of the hair can be the hair shaft and its reduced ability to function
achieved by using a separate conditioner following optimally. Some of the damage can be minimized
shampooing. The role of a conditioner is to mimic with a deep conditioner.
sebum in making the hair manageable, glossy, Deep conditioners are creams, rather than the
and soft. Conditioners also attempt to recondition liquid instant conditioners, which remain on the
hair that has been damaged by chemical or hair for 20 to 30 minutes and may include the
mechanical trauma.14 Common sources of trauma application of heat from a hair dryer or warm
include excessive brushing, hot blow-drying, towel.3 The extended application time allows
detergent shampoos, alkaline permanent waves, more conditioner to coat the hair shaft, while
and bleaching. Because hair is nonliving tissue, heat causes hair-shaft swelling and allows in-
obviously any reconditioning that occurs is minimal creased conditioner penetration. These products
and temporary until the next shampooing. Because are intended for damaged hair and work very
hair-loss patients frequently possess hair damage, well in the hair-loss patient.
the use of additional conditioning is important.
Additional conditioning is imparted to the thin-
Hair Conditioner Formulation
ning hair by applying a separate conditioner after
shampooing. These conditioners are applied in As discussed previously for shampoos, a variety of
the shower to wet hair and then rinsed immediately ingredients are used in combination to create
before exiting; they are known as instant condi- a hair conditioner that beautifies thinning hair.
tioners, because they are left on the hair a very Although some conditioners are labeled for thin-
short time.15 All formulations of instant condi- ning hair, individuals with thinning hair usually
tioners are good at detangling hair by smoothing can use products developed for damaged hair,
the cuticle and reducing friction. However, if the as the formulations are usually identical even
hair has been severely damaged and the cuticular though the packaging contains different wording.
scales are sparse, only a protein-containing condi- Some instant hair conditioners applied immedi-
tioner can penetrate the hair shaft and temporarily ately following shampooing and rinsed are based
increase hair strength. Because hair breakage is on ingredients previously discussed for hair
an important cause of accelerated hair loss in the shampoos.16 Cationic detergents, also known as
alopecia patient, strengthening the hair to resist quaternaries or quaternary ammonium compounds
breakage is important. Protein-containing condi- or quats, are excellent at increasing adherence of
tioners can increase hair strength by up to 5%, the cuticular scales to the hair shaft, which
but the protein that penetrates the hair shaft during increases the light-reflective abilities of the hair,
conditioning will exit the hair shaft during the next adding shine and luster. In addition, they are able
shampoo, requiring reapplication. Proteins can to electrically neutralize static electricity based on
also coat the hair shaft, temporarily increasing its the negative (anionic) charge of processed or
thickness; this is the basis of many of the “hair- damaged hair, which attracts the positively
thickening” conditioners. These conditioners do (cationic) charged quaternary compound to adhere
not increase hair thickness by promoting growth, to the hair shaft, thus improving manageability.17
but temporarily increase hair-shaft thickness until These qualities make them an excellent conditioner
 Shampoos, Conditioners, and Camouflage Techniques 177

choice in patients with permanently dyed or perma- One quick way to increase the appearance of
nently waved hair, in addition to hair loss. hair volume is to massage a small amount of styling
Another category of conditioners, known as gel or mousse into the base of the hair shafts fol-
leave-in conditioners, are designed to stay on the lowed by drying the hair with a blow dryer, while
hair shaft until removal by the next shampooing. combing the hair away from the scalp or bending
These film-forming conditioners apply a thin layer over with the hair falling away from the scalp
of polymer, such as polyvinylpyrrolidone (PVP), because of gravity. This maneuver stiffens and
over the hair shaft.18 The polymer fills hair-shaft fixes the hair in place away from the scalp, creating
defects, creating a smooth surface to increase the illusion of fullness. The styling products create
shine and luster while eliminating static electricity temporary bonds between adjacent hair strands
owing to its cationic nature. The polymer also and allow the hair to defy gravity. These styling
coats each individual hair shaft, thus “thickening” products contain polymers, such as vinyl acetate
the hair shaft. This type of conditioner is excellent and polyvinyl pyrrolidone, which coat the hair shaft
for hair-loss patients because the hair feels thicker with a clear stiff layer, allowing the hair to stand
and retains a style better. away from the scalp. The products are easily
removed with shampooing, and must be reapplied
after water contact or if the bonds are broken with
HAIR GROOMING FOR THE HAIR-LOSS pulling, combing, or brushing. The products can be
PATIENT reapplied daily or as needed, to restore the hair
style or create a new hair style with fresh shampoo-
The dermatologist should also provide some hair-
ing or between shampoos.
grooming tips to hair-loss patients, focused on
A variant of hair gel is hair spray, the most impor-
using the patient’s remaining natural hair to cam-
tant styling product for hair-loss patients. Hair
ouflage thinning where possible. Because hair is
spray is dispensed from an aerosol can or nonaer-
nonliving, any hair damage that results from
osol bottle to create a thin polymer film that can be
grooming should be minimized. The first rule of
used to keep the final hairstyle in place. For
hair care is to avoid manipulating wet hair. Hair
example, hair can be rearranged to cover thinning
shafts are most subject to fracture when wet,
areas and then kept in place with a high-hold hair
because of increased elasticity. Thus, it is much
spray. This camouflage technique is the easiest to
easier to stretch wet hair to breaking point than
master and can be used in men, women, and chil-
dry hair. Wet hair should be initially detangled
dren. The pump aerosol hair sprays are preferred
with the fingers and slightly dried, before detan-
because of their safety, and can be easily removed
gling with a wide-toothed comb. Brushes should
with shampooing.
not be used for detangling wet hair. Further, all
combing and brushing should be kept to
a minimum to avoid hair damage. In short, the SUMMARY
less done to thinning hair, the better.
Hair loss is a traumatic condition for any patient.
Providing shampoo, conditioner, and hair-styling
HAIR-STYLING PRODUCT CAMOUFLAGE product advice is important because it lets
TECHNIQUES patients know that the dermatologist understands
their concerns and wants to move forward with
Hair-styling products are the easiest way to treatment. Most hair-loss treatments do not
decrease the appearance of thinning hair besides produce immediate results; however, proper
wearing a hairpiece. Most patients are highly moti- hair-care measures can increase the cosmetic
vated to take measures to prevent the purchase of value of the hair following one application.
a wig, making the understanding of hair-styling Because hair is nonliving, medical treatments are
products very important. Styling products can limited to only inducing change in the follicles
keep the hair in place and add volume by allowing within the scalp skin and do not improve the hair
the hair to stand away from the scalp, defying gravity loss actually witnessed by the patient. This aspect
and creating the illusion of fullness. Available styling explains the need to accompany the medical treat-
product categories include styling gels, sculpturing ment of hair loss with cosmetic hair treatment to
gels, mousses, and hair sprays. Styling gels, sculp- optimize patient satisfaction.
turing gels, and mousses are generally applied to
towel-dried hair whereas hair sprays are used to REFERENCES
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178 Draelos

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