Health risks of the
clean-shave chiskop haircut

1Division
of Dermatology, Faculty of Health Sciences, University of Cape
Town, South Africa

2Department
of Statistical Sciences, University of Cape Town, South Africa

3Langa
Community Health Clinic, Cape Town Central Health District,
Western Cape, South Africa

Corresponding author: N P Khumalo (n.khumalo@uct.ac.za)

The clean-shave haircut
known locally as the chiskop is rare among females but
popular with black South African men, who are also predisposed
to folliculitis keloidalis nuchae (FKN) (keloids on the back
of the head). During a previous study, participants described
an unexpected symptom of haircut-associated bleeding. As this
is not a widely recognised entity, we conducted the present
study at an HIV clinic servicing the same population, with the
objective of comparing the prevalences of haircut-associated
bleeding and FKN in 390 HIV-positive subjects with published
data for Langa (Western Cape, South Africa). The results for
HIV-positive participants were similar to the population data,
but in both groups the prevalence of haircut-associated
bleeding (24.5% v. 32%; p=0.17) was much higher than that
of FKN (10.2% v. 10.5%), suggesting that the hairstyleincreases
the risk of bleeding even in people with healthy scalps
without folliculitis. This study does not (and was not
intended to) prove a higher HIV prevalence in chiskop wearers or in FKN sufferers,
but it confirms a history of haircut-associated bleeding in at
least a quarter of our male study participants. The risk of
transmission of blood-borne infection via haircuts is likely
to be low, but requires formal quantification. Public
education on adequate sterilisation of barber equipment
between haircuts and promotion of individual hair-clipper
ownership for chiskop clients should not be delayed.
Depilatory creams formulated for African hair offer a
non-mechanical means of achieving clean-shave hairstyles.

S Afr Med J 2013;103(7):489-490.
DOI:10.7196/SAMJ.6675

Close-shave haircuts are
rare among females but worn by over 70% of black males in the
Langa population (Western Cape, South Africa).1 The most popular of these is
the ‘clean-shave’ or ‘chiskop’ style, which is achieved when
the metal of the electric clipper is pressed directly onto the
scalp to produce a shiny look similar to that achieved with
razor blades. Folliculitis keloidalis nuchae (FKN), also
incorrectly called acne keloidalis, is shaving-bump-like keloids on the
back of the head (Fig. 1); the condition predominantly affects
black males (5.4% of high-school boys v. 0% of girls;2 10.5% of men v. 0.3% of women1 ). We had an unexpected finding
during a population study; 32% of male participants described
having experienced haircut-associated bleeding,3 which may be significant in our
country with its high burden of HIV infection.4 Only a few small studies have
investigated knowledge of HIV and sterilisation practices
among barbers.5,6 Haircut-associated bleeding is
not a widely recognised entity, and has only been reported in
one population study.1

Fig. 1. A patient with keloidal
papules and plaques on the nuchal scalp (folliculitis keloidalis nuchae) is wearing a clean-shave chiskop
haircut.

Methods

We conducted a cross-sectional study of attendees at the Langa
HIV Clinic, which serves the same community (including schools,
churches and community groups) that featured in our original
studies.1,2
We obtained approval from the Ethics Committee of the Faculty of
Health Sciences, University of Cape Town, permission from the
Cape Town Central Health District, Western Cape, and informed
consent from participants. Our aim was to compare the
prevalences of haircut-associated bleeding and FKN with existing
Langa population data. The clinical diagnosis of FKN was based
on the presence of keloidal papules or plaques on the nuchal
scalp. A brief questionnaire included questions on the history
of haircut-associated bleeding and scalp symptoms, as well as
past/present sexual partners’ hair care practices and whether
they had scalp keloidal lesions. STATA software version 10 was
used for statistical analysis and the chi-square test or
Fisher’s exact test and a 95% confidence interval for
comparison.

Results

During the 1-year study
period, 390 participants were recruited: 158 males (mean age
38.6 years, range 20 - 71 years) and 232 females (mean age
34.5 years, range 18 - 78 years). The prevalence of FKN in
HIV-positive participants was 10.2% (15/147) for males versus
0.9% (2/220) for females. In addition, 10.05% of females
(22/219) as opposed to 1.4% of males (2/147) reported ever
having had had sexual intercourse with a partner who had FKN
(‘scalp pimples as in the picture’). There was an association
between haircut symptoms and FKN (p<0.0001).
In addition, 24.7% of males (36/145) had ‘ever bled’ from a
haircut.

The prevalence of FKN in
HIV-positive males was similar to the Langa population data
(10.2% v. 10.5%), while that in females was higher, but not
significantly so (0.9% v. 0.3%; p=0.30). In male partners of
female participants, the prevalence of FKN was similar to the
male population data (10.05% v. 10.5%), and in female partners
of male participants it was higher, but again not
significantly higher, than the female population data (1.4% v.
0.3%; p=0.12). Although the prevalence
of haircut-associated bleeding was lower than in the previous
study1 (but not significantly lower,
24.6% v. 32%; p=0.17), it was noteworthy that
bleeding was common in both studies. Additionally, more
participants had a history of bleeding from a haircut than
were diagnosed with FKN, suggesting that this haircut
increases the risk of bleeding even in people with healthy
scalps.

Discussion

Unlike other inflammatory skin disorders, FKN does not appear
to be more prevalent in people with HIV infection. The scalp
lesions of FKN would be expected to increase the risk of injury
during chiskop haircuts. What we
found more worrying was that the popular chiskop
haircut is a risk factor for injury independent of the presence
of FKN. To maintain the chiskop
style, the scalp has to be shaved at 1 - 2-weekly intervals;
this is often done at facilities (such as old shipping
containers and informal structures) with a high client turnover,
no running water, and little (e.g. methylated spirits) or no
disinfection/sterilisation of razors between clients.5,6
Accidental cuts (involving 3.3% of clients ) have been reported.
6
Hepatitis B virus has been detected on 6.6% of barbering blades,7 but we
found no data investigating associations with HIV.

Shaving of part of or the whole scalp was routinely performed
for religious expression in medieval times. Tonsure is still
widely practised as a sacrifice in Hindu temples, but at most
several times during a believer’s life,8 which is much less frequent
than the 1 - 2-weekly shaves required to maintain a chiskop. There are no published data on
whether inadequate sterilisation of blades contributes to the
high HIV burden in India. The prevalence of HIV in Nigeria, the
most populous African country, is significantly lower than that
in South Africa (3.6% v. 17.8%). The only published data on
disease transmission by barbering blades come from Nigeria,5,6 which
is also the country in which the concept of individuals bringing
their own hair clippers to the barber shop originated; this may
be coincidental, or represent awareness of risk of HIV
transmission that contributes to that country’s lower HIV
burden.

The risk of disease
transmission per haircut with a contaminated clipper is likely
to be low, but overall the risk may not be insignificant
taking into account the popularity of the chiskop and the prevalence of HIV in
our population. Clean-shave haircuts are risk factors for
injury independent of FKN. Contrary to popular belief, the HI
virus remains viable for several days at room temperature in
dried blood on surfaces9 and may be resistant to
commonly used disinfectants.10 Since a cure and/or an
effective HIV vaccine remain elusive, potential methods of
disease transmission should be identified for disease
prevention. This study does not (and was not intended to)
prove a higher HIV prevalence in chiskop wearers or in FKN sufferers,
but confirms a history of haircut-associated bleeding in at
least a quarter of our male subjects. The potential
contribution to HIV transmission requires quantification, but
public education regarding adequate sterilisation of barbering
equipment between clients and promotion of individual
hair-clipper ownership for chiskop
wearers should not be
delayed. Chemical depilatories may offer a safe alternative to
mechanical clean-shave haircuts.

Acknowledgements.
We are grateful to Sr Petlho, Sr Kwini, Mr Joboda and the rest
of the Langa Clinic staff, without whom the study would not
have been possible.