BACKGROUND Hair loss occurs in all ethnic populations, but the etiology varies considerably from group to group. In black women, many forms of alopecia are associated with hair care practices. However, the causes of alopecias in African women have not been extensively investigated. OBJECTIVE This descriptive, cross-sectional, hospital-based study was undertaken to document common complaints on initial presentation for hair loss, hair care practices and patterns of hair loss, and to determine if there is a relationship between hair loss and hair care practices. METHODS A total of 39 female patients seen over a 12 month period were enrolled in the study. Demographic information recorded included age, sex, marital status and occupation. Information regarding medical history included initial presenting complaints, duration of hair loss, site of hair loss, whether there was skin or systemic involvement, hair care practices and the duration of these practices. Examination of the scalp, a hair-pull test, documentation of the pattern of hair loss, relevant laboratory tests and biopsies were carried out. RESULTS All 39 patients were adults. Major complaints at initial presentation, apart from hair loss, included itchy scalp in 17 patients (43.6%), painful scalp in 11 patients (28.2%), hair breakage in seven patients (17.9%) and flaking scalp in four patients (10.3%). All the women relaxed their hair at some point in time. Chemical relaxants were consistently used by 22 patients (53.7%), eight patients (20.5%) alternated these with plaits/braids, and nine patients (23.1%) wore extensions. The use of local concoctions in hair care management was reported by three patients (7.7%). Scarred alopecias were observed in 20 patients (51.3%), while 19 (48.7%) had non-scarred alopecias. Those who reported prolonged and frequent use of chemical relaxants [mean duration (+/- standard deviation) 23.2+/-9.3 years] exhibited scarred alopecia more commonly than those who did not often use chemical relaxants (P<0.001). The application of local concoctions or pomades was also a regular practice amongst females with scarred alopecias. CONCLUSIONS Itchiness, pain, ready hair breakage and flaking scalp were common complaints at initial presentation. A range of alopecias were documented, and it was also observed that duration of hair care practice and hair styling were relevant to hair loss, particularly for women with central centifugal cicatricial alopecias (CCCAs), which resulted in scarring.