Traction alopecia

Traction alopecia is hair loss (alopecia) that can occur if you wear pigtails, braids or cornrows, or use tight hair rollers and especially, when “relaxer” chemical treatments are used to straighten hair of the African type ¹. In fact, one-third of women of African descent are affected ². Traction alopecia is a form of acquired hair loss that results from prolonged or repetitive tension on the scalp hair. It is now generally agreed upon that the extent of pulling and the duration of traction increase the risk of traction alopecia and that treated hair may be less resistant to traction ³. In its later stages, traction alopecia may progress into an irreversible scarring alopecia if traumatic hairstyling continues without appropriate intervention.

Traction alopecia was first described in 1907 in subjects from Greenland who had developed hair loss along the hairline due to prolonged wearing of tight ponytails. In 1907, Trebitsch ⁴, an Austrian dermatologist, reported a characteristic marginal temporoparietal alopecia among Greenlandic women who wore their hair in a traditional tight coiffure arranged on the crown of the head but absent among Greenlandic women whose hair was arranged in looser, European styles.

Traction alopecia affects people of any ethnic background or age. The likelihood of developing traction alopecia increases with age, likely due to a prolonged history of these hair practices.

The risk of traction alopecia is increased by the extent of pulling and duration of traction, as well as the use of chemical relaxation ⁵. The frequent use of tight buns or ponytails, the attachment of weaves or hair extensions, and tight braids such as cornrows and dreadlocks are believed to be the highest risk hairstyles. Traction alopecia can also occur in the setting of religious and occupational traumatic hairstyling.

Today, traction alopecia is commonly associated with African-American females who wear tight braids resulting in hair loss on sides of the head (temporal scalp). Traction alopecia has also been described in Sikh males who twist their uncut scalp hair tightly on the scalp (resulting in scalp alopecia) or their uncut beard below the chin (causing submandibular traction alopecia).

In the study by Wright et al ⁶, 201 caregivers of African girls aged 1–15 years reported that within the past 12 months, 81% wore ponytails, 67% wore braids, and 49% wore cornrows. There was a significant risk of developing hair thinning along the hairline in the girls who wore cornrows within the last 12 months, which had a stronger association after controlling for use of chemical relaxers ⁶. Oftentimes, children of African descent will attach plastic beads and barrettes to their braids, which add additional traction. Samrao et al ⁷ reported that Hispanic women who presented with traction alopecia began wearing tight ponytails in childhood or their teenage years.

Sikh boys wear their hair and turbans very tightly to avoid loosening while playing, increasing the degree of traction on the hair shaft beginning in adolescence ⁸. The two Sikh men presenting in Austria had sharply demarcated scarring alopecia of the frontal hairline at the age of 12 and 19 years ⁹.

Chronic traction alopecia may, in its later stages, develop into an irreversible scarring alopecia not remediable to therapy. Therefore, it is imperative that clinicians educate high-risk populations
about traction alopecia and those practices that may convey the risk of hair loss.

The first step in treating traction alopecia is taking away the strain on the hair. This can mean not wearing certain hairstyles or helmets or stopping use of chemical relaxers. Sometimes dermatologists will suggest minoxidil to stimulate hair growth, or topical corticosteroids to help with itching or redness.

Is traction alopecia permanent?

Traction alopecia is not usually permanent, especially if it is diagnosed early. Often, recognizing the problem and avoiding putting strain on the hair will allow full regrowth. If traction alopecia is diagnosed too late, the hair follicles may have been destroyed and hair will not regrow.

Traction alopecia causes

Traction alopecia is caused by repeated strain (or pulling) on the hair, over a long period of time. It can affect people of all ages but is more common in older people as the hair follicles weaken over time. Some of the things that can cause traction alopecia include:

• Tight hairstyles, like dreadlocks, braids, cornrows, and tight ponytails.
• Hair extensions and weaves.
• Tight headwear, like such as helmets, tight hair grips or tight elastic headbands.
• Very long hair, including beard hair can pull on the hair follicles.
• Hair relaxers and other chemical treatments.
• Using extensions and relaxers together.

The hair loss seen in traction alopecia is thought to be caused by the exertion of excessive pulling forces, leading to mechanical damage of the hair follicles ³. The damage induces an inflammatory response, which presents as perifollicular erythema with pustules and/or papules in areas of traction ¹⁰. Chronic and repeated traction causes repeated follicular damage and eventually hair loss ³.

Traction alopecia can also be due to the weight of excessively long hair. Traction alopecia is commonly associated with African American females who wear tight braids resulting in hair loss on sides of the head (temporal scalp). Traction alopecia has also been described in Sikh males who twist their uncut scalp hair tightly on the scalp (resulting in scalp alopecia) or their uncut beard below the chin (causing submandibular traction alopecia).

Association with specific hair morphology

The hair of persons of African descent is uniquely distinct from the hair of persons originating in European and Asian populations ¹¹. There are several factors that make African hair more susceptible to chronic mechanical trauma.

1. On transverse sections, the African hair shaft has an elliptical or “kidney-like” shape, whereas the hair of Caucasians and Asians has a uniformly circular shape on transverse sections ¹².
2. The African hair shaft has an asymmetrical position ¹². The African hair follicle is curved at its insertion into the dermis and exhibits retro-curvature at the level of the follicular bulb. This is thought to be responsible for the helical morphology of the African hair follicle ¹³.
3. The follicular bulb is asymmetrically curved resembling a golf club.
4. The hair follicle is helically shaped with each concave and convex turn contributing to geometric points of weakness ¹⁴.

The axial asymmetry and helical shape lead to the presence of geometric points of weakness, which make African hair more susceptible to breakage during combing and to the development of traction alopecia secondary to tight hairstyles that subject the hair shaft to prolonged mechanical trauma ¹².

Association with chemical relaxation

Certain hairstyles convey a particularly high risk of traction alopecia. The frequent use of tight buns or ponytails, the attachment of weaves or hair extensions, and tight braids (such as cornrows
and dreadlocks) are believed to be the highest risk hairstyles. The risk of these hairstyles contributing to traction alopecia is increased when the patient has undergone chemical relaxation of their hair ¹. Chemical relaxation of the hair through interruption of disulfide bonds weakens the hair shaft, and the experience of a “stinging” association during the relaxing process has been identified as predicting a higher risk of future traction alopecia. Only 18.9% of patients suffering traction alopecia denied ever experiencing painful symptoms during or following hairdressing ¹⁵. Among patients who continue to wear high-risk hairstyles and repeatedly use chemical relaxers, the prevalence of traction alopecia increases over time. In a study at a South African school, the prevalence of traction alopecia in schoolgirls was found to be 8.6% among first-year students and 21.7% among those girls in the last year of school ¹⁶.

Association with cultural practice

Traction alopecia has been associated with numerous types of hairstyling related to cultural, religious, and occupational practices.

People of African descent wear many types of hairstyles that put them at increased risk for developing traction alopecia. The hairstyles most commonly associated with traction alopecia in this patient population include braids, including cornrows, weaves, and dreadlocks ¹⁷. Khumalo et al ³ reported an increase risk of developing traction alopecia in Africans who combine these traumatic hairstyles in the setting of chemically relaxed hair. Chemically relaxed hair is a commonly practiced styling technique producing a more straight and soft appearance and can be achieved through different processes. Lye relaxers contain sodium hydroxide and non-lye relaxers contain guanidine hydroxide, both of which use the hydroxide molecule to cleave the disulfide bond in the hair fiber ¹. These chemical straighteners reduce the tensile strength of the hair follicle ¹⁸ and increase hair brittleness ¹⁹, which contribute to hair loss when compounded by mechanical stress of traumatic styling. However, the traction exerted on the hair root by these traumatic hairstyles is enough to cause alopecia in a background absent of chemical relaxers ²⁰. These hairstyles are utilized in this patient population because they contribute to hair manageability, flexibility, and appearance while also providing a means for celebration of cultural heritage ¹⁷.

Similarly, Samrao et al ⁷ reported on the increased risk of developing traction alopecia in Hispanic women who wore their hair in a tight ponytail for many years. The association was seen in Hispanic women with long, thick hair and presented with areas of hair loss primarily on the frontal and temporal scalp but also, less frequently, on the vertex and occipital scalp.

Association with religious practice

The literature has noted traction alopecia in association with religious practices. Sikhism is a religion originating in the Punjab region of India, which prohibits its men and women followers from cutting their hair to convey respect for God’s creation of man as he was intended. As a child, ranging from 11 to 16 years of age, the Sikh men participates in a ceremony called “dastaar bandi” in which he tries on his first turban. From this time onward, the Sikh men will tightly twist all of his hair into a knot that sits on the frontal scalp ²¹. Then he will wrap a turban tightly around the hair to cover the top of the head which will be worn for 24 hours before being removed so the hair can be combed ²². Karimian-Teherani et al ⁹ reported on two formerly Sikh brothers who wore turbans since childhood who moved to Austria aged 12 and 19 years and removed their headgear after rescinding the religion. They presented with sharply demarcated band-like scarring alopecia localized to the frontal hairline. Submandibular alopecia can also occur as the Sikh men tie their beards into tight knots that sit on the chin ²². Moreover, turban-wearing is commonplace in Islamic countries and has become increasingly popular in Turkey over the last three decades ²³. In the study conducted by Polat ²³, Turkish women who wore their turban for less than 10 years were noted to have frontal alopecia, whereas Turkish women who wore their turban for more than 10 years were noted to have extension of hair loss into the fronto-parietal and fronto-temporal regions.

Association with occupational practice

Trüeb ²⁴ reported on three women who presented with localized occipital alopecia in the context of twisting the hair into tight bun, proposing “chignon alopecia” as a new entity. Similarly, traction alopecia in a ballerina who wore her hair in an uncomfortably tight bun to dance class 4 days a week for 13 years presented with symmetrical temporal patches of hair loss ²⁵. To cover up the patches of hair loss, the ballerina began wearing a 1.5-pound hairpiece every day for 2 years, subjecting her to greater traction and resulting in aggravation of hair loss. Additionally, in a report studying 143 South Korean nurses, seven developed localized parieto-occipital alopecia at the site where the cap was attached to the scalp by two bobby pins for 8 hours a day with a 9.8 years average duration of cap wearing ²⁶.

Traction alopecia stages

The histological findings of a skin biopsy taken from an area of traction alopecia differ depending on its stage of progression.

Early stage traction alopecia

Early stages present with:

• Trichomalacia (thinned out hair)
• An increased number of catagen (intermediate stage of hair cycle) and telogen hairs (bulb hair)
• The normal number of telogen follicle
• Preserved sebaceous (oil) glands.

In the early stage, patients typically present with patches of non-scarring hair loss along the area of the scalp that is undergoing tension. The hair loss can occur at any area of the scalp depending on the configuration of the hairstyle. Broken hairs and pustules within the follicles are often appreciated ²⁷.

Late stage traction alopecia

At a later stage:

• Vellus hairs (fine short hairs) develop
• Sebaceous glands and terminal hair follicles reduce and are replaced by fibrotic fibrous tracts (scars).
• Inflammation is mild to absent.

In its later stages, traction alopecia may progress into an irreversible scarring alopecia if traumatic hairstyling continues without appropriate intervention. Patients may also report tenderness, itching, paresthesias, and headache ²⁶.

Traction alopecia signs and symptoms

There is a large variation in the pattern of clinical presentation of traction alopecia. It there is no suspicion of traction, it can be difficult to diagnose.

The signs of traction alopecia may include:

• Pimples
• Redness
• Itching
• Scaling
• Ulcers on the scalp
• Patches of thin or short broken hair in places where the hair has been under strain
• Patches of shiny, scarred skin
• Folliculitis or pustules
• Thinning and hair loss

Traction alopecia mostly affects the front (frontal) and sides of the scalp but the location of traction alopecia wholly depends on an individual’s hair care practice, which may or may not is related to their ethnic background. “Fringe sign” is commonly found in patients with traction alopecia of the marginal hairline – this means that some hair is retained along the frontal and/or temporal rim of the hairline. Initially, traction alopecia is noncicatricial (without scarring), but prolonged and excessive tension leads to destruction of the hair follicles and permanent alopecia.

Signs of traction alopecia

The earliest clinical sign of traction alopecia is perifollicular erythema that develops into a folliculitis characterized by perifollicular pustules and papules ²⁸. In its later stages, traction alopecia evolves into a scarring alopecia with decreased follicular markings ⁷. The most common sites of hair loss are the frontal and temporoparietal areas, although any area of the scalp can be affected depending on the hairstyle worn ²⁸. Marginal traction alopecia refers to hair loss and thinning that is seen along the frontal and temporoparietal margin of the hairline ²⁹. Marginal traction alopecia is often accompanied by a strip of thin hair at the distal end of the patch of alopecia that is referred to as “the fringe sign” ⁷. Non-marginal, or patchy, alopecia is another variant of traction alopecia that refers to patches of hair loss and thinning that occur on less commonly affected areas of the scalp that can occur secondary to hair wefts, hair pins, or clips. For example, chronic use of hair wefts, which are a component of weaves, have been described to cause a “horseshoe” pattern of hair loss ²⁹. Additionally submandibular alopecia has been reported in Sikh men who tie their beard hair in a tight knot on their chin ²².

Trichoscopy of patients with both marginal and nonmarginal distributions of traction alopecia will demonstrate:

1. Reduced hair density with absence of follicular openings ³⁰ or
2. Absence of hairs with preserved in-brown-outlined follicular openings that correspond on pathology to the pigmented basal cell layer of follicular infundibulum.

If there are any hairs remaining in the patches, they are exclusively of vellus origin. Patches of acute traction alopecia can present with broken hairs at different length in similarity to trichotillomania. Numerous hair casts, yellowish-white cylinders that accumulate around traumatized hair shafts, may be appreciated on dermatoscopy at the border of the area of hair loss. They slide easily along the hair shaft and correspond on pathology to the desquamated root sheaths. Their presence indicates the persistence of mechanical traction on the affected hair shafts ³⁰.

Traction alopecia diagnosis

Your doctor will diagnose traction alopecia using your medical history, and examination of hair styling habits, trichoscopy (an examination of the scalp using a microscope) and a scalp biopsy if necessary.

Traction alopecia histological findings

The histological findings of a skin biopsy taken from an area of traction alopecia differ depending on its stage of progression.

• Early stages present with:
  • Trichomalacia (thinned out hair)
  • An increased number of catagen (intermediate stage of hair cycle) and telogen hairs (bulb hair)
  • The normal number of telogen follicle
  • Preserved sebaceous (oil) glands.
• At a later stage:
  • Vellus hairs (fine short hairs) develop
  • Sebaceous glands and terminal hair follicles reduce and are replaced by fibrotic fibrous tracts (scars).
  • Inflammation is mild to absent.

Traction alopecia treatment

People with traction alopecia should consider changing hair care and styling practice to prevent further deterioration.

• Loosen the hairstyle.
• Cut long hair.
• Avoid exposing affected hair and scalp to chemicals and heat.

Medical treatment options reported to have been used in traction alopecia include:

• Antibiotics to prevent infection
• Topical or intralesional steroids
• Topical antifungal shampoos
• Biotin supplements
• Minoxidil
• Hair replacement surgery

Khumaloand Ngwanya reported two cases of women suffering late stage traction alopecia who experienced hair regrowth at 3 months and significant hair regrowth after 6 and 9 months, respectively, with the topical application of 2% minoxidil ³¹. Same patients had previously experienced no response with 1– 2 years of abstention from traumatic hairstyling practices. Additionally, Callender et al ¹⁷ reported anecdotal success with topical minoxidil in a subset of traction alopecia patients. Further study is required in order to determine the optimal duration and concentration of minoxidil therapy in the treatment of traction alopecia. Although there are no reports on the use of 5% minoxidil in traction alopecia, it may be considered as an alternative therapeutic option. Latanoprost has not been studied in traction alopecia.

The advanced stages of traction alopecia, characterized by scarring and follicular atrophy, are less amenable to medical therapy, but surgical treatment through hair transplantation may be an option for some patients. Successful hair transplantation for patients with advanced traction alopecia has been documented with multiple techniques, including punch grafting with rotation flaps ³², micro (1–2 follicular unit grafts), and mini (3–4 follicular unit grafts) grafting ³³. Ozcelik ³³ reported a case of a 23-year-old woman with a 5-year history of wearing an extremely tight ponytail every day in order to elevate her eyebrows who presented with bilateral temporal scarring alopecia and underwent one session of micro- and minigraft transplantation. At 1-year follow-up, the patient had 90%–95% survival of hair at the recipient site with a natural direction of hair growth and reported satisfaction with cosmesis. With hair transplantation, it is important to counsel the patient on realistic outcomes and likelihood of multiple sessions in order to achieve cosmetically favorable outcomes.

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