Are You Confident of the Diagnosis?
What you should be alert for in the history

Patients often report that hair no longer grows. They also often complain that the scalp “hurts” in the areas of increased tension. The onset of traction alopecia is slow and insidious, often without any symptoms. It is localized most commonly to the peripheral scalp.

Traction alopecia results from unintentional forces on hair from hair styling practices. It is often seen in setting of braids, corn rows, ponytails, hair extensions, or rolling curlers (especially sponge rollers which may not have any give) (Figure 1). Remember to ask about hair care practices.

Figure 1.

Classic temporal traction with intact frontal fringe of hairs.

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Characteristic findings on physical examination

Classify as a marginal pattern, which is most common (affecting the scalp periphery), or nonmarginal (affecting the central portions of scalp).

Gradual hair loss is found at the points of maximal traction. In children, the most common site is the temporal region, with an intact frontal ringe of hair (Figure 2). In adults, the most common sites are the temporal and frontal regions. It can be seen in the occipital scalp with use of bun or chignon

Figure 2.

Hair extensions woven into scalp hair can lead to traction alopecia.

Shorter hairs often present in an anterior rim because these hairs are too short to be pulled back and are spared the excessive traction. Chronic traction alopecia is characterized by permanent scarring alopecia with loss of the follicular orifices.

Diagnosis confirmation

Diagnosis is often clinical, based on history and physical examination. A biopsy with histopathology can be used for confirmation.

Acute: subacute perifollicular inflammation. Papules and pustules (often sterile when cultured) can be seen at site of maximal tension (remember to rule out tinea capitis, especially in African-Americans) (Figure 3).

Figure 3.

Pustules can develop at sites of increased traction.

Chronic: noninflammatory loss of follicles with intact sebaceous glands.

The differential diagnosis includes frontal fibrosing alopecia, which is most common in postmenopausal women, and presents as “slick cement” skin surface with absence of follicular orifices and perifollicular erythema and scale affecting the anterior hairline. The hair loss extends 1-3 cm along the anterior hairline. Eyebrow involvement occurs.

Who is at risk for Developing Traction Alopecia?

All ethnicities can be affected. African-Americans are the most commonly affected, which is usually attributed to the higher incidence of braids in this population. Sikhs are also at a high risk, because their religious beliefs prohibit them from cutting their their hair and require them to wear a turban. Chronic unidirectional tension results from a tightly braided knot placed under the turban.

What is the Cause of Traction Alopecia?

Damage to the hair shaft can be sustained by any prolonged unidirectional force creating tension on the follicles. After 3-5 years of increased traction, permanent hair loss can be seen

Systemic Implications and Complications

No specific systemic complications are associated with traction alopecia.

Treatment Options

Conservative Measures

Conservative treatment is the gold standard and often leads to reversal. Intervene early by educating patient/family in order to avoid permanent hair loss. Patients/parents must be told not to place so much tension on the hair; ie, loosen the ponytail (the scalp should not be painful). Instruct the patient to redirect the tension of the hair every 2-4 weeks by referring to a skilled stylist.

Medical Therapies

Topical minoxidil in 2% or 5% concentrations has been reported to help in certain case studies, but no randomized clinical trials have been reported yet. Minoxidil can stimulate existing, spared hairs to stay in anagen (growth) phase longer, thereby leading to thicker hairs.

If secondary folliculitis is suspected during the acute phase, bacterial and fungal cultures should be performed; treatment is based on culture results. However, with reversal or redirection of traction on the hairs, the inflammation subsides without medical therapy A trial of doxycyline (> 8 y.o.) 20mg BID may provide benefit from an antiinflammatory perspective.

Surgical Treatments

Hair transplantation (taking donor hair from spared scalp, usually the occipital area, and placing into recipient scarred area) can be effective. An experienced hair transplant surgeon is necessary.

Optimal Therapeutic Approach for Traction Alopecia

Identify the patient at risk for traction alopecia by observing increased tension on hair. Instruct the patient to see a skilled stylist in order to identify hair styles that result in a redirection of the tension every 4-6 weeks.

If scarring is evident, attempt a trial of topical minoxidil solution or foam once or twice daily to stimulate thickening of existing hairs. Set the goal of maintaining current hair density and/or improvement in current hair density after 6 months of treatment.

If minoxidil fails, referral to a hair transplant surgeon is appropriate.Recommend a stylist who can work with existing hair and who may have recommendation for a hair replacement system

Patient Management

Periodic monitoring is necessary to evaluate for improved hair growth. It usually takes at least 4-6 months after to see results from topical minoxidil. Patient education on decreased hair tension along with tension redirection should be reinforced at each visit

Attend to psychological implications of permanent hair loss.

Unusual Clinical Scenarios to Consider in Patient Management

Pressure alopecia, as may occur with orthodontic headgear, for example, may yield a clinical appearance similar to traction alopecia.

What is the Evidence?

Fox, GN, Stausmire, JM, Mehregan, DR. “Traction folliculitis: an underreported entity”. Cutis. vol. 79. 2007 Jan. pp. 26-30. (An article stressing the importance of keeping traction folliculitis in the differential in patients who present with painful, perifollicular erythema and pustules. If this goes unnoticed and hairstyles are not altered, there is a risk of progressing to traction alopecia.)

Goldberg, LJ. “Cicatricial marginal alopecia: is it all traction?”. Br J Dermatol. vol. 160. 2009 Jan. pp. 62-8. (This article reviews the cases of 16 different patients with hair loss at the scalp periphery without erythema or clinical evidence of scarring and biopsies consistent with scarring alopecia. Since their histories did not reveal any practices consistent with traction alopecia, the term cicatricial marginal alopecia (CMA) was coined. This condition appears clnically like alopecia areata, which is why a biopsy is needed to assess prognosis in these patients.)

James, J, Saladi, RN, Fox, JL. “Traction alopecia in Sikh male patients”. J Am Board Fam Med. vol. 20. 2007 Sep-Oct. pp. 497-8. (A focused study describing the increased risk of traction alopecia in Sikh males. The article discusses the fact that treatment in this population is difficult, because for religious reasons these males may not cut their hair or remove their turban. Thus their hair remains in tightly wound ponytails under the added stress of a turban for the majority of each day.)

James, WD, Berger, TG, Elston, DM, Odom, RB. “Diseases of the Skin Appendages”. Andrews’ diseases of the skin: clinical dermatology. 2006. pp. 761(A very brief synopsis on traction alopecia’s etiology and location.)

Khumalo, NP, Ngwanya, RM. “(2007). Traction alopecia: 2% topical minoxidil shows promise. Report of two cases”. J Eur Acad Dermatol Venereol. vol. 21. 2007 Mar. pp. 433-4. (This article examines two patients diagnosed with traction alopecia who did not begin to regrow hair even after releasing the tension of their previous hairstyles for a minimum of 1 year. These patients were started on 2% minoxidil and showed substantial growth by 6 and 9 months, respectively. The author suggested that follicular miniaturization may play a role in the pathophysiology of traction alopecia.)

Wilborn, WS, Olsen, EA. “Disorders of Hair Growth in African Americans”. Disorders of hair growth: diagnosis and treatment. 1994. pp. 399-401. (Provides a basic overview of the etiology, progression from traction folliculitis to permanent alopecia, as well as prevention and treatment measures for traction alopecia.)

Samrao, A, Chen, C, Zedek, D, Price, VH. “Traction alopecia in a ballerina: clinicopathologic features”. Arch Dermatol. vol. 146. 2010 Aug. pp. 930-1. (The first case of traction alopecia reported in a ballerina, due to a tightly wound ponytail. Stresses the importance of histopathology in making the correct diagnosis of traction alopecia versus other cicatricial alopecias in order to recognize reversible causes of hair loss)

Urbina, F, Sudy, E, Barrios, M. “Traction folliculitis: 6 cases caused by different types of hairstyle that pull on the hair”. Actas Dermosifiliogr. vol. 100. 2009 Jul-Aug. pp. 503-6. (This article examines six different females with: ponytails (2), cornrows, extensions (2), and braids. Each presented with a short history of small painful follicular pustules on their scalp at areas of maximal traction. Two cultures were collected, both were positive for Staphylococcus aureus. Surrounding unstressed hair follicles were unaffected, leading to the hypothesis that bacteria in this case are opportunistic affecting only the irritated follicles at sites of maximal tension. All patients improved by reducing the tension in their hairstyles and taking a short course of oral antibiotics. The author suggests that this presentation of traction folliculitis should help a clinician recognize the need to councel the patient on the risk that their current hairstyle could eventually lead to a scarring alopecia.)