- Nonhlanhla P Khumalo, MBChB, FCDerm, PhD
Nonhlanhla P Khumalo, MBChB, FCDerm, PhD
- Associate Professor, Head of Dermatology
- Groote Schuur Hospital and The University of Cape Town
- Paradi Mirmirani, MD
Paradi Mirmirani, MD
- Department of Dermatology
- The Permanente Medical Group, Vallejo CA
Traction alopecia is a form of hair loss that results from prolonged or repetitive tension on hair. Traction alopecia most commonly occurs along the frontal or temporal scalp, but can also occur in other sites of the scalp and in other hair-bearing areas (picture 1A-C).
Having a high clinical suspicion for traction alopecia in at-risk populations and obtaining a detailed history of current and past hair care practices is essential for making the diagnosis. Early recognition and cessation of the offending hair care practice is critical because sustained traction can lead to permanent hair loss.
The clinical features, diagnosis, and management of traction alopecia will be reviewed here. An overview of the evaluation of patients with hair loss is provided separately. (See "Evaluation and diagnosis of hair loss".)
EPIDEMIOLOGY AND RISK FACTORS
Traction alopecia can occur when hair follicles are subjected to prolonged or repetitive tension. Although epidemiologic data on traction alopecia are limited [1-4], it appears that traction alopecia is most frequently diagnosed in females of African descent with Afro-textured hair. The relatively high prevalence in this population is most likely related to the frequent use of traction hairstyles (eg, braids or hair weaves) in this population. In support of this theory, traction alopecia occurs in other populations in association with the use of traction hairstyles, such as tight ponytails [5,6], chignon or bun hairstyles (as often worn by ballerinas) [7,8], hair extensions , hair pins (as for securing nursing caps) , and the Sikh practices of tightly twisting long hair on the scalp and knotting the beard hair [11,12].
Differences in exposure to traction hairstyles likely contributes to the higher prevalence of traction alopecia in females compared with males and adults compared with children in populations of African descent. In a study of 874 adults in South Africa, traction alopecia was detected in 32 percent of women compared with only 2 percent of men . Increasing prevalence with age was demonstrated in a study of 1042 schoolchildren (ages 6 to 21 years) in South Africa; traction alopecia was present in 9 percent in girls in their first year of school (age 6 to 7 years) compared with 22 percent in girls in their last year of high school (age 17 to 21 years) . No male schoolchildren had traction alopecia. Traction alopecia can also occur in infants. A case report documents traction folliculitis (an early presentation of traction alopecia) in an eight-month-old child .
- Khumalo NP, Jessop S, Gumedze F, Ehrlich R. Hairdressing and the prevalence of scalp disease in African adults. Br J Dermatol 2007; 157:981.
- Khumalo NP, Jessop S, Gumedze F, Ehrlich R. Hairdressing is associated with scalp disease in African schoolchildren. Br J Dermatol 2007; 157:106.
- Rucker Wright D, Gathers R, Kapke A, et al. Hair care practices and their association with scalp and hair disorders in African American girls. J Am Acad Dermatol 2011; 64:253.
- Khumalo NP, Jessop S, Ehrlich R. Prevalence of cutaneous adverse effects of hairdressing: a systematic review. Arch Dermatol 2006; 142:377.
- HJORTH N. Traumatic marginal alopecia; a special type: alopecia groenlandica. Br J Dermatol 1957; 69:319.
- Samrao A, Price VH, Zedek D, Mirmirani P. The "Fringe Sign" - A useful clinical finding in traction alopecia of the marginal hair line. Dermatol Online J 2011; 17:1.
- Samrao A, Chen C, Zedek D, Price VH. Traction alopecia in a ballerina: clinicopathologic features. Arch Dermatol 2010; 146:930.
- Trüeb RM. "Chignon alopecia": a distinctive type of nonmarginal traction alopecia. Cutis 1995; 55:178.
- Yang A, Iorizzo M, Vincenzi C, Tosti A. Hair extensions: a concerning cause of hair disorders. Br J Dermatol 2009; 160:207.
- Renna FS, Freedberg IM. Traction alopecia in nurses. Arch Dermatol 1973; 108:694.
- Kanwar AJ, Kaur S, Basak P, Sharma R. Traction alopecia in Sikh males. Arch Dermatol 1989; 125:1587.
- James J, Saladi RN, Fox JL. Traction alopecia in Sikh male patients. J Am Board Fam Med 2007; 20:497.
- Fox GN, Stausmire JM, Mehregan DR. Traction folliculitis: an underreported entity. Cutis 2007; 79:26.
- Khumalo NP, Jessop S, Gumedze F, Ehrlich R. Determinants of marginal traction alopecia in African girls and women. J Am Acad Dermatol 2008; 59:432.
- Miteva M, Tosti A. 'A detective look' at hair biopsies from African-American patients. Br J Dermatol 2012; 166:1289.
- Sperling LC, Lupton GP. Histopathology of non-scarring alopecia. J Cutan Pathol 1995; 22:97.
- Beach RA, Wilkinson KA, Gumedze F, Khumalo NP. Baseline sebum IL-1α is higher than expected in afro-textured hair: a risk factor for hair loss? J Cosmet Dermatol 2012; 11:9.
- Heath CR, Taylor SC. Alopecia in an ophiasis pattern: traction alopecia versus alopecia areata. Cutis 2012; 89:213.
- Ahdout J, Mirmirani P. Weft hair extensions causing a distinctive horseshoe pattern of traction alopecia. J Am Acad Dermatol 2012; 67:e294.
- Tosti A, Miteva M, Torres F, et al. Hair casts are a dermoscopic clue for the diagnosis of traction alopecia. Br J Dermatol 2010; 163:1353.
- ROLLINS TG. Traction follicultis with hair casts and alopecia. Am J Dis Child 1961; 101:639.
- Ozuguz P, Kacar S, Takci Z, et al. Generalized hair casts due to traction. Pediatr Dermatol 2013; 30:614.
- Zhang W. Epidemiological and aetiological studies on hair casts. Clin Exp Dermatol 1995; 20:202.
- Goldberg LJ. Cicatricial marginal alopecia: is it all traction? Br J Dermatol 2009; 160:62.
- Mirmirani P. Ceramic flat irons: improper use leading to acquired trichorrhexis nodosa. J Am Acad Dermatol 2010; 62:145.
- Khumalo NP, Stone J, Gumedze F, et al. 'Relaxers' damage hair: evidence from amino acid analysis. J Am Acad Dermatol 2010; 62:402.
- Mkentane K, Maneli M, Khumalo NP, et al. Relaxers damage hair and increase fragility. Int J Dermatol 2014; 53:e200.
- Shim WH, Jwa SW, Song M, et al. Dermoscopic approach to a small round to oval hairless patch on the scalp. Ann Dermatol 2014; 26:214.
- Tosti A, Miteva M, Torres F. Lonely hair: a clue to the diagnosis of frontal fibrosing alopecia. Arch Dermatol 2011; 147:1240.
- Haskin A, Aguh C. All hairstyles are not created equal: What the dermatologist needs to know about black hairstyling practices and the risk of traction alopecia (TA). J Am Acad Dermatol 2016; 75:606.
- Callender VD, McMichael AJ, Cohen GF. Medical and surgical therapies for alopecias in black women. Dermatol Ther 2004; 17:164.
- Messenger AG, Rundegren J. Minoxidil: mechanisms of action on hair growth. Br J Dermatol 2004; 150:186.
- Khumalo NP, Ngwanya RM. Traction alopecia: 2% topical minoxidil shows promise. Report of two cases. J Eur Acad Dermatol Venereol 2007; 21:433.
- Olsen EA, Messenger AG, Shapiro J, et al. Evaluation and treatment of male and female pattern hair loss. J Am Acad Dermatol 2005; 52:301.
- Blumeyer A, Tosti A, Messenger A, et al. Evidence-based (S3) guideline for the treatment of androgenetic alopecia in women and in men. J Dtsch Dermatol Ges 2011; 9 Suppl 6:S1.
- Fu JM, Price VH. Approach to hair loss in women of color. Semin Cutan Med Surg 2009; 28:109.
- Ozçelik D. Extensive traction alopecia attributable to ponytail hairstyle and its treatment with hair transplantation. Aesthetic Plast Surg 2005; 29:325.
- Earles RM. Surgical correction of traumatic alopecia marginalis or traction alopecia in black women. J Dermatol Surg Oncol 1986; 12:78.
- Rogers NE, Callender VD. Advances and challenges in hair restoration of curly Afrocentric hair. Dermatol Clin 2014; 32:163.
- Donovan JC, Shapiro RL, Shapiro P, et al. A review of scalp camouflaging agents and prostheses for individuals with hair loss. Dermatol Online J 2012; 18:1.
- EPIDEMIOLOGY AND RISK FACTORS
- CLINICAL FEATURES
- Physical examination
- DIFFERENTIAL DIAGNOSIS
- Traction folliculitis
- Marginal traction alopecia
- Non-marginal traction alopecia
- Early-stage traction alopecia
- - Cessation of traction hairstyles
- - Adjunctive interventions
- Topical minoxidil
- Local corticosteroids
- Oral antibiotics
- Late-stage traction alopecia
- - Hair transplantation
- - Cosmetic camouflage
- SUMMARY AND RECOMMENDATIONS