Traction alopecia is a form of non-permanent alopecia, or gradual hair loss, that results from a continuous physical damage to the hair shaft. It is frequently caused by hairstyles that produce a constant tension or pull on hair follicles such as tight ponytails, dreadlocks, braids, or other forms of habitual stress on the scalp. In most cases, where the stress on the scalp is blocked early, the chances of regrowth of hair are high, however, in cases where scarring develops due to long term traction, the outcome is likely to result in permanent alopecia.
How does Traction Alopecia manifest itself?
Receding hairlines are often the most common presentation in patients with this form of hair loss. In addition, repeated strain on hair follicles may not only cause redness, itching, and damage to hair follicles but can also increase the risk of developing pus-producing ulcers and infections. Patients also report an increased incidence of paresthesia and headaches. On physical examination, a characteristic fringe is observed along the marginal line that serves as a useful marker for diagnosis.
Traction alopecia might not be a serious medical condition, but it imparts a significant physiological effect on the sufferer, as receding hairline and thinning hair often drastically impacts a person’s self-esteem. Therefore, early diagnosis and management can effectively restore confidence and quality of life in patients with this condition.
Who does it affect?
This hair loss is relatively common in African American communities and in ethnicities that culturally practice hairstyles that cause traction, such as, for example, braids. It is estimated that around one-third of African descent women face this complaint either due to their tight braiding traditions, or to the use of chemical relaxers for hair straightening. Traction alopecia is also observed in high frequency in professions that require a particular type of hairstyle, such as gymnasts, ballerinas, and military personnel.
This condition was first identified in Greenland in the early 1900s among women who wore tight ponytails and observed a receding hairline.
Signs of traction alopecia include:
- a receding hairline typically around the forehead, temples, or nape,
- pimples or pustules on the hair margins or at the base of braids,
- redness and tenderness of the scalp,
- itching, scaling, and ulcers on the scalp,
- widening of hair part,
- multiple short broken hair,
- patches of shiny, scarred skin (in more advanced cases).
Possible causes of traction alopecia include:
- Certain hairstyles including dreadlocks, braids, cornrows, tight ponytails and chignons.
- Hair extensions or weaves that are tightly tied or glued to the base of the hair.
- Headwear such as helmets or tight elastic headbands that come in contact with the scalp for a long duration.
- Hair accessories such as hair slides or grips that are tightly worn in the same position daily.
- Hair relaxers and rollers.
- Using extensions and relaxers together.
The histological findings of a scalp biopsy taken from an area of traction alopecia vary upon the stage of disease progression.
In early stages the scalp biopsy showed:
- Trichomalacia, i.e. soft fragile and swollen hair,
- An increased number of catagen (intermediate stage of hair cycle) and telogen hairs (resting phase of growth),
- Preserved sebaceous (oil) glands.
Whereas in the late stage of the disease, the biopsy showed:
- Fall out of terminal hair with retention of Vellus hairs (fine short hairs) on the hairline.
- A decrease in sebaceous glands and terminal hair follicles as they are majorly replaced by fibrotic fibrous tracts (scars).
- The absence of inflammatory infiltrates at all times of disease progression.
Managing traction alopecia
As the cause behind traction alopecia remains mechanical rather than chemical, pharmaceutical therapies are generally not needed. The most effective action in cases identified early, was ceasing the chronic traction inflicted on the scalp. In cases where desired results of hair regrowth are not achieved, cosmesis, and surgical restoration can be employed.
Some simple changes that can restore hair loss caused by traction alopecia include:
- Avoiding tight hairstyles as much as possible and wearing hair loosely (especially overnight) as frequently as is possible.
- Avoiding or cutting down on chemical relaxers. Their use combined with extensions should be avoided at all costs. Hair products with complex formulas such as hair dyes, chemical straighteners, should also be limited.
- Changing the side of hair parting as regularly as possible to avoid traction alopecia in one focused area.
- Multiple hair growth serums such as pharmaceutical preparations or herbal products can be used to restore lost hair. These include minoxidil, saw palmetto, essential oils such as castor oil, rosemary oil, and dietary nutrients such as biotin.
- The presence of scalp tenderness, inflammation, and ulcers can be treated with topical steroids, antibiotics, and fungal shampoos. For severe advanced cases, oral antibiotics, injectable steroids, and hair replacement surgeries are also recommended.
SLEPYAN AH. Traction alopecia. AMA
Archives of dermatology. 1958 Sep 1;78(3):395-8.
ROLLINS TG. Traction folliculitis with hair casts and alopecia. American Journal of Diseases of Children. 1961 May 1;101(5):639-40.
James J, Saladi RN, Fox JL. Traction alopecia in Sikh male patients. The Journal of the American Board of Family Medicine. 2007 Sep 1;20(5):497-8.
Özçelik D. Extensive traction alopecia is attributable to ponytail hairstyle and its treatment with hair transplantation. Aesthetic plastic surgery. 2005 Aug 1;29(4):325-7.
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). Journal of the American Academy of Dermatology. 2016 Sep 1;75(3):606-11.
Kundu RV, Patterson S. Dermatologic conditions in skin of color: part II. Disorders occurring predominately in the skin of color. American family physician. 2013 Jun 15;87(12):859-65.
Billero V, Miteva M. Traction alopecia: the root of the problem. Clinical, cosmetic, and investigational dermatology. 2018;11:149.
Goren A, Wei L, Tan Y, Kovacevic M, McCoy J, Lotti T. Frontal pattern hair loss among Chinese women is frequently associated with a ponytail hairstyle. Dermatologic therapy. 2019 Jan;32(1):e12784.
Khumalo NP, Jessop S, Gumedze F, Ehrlich R. Hairdressing, and the prevalence of scalp disease in African adults. British Journal of Dermatology. 2007 Nov;157(5):981-8.