eMedicine Specialties > Dermatology > Diseases of the Adnexa

Traction Alopecia: Differential Diagnoses & Workup

Author: Basil M Hantash, MD, PhD, Instructor of Dermatology and Plastic Surgery, Department of Dermatology, Division of Plastic Surgery, Stanford University School of Medicine
Coauthor(s): Robert A Schwartz, MD, MPH, Professor and Head of Dermatology, Professor of Medicine, Professor of Pediatrics, Professor of Pathology, Professor of Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Contributor Information and Disclosures

Updated: Jan 27, 2009

Differential Diagnoses

Alopecia Areata
Telogen Effluvium
Alopecia Mucinosa
Tinea Capitis
Anagen Effluvium
Trichorrhexis Nodosa
Androgenetic Alopecia
Trichotillomania
Aplasia Cutis Congenita
Sarcoidosis
Syphilis

Other Problems to Be Considered

Discoid lupus erythematosus
Senescent alopecia
Circumscribed scleroderma
Congenital vertical alopecia
Familial focal aplasia
Occipital pressure alopecia
Central centrifugal cicatricial alopecia9

Workup

Laboratory Studies

  • Traction alopecia is usually diagnosed with thorough history taking and meticulous physical examination without laboratory testing.
  • History of tight braids, "pulled-back" hairstyle, or chemical straightening suggests a diagnosis of traction alopecia.
  • History of systemic/chronic illness suggests alopecia areata, cicatricial alopecia, or telogen effluvium.
  • History of scalp infection suggests tinea capitis.
  • Exposure to medications such as chemotherapeutic agents 3-4 months prior to onset of alopecia suggests telogen effluvium. Physical stressors such as pregnancy, surgery, malnutrition, or traumatic emotional life events are also causative factors.
  • History of psychiatric disorder suggests trichotillomania.
  • Androgenetic alopecia in women should be considered in the presence of signs or symptoms of hormonal abnormalities such as hirsutism, amenorrhea, or infertility.
  • A history of hypothyroidism or other endocrine disorders associated with hormonal abnormalities may be associated with telogen effluvium or alopecia areata.10

Other Tests

Khumalo and colleagues developed a Marginal Traction Alopecia Severity scoring system to help guide behavioral modification decisions. The odds ratio was higher in adults than in children (<18 y) (1.87 [P <.001; 95% confidence interval, 1.28-2.72]) and was higher with braiding-related than chemical-related symptoms. The highest risk of traction alopecia, compared with natural hair, occurred when traction was added to relaxed hair (odds ratio 3.47 [P <.001; 95% confidence interval, 1.94-6.20]). Greater than 80% of patients with traction alopecia reported symptoms related to hairdressing. The authors concluded that traction alopecia severity was associated with age group, current hairstyle, and hairdressing symptoms, but larger studies are required to validate the use of the severity scoring system for marginal traction alopecia management.7

Histologic Findings

Early in the condition, lymphocytes surround a lichenoid perifolliculitis with infundibula.11 Later, as the process evolves, a zone of fibroplasia separates this infiltrate.

Fully developed traction alopecia involves a mild lymphocytic perivascular infiltrate, a markedly thinned lower infundibulum, and an isthmus surrounded by a band of fibroplasia. Foreign body granuloma may be evident. The late process has a reduced number of hair follicles and thickened fibrous bands in much of the reticular dermis that extend into subcutaneous fat.

In early in traction alopecia, a subacute perifollicular inflammation is accompanied by mild-to-moderate hyperkeratosis. In cases of prolonged traction, decreased hair follicle and sebaceous gland density, perifollicular fibrosis, and vertical bands of follicular scarring are seen. However, blood vessels and eccrine sweat glands remain unaffected.

More on Traction Alopecia

Overview: Traction Alopecia
Differential Diagnoses & Workup: Traction Alopecia
Treatment & Medication: Traction Alopecia
Follow-up: Traction Alopecia
Multimedia: Traction Alopecia
References
[ CLOSE WINDOW ]

References

  1. Kanwar AJ, Kaur S, Basak P, Sharma R. Traction alopecia in Sikh males. Arch Dermatol. Nov 1989;125(11):1587. [Medline].

  2. Singh G. Letter: Traction alopecia in Sikh boys. Br J Dermatol. Feb 1975;92(2):232-3. [Medline].

  3. Harman RR. Traction alopecia due to "hair extension". Br J Dermatol. Jul 1972;87(1):79-80. [Medline].

  4. Trueb RM. "Chignon alopecia": a distinctive type of nonmarginal traction alopecia. Cutis. Mar 1995;55(3):178-9. [Medline].

  5. Hwang SM, Lee WS, Choi EH, Lee SH, Ahn SK. Nurse's cap alopecia. Int J Dermatol. Mar 1999;38(3):187-91. [Medline].

  6. Renna FS, Freedberg IM. Traction alopecia in nurses. Arch Dermatol. Nov 1973;108(5):694-5. [Medline].

  7. Khumalo NP, Jessop S, Gumedze F, Ehrlich R. Determinants of marginal traction alopecia in African girls and women. J Am Acad Dermatol. Sep 2008;59(3):432-8. [Medline].

  8. Ozcelik D. Extensive traction alopecia attributable to ponytail hairstyle and its treatment with hair transplantation. Aesthetic Plast Surg. Jul-Aug 2005;29(4):325-7. [Medline].

  9. Whiting DA, Olsen EA. Central centrifugal cicatricial alopecia. Dermatol Ther. Jul-Aug 2008;21(4):268-78. [Medline].

  10. Steck WD. Telogen effluvium: a clinically useful concept, with traction alopecia as an example. Cutis. Apr 1978;21(4):543-8. [Medline].

  11. Ackerman AB, Walton NW III, Jones RE, et al. Hot comb alopecia/follicular degeneration syndrome in African American women is traction alopecia. Dermatopathol Pract Concept. 2000;6:320-36.

  12. Earles RM. Surgical correction of traumatic alopecia marginalis or traction alopecia in black women. J Dermatol Surg Oncol. Jan 1986;12(1):78-82. [Medline].

  13. Aaronson CM. Etiologic factors in traction alopecia. South Med J. Feb 1969;62(2):185-6. [Medline].

  14. Callender VD, McMichael AJ, Cohen GF. Medical and surgical therapies for alopecias in black women. Dermatol Ther. 2004;17(2):164-76. [Medline].

  15. Clore ER, Corey A. Hair loss in children and adolescents. J Pediatr Health Care. Sep-Oct 1991;5(5):245-50. [Medline].

  16. Halder RM. Hair and scalp disorders in blacks. Cutis. Oct 1983;32(4):378-80. [Medline].

  17. Hantash BM, Schwartz RA. Traction alopecia in children. Cutis. Jan 2003;71(1):18-20. [Medline].

  18. Ikeda T, Yamada M. [Factors in telogen affluvium and traction alopecia]. Acta Dermatol Kyoto Engl Ed. May 1967;62(2):109-13. [Medline].

  19. Kanwar AJ, Ghosh S, Thami GP, Kaur S. Alopecia and cutis verticis gyrata due to traction presenting as headache. Int J Dermatol. Sep 1992;31(9):671-2. [Medline].

  20. Laude TA. Approach to dermatologic disorders in black children. Semin Dermatol. Mar 1995;14(1):15-20. [Medline].

  21. Monk BE, Neill SM, du Vivier A. Fashion causes traction alopecia. Practitioner. May 1986;230(1415):401-2. [Medline].

  22. Phillips JH 3rd, Smith SL, Storer JS. Hair loss. Common congenital and acquired causes. Postgrad Med. Apr 1986;79(5):207-15. [Medline].

  23. Scott DA. Disorders of the hair and scalp in blacks. Dermatol Clin. Jul 1988;6(3):387-95. [Medline].

  24. Shapiro J, Wiseman M, Lui H. Practical management of hair loss. Can Fam Physician. Jul 2000;46:1469-77. [Medline].

  25. Sperling LC, Mezebish DS. Hair diseases. Med Clin North Am. Sep 1998;82(5):1155-69. [Medline].

  26. Springer K, Brown M, Stulberg DL. Common hair loss disorders. Am Fam Physician. Jul 1 2003;68(1):93-102. [Medline].

  27. Stroud JD. Diagnosis and management of the hair loss patient. Cutis. Sep 1987;40(3):272-6. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

traction alopecia, traumatic alopecia marginalis, chignon alopecia, nurse's cap alopecia, nonmarginal traction alopecia, alopecia linearis frontalis, hot comb alopecia, follicular degeneration syndrome, hair loss, marginal alopecia, trichotillomania

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Basil M Hantash, MD, PhD, Instructor of Dermatology and Plastic Surgery, Department of Dermatology, Division of Plastic Surgery, Stanford University School of Medicine
Basil M Hantash, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Society for Dermatologic Surgery, Sigma Xi, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

Coauthor(s)

Robert A Schwartz, MD, MPH, Professor and Head of Dermatology, Professor of Medicine, Professor of Pediatrics, Professor of Pathology, Professor of Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

James W Patterson, MD, Director of Dermatopathology, Professor of Pathology and Dermatology, Departments of Pathology and Dermatology, University of Virginia Medical Center
James W Patterson, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, American Medical Association, American Society of Dermatopathology, Medical Society of Virginia, Royal Society of Medicine, Society for Investigative Dermatology, and United States and Canadian Academy of Pathology
Disclosure: Nothing to disclose.

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: 3M Pharmaceutical Grant/research funds Other; Graceway Pharmaceuticals Grant/research funds Other

Managing Editor

Warren R Heymann, MD, Head, Division of Dermatology, Professor, Department of Internal Medicine, University of Medicine and Dentistry of New Jersey
Warren R Heymann, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

CME Editor

Glen H Crawford, MD, Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital
Glen H Crawford, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Phi Beta Kappa, and Society of USAF Flight Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.