eMedicine Specialties > Dermatology > Diseases of the Adnexa

Traction Alopecia

Basil M Hantash, MD, PhD, Instructor of Dermatology and Plastic Surgery, Department of Dermatology, Division of Plastic Surgery, Stanford University School of Medicine
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

Updated: Jan 27, 2009

Introduction

Background

In 1907, the first example of traction alopecia was reported in girls and women from Greenland who styled their hair in a ponytail. A similar pattern of hair loss was later noted in Japanese women who wear a traditional hairdo. In Sikhism, one of the religions practiced in India, men grow both scalp hair and beard hair. To keep their hair from falling in front of their face, it is tightly pulled into a bun. This practice has led to traction alopecia in Sikh men.^{[1,2 ]}The tight rolling of beard hair into a pocket in the submandibular region also results in a similar phenomenon. The use of hair extensions, a common treatment for male or female pattern baldness, is also associated with a similar type of hair loss.^{[3 ]}

Traction alopecia is a common cause of hair loss due to pulling forces exerted on the scalp hair. This excessive tension leads to breakage in the outermost hairs. This condition is seen in children and adults, but it most commonly affects African American women. The 2 types of traction alopecia are marginal and nonmarginal. Unlike trichotillomania, a psychiatric disorder of compulsive hair pulling that leads to patchy hair loss, traction alopecia is unintentionally induced by various hairstyling practices (eg, use of braids, hair rollers, weaves, twists, locks, or "cornrows"). In the initial stages, this hair loss is reversible. With prolonged traction, alopecia can be permanent. Physicians, especially dermatologists, must recognize this condition early to prevent irreversible hair loss.

Pathophysiology

Typically, traction alopecia is associated with sustained tension on the scalp hair. In theory, this phenomenon can also occur on areas of the face where hair is grown and styled. Traction causes hair to loosen from its follicular roots; however, hair loss also occurs secondary to follicular inflammation and atrophy. Hair loss is often symmetric and along the frontotemporal hairline; occipital scalp involvement is less common. Vellus hair is usually spared in the affected area.

Traction alopecia tends to follow a series of progressive events. Initially, pruritus and perifollicular erythema may be present. These may be accompanied by hyperkeratosis, creating a seborrheic picture. Pustules and scales may form. Eventually, an abundance of broken hairs can be detected. With persistent traction, the follicles atrophy and no longer produce the typical long and coarse hair. Instead, thinner, fine, short hair is generated.

When tensile forces are chronically present, an irritant type of folliculitis develops. Follicular scarring and permanent alopecia may result. In some cases, peripilar hair casts form. The casts are fine, yellowish white keratin cylinders smaller than 1 cm in diameter that ensheathe the hair follicle. Often, peripilar hair casts occur in isolation; however, they have also been known to occur in association with hyperkeratotic scalp disorders. The hair loss pattern entirely depends on the specific grooming pattern of each patient. Marginal and nonmarginal types may be seen.

Alopecia linearis frontalis, more commonly known as marginal alopecia, is a hair-loss pattern that usually results from the use of tight curlers, rollers, or straighteners during childhood. In this condition, the distribution of hair loss follows a characteristic pattern in the temporal scalp, starting in the periauricular area and extending forward in a triangular manner. The involved area is approximately 1-3 cm in width in most cases. For example, the constant contraction of the muscles used in facial expression, in addition to the tension caused by braiding, may partially account for why this pattern is often seen in the temporal region.

On the other hand, chignon alopecia is a type of nonmarginal alopecia that is characterized by hair loss in the occipital scalp region where the bun rests.^{[4 ]}This condition is seen in patients with a long-standing history of pulling their hair into a bun. The typical patient is a 40-year-old woman who initially complains of itching and dandruff localized to the occipital area. Similar to marginal alopecia, perifollicular erythema with occasional peripilar hair casts can be seen.

The natural history of chignon alopecia mirrors that of marginal alopecia, with the eventual formation of pustules and the development of folliculitis. Permanent alopecia can also result if this condition remains undetected and the traction continues. Sometimes, the frontomarginal part of the scalp may also be involved because the longest hair roots originate in this region, and may be subjected to traction. When an examining physician notices both chignon alopecia and marginal alopecia, the index of suspicion should be high, and the diagnosis of chignon alopecia should be considered.

Frequency

United States

This condition is most commonly seen in African American population because of the practice of styling the hair in tight braids or the use of chemical hair straighteners. An estimated three fourths of African American females straighten their hair. More recently, female athletes who pull their hair tightly have been found to develop from this problem. Traction alopecia is also reported in nurses who secure their nurse's caps to their scalp with bobby pins.^{[5,6 ]}The exact frequency of traction alopecia in the United States has yet to be documented.

International

Traction alopecia is seen worldwide. Its frequency usually depends on cultural customs. Japanese women who wear a traditional hairdo, Sikh men in India, and others who wear ponytails are examples of individuals who may be affected.

Population studies show a prevalence of 17.1% in African schoolgirls (6-21 y) and of 31.7% in women (18-86 y).^{[7 ]}

Mortality/Morbidity

Traction alopecia may lead to permanent hair loss if it is undetected for a protracted period. For females especially, this can lead to significant emotional trauma. Changes in self-perception, including lower self-esteem and social problems, are frequently reported by women who have traction alopecia.

Race

This condition can be seen most commonly in African Americans, Japanese women, and Sikh men in India. See Frequency above.

Sex

Traction alopecia is more common in women than in men because women are more involved with hairstyling practices such as braiding or chemical hair straightening, and they are more likely to use tight curlers and nylon brushes and to wear chignons.

Women wear ponytails more frequently than men. Women use chemical straighteners more frequently than men.
Traction alopecia is becoming more prevalent in men who are concerned about hair loss because, ironically, it can result from treatments for alopecia itself (eg, use of hair extensions). In addition, males, especially of African descent, commonly use cornrows and this, in part, explains the increased prevalence of traction alopecia in this population.
Traction alopecia develops in Sikh men because they tightly pull their hair into a bun and roll their beard hair.

Age

Traction alopecia is initially seen in children and young adults.

Traction alopecia is an uncommon overall cause of hair loss in adults. However, in the African American population, this entity is a significant cause of alopecia.
The exact frequency has yet to be documented in children, young adults, and adults.

Clinical

History

Patients usually complain of itching and dandruff.
Otherwise, no other complaints are offered.

Physical

Patients usually have patchy areas of hair loss.
The hair-pulling test results in the detachment of more than 6 strands.
Closer inspection of the scalp reveals perifollicular erythema, scales, and pustules.
Hair loss may be symmetric, and marginal traction alopecia may be present in the temporal region.
With chignon alopecia, hair loss may be in the occipital area.
With cornrowing, the area most commonly affected is that adjacent to the region that is braided.
In patients who tie their beards into knots, areas of alopecia can be detected along the sides of the mandible.

Causes

Three basic mechanisms of traction alopecia have been proposed: trichotillomania, telogen conversion, and overprocessing. In all cases, immediate cessation of the underlying cause can reverse the alopecia.

In trichotillomania, patients compulsively pull out their own hair.
Telogen conversion appears to be the most common cause.
- Usually, the hair follicle can sustain trauma and still remain in the anagen growth phase.
- Excessive traction for prolonged periods (eg, tight braiding, wearing of ponytails^{[8 ]}) leads to conversion of the anagen phase to the telogen phase.
- In the telogen phase, the hair follicle ceases to grow and alopecia results.
In overprocessing, chemical treatment of hair with dyes, bleaches, or straighteners disrupts the keratin structure in a manner that reduces its tensile strength.
The hair becomes fragile and is unusually susceptible to breakage.
Normal combing can lead to the sudden loss of hair en masse.

Differential Diagnoses

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

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.

Treatment

Medical Care

The physician must identify traction alopecia early. Failure to do so places the patient at risk for irreversible alopecia.

Immediately after traction alopecia is diagnosed, any practices that exert traction on the hair must be discontinued. Discontinuing any such practices leads to complete reversal of the hair loss and regrowth within several months.
Topical or oral antibiotics may be prescribed to aid in the reduction of inflammation and to prevent superinfection.
When traction alopecia is detected later in its natural course, hair loss may be irreversible. Currently, no medical treatment is available to reverse late-stage traction alopecia.

Surgical Care

Despite the lack of medical options for the treatment of late-stage traction alopecia, achieving cosmetically acceptable correction of alopecia by means of surgical hair transplantation procedures (eg, punch grafting, flap rotation) is possible.^{[12 ]}

Diet

Sufficient levels of iron and protein in the diet may help promote normal hair growth.

Medication

Medical therapy has no role in the treatment of traction alopecia.

Follow-up

Deterrence/Prevention

Patients should discontinue any practices that exert traction on the hair.
These practices to avoid include the following:
- Hairstyling practices such as braiding and chemical hair straightening
- Use of tight curlers and nylon brushes
- Wearing the hair in a chignon

Prognosis

Traction alopecia is reversible in a few months if the hairstyling practice in question is discontinued.
Traction alopecia may lead to permanent hair loss if it is undetected for a protracted period.

Patient Education

Instruct patients to discontinue hairstyling practices that cause traction alopecia.

Miscellaneous

Medicolegal Pitfalls

Potential medical/legal pitfalls include the late diagnosis of traction alopecia.
- Failure to detect this condition early in its course may result in permanent hair loss.
- Thus, meticulously inspecting the scalp in all patients is crucial. This practice promotes the early rather than late diagnosis of traction alopecia, which allows the physician to make recommendations to reverse the ongoing hair loss.

Special Concerns

Special attention should be paid to the pediatric population, especially individuals who engage in hair- grooming practices such as braiding.
- As mentioned earlier, the failure to recognize this condition early may lead to irreversible hair loss.
- Thus, examination of the scalp in all pediatric patients is critical.

Multimedia

Media file 1: Girl with braids comfortably set on the scalp.

Media file 2: Elderly woman with traction alopecia.

References

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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

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.

Further Reading