Causes and Treatment of Traction Alopecia

Traction alopecia is a non-scarring alopecia due to prolonged tension exerted on the hair. Traction alopecia was described as early as 1907 in West Greenland by Austrian dermatologist Trebitsch. The traditional Greenlandic hairstyle at that time resembled the modern-day ponytail, and women developed a characteristic alopecia on the parietal and temporal scalp. In later stages, the hair loss progressed to the posterior scalp. Trebitsch named this pattern of alopecia “alopecia Groenlandica.”1 Similar patterns of alopecia were described in Japanese women by Aramaki and in European women by Sabaroud in 1931.2,3 Sabaroud proposed the name “alopecie liminaire frontale” to describe this progressive alopecia of the frontal hairline.3 In Brazil, Ribeiro described alopecia above and anterior to the ears in women of African descent. He named the condition “traumatic marginal alopecia.”4 Similar patterns of hair loss were later described in other populations ranging from young Danish girls who wore ponytails in the 1950s to the women of Northern Sudan who traditionally wore their hair in tight cornrows with long extensions.5,6 The Northern Sudanese women developed a coronal hair loss due to significant traction at the midline part. In all descriptions, the alopecia was associated with and attributed to hairstyles or haircare practices that resulted in prolonged tension on the hair. The term traction alopecia was adopted in 1958 to describe all forms of hair loss resulting from continued prolonged traction on the hair.7 Detecting this Condition Although described in many different cultures and ethnicities, traction alopecia is especially prevalent in women of African descent. In this population, prolonged traction is often maintained to minimize the kinky, curly texture of the hair. Today, traction alopecia is most common in African-American women and is characterized by symmetric patches of alopecia above and anterior to the ears. Additionally, a thin rim of hair at the frontal hairline is maintained as the hair in this area is too short to be gathered.8 In later stages, the hair loss can progress to involve the entire frontal and occipital hairlines. Hairstyles that contribute to traction alopecia include tight ponytails, tight cornrows and prolonged use of curlers. In the latter two examples, alopecia can be observed between the individual cornrows or curlers, in addition to the characteristic presentation on the temporal scalp. The marginal pattern of traction alopecia described above is most common; however, a non-marginal pattern has been described. In chignon alopecia, the hair loss is localized to the occipital scalp at the level of the lambda where the chignon, or bun, rests on the scalp. The cause is attributed to traction induced by twisting the hair to maintain a bun.9 Non-marginal traction alopecia has also been described in nurses in South Korea who use pins to firmly attach their nurses’ caps. These patients presented with symmetric, well-circumscribed hair loss on the parieto-occipital scalp where the cap is secured with two bobby pins.10 A combination of non-marginal and marginal traction alopecia is commonly observed in African-American women when long extensions are sewn into the hair. As reported by Morgan in Northern Sudanese women, extensions that are braided into the hair can sometimes weigh up to 450 gm.6 This weight can cause significant traction on the individual braids leading to a patchy mixed form of traction alopecia.11 Traction alopecia is most often observed in women; however, it has been described in Sikh boys whose long hair is twisted into a tight bun on top of the scalp.12 Similarly, traction alopecia has been described in the submandibular beard region of Sikh adult men who also twist and tie their beards into a tight knot under the chin.13 The presence of inflammation in traction alopecia is varied. Some authors describe perifollicular erythema in the areas of greatest traction. Additionally, follicular hemorrhage, follicular pustules, and hyperkeratosis suggestive of seborrhea have been described.8,10 Others have commented on the absence of inflammation clinically.6 A range of presentations can occur. Other Conditions that Mimic Traction Alopecia Classic traction alopecia of the temporal scalp has a characteristic distribution that makes diagnosis quite simple. However, the non-marginal forms of traction alopecia are often more difficult to diagnose. Chignon alopecia is most frequently misdiagnosed as alopecia areata. Other differential diagnoses for traction alopecia include trichotillomania, congenital vertical alopecia, aplasia cutis congenita, and occipital pressure alopecia.9 Pathology of Traction Alopecia Histologic findings in early traction alopecia are similar to that of trichotillomania. Microscopic findings include increased catagen hairs, pigment casts, and traumatized hair bulbs. Early traction alopecia differs from trichotillomania in that fewer follicles are involved, vellus hairs are preserved, and the findings are less dramatic. Late traction alopecia is characterized by a marked decrease in the total number of hairs. Columns of fibrosis replace hair follicles making it indistinguishable from a “burnt out” scarring alopecia. Inflammation is absent in the end stages of traction alopecia.14 Treating this Condition When diagnosed early, treatment of traction alopecia involves modification of hairstyling techniques. In young African-American girls with traction alopecia, the parents must be educated on the cause of the alopecia. Frequently, patients believe that this condition is genetic since many of the female family members share this pattern of hair loss. Although there may be a genetic predisposition to traction alopecia, this phenomenon is primarily due to the hair-styling practices that are passed along from generation to generation. As a dermatologist, you must approach this subject with care, as haircare practices and hairstyling techniques hold great cultural significance for many African-Americans. Cultural sensitivity is important to effectively convince parents to avoid tightly styling the hair. Patients may continue to use ponytails or braids as long as they are made less tautly to avoid constant traction on the hair. Once the patient’s hairstyle has been modified, she can achieve partial and even complete regrowth of affected hair.6, 14 Adults who develop traction alopecia and are diagnosed early can have an equally good prognosis. In the later stages of the disease, traction alopecia is irreversible. Patients with longstanding disease develop a scarring alopecia with fibrosis of the hair follicles. In those cases, hair transplantation and flaps have been described with good results. A combination of flaps and grafts tailored to the extent and distribution of the patient’s alopecia has also been reported.15 Preventing this Common Condition In summary, traction alopecia is a common condition that is entirely preventable. Patient education in a culturally sensitive manner is essential to prevent permanent hair loss.