The Impact of Traction Alopecia

This blog series highlights conditions that have a strong impact on people of color and appears as part of Project IMPACT: Improving Medicine’s Power to Address Care and Treatment.

Traction alopecia (TA) is characterized by hair loss due to repeated tension and trauma on the hair shaft. It can present as areas of hair loss and breakage along the bilateral temples, nape of the neck, and any other areas subject to repetitive or prolonged pulling. Hairstyling practices such as tight ponytails, braids, weaves, and locs exacerbate the condition.

How does traction alopecia impact people of color?

TA can affect anyone; however, it is overrepresented in Black people due to certain hair styling practices. For people with African ancestry, high-tension hair practices such as braids, weaves, and locs can predispose individuals to this condition. Tensive styles can begin at a young age, during which alopecia tends to be transient and nonscarring, with high regrowth rates. This can cause delay in recognition and diagnosis. Furthermore, patients may mask hair loss with other styles, or accept hair loss associated with certain styles as normal, rather than seek treatment or intervention.

TA occurs more often in women and girls with African ancestry; however, it can occur in anyone who practices repetitive tensive styling.

Synopsis:

TA is hair loss that results from repeated pulling and trauma of the hair shaft. It is caused by high-tension hairstyles and headwear such as tight ponytails, braids, cornrows, locs, weaves, helmets, nurse caps, and coifs. TA usually presents in the frontotemporal, frontoparietal, and occipital regions, although it can occur anywhere on the scalp. Repetitive trauma and lack of intervention can lead to destruction of the hair follicles and thus scarring alopecia in the faulted areas.

TA particularly impacts people with African ancestry due to cultural hair practices and structural hair properties. The structural properties of Afro-textured hair usually contribute to the reason cultural hair practices are employed, in an effort to reduce manipulation and consequent breakage. However, the risk for TA and other forms of hair loss calls for low-tension protective styling.

TA was first reported in 1907 in Greenlandic women who practiced their traditional tight coiffure hairstyle. It has since been described in the literature among numerous populations. TA has been reported in ballet dancers due to twisting of their hair into a tight bun and/or wearing heavy hairpieces. It has been reported in South Korean nurses due to extended periods of fastening a nursing cap to their scalps using bobby pins. Other occupational associations include helmet wearing, headbands, and hair caps. TA is also associated with religious practices, including turban wearing in Sikh men and coif wearing in nuns.

What to look for:

Hair loss in the distribution of the tensive styling pattern is characteristic of TA. This usually includes the margins of the scalp and other areas under traction. These regions would have reduced hair density. Early disease may exhibit perifollicular erythema (which may appear violaceous on darker skin). Folliculitis may also be present in early disease, appearing as perifollicular papules and pustules. The patient may present with a headache that is alleviated with loosening of their hairstyle. TA involving the marginal hairline usually exhibits the fringe sign: retention of hairs along the frontal and temporal rim anterior to the marginal alopecic regions.

Dermoscopy would reveal yellowish-white casts encircling the proximal hair shaft. A biopsy is not often necessary, but histology would reveal increased telogen and catagen hair follicles, trichomalacia, fewer terminal hairs, and increased vellus hairs. When examining the patient, obtain a detailed history of their styling practices, and compare their current presentation to past pictures if handy.

Differential:

A nonexhaustive differential for TA includes:

 

Sources:

Billero V, Miteva M. Traction alopecia: the root of the problem. Clin Cosmet Investig Dermatol. 2018;11:149-159.

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(3):606-611.

Khumalo NP, Jessop S, Ehrlich R. Prevalence of cutaneous adverse effects of hairdressing: a systematic review. Arch Dermatol. 2006;142(3):377-383.

Khumalo NP, Jessop S, Gumedze F, Ehrlich R. Determinants of marginal traction alopecia in African girls and women. J Am Acad Dermatol. 2008;59(3):432-438.

Khumalo NP, Jessop S, Gumedze F, Ehrlich R. Hairdressing is associated with scalp disease in African schoolchildren. Br J Dermatol. 2007;157(1):106-110.

Mkhize Z, Mosam A, Dlova NC, Tan B, Oyerinde O, Iwuala C, Burgin S. Traction alopecia. VisualDx. Updated March 31, 2021. Accessed July 20, 2021. https://www.visualdx.com/visualdx/diagnosis/traction+alopecia?moduleId=101&diagnosisId=53003.

Pulickal JK, Kaliyadan F. Traction Alopecia. [Updated 2020 Aug 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470434/.

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(11):1.

Thibaut S, Bernard BA. The biology of hair shape. Int J Dermatol. 2005;(44 Suppl 1):2-3.

Trebitsch R. Die Krankheiten der Eskimos in West-Grönland. Wiener Klin Wochenschr. 1907;20:1404–1408.

This Project IMPACT blog series was created to highlight dermatologic conditions that disproportionately affect people of color. By improving diagnosis in skin of color we can reduce racial disparities in healthcare.

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