Helping Patients with Traction Alopecia: Basics, Treatment, and Prevention

Dermatology Times® spoke with 2 experts about TA: Sherry L. H. Maragh, MD, board-certified general, surgical, cosmetic, and laser dermatologist who practices at Advanced Dermatology and Cosmetic Surgery in Ashburn and Warrenton, Virginia, and Rockville, Maryland; and Oma Agbai, MD, of the department of dermatology at the University of California Davis School of Medicine in Sacramento, California.

What is traction alopecia? How does it present?

Agbai and Maragh explained that traction alopecia (TA) is hair loss caused by repeatedly wearing tightly pulled hairstyles. Maragh noted that “early on, TA may present as tiny, pimple-like bumps along the hairline, with inflammation around the hair follicles that may be associated with itching, flaking, and soreness of the scalp. The hairs that grow in the affected area will become broken and weak.” Maragh explained that over time, permanent damage to the hair follicle will occur. “There is a decrease in the growth rate of the hair in the affected area followed by thinning of the hair in the area as some follicles die off. This may eventually lead to a permanent loss of growth in the area,” Maragh said.

Agbai added that patches of hair loss in TA will appear where the tension on the hair is causing hairs to be pulled out. “For example, if you wear tight ponytails, the areas around the frontal or posterior hairline could develop patches of alopecia in a band-like distribution. Commonly, there is a fringe of retained fine wispy hairs across the hairline, which leads to the characteristic fringe sign of traction alopecia,” she said. She explained that rubber band use, weaves, braids, locks, cornrows, and other tightly pulled styles can predispose patients to TA.

“If TA is sustained, it can progress to cicatricial (scarring) alopecia,” Agbai noted.

She said the bitemporal area of the scalp is affected most commonly. “The entire scalp may even be involved and this is dictated by the hairstyling technique,” Agbai added. “Hair casts can be seen with severe cases of traction,” she said.

How common is traction alopecia? 

Maragh said the number of people affected by traction alopecia varies by race, gender, and cultural hair styling practices. “While the exact percentage is unknown, traction alopecia is most common in women of African descent,” she said. She added that traction alopecia dates back centuries and has affected mainly women of various ethnicities because of traditional tight hairstyling practices.

Agbai said there is an increased prevalence in Black men, women, and children. “African American hairstyling techniques can predispose this population to hair shaft damage from traction due to increased use of tightly pulled hairstyles. Still, individuals of any ethnicity can develop traction alopecia,” she noted. She added that many people do not seek medical care for the condition, which contributes to the difficulty in assessing its prevalence. “I have, however, seen that is a common diagnosis in my hair loss clinic,” Agbai said.

Can patients experience traction alopecia lying dormant for years, and then presenting?

Maragh said TA can take several years to fully present with noticeable hair loss in the affected areas. “It can even present after a person has stopped wearing tight styles if the damage has already been done over several preceding years,” she said. She explained that often patients who present with TA do not have a recent history of tight, pulling, or high-tension hairstyles but they do have a history of these kinds of styles 2 or 3 years before the onset of noticeable hair loss.

Agbai explained it is possible that other forms of alopecia can be misdiagnosed as TA. “For example, I have had patients with biopsy-proven frontal fibrosing alopecia, lichen planopilaris, alopecia areata, and even cutaneous sarcoidosis of the scalp present with a previous diagnosis of traction alopecia,” she noted, adding that this has been especially common among black female patients. Dermatologists should be aware of the possible differential diagnosis when assessing patients.

 How is traction alopecia currently treated?

Agbai said treatment for TA is aimed at decreasing inflammation and promoting hair growth. To accomplish this, TA can be treated with topical antibiotics such as clindamycin and a topical corticosteroid for early papular lesions. “For more severe cases, oral antibiotics like doxycycline can decrease inflammation, especially when folliculitis is present,” she said, adding that topical minoxidil 5% foam or solution is also recommended as a nonspecific promoter of hair growth. “I also routinely recommend intralesional triamcinolone injections every 6 to 8 weeks until the alopecia is stabilized and regrowth is evident. Hair transplantation can be effective after the condition is stabilized by medical therapies,” Agbai said.

Maragh added that platelet-rich plasma injections may be used for their regenerative properties to restore damaged hair follicles in traction alopecia.

AAD Recommendations to Prevent TA

Dermatologists can share recommendations to help patients prevent TA. The American Academy of Dermatologists (AAD) recommends that patients wear tight styles such as buns, ponytails, tightly pulled updos, cornrows, dreadlocks, hair extensions or weaves, and tight braids only once in a while.¹ The AAD says wearing rollers to bed most of the time can also cause hair loss and recommends saving this practice for special occasions.¹

AAD recommends loosening braids especially around the hairline, not wearing braids for longer than 2 to 3 months, and choosing thicker dreadlocks or braids to prevent hair loss. Patients are also advised to change their styles, such as going from cornrows to loose braids, to give the hair some time to recover.¹ They said weaves should be worn only for short periods and be removed right away if they cause pain or irritation. AAD recommends sewn-in weaves over glued-in weaves.¹

AAD says patients should watch for early hair loss, such as broken hairs around the forehead, a receding hairline, and patches of hair loss where the hair is tightly pulled.¹ It urges patients to be alert to pain, stinging or crusts on the scalp, or raised sections or tenting of the scalp.¹ Patients should stop wearing tight hairstyles if they notice any of these issues and consult a dermatologist.

Reference

1. Hairstyles that pull can lead to hair loss. American Academy of Dermatology. Accessed October 27, 2022. https://www.aad.org/public/diseases/hair-loss/causes/hairstyles