Traction Alopecia

Hair loss caused by prolonged or repeated tension on the hair follicles. In early stages the loss is reversible (non-scarring), and with continued traction it becomes permanent (scarring), because the follicles are damaged and replaced by fibrosis.

• Causes: tight braids, cornrows, weaves, extensions, locs, tight ponytails, buns, chignons, hair rollers, wigs and hair clips, headgear, turbans, helmets, and religious head coverings, combined with chemical relaxers and heat styling. Traction on tight styles worn for years in childhood raises the risk.
• Prevalence is about 17 to 31% in women of African ancestry, and it is also common in South Asian, Sikh and other populations with tight hairstyles. It affects mostly women but also men with braids or topknots.
• Risk factors: tight styles worn for more than 1 to 2 years, repeated installation, heavy extensions, chemical relaxers, fine hair, a family history, and early age of onset.
• Early recognition determines whether hair regrows. If the stimulus continues beyond about 12 months (some estimates 2 to 5 years of tension), the loss may be irreversible.

• Hair thinning and recession at the frontal and temporal hairlines (marginal), and along parting lines, with the "fringe sign" (a band of preserved, thin vellus hairs along the frontal hairline) in many patients.
• Early signs: tenderness, tingling, headache or pain at the roots, follicular papules, pustules, erythema, perifollicular scale, and hair casts (cylindrical sheaths around the hair shaft).
• Late disease: smooth shiny scalp with loss of follicular openings (scarring), permanent alopecia with no fringe regrowth, and a typical diffuse thinning of the hairline in a pattern that matches the hairstyle.
• Differential diagnosis: frontal fibrosing alopecia (loss of eyebrows, perifollicular erythema, sometimes lichenoid), central centrifugal cicatricial alopecia (vertex), alopecia areata (ophiasis type), trichotillomania, androgenetic alopecia (female pattern), telogen effluvium, lichen planopilaris, discoid lupus, tinea capitis, and thyroid disease or iron deficiency.
• Complications: permanent scarring alopecia, folliculitis, scalp pain, psychological distress and reduced quality of life.

• Clinical, from the hairstyle history and the pattern of loss. Ask about styles, duration, extensions, chemical relaxers, tension, family history and pain.
• Dermoscopy (trichoscopy): hair casts, broken hairs, loss of follicular openings in late disease, perifollicular erythema, and the flambe sign (broken hairs with an orange hue), and the presence of vellus hairs in the fringe zone.
• Pull test and hair examination for other forms of hair loss.
• Check serum ferritin, full blood count, thyroid function, 25-hydroxyvitamin D, and in women with irregular periods or hirsutism, androgen levels.
• Scalp biopsy (4 mm punch with horizontal sections) when the diagnosis is uncertain or scarring is suspected, showing reduced terminal hairs, increased catagen and telogen follicles, and trichomalacia, followed by fibrosis in the late stage.

• The primary treatment is removing the tension, because without this nothing else works:
  • Stop tight hairstyles, extensions, weaves and tight ponytails, and allow the hair rest (a minimum of 3 to 6 months, preferably longer).
  • Avoid chemical relaxers and bleaching in affected areas, and reduce heat styling.
  • Use looser styles, and rotate styles so the same area is not under repeated tension, and keep styles in place for no longer than 6 to 8 weeks.
  • Avoid styles that are painful or cause bumps at the follicles, which are a warning sign.
  • Take care with children's hair, since tight styles in childhood cause early permanent damage.
• Medical treatment of early, reversible disease:
  • Minoxidil 5% solution or foam, 1 mL (or half a capful of foam) applied to the affected area twice daily, continued for at least 6 to 12 months. Expect initial shedding in the first 4 to 8 weeks.
  • Topical corticosteroid for perifollicular inflammation: clobetasol propionate 0.05% solution or foam once daily for 2 to 4 weeks, then 2 to 3 times weekly, or intralesional triamcinolone acetonide 2.5 to 5 mg/mL, 0.1 mL per site at 1 cm spacing, every 4 to 6 weeks for 3 to 6 sessions (maximum 20 mg per session).
  • Topical tacrolimus 0.1% ointment twice daily as a steroid sparing agent in long term inflammation.
  • Oral doxycycline 100 mg 12 hourly for 6 to 12 weeks for follicular pustules and folliculitis (not in pregnancy, lactation or under 8 years).
  • Low dose oral minoxidil 0.25 to 1 mg daily has emerging evidence, with monitoring for hypotension, tachycardia, oedema and hypertrichosis, and it should be avoided in pregnancy and in cardiac disease.
  • Treat iron deficiency (ferrous sulphate 200 mg orally once or twice daily to ferritin above 50 to 70 ng/mL), vitamin D deficiency and thyroid disease if present.
• Established scarring alopecia: no medical treatment will regrow hair. Options are camouflage (wigs, hair fibres, scalp micropigmentation), styling that conceals the thinning without traction, and hair transplantation (follicular unit extraction or strip), considered only when the disease has been stable for at least 12 months, with a recommendation to stop traction permanently. A biopsy before surgery excludes active inflammatory disease.
• Counselling: explain that regrowth is possible only if the traction stops, that new hair takes 6 to 12 months to appear, and that the loss will recur if the same styles are resumed.
• Special groups:
  • Children: strong advice to parents to avoid tight braids, and review family hairstyling practices respectfully.
  • Pregnancy: minoxidil is avoided, doxycycline is avoided, and traction avoidance remains the main treatment.
  • Cultural and religious hair practices: offer adapted styles (looser braids, satin or silk lining, and alternative head coverings with soft bands).
• Follow up: review every 3 months for the first year with serial photographs and trichoscopy. Refer to dermatology for suspected scarring, resistant disease, or surgical planning.