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Table of Contents 
Year : 2021  |  Volume : 66  |  Issue : 4  |  Page : 445
Traction Alopecia: Clinical and Cultural Patterns

1 Department Dermatology, University of Baghdad College of Medicine, Baghdad, Iraq and Iraqi and Arab Board for Dermatology and Venereology, Iraq
2 Dermatology, Pathology, and Pediatrics, Rutgers New Jersey Medical School, Newark, New Jersey, US
3 Dermatology Center, Medical City, Baghdad, Iraq
4 Dermatology and Pediatrics, Rutgers New Jersey Medical School, Newark, New Jersey, US

Date of Web Publication17-Sep-2021

Correspondence Address:
Robert A Schwartz
Professor & Head, Dermatology, Department of Dermatology, Rutgers New Jersey Medical School, Rutgers, The State University of New Jersey, 185, South Orange Avenue, MSB H-576, Newark, New Jersey 07103
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijd.IJD_648_20

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Background: Traction alopecia is common and preventable but frequently overlooked disorder. Objective: To evaluate patients with traction alopecia. Patients and Methods: This study was conducted at the Dermatology Center, Medical City, Baghdad, Iraq, during the period from November 2005 to October 2019. Demographic features like age, gender, disease duration and special hair styling practices and accessories were recorded. Clinical patterns were studied. Results: Thirty female patients were included in this study. Their ages ranged from 6 to 47 years with mean age ± SD was 15.63 ± 9.806. Twenty-one (70%) were below the age of 16 years. No patient had tightly curled hair. All cases were asymptomatic apart from hair loss. The fringe sign was observed in 27 (90%) of cases. The response to therapy was poor. Conclusion: Traction alopecia is an important type of pressure-induced hair loss evident in children and adults with or without curly hair due mainly due to cultural hair styling practices with its frequency apparently increasing in recent years. The fringe sign is common and of diagnostic importance. It is a preventable form of hair loss which can be reversed if diagnosed early; otherwise, permanent scarring alopecia results. It represents a pressure phenomenon evident worldwide in both non-Sub-Saharan lineage and Sub-Saharan lineage individuals.

Keywords: Fringe sign, hair styles, Iraq, pressure atrophy, scarring alopecia, Sharquie, traction alopecia

How to cite this article:
Sharquie KE, Schwartz RA, Aljanabi WK, Janniger CK. Traction Alopecia: Clinical and Cultural Patterns. Indian J Dermatol 2021;66:445

How to cite this URL:
Sharquie KE, Schwartz RA, Aljanabi WK, Janniger CK. Traction Alopecia: Clinical and Cultural Patterns. Indian J Dermatol [serial online] 2021 [cited 2023 Feb 5];66:445. Available from:

   Introduction Top

Traction alopecia (TA) is a type of hair loss due to repetitive traction and tension on the hair.[1] The main risk factors for TA are associated hair care practices and not hair types. The applied trauma is often unintentional and usually secondary to cultural, social, religious, and occupational practices given known associations with grooming accessories and particular hairstyles.[1],[2],[3],[4] High-risk hairstyling practices include tight buns, ponytails, pigtails, chignons, braids, cornrows, and dreadlocks; application of weaves, braids, or hair extensions to relaxed hair; and any hairstyles that cause pain, crusting, tenting, or folliculitis.[1],[2]

There is a paucity of data concerning the prevalence of traction alopecia among the general population. The data may be underreported based on cultural acceptance of the normality of hair loss associated with certain hairstyles. For this reason, investigation of the effects of cultural practices on TA risk is of essential importance.[4]

   Patients and Methods Top

This study was conducted at the Dermatology Center, Medical City, Baghdad, Iraq, during the period from November 2005 to October 2019. Cases of traction alopecia were evaluated for demographic features like age, gender, disease duration and special hair styling practices and accessories. Clinical patterns were studied. Other similar causes of traumatic patchy hair loss like trichotillomania were excluded.

   Results Top

Thirty female patients were included in this study. Their ages ranged from 6 to 47 years with mean age ± SD being 15.63 ± 9.806. Twenty-one (70%) were below the age of 16 years. All cases were asymptomatic apart from hair loss [Figure 1]. Most patients were unaware that the hair loss was induced by hair traction. No patient had tightly curled hair; none gave a history of using chemical or thermal relaxants or hair extensions. All patients were utilizing elastic bands attached to hair. Nine (30%) were adult females employing large flower-like hair clips and a cap and ponytail hairstyle. Braiding and ponytails were employed mainly by younger female adolescents and children. Although all patients were Muslims, none used a turban. The disease duration ranged between 0.6 and 6 years. The areas of scalp hair affected by TA were as follows: in ten (33.3%) cases both the sides and frontal part of scalp hair were affected, eight (26.6%) cases with frontal hair loss only, 7 (23.3%) cases showed sides of scalp only. Three (10%) cases had occipital involvement only, one (3.3%) showed both sides and occiput hair loss, while only one (3.3%) presented with diffuse hair thinning. Thus, the clinical pattern of marginal (frontal, temporopareital, occipital or a mixture of them) hair loss was predominant in 29 (96.6%) patients, with non-marginal diffuse hair loss in only one (3.3%) case. The affected areas were partially or completely bald. There were no traumatic broken hairs, as in trichotillomania, nor exclamation mark hairs as noted in alopecia areata, while the opening of hair follicles was lost. The fringe sign was seen in 27 (90%) of patients. The response to therapy was poor, even after stopping traction and hair styling, especially in old areas. All patients were treated with topical caffeine lotion and oral multivitamins for at least two months, with a poor response in older cases and good hair growth observed in very early ones.
Figure 1: Traction alopecia: A 13-year-old girl with frontal hair loss and fringe hair sign

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   Discussion Top

Traction alopecia is a common type of hair loss among individuals of sub-Saharan African lineage,[4],[5],[6],[7],[8],[9],[10],[11] but in the present study there were no patients with tightly curled hair or of sub-Saharan African lineage. The prevalence of TA is highest among women, including children, of sub-Saharan African descent due to mechanical characteristics of their hair follicles. The axial asymmetry in form of curved bulb, shaft insertion, and helical shape lead to the presence of geometric points of weakness, as do cultural hairdressing practices.[4],[11] TA is much more common among women than men.[4],[12] Population data from South Africa demonstrates that it occurs in both children and adults. In this population, TA is ubiquitous in females with up to one-third (31.7%) of adult women showing hair changes, while in children of age between 6 and 15, the prevalence of this disease ranged from 8.6% to 21.7%. The prevalence is also higher in African schoolgirls than boys (17.1% versus 0%) and is higher in females as compared with males (31.7% versus 2.3%, respectively). Affected men are more likely to wear cornrows and dreadlocks. The youngest reported case of traction alopecia to our knowledge is a child of eight months of age. Although it is seen in school-aged children, the prevalence increases with age and is highest among adult women.[13] Traction alopecia was seen in 18 pediatric (out of 134) patients, mainly around hairline, in a study done at Mutah University in Jordan for diagnosing hair loss diseases in children.[14]

Traction alopecia typically starts in childhood,[14],[15],[16],[17],[18],[19],[20],[21],[22],[23] as documented in the present work, in which 70% of patients were below the age of 16 years. All were females, although Sikh boys have been described with TA due to special religious hairstyling and turban use.[24] All the studied patients were using elastic bands together with a pony tail in adult females and braiding in pediatric patients, which is consistent with the aforementioned hair styling causality.[1],[14] The clinical pattern of marginal (frontal, temporopareital occipital, or mixed) hair loss was predominant in 96.6%, while non-marginal diffuse hair loss seen in one (3.3%) case. TA is a "biphasic" disease with early non-scarring and reversibility, whereas in chronic state there is scarring and permanent hair loss.[14] In the present work, most patients were first seen with a late stage of scarring and with partial or complete permanent alopecia.

Our findings in these 30 Iraqi females are noteworthy. The fringe sign, as evident in 90% of patients in the present work, has diagnostic importance, as it is absent in other types of alopecia such trichotillomania, alopecia areata, and scarring alopecia like follicular lichen planus.[25] We postulate that the hair at the front and sides of scalp is short and uninvolved by stress of traction. Wearing a turban is increasingly being utilized by Iraqi females as part of a modern hairstyle or hijab, especially in the last 10 years, so we can anticipate more associated traction alopecia as has become evident in Turkish women.[26] Mirmirani and Khumalo proposed two slogans, "Tolerate pain from a hairstyle and risk hair loss" and "No braids or weaves on relaxed hair," in order to bridge patient–provider knowledge gaps in the avoidance of traction alopecia.[27] There was a poor response in older cases to topical caffeine lotion and systemic multivitamins among the present study patients probably due to end-stage scarring, but good hair growth was documented in very early ones.

Clinical presentation follows a predictable natural history, with early development of perifollicular erythema, pustules, scaling, and broken hairs and late sequelae of follicular scarring and permanent alopecia. In children, marginal hair loss along the temporal hairline is commonly observed, although non-marginal occipital and frontal marginal patterns can also occur depending on the hairstyle.[15] Interestingly, Hjorth[7] noted the retention of "a thin straggling strip of hair" at the distal margin of the zone of alopecia as a characteristic of this disorder, reminiscent of the "fringe sign" described by Samrao et al.[16] in 2011, the retention of hairs along the frontal or temporal rim highly suggestive of excessive tension. Tenting of hair follicles refers to the raising of skin on the scalp when hair is pulled extremely tightly. Both are important examination findings for diagnosing traction alopecia.[2],[16] The onset of hair loss occurs commonly in the temporal regions, preauricular region, and above the ears, but may involve other parts of the scalp, particularly where "corn row" patterns are adopted. The other findings that may also occur include folliculitis, hair casts, reduction in hair density, and replacement of a few terminal hairs with vellus ones plus the occasional presence of broken hairs in affected areas. This process proceeds to become a scarring alopecia. It can be associated with a headache, relieved when the hair is loosened. This pattern of this alopecia is characteristic and reflects the distribution of the traction. Problems typically start in childhood at which time they may initially be reversible. A degree of temporal thinning may also be part of a genetic hair pattern seen in those without traction.[1],[17],[18],[19] The severity and response to treatment of traction alopecia can be assessed by using the Marginal Traction Alopecia Severity Score. Trichoscopic findings tend to be nonspecific; one may see black dots, broken hairs, circle hairs, and erythema.[1] Many vellus and thin hairs may be evident. The presence of hair casts may be typical of early traction alopecia while non-significant in old cases.[1] One should also recall that pressure-induced alopecia can occur in a variety of settings, including following electroencephalography scalp electrodes employed for monitoring, and the use of headgear.[28],[29],[30]

Traction alopecia exhibits variable features histopathologically, depending upon the stage of the disease. The early stage is characterized by an increased number of telogen and catagen hair follicles, with a normal number of hair follicles and trichomalacia with soft fragile and swollen hair. This is followed by dropout of the terminal hairs and retention of smaller-caliber hairs along the frontotemporal hairline, reflected as vellus hairs. In later stages of traction alopecia, there is a decrease in the terminal follicle count, as terminal hairs become replaced with fibrotic fibrous tracts. There is a characteristic absence of any inflammatory infiltrate at any time during the course of this disease,[1] with preservation of sebaceous glands.[4] In its early stage, patients with TA typically have patches of non-scarring hair loss along the area of the scalp that is undergoing tension, which can mimic trichotillomania and alopecia areata by the presence of non-scarring alopecia and broken hairs. In the late stage, there are smooth hairless patches with follicular drop out, which need to be distinguished from other scarring alopecias such as frontal fibrosing alopecia (FFA) and patchy central centrifugal cicatricial alopecia (CCCA).[4] In addition, a pseudo-fringe sign is sometimes evident in frontal fibrosing alopecia.[31],[32] Sometimes other types of alopecia may be concurrent.[33] Currently, there is no cure for TA. Therefore, it is imperative that clinicians educate high-risk populations about it and those practices that may convey the risk of hair loss.[4]

In the stage of early traction alopecia, when the follicular units are still intact, the strategy is aimed at reduction of the hair tension by use of hairstyles which reduce the tightness of the braid. Other strategies include complete avoidance of chemicals or heat and brushing the affected area. The use of topical or intralesional corticosteroids is recommended if there is evidence of inflammation, in the form of scaling, erythema, or scalp tenderness. The use of intralesional triamcinolone to the peripheries of the hair loss is advocated in such cases. Pustules may be treated with oral or topical antibiotics, considering their anti-inflammatory effect.[1],[20] Topical minoxidil 2% has been tried with success.[21]

In the long-standing disease stage, surgical options are the most viable ones. Hair transplant using techniques like micro-grafting, mini-grafting, and follicular unit transplantation can be effective.[22],[23] A novel therapy using alpha-1 adrenergic receptor agonists in the management of early traction alopecia has been recently explored. The suggested hypothesis is that alpha-1 adrenergic receptor agonists induce contraction of the arrector pili muscle, thus increasing the force required to pluck the hair. Hence, topical phenylephrine, a selective alpha-1 adrenergic receptor agonist, has been found to reduce hair loss secondary to traction in a sample of female patients. The same study also found that the threshold of traction required in causing epilation increased after the application of topical phenylephrine.[1]

   Conclusion Top

Traction alopecia is a relatively common disorder among children with and without curly hair; its frequency may be increasing as a result of excessive use of unusual hair styling. Raising awareness regarding the loosening of traction exerted by hair styling, especially among parents, and avoidance of chemical and thermal hair relaxing agents that traumatize hair, would likely reduce its incidence.

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Conflicts of interest

There are no conflicts of interest.

   References Top

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