Traction Alopecia

Etiology

Traction alopecia stems from prolonged or repeated tension on hair follicles, leading to follicular damage and hair loss. The condition is most commonly associated with tight hairstyles, such as braids, cornrows, ponytails, weaves, and dreadlocks, which place mechanical stress on the scalp. Additional risk factors include the use of chemical relaxers, heat styling, and hair accessories that increase tension. Occupational and cultural hairstyling practices, such as those seen in ballet dancers, military personnel, and Sikh boys, also contribute to the development of this condition. Over time, continuous traction leads to inflammation, follicular miniaturization, and, in chronic cases, permanent scarring alopecia.[3][4]

Epidemiology

Traction alopecia commonly occurs in Afro-Caribbean hairstyles that involve tight braids. Hair loss typically begins in childhood and may initially be reversible. The condition follows a biphasic pattern, with early-stage disease being nonscarring and reversible, while chronic cases result in permanent scarring alopecia.

Data from South Africa indicate that traction alopecia affects both children and adults, with up to 31.7% of adult women showing hair changes. Among children aged 6 to 15, prevalence ranges from 8.6% to 21.7%. A study of African American girls aged 5.4 to 14.3 years found signs of traction alopecia in 18%. The condition is more prevalent in African schoolgirls than boys (17.1% vs. 0%) and is significantly more frequent in women than men (31.7% vs. 2.3%), with affected men more likely to wear cornrows or dreadlocks.

The youngest reported case involves an 8-month-old infant. Although traction alopecia is observed in school-aged children, the prevalence increases with age, peaking in adult women.[5]

Pathophysiology

Traction alopecia arises from repeated tension on the hair roots, leading to mechanical damage to the hair follicle and dermal papilla, which are essential for new hair growth. The risk increases when tension is applied to chemically relaxed or thermally straightened hair, as these treatments compromise the hair shaft, making it more susceptible to breakage. While these chemical and thermal processes alone do not cause traction alopecia, they heighten susceptibility when combined with high-tension hairstyles.

Hair phenotype also plays a role, with structural and biochemical characteristics of certain hair types contributing to increased risk. Although traction alopecia can occur in individuals of all ethnic backgrounds, the condition is more prevalent in those with tightly curled hair, particularly Black patients. The condition primarily affects the frontotemporal scalp but may involve other areas depending on the specific hairstyle.[6]

Histopathology

The histopathologic features of traction alopecia vary depending on the disease stage. In the early phases, findings include an increased number of telogen and catagen hair follicles, a normal overall follicle count, and trichomalacia, characterized by soft, fragile, and swollen hair shafts. Terminal hairs gradually disappear, with smaller-caliber hairs persisting along the frontotemporal hairline as vellus hairs. In later stages, terminal follicles decrease in number and are replaced by fibrotic tracts. While significant inflammatory infiltrates are not typical of traction alopecia, mild perifollicular inflammation may occur in chronic cases. A defining feature of traction alopecia is the absence of prominent inflammatory infiltrates at all stages of the disease.[7][8][7]

History and Physical

Traction alopecia is frequently associated with Afro-Caribbean hairstyles, particularly tight braids. Hair loss typically begins in the temporal and preauricular regions and above the ears but may extend to other areas of the scalp, especially in "cornrow" patterns. Additional findings may include folliculitis, hair casts, decreased hair density with some replacement by vellus hairs, and occasional broken hairs in affected areas, eventually leading to scarring alopecia.[9] Headache may accompany the condition and is relieved when the hair is loosened. The pattern of hair loss is characteristic and corresponds to the areas of traction.

Hair loss often begins in childhood, where it may initially be reversible. A degree of temporal thinning can also occur as part of a genetic hair pattern in individuals without traction. Other hairstyles that may contribute to traction alopecia include ponytails, hair twisting in Sikh boys, and tight scarf styles (see Image. Turban-Related Traction Alopecia). Common hair care practices involving tension include ponytails, pigtails, chignons, braids, cornrows, twists, sister locks, dreadlocks, weaves, extensions, and curlers.[10][11][12]

On scalp examination, traction alopecia presents with hair loss primarily along the marginal hairline, including the frontal, temporal, and occipital regions. Retained follicular markings are decreased, and a “fringe” of finer, miniaturized hairs is often observed. A key feature is the persistence of hair follicles with a smaller diameter along the frontal or temporal hairline, known as the "fringe sign," which corresponds to the presence of vellus hairs on histologic analysis. The presence of hair casts indicates ongoing or persistent disease. Linear, curved, or geometric patterns of hair loss should raise suspicion for traction alopecia. Body hair, eyebrows, skin, and nails remain unaffected.

Evaluation

The severity of traction alopecia is assessed using the M-TAS, a validated photographic scale that quantifies the severity of marginal disease. Anterior and posterior hairlines are identified using anatomic landmarks and graded on a scale of 0 to 9. Clinical studies have used this scale to correlate disease severity with potential risk factors. The M-TAS may also serve as a tool for monitoring treatment response.

Dermoscopy aids in diagnosing traction alopecia. The presence of hair casts is a characteristic finding (see Image. Traction Alopecia, Early Stage). In patients with patchy and marginal alopecia due to traction, dermoscopy reveals reduced hair follicle density, absent follicular openings, and numerous freely mobile hair casts at the periphery of the affected area. In diffuse alopecia caused by traction, dermoscopy shows a normal hair density but an increased number of hair casts. These casts are nonadherent, white or brown, cylindrical, and encircle the proximal hair shaft.[13][14]

Treatment / Management

The treatment of traction alopecia depends on disease chronicity and the presence or absence of permanent alopecia. Management is determined by the disease stage, which is classified into prevention, early traction alopecia, and longstanding traction alopecia.[15][16]

In the prevention stage, strategies focus on educating parents, children, adolescents, and young adults about hair care practices. This intervention is critical, as hair follicles are most vulnerable during this period.

In early traction alopecia, when follicular units remain intact, the primary goal is to reduce hair tension by adopting looser hairstyles. Additional strategies include avoiding chemical treatments and heat application, as well as gentle brushing of the affected area. If inflammation, characterized by scaling, erythema, or tenderness, is present, topical or intralesional corticosteroids are recommended. Intralesional triamcinolone is advised for application at the periphery of hair loss. Pustules may be treated with oral or topical antibiotics due to their anti-inflammatory effects.[17]

In longstanding traction alopecia, surgical interventions are considered viable options. Hair transplantation techniques, including micrografting, minigrafting, and follicular unit transplantation, have shown effectiveness in restoring hair.

A novel approach involving α1-adrenergic receptor agonists has recently been explored for traction alopecia. The proposed mechanism suggests that these agents induce contraction of the arrector pili muscle, thereby increasing the force required for hair plucking.[18] Topical phenylephrine, a selective α1-adrenergic receptor agonist, has been investigated for this purpose. In one study involving female patients, its application was associated with reduced hair loss due to traction. The study also found that the threshold of traction needed to induce epilation increased following phenylephrine application.[19]

Differential Diagnosis

Traction alopecia must be distinguished from similar conditions, including the following:

• Atopic dermatitis
• Epidermal nevus
• Friction alopecia
• Histiocytosis
• Scleroderma
• Seborrheic dermatitis
• Secondary syphilis
• Tinea capitis
• Traction alopecia

A thorough evaluation is essential to differentiate traction alopecia from other conditions with overlapping clinical features. An accurate diagnosis ensures appropriate management strategies, preventing further hair loss and addressing underlying factors contributing to the condition.

Prognosis

The prognosis of traction alopecia depends on the duration and severity of follicular stress. In the early stages, when hair shaft tension is intermittent and mild, discontinuing the inciting hairstyle can lead to complete regrowth. However, chronic and repetitive traction results in follicular miniaturization, perifollicular fibrosis, and, eventually, permanent cicatricial alopecia due to irreversible stem cell damage. Early intervention, including hairstyle modification and topical therapies such as minoxidil, improves outcomes. In cases of extensive scarring, hair transplantation or scalp micropigmentation may be considered for cosmetic rehabilitation. Long-term prognosis is most favorable when preventive measures are implemented before significant follicular destruction occurs.

Complications

Traction alopecia can lead to various complications, particularly when prolonged tension is applied to hair follicles. Persistent pulling may initially cause scalp inflammation, redness, and pustules, sometimes leading to secondary bacterial infections such as folliculitis, which can further exacerbate hair loss. Over time, chronic strain results in follicular miniaturization, fibrosis, and eventual scarring, leading to permanent bald patches if left untreated. Some individuals experience discomfort, itching, or scalp sensitivity due to nerve irritation. Additionally, the psychological impact can be significant, particularly in cultures where hair is closely tied to identity and self-image. Early intervention is essential to prevent irreversible follicular damage and long-term hair loss.