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Traction Alopecia

Traction Alopecia:  hair shafts are extracted from their host follicles due to tight hair styling techniques e.g. pony tails, top knots, hair extensions, chignons, pleats, plaiting, tracks, cornrowing etc.   Hair follicles do not tolerate these traumatic potentially injurious activities well and many are destroyed thereby. Needless to say this can cause significant regions of permanent baldness.

Sites affected:  anywhere, however the the anterior and occipital margins, parietals and auriculars are frequently seen areas of such needless injury.

THE TRICHOLOGICAL SOCIETY

 Traction Alopecia

Dr Ruth Benjamin MB BS LTTS

INTRODUCTION:

Traction alopecia (TA) in women is also known as ballerina baldness that is caused by excessive tension or hair being pulled too tight in the same direction. 

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EPIDERMIOLOGY:

  • This is the most common form of alopecia seen in black community because of traditional method of hair styling. 
  • It is also seen in Asian Sikh boys who twist their hair and turbans very tightly on the scalp.
  • However, it can affect  any ethnic background or age. 

PREDISPOSING FACTORS AND PATHOGENESIS:

This type of alopecia can be caused by:

  • Chemical relaxers and rollers.
  • Regularly wearing tight cornrows, dreadlocks, chignon, weaves and braids
  • Hair extensions

All the above methods can cause mechanical damage of the hair follicles. Thus in area of traction inflammatory response is seen which presents as perifollicular erythema with pustules and papules. In case of chronic and repeated traction, atrophy of hair follicles occur which causes permanent hair loss. 

CLINICAL FEATURES:

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Early Stage: 

  • Itching
  • Redness
  • Folliculitis or perifollicular pustules and papules
  • Multiple short broken hairs
  • Thinning 
  • and hair loss 

Late stage:

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  • Scarring alopecia with decrease hair follicular marking occurs.

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  • Generally, traction alopecia affects the hair line. Thus the most common sites of hair loss in TA are frontal and temporoparietal areas but any area of the scalp can be affected because it depends on an individual’s hair hairstyle.  
  • “Fringe sign” is present, that means some hair is retained along the frontal and temporal rim of the hairline.   

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Fringe sign: Black arrows show the Diminutive hairs and white arrow show the region of hair loss along the temporal scalp.  

DIAGNOSIS:

PHYSICAL EXAMINATION AND HISTORY: 

  • TA people often complain the scalp hurts in the areas of increased tension.

DERMOSCOPY EXAMINATION:

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  • Broken and irregular coiled hair
  • Clustered short vellus hairs
  • Decreased hair density

HISTOPATHOLOGY EXAMINATION:

  • Early stage of TA is characterized by:
  • Increased number of catagen and telogen hairs.
  • Trichomalacia which is thinned out hair.
  • Generally sebaceous gland is saved.
  • In late stage:
  • Vellus hairs which are fine short hairs may develop.
  • Terminal hair follicles and sebaceous glands tend to decrease in number and gradually replaced by fibrous tracts (scars). 

DIFFERENTIAL DIAGNOSIS:

Dermoscopy can be very useful as the differential diagnosis between alopecia areata, traction alopecia, Frontal fibrosing alopecia, trichotillomania.

ALOPECIA AREATA: – 

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  1. Cadaverized or black dot hairs. 
  2. Exclamation mark hairs. 
  3. Broken hairs
  4. Normal terminal hair shafts
  5. And yellow dots are seen.

TRACTION ALOPECIA: – 

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  • Arrow shows: broken hair.
  • Triangle shows: black dots.
  • Others: miniaturized hairs, white dots and fractured hair shafts.

FRONTAL FIBROSING ALOPECIA: 

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  • Star shows: decrease of follicular openings 
  • White arrow shows: follicular hyperkeratosis, 
  • Black arrow shows : Perifollicular erythema

TRICHOTILLOMANIA: 

In this condition patient pulls out their own hair. 

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  • Broken hairs of different lengths, 
  • Black arrow shows broken hair with split end.  
  • Black dots which are numerous in number

TREATMENT:

  • Self care is very important in traction alopecia. Thus changing hair styles is a useful method to protect baldness for example:-  
  • Terminate tight hair styles 
  • Cuts long hair 
  • Avoid braiding and hair extensions.
  • Avoid chemical relaxants and excessive heat from hair straighteners and so on. 
  • Protect your scalp from sunlight especially bald areas. 
  • Medical treatment:
  • Topical minoxidil solution: may stimulate hair growth.
  • Topical corticosteroid: may improve symptom of itchiness or redness of the scalp. 
  • Surgical treatment:
  • Hair transplantation:  In case of permanent hair loss
  • Other methods of treatment:
  • Hair pieces and wigs
  • Cosmetic camouflage: this is a small pigmented spray that may help to hide the hair loss areas but these are not waterproof. Thus they are easily washed away if the hairs get wet.  

PROGNOSIS:

It can be cured but it depends on the stage of the hair loss. So if traction alopecia (TA) is identified earlier and the person stops his tight hair styles, then the hair can re-grow again but longstanding TA can cause permanent hair loss.    

 REFERENCES: