Review Article

Traction alopecia: A neglected entity in

2017?
Christiana Oyinlola Akingbola, Jui Vyas
Department of Dermatology, School of Medicine, Cardiff University, Cardiff, CF, UK

Abstract Correspondence:
Traction alopecia was first described in 1904 but is still a cause of scarring hair loss in young women worldwide. It is Dr. Christiana Oyinlola Akingbola,
unique in being initially a reversible then an irreversible (scarring) form of alopecia. Linked to tightly‑pulled hairstyles, Department of Dermatology,
School of Medicine, Cardiff
it is seen across all races. The pattern of hair loss depends on the style creating it but most commonly affects the
University, Cardiff, CF, UK.
frontotemporal hairline. There are some new examination findings associated with traction alopecia, which are traction
E‑mail: [email protected]
folliculitis, the fringe sign and hair casts (pseudonits) on dermatoscopy. These may prove key in prompting early specialist
referral. The mainstay of current treatment is cessation of the contributing hairstyles. Camouflage, anti‑inflammatory
or growth‑stimulating topical preparations are second line treatments. In later stages of severe traction alopecia hair
transplantation may be the only effective treatment. The evidence basis for medical intervention with topical agents
is anecdotal at best. Furthermore, additional research is required to clarify the pathogenesis of this biphasic alopecia.
Until then, prompt diagnosis and identification of causative hairstyles are focus of current dermatological practice.

Key words: Alopecia, hair loss, scarring alopecia, traction alopecia, traction hair loss

Introduction girls (ages 6–7) and 21.7% of older girls (ages 17–21).6 In contrast,
Traction alopecia is caused by persistent, pulling forces on the hair a Nigerian study found traction alopecia in only 7.7%  (3/39) of
follicles from traction‑inducing hairstyles. It has been reported women.7 Wright et al. (an American study) quoted traction alopecia
across all races.1‑3 Traction alopecia uniquely exists in both the in 18.4% (37/201) in a questionnaire‑based study in young girls (ages
scarring (cicatricial) and non‑scarring alopecia categories depending 1–15).8 Unfortunately, the Nigerian and American studies had small
on whether it is early and reversible or late and permanent. The sample sizes and very little detail of their clinical and histological
greatest risk from a delay in diagnosis is the progression to scarring criteria. Furthermore, there were potential confounders of pregnancy,
traction alopecia. malnourishment and recall bias about which specific hairstyles were
worn regularly. Interestingly, the American study relied solely on
This review will underline the current understanding of traction carer‑ or parent‑based diagnoses of traction alopecia. In contrast, with
alopecia’s pathogenesis, its management and their evidence bases. their larger sample sizes and dermatologist or experienced clinician
diagnoses, the South African studies had more robust findings.
Epidemiology
Nonetheless, these studies all agree that traction alopecia is
At present, traction alopecia has been described across most races.
frequently seen in women and children of African descent with a
Examples include young Sikh men with tight knots beneath their
greater prevalence noted with increasing age. They also underline
turbans,1 a Caucasian ballerina wearing tight buns for 13 years2 and
the scarcity of prevalence data from other populations.
Hispanic women with tight ponytails4. The prevalence of traction
alopecia in different populations is still uncertain.
Diagnosis
Two South African studies by Khumalo et  al. found that 31.7%5 The three key steps for diagnosing traction alopecia are
of women and 9.4%6 of children had traction alopecia. They also history‑taking, scalp examination and specialist tests.
showed a higher prevalence with increasing age in 8.6% of younger
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DOI:
10.4103/ijdvl.IJDVL_553_16 How to cite this article: Akingbola CO, Vyas J. Traction alopecia:
A neglected entity in 2017. Indian J Dermatol Venereol Leprol
PMID: 2017;83:644-9.
***
Received: June, 2016. Accepted: January, 2017.

644 © 2017 Indian Journal of Dermatology, Venereology, and Leprology | Published by Wolters Kluwer - Medknow
Akingbola and Vyas An update on traction alopecia

Pertinent questions in the history will be thin, vellus‑like hairs centrally with surrounding mid‑length
These include the duration of the hair loss, which styling practices thicker hairs  (broken terminal hairs).13 Table 1 summarizes the
were previously employed and traction symptoms while creating various patterns of hair loss (Adapted from Whiting14 Hantash and
such hairstyles. In 2008, Khumalo et  al. found that traction Schwartz15, Costa18 and Ahdout and Mirmirani17). Figure 2 shows
alopecia was almost twice as likely to be present in South African posterior margin traction alopecia.
women or children who had previously experienced tight, painful
braids (odds ratio [OR] =1.94 [P = 0.004]) or noted “pimples” at The “Fringe Sign”
the base of their braids  (OR  =  1.81  [P  =  0.046]) at the time of This sign, first suggested in 2011 by Samrao et al. describes short
styling, both of which were statistically significant.3 This suggests terminal hairs bordering areas of marginal hair loss.4 Interestingly,
a link between signs of traction during hairstyling and diagnosable
traction alopecia.
Table 1: Patterns of hair loss
Clinical examination Pattern of hair loss Causative style Differential
This begins at the scalp by looking at the area of hair loss and the diagnosis
hair strands. The hairstyle of the patient is also important. Below are Ophiasiform: Bitemporal, above Ponytails and long Ophiasis-pattern
signs that help strengthen a diagnosis of traction alopecia. ears, frontal margin, nuchal area braids alopecia areata
Frontoparietal hair loss Twisting long hair
Traction folliculitis (Sikh boys)
Fox et  al. first described this perifollicular erythema  (redness) Frontotemporal hair loss Hair rollers Frontal fibrosing
and/or pustules following long‑standing traction on the hair alopecia
strands.9 They noted that these changes were found in the areas Frontal hair loss only Tight scarves Frontal fibrosing
that were under maximal tension from the hairstyle.9 Later, (religious reasons) alopecia
Puttgen reported signs of a dry, itchy and flaky scalp and proposed Central “V” parting hair loss Tight plaiting of
that the pustules were usually sterile.10 Urbina et al. also presented hair
a case report of six Chilean ladies  (aged 12–26) with traction Crown hair loss Hair weaving
folliculitis after wearing tight braids, glued‑on hair extensions (weft attachment)
and ponytails.11 These resolved with traction‑avoidance advice Occipital hair loss Chignons (where
and oral antibiotics  (though only two cases were confirmed to chignon rests)
have Staphylococcus  aureus). Interestingly, such findings were “Horseshoe” – semicircle Repeated glued‑on
described by Hjorth in 1957 as “groups of inflamed follicles,” from temple, through crown to weft of hair
temple
“perifollicular erythema” and “firmly adherent crusts or scales
Adapted from Whiting, Hantash and Schwartz, Costa and Ahdout and
suggestive of seborrheic eczema” in his marginal traction Mirmirani
alopecia case report.12 Lastly, Khumalo et  al. also found that
24.3%  (150/604) of South African women with tightly braided
hairstyles reported symptoms and signs suggestive of traction
folliculitis.5 Discovering the true prevalence of traction folliculitis
would require larger, multi‑centered surveys with various racial
backgrounds included. An example of traction folliculitis is given
here [Figure 1].

Pattern of hair loss

Traction alopecia typically affects the frontotemporal margins of the
scalp. However, the specific causative hairstyle will determine any
other pattern of hair loss seen.12‑18 Within areas of hair loss, there

Figure 1: Traction folliculitis. Perifollicular erythema (blue arrows) Figure 2: Posterior hairline traction alopecia

Indian Journal of Dermatology, Venereology, and Leprology | Volume 83 | Issue 6 | November-December 2017 645
Akingbola and Vyas An update on traction alopecia

Figure 4: Dermatosopic Image x 20 magnifcation. Hair casts (yellow arrows),

vellus like hair (blue arrows), pinpoint white dots (red arrows). Image courtesy
of Dr Antonella Tosti

Figure 3: The fringe sign at the right frontotemporal hair margin Table 2: Changes seen in early and late traction alopecia
Features on Early TA Late TA
it is present before clinical hair loss and persists throughout to late biopsy
traction alopecia.4 Of note, Costa18 and Hjorth12 similarly described Terminal hair Reduced Markedly reduced
this “strip of peripheral hair” in 1946 and “a thin straggling strip density
of hair at the distal margin” in 1957. The historical constancy of Perifollicular Mild or no inflammation Fibrous tracts (scarring)
this sign lends credibility to its use as a clinical marker of traction appearance
alopecia. In addition, it rules out the main differentials of ophiasis Vellus‑like hairs Preserved Increased
pattern alopecia areata and frontal fibrosing alopecia, respectively Hair cycle changes Increased nonanagen hairs “Follicular dropout”
[Figure 3].4 Sebaceous glands Preserved Preserved
Adapted from the literature. TA: Traction alopecia
Supplementary tests
Medical photography of the scalp. Yin and Tosti suggest using it as a guide for choosing
This aims to accurately record the extent of traction alopecia and the biopsy site.21 Dermatoscopy in traction alopecia shows broken
the response to treatment. Khumalo et al. developed the Marginal hairs, miniaturized hairs, pin‑point white dots (loss of follicular
Traction Alopecia Severity Score in 2007, using photographs of openings or ostia), reduced hair density and hair casts.21,22
the anterior and posterior hair margins.19 While it showed good
inter‑observer agreement in the photograph‑matched severity Hair casts
scores  (interclass correlation coefficient  =  0.99), it was unreliable Hair casts (pseudonits) are 2–7 mm long, freely moveable, gray‑white
for diagnosing posterior margin traction alopecia.19 It still needs to cylinders wrapped around the proximal hair shaft of hairs surrounding
be validated for use in studies and trials. areas under tension.21,23 They were first associated with traction‑inducing
hairstyles in 1990 by Zhu et al.24 Zhang confirmed this in 1995 with
Dermatoscopy a prospective survey of 3548 school‑aged women and girls where
With its magnified images, dermatoscopy  (dermoscopy) allows 81% (1073/1332) of women and girls with tightly braided hair exhibited
finer details to be appreciated than naked eye examination.20 As a this sign in the areas under maximal tension.25 Recent case reports by
non‑invasive technique, it should be integral to clinical examination Tosti et al.26 and Ozuguz et al.27 have reinforced this finding [Figure 4].

646 Indian Journal of Dermatology, Venereology, and Leprology | Volume 83 | Issue 6 | November-December 2017
Akingbola and Vyas An update on traction alopecia

Histopathology of traction alopecia on looser hairstyles and the avoidance of chemical damage. In
Traction alopecia staging is based on its histological appearance as 2014, Mirmirani and Khumalo noted that caregivers (parents) and
seen in Table 2 (adapted from the Literature2,26‑33)and the histology hairdressers should be primary targets for any educational effort as
slides in Figures 5 and 6. Unlike other causes of scarring alopecia children and adolescents seemed most at risk.34
that show perifollicular fibrosis and inflammatory infiltrates with
loss of sebaceous glands, traction alopecia has preserved sebaceous Although wigs and scalp camouflage (sprays and lotions) help hide
glands, increased vellus‑like hairs and paucity of inflammation.2,28 areas of hair loss, hair pieces or extensions are discouraged. This
advice followed case reports of worsening traction alopecia in a
Follicular miniaturization 17‑year‑old ballerina2 and a “horseshoe” pattern of hair loss in two
In 2008, Khumalo et al. hypothesized that the presence of short vellus- women with glued‑in hair pieces.17
like hairs in early traction alopecia may lend credence to a follicular
miniaturization theory.3 This was supported in 2012 by Miteva and Medical management
Tosti’s  findings of miniaturized follicles (diameter <0.03 mm) in scalp Anti‑inflammatory preparations
biopsies [Figure 5] of African-American women with traction alopecia29 Oral and topical antibiotics are recommended for treating traction
and its persistence to late‑stage traction alopecia. Not surprisingly, they folliculitis for their anti‑inflammatory effects.9,11,34 Although some
highlighted the possible misdiagnosis of such findings as androgenetic articles have mentioned the anecdotal use of corticosteroids (either
alopecia in the absence of scarring changes in early traction alopecia. topically or intralesionally) in traction alopecia, there were no clear
Goldberg suggested a means of circumventing this obstacle by noting cases demonstrating the benefit of this treatment in the literature.34,35
the overall reduced follicular density of the specimen.13 He found only
7–8 follicles (on average) per 4 mm punch graft specimen in traction Topical minoxidil 2% preparations
alopecia compared to normal ranges of 21–38 follicles in his 15 biopsy Although mainly used in androgenetic alopecia where it stimulates
specimens.13 Nonetheless, this step in the pathogenesis of traction follicles to differentiate, minoxidil has been discretely used in
alopecia requires more research to determine if the miniaturization traction alopecia. In a case report by Khumalo and Ngwanya, traction
process is a viable target for future therapeutic options. alopecia refractory to cessation of traction‑inducing practices for up
to 2 years regrew after 3 months of treatment with 2% minoxidil in
Follicular drop‑out late‑stage (scarring) traction alopecia two women with long‑standing disease.36 It is also routinely used in
In this stage of traction alopecia, there are reduced follicular numbers the peri‑ and post‑operative period of hair transplantation to reduce
with minimal  or no surrounding inflammation.29 The presence of graft loss and encourage regrowth.35
fibrous tracts indicates a loss of the hair follicles (follicular dropout).
In further contrast to other forms of scarring alopecia, the sebaceous Surgical management
glands are preserved [Figure 6].28,31‑33 The point at which the above In refractory cases of late traction alopecia, surgical options include
changes occur is yet to be clarified. punch grafting, micro‑ or mini‑grafting and follicular unit transplants.37
The choice of technique is tailored to the patient and the pattern of
Current Management hair loss. Punch graft hair transplants, first described in 1959, involve
The treatment of traction alopecia begins with conservative measures transferring 2–4 mm round grafts to the area of alopecia.35 Follicular
and progresses through medical and surgical interventions. unit transplantation has superseded this technique. A microscopically
dissected follicular unit ‑ one to four follicles growing in a bundle – is
implanted at the recipient site.37 Advantages of the latter include the
Conservative management
seamless appearance of the transplanted hairline, the ability to move
The mainstay of management is the cessation of the traction‑inducing
more follicular units and the smaller wound size.38
hair practices. This is through patient education with clear guidance
Callender et  al. found that follicular unit transplants seemed
more suited to straighter Caucasoid hair strands while mini‑ and
punch‑grafting were better in those of African descent.35 They
postulated that the latter’s curved follicles were more likely to
be transected  (sliced) during follicular unit extraction. Bernstein
et  al. reported that this occurred in 1.7%–15% of such patients.38

Figure 5: Horizontal section of early traction alopecia with vellus-like follicles Figure 6: Horizontal section of late‑stage traction alopecia with preserved
(yellow arrows) and retained sebaceous glands (black arrows) (H and E, x10). sebaceous glands and fibrous tracts  (H  and  E, ×20)  (Image courtesy of
Image from Miteva and Tosti 201229. Copyright 2012 by John Wiley and Sons Dr. Kenneth May)

Indian Journal of Dermatology, Venereology, and Leprology | Volume 83 | Issue 6 | November-December 2017 647
Akingbola and Vyas An update on traction alopecia

Environmental
Genetic Factors Factors

Traction Inducing
Styles

Traction Folliculitis

Figure 7: Diagram showing predisposition of curly African hair (left) to

traction damage along its length versus straight Caucasian hair (right). (Points
Follicular
of weakness in red). Image from Miteva and Tosti, 201229 Copyright 2012 Miniaturisation
by John Wiley and Sons

However, the curly strands are purported to give a fuller‑looking

result using the traditional methods.35 The lack of statistical figures Early Traction
or analyses to support this assertion does limit its credence. Careful Alopecia
(Reversible)
patient selection is needed to minimize the risk of hypertrophic and
keloid scarring when considering hair transplantation.

Discussion Late Traction Alopecia

After reviewing the literature, it is clear that traction alopecia is not a (Scarring)

new condition. It progresses from a pre‑alopecic, inflammatory stage

that includes traction folliculitis, through a reversible alopecia (early Figure 8: A revised probable pathogenesis of traction alopecia with genetic
traction alopecia) to a scarring stage  (late traction alopecia)  –  as and environmental factors
seen in Figure  8. Such a timeline may allow earlier intervention
with medical therapies. Should these be successful, they would be “tenting.”34 This denotes a raised scalp or bumps from the excessive
clues to the pathogenesis from traction to inflammation and eventual pull on the hair in a braided or twisted style.34 Hairstyles eliciting
scarring [Figure 8]. this sign should be undone to prevent hair loss.

The high prevalence rates of traction alopecia noted in those of Finally, the psychosocial impact of traction alopecia has not been
African descent infers either a genetic susceptibility or persistent explored in the literature. Too often, the physician’s focus in
environmental factors not addressed by current clinical practice. making treatment decisions is on the clinical severity of hair loss
as evidenced by tools like the marginal traction alopecia severity
Genetic susceptibility to traction alopecia score. However, it has been shown that physician‑perceived hair
This genetic susceptibility may be due to the asymmetrical shape of loss severity does not correlate with the patient’s hair loss severity
the African hair follicle. It has a retrocurvature at the hair bulb and
or its effect on their quality of life.42 Accordingly, patients who felt
an S‑shaped hair shaft. Thibaut et al. argued that this shape creates
their disease was more severe or they had no control over it had
geometric points of weakness along the hair shaft.39 Coupled with
poorer quality of life outcomes.42 Furthermore, Cash found that
fewer anchoring fibers within the dermis, it may predispose them to
patients seeking professional consult have usually tried several
greater traction forces as shown in Figure 7.40
coping mechanisms (like camouflage) before presenting.43 Various
quality of life indices have been trialed including the Dermatology
Environmental contributors to traction alopecia
Life Quality Index, Skindex and Scalpdex.42 These tools can be
There are two main environmental factors for people of African
filled by patients on their first and subsequent consultations.
descent: the chemical processing or “relaxing” of hair strands to
achieve a straight appearance and braiding or twisting practices.34
By exploring the patient’s concerns regarding traction alopecia and
“Relaxers” have been in use since the early 1900s to straighten African its regrowth potential, physicians could improve the compliance
hair by breaking disulfide and hydrogen bonds within the strands. with medical advice and therapies.
Research has shown that relaxed hair is more fragile and probably
more prone to tension forces.5,6 With 59% of South African girls6 and Conclusion
80% of African‑American women41 chemically straightening their Although traction alopecia has long been agreed to be the end
hair, this may be a key factor in the development of traction alopecia. point of long‑standing tension hairstyles, steps in its pathogenesis
are still perplexing. The presence of vellus‑like hairs throughout
In 2014, Mirmirani and Khumalo have proposed a sign to alert its development points to follicular miniaturization as a yet
women to high tension levels in their braided or twisted hairstyles: under‑explored aspect of its pathogenesis. Furthermore, the

648 Indian Journal of Dermatology, Venereology, and Leprology | Volume 83 | Issue 6 | November-December 2017
Akingbola and Vyas An update on traction alopecia

progression from a reversible hair loss to scarring alopecia is still 17. Ahdout J, Mirmirani P. Weft hair extensions causing a distinctive
poorly understood. Nonetheless, traction folliculitis may represent horseshoe pattern of traction alopecia. J Am Acad Dermatol
the earliest point for medical intervention. Moreover, newer 2012;67:e294-e5.
18. Costa OG. Traumatic marginal alopecia due to traction on the hair. Br J
therapies targeting miniaturized follicles as in androgenetic alopecia
Dermatol Syph 1946;58:280-6.
may in turn revolutionize traction alopecia management.
19. Khumalo NP, Ngwanya RM, Jessop S, Gumedze F, Ehrlich R. Marginal
traction alopecia severity score: Development and test of reliability. J
Finally, a more robust evidence base for the current medical therapies Cosmet Dermatol 2007;6:262-9.
will hopefully produce a comprehensive treatment algorithm for the 20. Tosti A, Torres F, Misciali C, Vincenzi C, Duque-Estrada B. The role
optimal management of traction alopecia. of dermoscopy in the diagnosis of cicatricial marginal alopecia. Br J
Dermatol 2009;161:213-5.
Declaration of patient consent 21. Yin NC, Tosti A. A Systematic Approach to Afro Textured Hair Disorders:
Dermatoscopy and When to Biopsy. Dermatol Clin 2014;32:145-51.
The authors certify that they have obtained all appropriate patient
22. Miteva M, Tosti A. Hair and scalp dermatoscopy. J Am Acad Dermatol
consent forms. In the form, the patients have given their consent 2012;67:1040-8.
for their images and other clinical information to be reported in the 23. França K, Villa RT, Silva IR, de Carvalho CA, Bedin V. Hair casts or
journal. The patients understand that their names and initials will not pseudonits. Int J Trichology 2011;3:121-2.
be published and due efforts will be made to conceal their identity, 24. Zhu WY, Xia MY, Wu JH, Do DA. Hair casts: A clinical and electron
but anonymity cannot be guaranteed. microscopic study. Pediatr Dermatol 1990;7:270-4.
25. Zhang W. Epidemiological and aetiological studies on hair casts. Clin
Financial support and sponsorship Exp Dermatol 1995;20:202-7.
Nil. 26. Tosti A, Miteva M, Torres F, Vincenzi C, Romanelli P. Hair casts are a
dermoscopic clue for the diagnosis of traction alopecia. Br J Dermatol
2010;163:1353-5.
Conflicts of interest 27. Ozuguz P, Kacar S, Takci Z, Ekiz O, Kalkan G, Bulbul Sen B. Generalized
There are no conflicts of interest. Hair Casts Due to Traction. Pediatr Dermatol 2013;30:614-5.
28. Stefanato  CM. Histopathology of alopecia: A  clinicopathological
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