Traction Alopecia

Alopecia is the medical term used for hair loss or baldness. Traction alopecia (TA) is one of its types.

It predominantly affects women in communities that practice tight braiding of the hair. It was initially described by Trebitsch in 1907 while studying hair loss in Greenlandic women. Since then, it has been observed worldwide but at a higher frequency in various communities like Africans, and in certain religious groups.

Occupational traumatic hairstyling is also a known factor. Traction alopecia can lead to scarring of the scalp with permanent hair loss. When noticed early, it is a preventable condition. Longstanding cases may require a hair transplant.

What is Traction Alopecia?

Hair loss in traction alopecia is due to repetitive tension on the hair. It is linked to tightly pulled hairstyles and is seen in all races, though Afro-Caribbean hairstyles that involve tight braids are particularly prone to the development of traction alopecia.

Certain hair types are probably more prone to traction alopecia like the tight spiral black hair of African women. However, studies have shown that hair care practices are more important than hair type as evidenced by the development of the condition in women of European descent.

Chemical relaxation of hair is another important predisposing factor. Traction alopecia is non-scarring and reversible, especially early in the disease. When scarring alopecia develops, spontaneous hair restoration is unlikely.

In men

Traction alopecia is much less in men than women with studies showing a 2.3% prevalence of the condition in African males. The underlying mechanism is the same as in women, that is, chronic or repetitive pulling of the hair. Tight hairstyles, as in man buns, or the use of certain hairpieces can lead to traction alopecia in men. An increased frequency of the condition has been noted in Sikh men who wear a tight turban over their hair for religious reasons and the hair underneath is folded tightly. Common hairstyle practices in men that are more at risk of developing traction alopecia include ponytails, use of headbands, dreadlocks, and cornrows, etc.

In Women

The condition is more prevalent in women compared to men and African women, with some studies showing as many as 32% of African women having at least early signs of traction alopecia. In young African-American girls, up to 18% have evidence of the condition. For women, hairstyle is an important feature of appearance and identity and hair loss can, therefore, have significant psychological effects. Hairstyles that predispose women to traction alopecia include tight ponytails or buns, hair extensions, tight braids, dreadlocks, and putting one’s head up in rollers overnight.  Hair extensions pose a risk as they often involve making tight braids and attaching artificial hair to the braids.

When does hair loss in traction alopecia start?

Traction alopecia can affect people of all ages including children but is more common in adult women. The youngest reported case was an 8-months-old toddler.

Since the incidence and severity of the condition are directly related to the number of times the hair is subjected to traumatic styling and pulling, the incidence increases with age if the haircare practices are not changed.

As an example, in African-American schoolgirls, a 17% incidence of traction alopecia was found in a study, which increased to more than 30% in adult women. The corresponding values in men were 0% in school-age boys and 2.3% in adult men. Traction alopecia has been reported in Sikh boys aged 9-12 years who wore turbans.

Symptoms

Hair loss commonly starts at the temples and above the ears. Redness with swelling around the hair follicles is often the earliest sign which may not be noticed.

Hair casts, reduction in hair density, and finding broken hairs are early findings which progress to noticeable hair loss. Tight braids or ponytails may also cause headache, which is relieved when the hair is loosened. In longstanding cases, hair loss becomes permanent and there is scarring of the scalp skin.

Sites of hair loss: Frontal and tempo-parietal regions are the commonest sites where hair loss is first apparent but any site on the scalp can be affected depending on the hairstyle practiced. Hair at other body types like eyebrows, beard, chest hair, etc. is not affected though rare cases of beard-baldness have been described in Sikh men who tie their beard hair in a tight knot.

Variants: Two patterns of hair loss have been described depending on the areas of hair loss. In marginal traction alopecia hair, there is hair loss and thinning at the frontal and temporal margins of the hairline. The “fringe sign” is a useful clinical sign to identify marginal TA. It refers to the presence of a strip of thin hair at the end of the alopecia patch. In non-marginal or patchy TA, there are patches of hair loss at scalp areas that are otherwise less commonly affected by alopecia, due to the use of hair wefts or clips.

Other conditions: Sebhorric dermatitis, tinea capitis, alopecia areata, lichen, and discoid lupus are inflammatory conditions that can lead to hair loss.They may occasionally be confused withtraction alopecia but the inflammatory findings and early scarring are usually enough to distinguish among the disorders. Friction alopecia is another hair loss condition where the hair is damaged and easily broken due to the use of chemical relaxers, or heat-treatment for styling.

Stages

Hair loss in traction alopecia (TA) is not graded according to the Norwood scale which is a common classification system for androgenic alopecia.

There are two broad stages of the condition, with the alopecia being reversible and non-scarring in the early TA which may progress to scarring of the scalp skin and permanent hair loss in late-stage TA.

Early Traction alopecia: Early on in the condition, the hair loss is reversible and on close examination growth of thin hair may be appreciated in the bald patch. Common findings at this stage include hair casts, broken hair, and the appearance of villus hair at the margins. The presence of hair casts indicates persistent traction alopecia. Adopting a non-traumatic hairstyle at this stage can stop further hair loss and recovery is likely.

Late traction alopecia: This stage is observed in longstanding cases.As repetitive pulling of the hair continues, scarring of the scalp ensues, accompanied by permanent hair loss. Medications may not be effective at this stage to restore hair and hair transplant surgery may be required. 

Causes

Traumatic haircare practices, including certain hairstyles and hair treatment with chemicals, are the main cause of traction alopecia.

There is a clear genetic predisposition to the condition given its high prevalence in certain geographic areas. Religious and occupational practices are other known risk factors. For instance, in South Korea, several nurses developed hair loss involving the parietal and occipital regions after years of wearing caps for long hours that were tightly attached with bobby pins. Inflammatory diseases and infections of the scalp can accelerate the process of hair loss due to traction alopecia. Below, the causes and risk factors are discussed in more detail.

Genetic

Since the condition is more common in individuals of African ethnicity, genetic factors likely play an important role. The hair of African people differs from that of Europeans or Asians. Their hair is axially asymmetric and the follicle has a helical shape. This creates geometric weak points in the hair which make it more susceptible to breakage. However, the presence of traction alopecia in ethnicities other than African and a lesser incidence in African/African Americans who don’t practice traumatic hairstyles mean that genetic factors are not the sole cause of the condition. While genetics make people more susceptible to TA, it is less likely to occur in the absence of mechanical factors.

Lifestyle

This effect of traumatic hairstyles on hair loss has already been mentioned above. Cultural, religious, and occasionally occupational practices relating to haircare may lead to mechanical hair damage. Braids, hair beads, cornrows, and hair weave are common haircare routines in African children and adults. Dreadlocks is another hair trend more common in Africa but practiced by some Whites too. Ponytails are commons in Hispanics and Asians. Another important factor is the use of chemical relaxers. They make the hair more susceptible to mechanical damage. Many people who practice the religion Sikhism don’t cut their hair. Rather, Sikh men often twist their hair tightly into a knot and wear a turban over it, which can occasionally lead to traction alopecia.

Disease and infections

In people practicing traumatic hair care routines, certain medical conditions can have an added risk of hair loss. They include general medical conditions like autoimmune diseases (e.g., lupus), hormonal abnormalities (e.g., thyroid diseases), and the use of certain medications. Scalp diseases can also exacerbate hair loss traction alopecia like tinea capitis, which is a fungal scalp infection. Psychological pulling of the hair, a condition called trichotillomania, also leads to hair loss similar in pattern to traction alopecia. Alopecia areata, frontal fibrosing alopecia, and cicatricial alopecia are other hair loss conditions that can produce hair loss patterns similar to traction alopecia.

Prevention

Since traction alopecia is directly linked to lifestyle choices, preventive measures are easy to adopt and highly effective.

For management purposes, traction alopecia can be considered as a three-stage disease: stage of prevention, stage of early traction alopecia, and stage of longstanding traction alopecia. Preventive measures are effective when scarring of the scalp hasn’t yet occurred and hair loss is reversible.

Since hair damage starts in childhood in susceptible ethnicities, the children themselves, as well as their parents, need to be educated about harmful haircare practices. The goal here is to prevent the early signs from progressing to permanent hair loss. The steps that should be taken include:

• Avoid hairstyles that put excessive tension on the hair. For those who wear braids, the braids should not be too tight. Especially, avoid tight braids near the hairline. Tightly pulled ponytails should be avoided too. Buns should be loose and wear them high on the head rather than low.
• If you are using dreadlocks or cornrows, they should be sufficiently loose. Wear thick braids instead of thin ones. If you feel pain while styling, the weaves are too tight and need to be loosened. Don’t wear braids or dreadlocks if your hair is treated with chemicals.
• Change your hairstyle often. This avoids constant tension on a few hair units. Cut your hair a to healthy length and wear it naturally.
• At night, avoid sleeping in your rollers. Use a pin curl or wrap your hair.
• Avoid excessive use of hair relaxers. Both chemical relaxers and heat can damage your hair and make it susceptible to traction. Use a low setting on flat irons and blow dryers.
• Use extension for a short time only. They should not be too heavy and take them off if they are uncomfortable.
• See your doctor at the early signs of traction alopecia.

Treatment

Treatment options for traction alopecia include preventive measures described above, medications, hair transplant, and other treatments like platelet-rich plasma. Early-stage traction alopecia is reversible and abandoning high-risk haircare practices to avoid further hair loss may result in hair restoration.

If the hair loss is significant but no scarring has occurred, medications like minoxidil can be effective. A number of home remedies are also promoted but they lack clear scientific evidence of efficacy. In advanced stages, hair transplant surgery may be the only option.

Medical treatments

For cases where cessation of traction-inducing practices fails to result in hair recovery, medications may be used. Minoxidil is known to promote hair growth and is mainly used in androgenetic alopecia. It can be used in traction alopecia too. The medicine comes in the form of hair spray or cream and its regular application stimulates hair follicles. There are reports of cases with long-standing traction alopecia who responded to 3 months of treatment with Minoxidil.

Hair loss in traction alopecia is often associated with inflammation of the hair follicles. Local injections or topical solutions of corticosteroids have occasionally been used to alleviate the inflammatory process. Antibiotics, either locally applied or taken orally, are commonly used in traction alopecia to treat folliculitis and for their anti-inflammatory properties.

Finasteride is a medication commonly used in male-pattern baldness but has no role in the treatment of traction alopecia. For patients with trichotillomania, psychiatric consultation and behavioral therapy are important.

Hair transplants

Longstanding cases where scarring of the scalp has occurred are unlikely to respond to medications. Hair transplant surgery remains the mainstay of treatment in such patients. The most commonly used surgical techniques include follicle unit extraction (FUE), follicle unit transplant (FUT), and direct hair implant (DHI).  In FUT, a strip of hair follicles is cut from the donor area, usually the back of the head, and the follicles are then implanted into the bald area. In FUE, individual follicles rather than a whole strip are harvested. The follicles are collected in a medium to avoid desiccation and then implanted. It is the most commonly used hair transplant technique currently. DHI is a modification of FUE in which harvesting is immediately followed by implantation. It is a relatively new technique and is increasingly becoming common.

Hair transplant is performed under local anesthesia with good results. Follicle survival rates of more than 90% are reported. It is performed by dermatologists or plastic surgeons and being minimally invasive it is generally safe. The success and feasibility of the procedure depend in large part on the availability of a suitable area from which enough follicles can be harvested. Hair at the back of the head is a common donor site. The number of grafts required can range anywhere from 500 to 5000 depending upon the extent of hair loss. Complete hair restoration after a transplant takes 9-10 months.

Home remedies and other treatments

Platelet-rich plasma (PRP): PRP is an autologous preparation of platelets with growth-promoting and healing properties. Various chemical in PRP acts as growth factors in human bodies. Injections of PRP are used in a variety of conditions including hair loss, arthritis, and muscle injuries.

Scalp micro-pigmentation: It is a cosmetic procedure in which small dots are tattooed over areas of hair thinning on the scalp to give the appearance of a fuller head.

Stem cell treatment: Stem cell-based therapies have mainly been used in patterned hair loss with some success. Stem cells collected from adipose tissue, bone marrow, or healthy hair follicles are transplanted into the areas of hair loss where they transform into hair follicles.

Home remedies and alternative medicine approaches: Various natural remedies and alternative medicine approaches are being used for hair growth (in all types of alopecia), many of them without substantial scientific evidence. They include amino acids (cysteine and lysine), capsaicin, biotin, garlic gel, rosemary oil, and acupuncture, etc.