Key points

Introduction

Hair is an integral part of physical appearance, identity, and self-esteem. Hair care routines vary with factors such as age, gender, ethnicity, and religion. Hairstyles can lead to hair loss. Traction alopecia (TA) is hair loss due to ongoing or repetitive tension on the hair and is commonly seen in women of African descent who have tightly curly or spiral hair ( Fig. 1 ). Although prevalent, TA is preventable and with appropriate education and public awareness, could potentially be eradicated. In many individuals, the problem may have its beginnings in childhood when the hair is styled tightly by adults to keep it “neat” for extended periods or to avoid tangling. Years of unrecognized or subclinical inflammation may eventually lead to permanent follicular loss. TA is the only alopecia that is “biphasic” with early disease nonscarring and reversible, whereas chronic disease is scarring and permanent; this unique feature of TA is a call to action for prevention and early treatment.

Hair loss along the frontal marginal hairline due to prolonged use of hair braids.

Various studies have documented risk factors and hair care practices associated with TA. Can this study data be translated into education and public awareness efforts to prevent a problem that may have its beginnings in the preteen years? Such efforts may be most effective when representative groups of an at-risk population are surveyed about their knowledge, attitudes, and practices (KAP) regarding the particular health care issue. Tailoring and delivering public education messages to decrease the incidence of TA, and closing “the KAP gap” is a goal that is within reach and arguably more attainable in the age of Internet connectivity and social media.

Introduction

Hair is an integral part of physical appearance, identity, and self-esteem. Hair care routines vary with factors such as age, gender, ethnicity, and religion. Hairstyles can lead to hair loss. Traction alopecia (TA) is hair loss due to ongoing or repetitive tension on the hair and is commonly seen in women of African descent who have tightly curly or spiral hair ( Fig. 1 ). Although prevalent, TA is preventable and with appropriate education and public awareness, could potentially be eradicated. In many individuals, the problem may have its beginnings in childhood when the hair is styled tightly by adults to keep it “neat” for extended periods or to avoid tangling. Years of unrecognized or subclinical inflammation may eventually lead to permanent follicular loss. TA is the only alopecia that is “biphasic” with early disease nonscarring and reversible, whereas chronic disease is scarring and permanent; this unique feature of TA is a call to action for prevention and early treatment.

Hair loss along the frontal marginal hairline due to prolonged use of hair braids.

Various studies have documented risk factors and hair care practices associated with TA. Can this study data be translated into education and public awareness efforts to prevent a problem that may have its beginnings in the preteen years? Such efforts may be most effective when representative groups of an at-risk population are surveyed about their knowledge, attitudes, and practices (KAP) regarding the particular health care issue. Tailoring and delivering public education messages to decrease the incidence of TA, and closing “the KAP gap” is a goal that is within reach and arguably more attainable in the age of Internet connectivity and social media.

Clinical presentation

Making the diagnosis of TA requires the clinician to have a high index of suspicion and to ask appropriate and clinically relevant questions of the patient and/or parents. In children, or in patients with early disease, there are often perifollicular papules and pustules in areas of the scalp with the highest tension ( Fig. 2 ), but these lesions are often subclinical and go un-noticed. However, if asked specifically, many patients will admit to having hairdressing symptoms, including tenderness, pimples, stinging, and crusting. At the time of presentation, the patient may complain of sudden-onset patchy areas of hair loss and might deny any hair care practices that involve tension, which will often lead the clinician to a broad differential diagnosis. Clinical clues that should lead to further questions regarding hair care practices and TA include hair loss (most commonly noted along the marginal hairline: frontal, temporal, or occipital) with decreased but retained follicular markings and the presence of a “fringe” of finer, or miniaturized hairs ( Fig. 3 ). The presence of hair casts is a sign of ongoing or persistent TA. Linear, curved, or geometric patterns of hair loss should also alert the clinician to the possibility of TA ( Fig. 4 ). TA may be unmasked by an episode of telogen effluvium; as a result, patients who may have had thinning hair in areas of traction but were able to style their hair in a cosmetically acceptable manner are no longer able to do so. In other instances, trauma to the hair, such as removal of a hair weave, can unmask TA ; presumably, follicles under tension are miniaturized, or otherwise vulnerable and are unable to withstand additional stress.

Presence of perifollicular pustules in a child with early traction.

The presence of the “fringe sign” in a woman with advanced traction alopecia. There is a margin of retained but finer, thinner-caliber hairs along the hairline and in front of the patch of alopecia. There are decreased but retained follicular markings in the area of alopecia.

A “horseshoe” or curved pattern of traction alopecia along the frontal scalp. The patient developed hair loss after placement of a weave.

Histology

Because of the biphasic nature of TA, histologic changes in TA are variable and depend on the stage of disease. Reports of clinic-pathologic evaluations in TA are likely skewed toward late disease ; however, there is as yet no published data on the histopathologic spectrum of clinically graded mild to severe disease. In early TA, the histopathology shows trichomalacia, increased numbers of telogen and catagen hairs, a normal number of terminal follicles, and preserved sebaceous glands ( Fig. 5 ). Subsequently, there may be “follicular drop-out” of the terminal hairs where the follicles seem to have disappeared. The characteristic finding of retained but diminutive/smaller-caliber hairs along the frontal and/or temporal hairline (so-called fringe sign) may correlate with the vellus hairs seen on histology. With long-standing TA, sebaceous glands are present and vellus-sized hairs may be seen. There is a decrease in the number of terminal follicles, which are replaced with fibrotic fibrous tracts. Inflammation is little to absent in long-standing TA, but may be mild in some cases of early TA. Transverse sections may offer advantages over vertical sections in distinguishing between primary scarring alopecias and TA. Specifically, a diagnosis of TA should be considered if there is a low-power pattern of miniaturization and follicular dropout with retained sebaceous glands. In primary scarring, alopecias, the sebaceous glands, are absent in early-stage disease and even in clinically unaffected areas.

Scalp biopsy from a patient with chronic traction alopecia showing reduced follicular density, follicular miniaturization, and retained sebaceous glands (hematoxylin-eosin, original magnification ×40).

( From Samrao A, Price VH, Zedek D, et al. The “Fringe Sign”—A useful clinical finding in traction alopecia of the marginal hair line. Dermatol Online J 2011;17(11):1; with permission.)

Differential diagnosis of marginal traction alopecia

TA may be misdiagnosed as ophiasis pattern alopecia areata (AA) or frontal fibrosing alopecia (FFA), because these disorders can have a similar bandlike pattern of hair loss along the marginal hairline.

Clinical features that can help distinguish marginal TA from ophiasis pattern AA and FFA are summarized in Table 1 . It should be emphasized that follicular markings or ostia are maintained in AA, often decreased in TA (especially late stage), and are absent in FFA (occasionally difficult to see). Eyebrows, body hair, skin, and nails are unaffected in TA, whereas they may be affected in both AA and FFA. As stated earlier, a biopsy is crucial in definitively distinguishing these entities.

Disease prevalence

Recent studies have shed light on the high prevalence of disease. General population data has been reported from South Africa in cohorts of both children and adults. In this population, mild to moderate TA is somewhat ubiquitous in females with up to one-third (31.7%) of adult women showing hair changes. In children ages 6 to 15, prevalence of disease ranges from 8.6% to 21.7%. In a clinic population of African American girls aged 5.4 to 14.3 years, 18% showed signs of TA.

Clinical tools for quantifying disease severity

The Marginal Traction Alopecia Severity Score (M-TAS) is a validated photographic scale developed to determine severity of marginal TA. Both anterior and posterior hairlines are identified using anatomic landmarks and are graded on a scale of 0 to 9. The instrument has been used in clinical studies to correlate disease severity with potential risk factors for TA. Potentially, the M-TAS can be a useful tool used to monitor response to treatment.