Continuing Education Activity
Traction alopecia results from continuous pulling force on the hair roots. It usually occurs in women of African descent who have tight, spiral curling hair. Traction alopecia is preventable. This activity reviews the evaluation and management of traction alopecia and highlights the role of interprofessional team members in collaborating to provide well-coordinated care and enhance outcomes for affected patients.
Objectives:
Identify the cause of traction alopecia.
Explain the population most at risk for developing traction alopecia.
Explain how to prevent traction alopecia.
Explain the importance of improving coordination amongst the interprofessional team to enhance the delivery of care for patients affected by traction alopecia.
Introduction
Traction alopecia occurs in individuals having hairstyles that produce a continuous pulling force on the hair roots. It usually occurs in women of African descent who have tight and curly spiral hair. Traction alopecia ispreventable, with appropriateeducation, it could be eliminated.[1][2][3]
Etiology
Tractionalopecia (TA) is hair loss due to repetitivetension on the hair.
Epidemiology
Traction alopecia is a common occurrence in Afro-Caribbean hairstyles which involves tight braids. Problems typically start inchildhood, where they may initially be reversible. TA is “biphasic” with early diseasenonscarring and reversible, whereas chronicdisease is scarring and permanent. Population data from South Africa demonstrates it occurs in bothchildren and adults. In this population, TA isubiquitous in femaleswith up to one-third (31.7%) of adult womenshowing hair changes. In children of age between, six to 15, the prevalence of this disease ranged from 8.6% to 21.7%. In a study, among African American girls aged5.4 to 14.3 years, 18% showed signs of TA. The prevalence is also higher in African schoolgirls thanboys (17.1% versus 0%) and is higher in females ascompared with males (31.7% versus 2.3%, respectively); with affected men more likely to wear cornrowsand dreadlocks. The youngest reported case of traction alopecia is a child of eight months of age. Although it is seen in school-aged children, the prevalence increaseswith age and is highest among adult women.[4]
Pathophysiology
Although TA occurs is commonly seen in women ofAfrican descent who have tight spiralblackhair, it has been suggested from recent studies that the main risk factor for traction alopeciais the associated hair care practices and not the hair types. It isthoughtthat chronic traction could affect the dermal papilla thus leading to a diminution of the hair follicle.
Histopathology
Traction alopecia exhibits variable features in the histopathology depending on the stage of the disease. The early stage is characterized by an increasednumber of telogen and catagen hair follicles, with a normal number of hair follicles and trichomalacia (soft fragile and swollen hair). This is followed by drop-out of the terminal hairs and retained smaller-caliber hairs along the frontotemporal hairline reflected as vellus hairs. In later stages of traction alopecia, there is adecrease in the terminal follicle count whichis replaced with fibrotic fibrous tracts. There is a characteristic absence of any inflammatory infiltrate at any timeduring the course of this disease.
History and Physical
Traction alopecia is condition seen commonly associated with Afro-Caribbean hairstyles like tight braids. The onset of hair loss occurs commonly in the temporal regions, preauricular region and above the ears but may involve other parts of the scalp, particularlywhere "corn row" patterns are adopted. The other findings that may also occur include folliculitis, hair casts, reductionin hair density and replacement of few with vellus hairs and the occasional presence of broken hairsin the affected areas, which finally proceeds to alopecia that leaves scars. It can beassociated with a headache, relieved when the hair is loosened. The pattern ofthe alopecia is characteristic and reflects thedistribution of the traction. Problems typically start inchildhood, where they may initially be reversible. A degree oftemporal thinning may also be part of a genetic hair pattern seenin those with no traction.Ponytails, hair twisting in Sikh boys, and tight scarf stylescan all result in hair loss. Common hair care practices that involvetension are ponytails/pigtails, chignon, braids, cornrows, twists, sister locks, dreadlocks, weaves, extensions, and curlers.[5][6][7]
On examination of the scalp, TA manifests with hair loss usuallyalong the marginal hairline (frontal, temporal, oroccipital) with decreased retained follicularmarkings and the presence ofa “fringe” of finer, or miniaturized hairs.The characteristic finding is the retention of hair follicles of lesser diameter along the frontal and/or temporal hairline. This sign is called the 'fringe sign, ' and it correlates with the presence of vellus hairs seen in the histology. The presence ofhair casts is a sign of ongoing or persistentTA. Linear, curved, or geometric patterns of lost hair should alertthe clinician to the possibilityof TA. Body hair, eyebrows, skin, and nails are unaffectedin TA.
Evaluation
The severity of traction alopecia is assessed by using the Marginal Traction Alopecia Severity Score(M-TAS). This is a validated photographic scale used to ascertain the severity of marginal TA. Anterior and posterior hairlines are localized using anatomic landmarks and are graded on ascale of 0 to 9. Thescale has been used inclinical studies to correlate disease severity withpotential risk factors for TA. Potentially, theM-TAS may be a useful tool used to monitorresponse to treatment. Dermoscopy can be a useful aid in the diagnosis of TA. The presence of hair casts is typical of traction alopecia. In patients with a patchy and marginal type of alopecia secondary to traction, a reduction in the density of hair follicles, the absence of follicular openings and the presence of a large number of freely mobile hair casts at the periphery of the patch is seen on dermoscopy. In the patient with a diffuse type ofalopecia secondary to traction, dermoscopy reveals a normal density of hair with numerous hair casts. The hair casts due to traction alopecia are nonadherent, white or brown in color, cylindrical in shape and tend toencircle the proximal hair shaft.[8][9]
Treatment / Management
Treatment of traction alopecia is based on factors like the chronicity of the disease and presence and absence of permanent alopecia. The treatment is decided by the stage of the disease. For practical purposestraction alopecia has been classified into three stages namely stage of prevention, stage of early traction alopecia and stage of longstanding traction alopecia.[10][11]
In the stage of prevention, the strategies include educationalmessages for parents, children, adolescents and young adults, about hair care practices. This intervention is significant as hair follicles are most vulnerable during this period.
In the stage of early traction alopecia, when the follicular units are still intact, the strategy is aimed at reduction of the hair tension by use of hairstyles which reduce the tightness of the braid.Other strategies include complete avoidance of chemicals or heat and brushing the affected area. The use of topical or intralesional corticosteroidsis recommended if there is an evidenceof inflammation, in the form of scaling or erythema ortenderness in the scalp. The use of intralesionaltriamcinolone to the peripheries of the hairloss is advocated in such cases. Pustules may be treated with oral or topical antibiotics, considering their anti-inflammatoryeffect.
In long-standing disease stage, surgical options are the viable option considered. Hair transplant using techniques like micro-grafting, mini-grafting, and follicular unittransplantation is found to be effective. A novel therapy using alpha-1 adrenergic receptor agonists in the management of traction alopecia has been recently explored. The suggested hypothesis here is that alpha-1 adrenergic receptor agonists induce contraction of the arrector pili muscle thusincreasing the force required to pluck the hair. Hence topical phenylephrine- a selective alpha-1 adrenergic receptor agonist has been tried for traction alopecia. It was found that this medication reduced hair loss secondary to traction in one study involving a sample of female patients. The same study also found that the threshold of traction required in causing epilation increased after the application of topical phenylephrine.
Differential Diagnosis
Atopic dermatitis
Epidermal nevus
Friction alopecia
Histiocytosis
Scleroderma
Seborrheic dermatitis
Secondary syphilis
Tinea capitis
Traction alopecia
Enhancing Healthcare Team Outcomes
Traction alopecia is quitecommon in women and usuallyoccurs in individuals having hairstyles that produce a continuous pulling force on the hair roots. It usually occurs in women of African descent who have tight and curly spiral hair. The dermatology nurse and clinician should work together to educate the patient as traction alopecia ispreventable, and withappropriateeducation,it could be eliminated. [Level V]
Figure
Traction alopecia Image courtesy: https://commons.wikimedia.org/wiki/File:Traction_alopecia.jpg
Figure
Traction alopecia Image courtesy S Bhimji MD
References
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Xu L, Liu KX, Senna MM. A Practical Approach to the Diagnosis and Management of Hair Loss in Children and Adolescents. Front Med (Lausanne). 2017;4:112. [PMC free article: PMC5522886] [PubMed: 28791288]
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Disclosure: Joel Pulickal declares no relevant financial relationships with ineligible companies.
Disclosure: Feroze Kaliyadan declares no relevant financial relationships with ineligible companies.
