Traction alopecia

INTRODUCTION — Traction alopecia is a form of hair loss that results from prolonged or repetitive tension on hair. Traction alopecia most commonly occurs along the frontal or temporal scalp, but can also occur in other sites of the scalp and in other hair-bearing areas (picture 1A-C).

Having a high clinical suspicion for traction alopecia in at-risk populations and obtaining a detailed history of current and past hair care practices is essential for making the diagnosis. Early recognition and cessation of the offending hair care practice is critical because sustained traction can lead to permanent hair loss.

The clinical features, diagnosis, and management of traction alopecia will be reviewed here. An overview of the evaluation of patients with hair loss is provided separately. (See "Evaluation and diagnosis of hair loss".)

EPIDEMIOLOGY AND RISK FACTORS — Traction alopecia can occur when hair follicles are subjected to prolonged or repetitive tension. Although epidemiologic data on traction alopecia are limited [1-4], it appears that traction alopecia is most frequently diagnosed in females of African descent with Afro-textured hair. The relatively high prevalence in this population is most likely related to the frequent use of traction hairstyles (eg, braids or hair weaves). In support of this theory, traction alopecia occurs in other populations in association with the use of traction hairstyles, such as tight ponytails [5-7], chignon or bun hairstyles (as often worn by ballerinas) [8,9], hair extensions [10], hair pins (as for securing nursing caps) [11], the Sikh practices of tightly twisting long hair on the scalp and knotting the beard hair [12,13], and in females serving in the military who have to adhere to hairstyle regulations [14,15].

Differences in exposure to traction hairstyles likely contributes to the higher prevalence of traction alopecia in females compared with males and adults compared with children in populations of African descent. In a study of 874 adults in South Africa, traction alopecia was detected in 32 percent of women compared with only 2 percent of men [1]. Increasing prevalence with age was demonstrated in a study of 1042 schoolchildren (ages 6 to 21 years) in South Africa; traction alopecia was present in 9 percent in girls in their first year of school (age 6 to 7 years) compared with 22 percent in girls in their last year of high school (age 17 to 21 years) [2]. No male schoolchildren had traction alopecia. Traction alopecia can also occur in infants. A case report documents traction folliculitis (an early presentation of traction alopecia) in an eight-month-old child [16].

Limited data suggest that use of chemical relaxers may increase risk for traction alopecia. In a study of 574 South African schoolgirls and 604 South African adult women, girls or women with a history of traction applied to chemically relaxed hair had the highest likelihood for traction alopecia (odds ratio 3.47, CI 1.94-6.20) [17]. A history of certain hair dressing-associated symptoms (pain, pimples, crusts) may also be associated with increased risk for traction alopecia. The same study found that the majority of patients (81 percent) with traction alopecia admitted to a history of tight painful braids, painful pimples, and stinging sensations during chemical relaxers with or without formation of crusts [17].

PATHOGENESIS — The exact pathogenesis of traction alopecia is yet to be elucidated. Traction on hair may induce a perifollicular inflammatory process that is asymptomatic or associated with clinical signs of folliculitis. As a result of this inflammation, follicles may become miniaturized or dormant, resulting in finer hairs, vellus-like hairs, and reduced hair density [6,18,19].

Initially, hair loss secondary to traction alopecia is nonscarring and reversible if the cause of traction and the inflammatory reaction is discontinued. With persistent traction, irreversible damage to the hair follicles leads to permanent (scarring) alopecia.

Further study is necessary to clarify whether the high levels of interleukin (IL) 1-alpha (a proinflammatory cytokine) in scalp sebum relative to levels of IL-1 receptor antagonist (a competitive inhibitor of IL-1-alpha) in scalp sebum detected in a study of 36 asymptomatic Black South African women indicates a proinflammatory state that may predispose women with Afro-textured hair to scalp inflammation and alopecia [20]. Pending further data, exposure to traction hairstyles is considered the primary factor contributing to the development of traction alopecia.

CLINICAL FEATURES — The clinical findings of traction alopecia can include inflammatory papules, pustules, reduced hair density, reduced hair length and caliber, and alopecic patches (table 1). The manifestations depend on the stage and severity of disease. The scalp is the most common site of traction alopecia, with the frontal hairline and the temporal scalp above the ears most frequently affected. However, traction alopecia may appear in other sites on the scalp or in other body areas in which hair follicles are subjected to traction.

In the earliest stages of traction alopecia, hair loss may be absent or limited to a subtle decrease in hair density. At this stage, patients may have only traction folliculitis, manifesting as perifollicular erythema, perifollicular inflamed papules, or perifollicular sterile pustules in sites of traction (picture 2) [16]. Patients may describe this presentation as "pimples on the scalp." Scalp scaling and pruritus may accompany traction folliculitis.

Traction folliculitis can be transient, resolving as tension on the hair follicles decreases due to the removal of traction or hair growth. Therefore, direct questioning may be necessary to determine whether a patient has experienced traction folliculitis.

With persistent traction, noticeable hair loss occurs, which may progress from decreased hair density to patches of complete alopecia. Marginal traction alopecia, the most common presentation, affects the frontal and temporal scalp above the ears (picture 1A). However, hair loss in the back of the scalp or occiput can also be seen. The "fringe sign," which is defined as fine or miniaturized residual hairs retained at the margin of the anterior hairline with hair loss posterior to the fringe, typically is present (picture 1B) [6]. Marginal alopecia often occurs in association with hairstyles incorporating tight ponytails, buns, or braids [5,6].

Nonmarginal alopecia occurs in areas other than the frontal or temporal scalp. For example, women who frequently wear their hair in a tight chignon or bun can develop patchy hair loss of the occipital scalp. Nonmarginal traction alopecia can also occur as a result of hair extensions [10], pins used to secure hats [11], or other regular use of hair accessories (picture 3) [10]. Linear, curved, or horseshoe patterns of hair loss can occur when hair is tightly braided on the scalp in preparation for the attachment of sewn-in or glued-in curtain-like hair extensions (hair wefts), as is often done for hair weaves (picture 1C) [16,21,22].

The presence of hair casts can be a sign of ongoing traction alopecia [23-26]. Hair casts are moveable collections of white scale that encircle the hair (picture 4). Hair casts are composed of keratin derived from root sheath cells and occur in association with a variety of scalp disorders [25].

HISTOPATHOLOGY — The histopathologic findings in traction alopecia may differ based upon the stage of disease:

●Early traction alopecia – Biopsies of traction alopecia less than one year in duration may demonstrate trichomalacia (twisted or deformed anagen bulbs), increased numbers of telogen and catagen hairs, a normal number of terminal follicles, and preserved sebaceous glands [6]. The dermis may exhibit mild perifollicular chronic inflammation.

●Late-stage traction alopecia – Long-standing traction alopecia characteristically demonstrates follicular miniaturization, follicular "drop-out" (loss of terminal hair follicles), and retained sebaceous glands (picture 5) [6,18,19,27]. Lost terminal follicles are replaced with fibrous tracts. Dermal inflammation is minimal or absent.

Although fibrosis is considered a histopathologic feature of late-stage traction alopecia, histopathologic assessment for fibrosis may not be a reliable indicator of the stage of traction alopecia (early versus late-stage) and, additionally, may not correlate with the overall severity of hair loss. A study of specimens from 45 patients with traction alopecia found poor agreement among three dermatopathologists in the assessment for perifollicular and interfollicular fibrosis and did not find a correlation between fibrosis and the clinical severity score [28].

DIAGNOSIS — The diagnosis of traction alopecia usually can be made based upon the clinical evaluation. A history of traction hairstyles with hair loss in a concordant distribution is essential for diagnosis. A history of signs of traction folliculitis (perifollicular erythema, inflamed papules, or pustules at sites of traction) prior to significant hair loss offers additional support for the diagnosis. (See 'Clinical features' above.)

A variety of other scalp and hair disorders can result in patterned hair loss that may be mistaken for traction alopecia. When the diagnosis is uncertain, a skin biopsy can be performed to aid in ruling out other disorders as the cause of hair loss and confirming the diagnosis. The histopathologic findings of traction alopecia are not pathognomonic; therefore, the biopsy must be interpreted in the context of the clinical findings. (See 'Histopathology' above.)

History — A high index of suspicion is often necessary to diagnose traction alopecia, particularly since patients may not associate hair loss with their hairstyling practices. Questions that can be helpful in the evaluation include:

●"When did the hair loss start?" and "Was the hair loss sudden in onset or gradual?" – Hair loss in traction alopecia typically is gradual. Occasionally, hair loss is perceived as acute if associated with another cause of hair shedding (eg, telogen effluvium) or is noted upon removal of braids or weaves [21].

●"Where have you noticed the most hair loss?" – Localized or patchy hair loss is characteristic of traction alopecia. Diffuse hair loss or a complaint of hair loss "all over" is not typical of traction alopecia.

●"Have you had symptoms in the area of hair loss?" – If asked specifically, many patients with traction alopecia will admit to symptoms including tenderness, pimples, stinging, or crusting at some point prior to hair loss [1,2].

●"What is your normal hair care routine?" – A history of current or previous traction hairstyles is necessary for a diagnosis of traction alopecia. Knowledge of other hair care practices, such as frequent use of direct heat (eg, flat irons or curling irons) on the hair shaft [29] and chemical relaxers, is useful because such measures increase hair fragility and may contribute to additional hair loss [30,31]. Additionally, patients may use various techniques to maintain their hairstyles while sleeping in order to avoid time-consuming and/or expensive hair care [32]. Increased awareness of "nocturnal traction" and asking patients "How do you wear your hair when you sleep?" may further help identify at-risk patients.

Physical examination — The physical examination of a patient with suspected traction alopecia on the scalp should include assessment of both the scalp and hair.

The examination should begin with a global assessment of the general appearance of the hair. The texture, color, and length of the hair as well as the current hairstyle should be noted, as variations of these features can mask or augment the appearance of hair loss. If there is recognizable hair loss, the pattern and severity of hair loss should be assessed. In traction alopecia, the distribution of hair loss should correlate with the areas subjected to traction.

Examination of the scalp can be performed by examining the skin along the hairline, then parting the hair in a systematic manner that allows for a thorough assessment of the scalp skin. Particular attention should be paid to signs of inflammation (eg, erythema, inflamed papules, pustules, or scale) as these may indicate traction folliculitis, as well as to the presence or absence of follicular ostia in the involved areas. In traction alopecia, follicular ostia are usually retained, with the exception of late-stage disease, which may have diminished follicular ostia.

Closer examination should include visual assessment of hair fibers in the involved areas. In traction alopecia, hair fibers often become finer as a result of follicular damage or follicular miniaturization. The clinician should also examine the patient for the presence of hair casts. Hair casts frequently occur in traction alopecia and are an indicator of persistent traction [23-26]. Hair pull tests, which are used to assess for hair cycle disturbances resulting in hair loss, are typically negative in traction alopecia. (See "Evaluation and diagnosis of hair loss", section on 'Hair pull test'.)

In clinical studies, the severity of marginal traction alopecia has been assessed using the Marginal Traction Alopecia Severity (M-TAS) score [17].

Dermoscopic examination is a useful adjunctive tool in the diagnosis of traction alopecia. Dermoscopy may detect hair casts that are less easily seen with the naked eye [23]. In addition, dermoscopy may be helpful in visualizing the follicular ostia (pinpoint white dots), which can be diminished in persistent traction alopecia. The presence of empty follicles, vellus hairs, broken hairs, black dots, and circular hairs may also help support the diagnosis of traction alopecia, though these changes may vary depending on whether the traction is early or late stage [33,34]. (See "Overview of dermoscopy".)

Biopsy — A biopsy is not necessary for the diagnosis of traction alopecia in the majority of cases but should be done when there is doubt regarding the diagnosis. In contrast to many other hair loss disorders, the biopsy should be from the center as opposed to the periphery of an alopecic area. (See "Skin biopsy techniques".)

One 4 mm punch biopsy sectioned horizontally may allow for the detection of histologic findings consistent with traction alopecia. However, many dermatopathologists prefer two biopsies to allow for examination of both horizontal and vertical sections. (See 'Histopathology' above.)

DIFFERENTIAL DIAGNOSIS — The differential diagnosis of traction alopecia differs based upon whether the patient presents with traction folliculitis, marginal tractional alopecia, or nonmarginal alopecia (table 1).

Traction folliculitis — Pustular eruptions secondary to bacterial folliculitis or tinea capitis are in the differential diagnosis of early traction folliculitis. Bacterial or fungal cultures can differentiate these conditions from the sterile pustules of traction folliculitis. Of note, the lymphadenopathy often present in tinea capitis is absent in traction alopecia. (See "Infectious folliculitis" and "Tinea capitis".)

Marginal traction alopecia — Marginal traction alopecia may resemble the ophiasis pattern of alopecia areata and frontal fibrosing alopecia:

●Alopecia areata – Alopecia areata is an autoimmune condition that usually presents with sudden-onset patchy hair loss. Occasionally, hair loss occurs in a band-like distribution along the hairline, known as the ophiasis pattern (picture 6). This presentation can be difficult to distinguish clinically from traction alopecia. Both disorders usually exhibit retained follicular ostia. The presence of exclamation point hairs (short hairs less than a few millimeters in length with tapered bases) within the involved area suggests alopecia areata (picture 7). When necessary, a biopsy can aid in distinguishing these disorders. Histopathologic examination of alopecia areata reveals peribulbar lymphocytic inflammation and an absence of fibrotic fibrous tracts. (See "Alopecia areata: Clinical manifestations and diagnosis".)

●Frontal fibrosing alopecia – Traction alopecia involving the frontal and temporal hairline can be difficult to distinguish from frontal fibrosing alopecia (FFA), an uncommon form of cicatricial (scarring) alopecia (picture 8A-B). Both conditions present with hair loss in a band-like pattern along the frontal hairline. In FFA, there is loss of the follicular ostia, and the involved scalp appears pale and sclerotic. Isolated terminal hairs may remain in areas of involvement (the "lonely hair sign") and there is an absence of vellus hairs [35]. The "fringe sign" of traction alopecia is absent. Eyebrow loss is a common associated feature of FFA. Hyperpigmentation of the face and neck consistent with lichen planus pigmentosus may be another frequent associated finding in patients with highly pigmented skin [36]. Histopathologic examination of FFA shows a loss of sebaceous glands and an inflammatory infiltrate and interface dermatitis around hair follicles. (See "Lichen planopilaris", section on 'Frontal fibrosing alopecia'.)

Nonmarginal traction alopecia — Nonmarginal traction alopecia should be distinguished from hair loss secondary to trichotillomania, syphilis, alopecia areata, or tinea capitis:

●Trichotillomania – Trichotillomania is a condition in which a person pulls, twists, plucks, or otherwise manipulates the hair in an obsessive or repetitive manner to the point where there is visible hair loss (picture 9). Unlike many cases of traction alopecia, the hair loss in trichotillomania usually spares the marginal hairline because manipulation of hair in these areas may be more painful. In the areas of hair loss, the hair shafts are broken, with blunt ends, and there may be signs of irritation or trauma of the scalp. Often, trichotillomania is associated with other behavioral or psychiatric disorders including anxiety, depression, obsessive-compulsive disorders, or others. On histologic examination, pigment casts, trichomalacia (twisted or deformed hairs), and a catagen shift may be present. (See "Skin picking (excoriation) disorder and related disorders", section on 'Trichotillomania'.)

●Syphilis – Patchy hair loss often described as a "moth-eaten" pattern can occur in secondary syphilis (picture 10). This pattern of hair loss may be similar to the patchy traction alopecia that can occur as a result of hair extensions. A high level of suspicion is always warranted, and appropriate serology should be ordered if syphilis is suspected. (See "Syphilis: Screening and diagnostic testing" and "Syphilis: Epidemiology, pathophysiology, and clinical manifestations in patients without HIV", section on 'Clinical manifestations'.)

●Alopecia areata – Patchy alopecia areata can resemble nonmarginal traction alopecia. The onset of alopecia areata tends to be sudden, unlike the typical gradual onset of traction alopecia. Alopecia areata is also in the differential diagnosis of marginal traction alopecia. (See 'Marginal traction alopecia' above and "Alopecia areata: Clinical manifestations and diagnosis".)

●Tinea capitis – Tinea capitis is a common disorder in children that may present with patchy hair loss. Scale is usually present and is typically more prominent than the mild scale that may accompany traction alopecia (picture 11). A potassium hydroxide (KOH) preparation of involved hairs or fungal culture confirms a diagnosis of tinea capitis. (See "Tinea capitis".)

MANAGEMENT — Data on the treatment of traction alopecia are limited. No controlled trials have been performed, and recommendations in the literature are primarily based on case reports and expert opinion.

The therapeutic options for traction alopecia include behavioral changes and medications aimed at halting progression of the disorder and promoting regrowth of hair. When treatment is unable to induce adequate hair regrowth, as is often the case for late-stage disease, hair transplantation or cosmetic techniques to camouflage hair loss can be beneficial. (See 'Early-stage traction alopecia' below and 'Late-stage traction alopecia' below and 'Cosmetic camouflage' below.)

Early-stage traction alopecia — The detection of traction alopecia at an early stage (within one year of onset) is desirable because the potential for hair regrowth diminishes with increasing duration of traction and increasing severity of alopecia. The most important intervention for early-stage traction alopecia is discontinuation of the traction hairstyle. Adjunctive interventions, such as topical or intralesional corticosteroids, oral antibiotics, and topical minoxidil are often used to in an attempt to minimize additional hair loss and augment regrowth of hair. (See 'Cessation of traction hairstyles' below and 'Adjunctive interventions' below.)

Cessation of traction hairstyles — Discontinuation of traction hairstyles is recommended for all patients with traction alopecia. In general, this would include avoidance of particular styles of braids, weaves, twists, dreadlocks, ponytails, hair buns, hair extensions, or other styling techniques that exert tension on the hair. Loose, low-hanging ponytails or buns are preferred methods for tying hair because of a lower risk of TA, especially in natural hair [17,37].

However, changing hairstyling techniques can be difficult for patients because of strong personal preference or cultural, religious, or professional requirements. Patients who are unable to completely discontinue a traction hairstyle should be encouraged to alter the hairstyle in a manner that minimizes tension on the hair. In addition, patients should be educated that the development of pain, tenderness, or pimples from a hairstyle should not be tolerated. If such symptoms occur, the hairstyle should be removed or adjusted immediately. Taking down the traction hairstyle when at home may be an additional helpful measure for patients who are required to wear a traction hairstyle in professional or social settings.

In addition, we typically encourage patients to avoid insults to the hair that may cause hair breakage, augmenting the extent of hair loss. Avoidance of chemical relaxers and appliances that directly apply heat to the hair shaft (eg, curling irons or flatirons) is preferred, though not always feasible for patients. In particular, because limited data suggest that wearing traction-inducing hairstyles on chemically relaxed hair may increase risk for traction alopecia [17], we encourage patients who are unable to stop traction hairstyles to discontinue use of chemical relaxers.

Adjunctive interventions — Minoxidil is often used in an attempt to augment the growth of hairs in affected areas. In addition, interventions to reduce active inflammation, such as topical or intralesional corticosteroid therapy and oral antibiotics with antiinflammatory properties are often prescribed in an attempt to reduce the inflammatory response that may contribute to hair loss in traction alopecia. Although these treatments are commonly used [38], they have not been evaluated in clinical trials.

Our typical initial approach to adjunctive therapy consists of treatment with topical minoxidil for patients with early-stage traction alopecia who present without clinical signs of active inflammation (eg, erythema, inflamed papules, pustules, or scale). When patients present with clinical signs of inflammation, we usually begin with either local administration of a corticosteroid or administration of an oral tetracycline antibiotic. The latter is preferred when pustules are present [38]. Patients are transitioned to topical minoxidil therapy once signs of inflammation subside.

Minoxidil — Minoxidil, a drug frequently used for androgenetic alopecia, is also used in an attempt to improve hair growth in traction alopecia. It is theorized that minoxidil may prolong the anagen (growth) phase of hair follicles, shorten the telogen (resting) phase, and induce enlargement of miniaturized follicles, thereby contributing to the conversion of miniaturized hairs to terminal hairs [39].

Minoxidil can be used either topically or orally, with the former being available over the counter and the latter given as a prescription. We generally start with topical minoxidil due to its favorable safety profile. We consider oral minoxidil therapy for patients who have had no significant improvement with topical minoxidil after six to nine months of daily treatment. Data on the efficacy for traction alopecia are limited to case reports and case series [40-42]. (See "Male pattern hair loss (androgenetic alopecia in males): Management".)

Topical minoxidil is commercially available in a 5% solution or foam and a 2% solution. We typically instruct patients to apply minoxidil 5% solution or foam once daily to the scalp. Twice-daily application of minoxidil 2% solution is an alternative. Oral minoxidil is generally prescribed in doses of 0.625 to 5 mg daily.

Treatment should be continued for at least four months prior to assessing for initial signs of a response. A full year of treatment may be necessary to judge efficacy. If hair growth improves, treatment should be continued until regrowth is stable for at least three to four months.

Skin irritation and facial hair growth are potential side effects of topical minoxidil. The 5% foam formulations may be less likely to cause skin irritation than 2% solutions. However, in women, the risk for facial hypertrichosis may be greater with the 5% formulation than with the 2% formulation [43]. Facial hypertrichosis typically resolves within a few months after cessation of minoxidil [43]. Initial shedding of hair during the first several weeks of treatment may also be seen [44].

Potential side effects of low-dose oral minoxidil include hypertrichosis, light headedness, tachycardia, and fluid retention (leg swelling), though the low doses of this antihypertensive drug are generally well tolerated [41,45].

Local corticosteroids — Patients with clinical signs of inflammation may benefit from local corticosteroid therapy. Local corticosteroids can be administered through application of medium- to high-potency topical corticosteroids (group 2 to 4 (table 2)) or through intralesional injection [6,38,46,47].

Topical corticosteroid therapy is usually applied twice daily to the entire affected area. Intralesional corticosteroid therapy is often administered as a 10 mg/mL concentration of triamcinolone acetonide. Both the center and periphery of the area of hair loss should be injected. Individual injections are typically spaced approximately 1 cm apart with approximately 0.1 mL injected per site. Injection sessions are typically performed at an interval of four to six weeks. We typically do not administer more than 20 mg of triamcinolone acetonide per treatment session. (See "Intralesional corticosteroid injection".)

Treatment with these agents is discontinued once clinical signs of inflammation resolve. A typical course of treatment is one to two months for topical corticosteroids and two injection sessions for intralesional corticosteroids.

Skin atrophy is a potential adverse effect of local corticosteroid therapy. The side effects of topical and intralesional corticosteroid therapy are reviewed in detail separately. (See "Topical corticosteroids: Use and adverse effects", section on 'Adverse effects' and "Intralesional corticosteroid injection", section on 'Adverse effects and pitfalls'.)

Oral antibiotics — Oral tetracycline antibiotics (eg, tetracycline, doxycycline, minocycline) are commonly used for traction alopecia in patients with clinical signs of inflammation based upon the antiinflammatory effects of these drugs. Use of these agents is preferred over local corticosteroids when pustules are present [38].

Typical adult doses are similar to those used for acne and include tetracycline (500 mg twice daily), doxycycline (50 to 100 mg twice daily), or minocycline (50 to 100 mg twice daily). Treatment is continued until clinical signs of inflammation resolve. A typical treatment course is one month or until resolution of the folliculitis.

Tetracyclines should not be administered to children under the age of nine years or pregnant women because of risk for discoloration of developing permanent teeth. Common side effects of tetracycline and doxycycline include gastrointestinal distress and photosensitivity. Minocycline use may be associated with gastrointestinal distress, dizziness, skin discoloration, serum sickness, or a lupus-like syndrome.

Late-stage traction alopecia — Patients presenting with traction alopecia that has persisted for years are unlikely to experience significant hair regrowth with treatment. Still, attempts to maximize any potential for regrowth through removal of the traction-inducing hairstyle (if still in use) and a trial of topical minoxidil is reasonable [40]. (See 'Cessation of traction hairstyles' above and 'Minoxidil' above.)

Patients with permanent hair loss may achieve cosmetic benefits from hair transplantation. Cosmetic camouflage techniques are an alternative to hair transplantation. (See 'Hair transplantation' below and 'Cosmetic camouflage' below.)

Hair transplantation — Hair transplantation can restore hair growth in areas of traction alopecia. Hair transplants performed with micro-grafting, mini-grafting, and follicular unit transplantation have been reported as effective in individual patients [38,48,49]. Of note, special consideration should be given to hair shape and styling methods to achieve the best results from hair transplantation in patients with curly, Afro-textured hair [50,51]. For example, care must be taken to avoid transection of curved hair follicles when separating grafts [50].

Cosmetic camouflage — A variety of interventions can effectively conceal areas of hair loss [52]. Cosmetics that decrease the color contrast between the scalp and hair can reduce the visibility of hair loss and are available in a variety of application methods (eg, topical hair fibers, powders, camouflaging lotions or sprays, and scalp tattoos) [52]. Use of a hair piece or wig is also helpful for camouflaging hair loss from traction alopecia, provided tight clips, glues, or tape are not used.

PROGNOSIS — The prognosis for traction alopecia is excellent if traction is stopped early in the course of the disorder. However, chronic traction alopecia eventually becomes permanent and unresponsive to cessation of traction and pharmacologic interventions. (See 'Management' above.)

PREVENTION — Traction alopecia is preventable. Unfortunately, knowledge about traction alopecia is still poor among teenagers and many communities [53]. Programs to educate adults and parents or guardians of children and adolescents about the risk factors for traction alopecia and early signs of traction alopecia may aid in reducing incidence [37,54]. Educating hairdressers may also be of benefit for the prevention and early detection of traction alopecia.

Key messages to communicate to the public include:

●Hairstyles should be painless; a painful hairstyle should be removed immediately.

●Hairstyles causing skin redness, pimples, or hair loss should be removed immediately.

●Traction hairstyles (eg, braids or weaves) should be worn infrequently and for short periods.

●It is preferable to avoid traction hairstyles on chemically relaxed hair.

●Massaging or vigorously brushing the affected scalp does not stimulate hair regrowth and is not recommended for traction alopecia.

Clinicians may also help to reduce the burden of traction alopecia by recognizing signs of traction alopecia in children or adults who present for the evaluation of other medical conditions. A discussion about methods to avoid additional hair loss may stimulate behavioral changes and benefit patients with traction alopecia.

SUMMARY AND RECOMMENDATIONS

●Risk factors – Traction alopecia is a type of hair loss that occurs as a result of prolonged or repetitive tension on hair and hair follicles. Traction hairstyles, such as braids, hair weaves, tight ponytails, or tight hair buns can lead to the development of traction alopecia. (See 'Epidemiology and risk factors' above.)

●Epidemiology – Traction alopecia is most frequently diagnosed in females of African descent with Afro-textured hair because of the common use of traction hairstyles in this population. However, traction alopecia can occur in children or adults with any type of hair. (See 'Epidemiology and risk factors' above.)

●Clinical features – The earliest clinical sign of traction alopecia may be the development of traction folliculitis. Traction folliculitis is characterized by the development of perifollicular erythema, inflamed papules, or pustules in sites of traction on hair (picture 2). (See 'Clinical features' above.)

The location of hair loss in traction alopecia correlates with the site(s) of traction. Hair loss most frequently occurs on the frontal or temporal scalp (picture 1A). The "fringe sign," persistence of fine or miniaturized hairs in the anterior hairline with greater hair loss posterior to this fringe, is a common finding (picture 1B). (See 'Clinical features' above.)

●Diagnosis – The diagnosis of traction alopecia usually can be made based upon the clinical evaluation. A history of a traction hairstyle and hair loss in a correlating distribution is essential for diagnosis. A biopsy can be helpful if the diagnosis is uncertain. (See 'Diagnosis' above.)

●Management – Early recognition of traction alopecia is critical. Patients with early traction alopecia may experience significant hair regrowth with treatment. Hair regrowth is less likely to occur in longstanding traction alopecia (see 'Prognosis' above):

•Cessation of traction – Discontinuation of traction hairstyles is the primary treatment for traction alopecia. Modifications of hairstyling routines may be necessary for patients who cannot completely discontinue traction hairstyles for professional, cultural, religious, or other reasons. (See 'Management' above.)

•Adjunctive therapies – Adjunctive therapies are often prescribed in an attempt to minimize additional hair loss and augment hair regrowth. We suggest a trial of topical minoxidil for patients who desire treatment (Grade 2C). If signs of inflammation are present, treatment with local corticosteroids or oral antiinflammatory antibiotics is typically given prior to minoxidil treatment. Oral minoxidil is an option for patients who respond insufficiently to topical minoxidil treatment. (See 'Adjunctive interventions' above.)

●Prevention – Traction alopecia is preventable. Education of the public may help to reduce the incidence of traction alopecia. (See 'Prevention' above.)