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Traction Alopecia, Scalp Pulling & Hair Loss

Unlike alopecia areata, which is an autoimmune disorder, traction alopecia is preventable and has a known underlying cause. While traction alopecia is not tied to a disease, it can still lead to permanent hair loss if a person wears certain hairstyles resulting in long-term scalp pulling. The good news is avoiding certain hairstyles treatment can usually reverse hair loss caused by traction alopecia.

Traction Alopecia Causes

Traction and friction related to certain hairstyles, combing/brushing hair too vigorously or tugging at it over time can cause traction alopecia. Persistent gentle pulling is typically painless and may go unnoticed until bald spots or alopecia starts to appear. Any of the following can cause stress and tension to one’s hair:

  • Very tight ponytails or pigtails
  • Tight braids or cornrows
  • Dreadlocks
  • Extension (single) braids
  • Hair weaves or wigs attached with glue, clips, or tape
  • Headbands (even fabric ones) worn day after day
  • Tight hairpieces
  • Frequent use of hair pins, hair bands, and clips (especially day after day in the same hairstyle)
  • Tight headgear worn frequently or for long stretches of time that tend to rub or pull repeatedly on the same area of hair (e.g. cycling helmets)
  • Repeated use of hair rollers
  • Repeated pulling of the hair with the hands (a condition called trichotillomania)

Risk Factors

Traction alopecia can impact people of all ages and both females and males, however, it affects specific populations more frequently due to differences in hair structure, hairstyles, and sometimes lifestyle factors or career choices. For instance, traction alopecia is more common in black people of African descent because their hair is tight and curly, causing hair to be more fragile and prone to breakage. Tight curls affect how hair is anchored into the follicle beneath the skin surface. Many black women in particular use hair treatments and hairstyles to control the curl such as straightening, relaxing and braiding, which can cause damage to the hair root and follicles and eventual hair loss. In fact, research shows women with relaxed hair have the highest prevalence of traction alopecia. Ballerinas and gymnasts who frequently pull their hair back tightly in buns or ponytails may be more vulnerable to traction alopecia. Other professional athletes who wear headgear that places tension on the hair may also be at greater risk of developing traction alopecia (e.g. swim caps and cycling helmets).

Traction Alopecia Signs

If hair is pulled back in a ponytail, the hairs at the margins of the scalp are put under the greatest friction and tension, with early hair loss resulting in a receding hairline. Tight braiding in cornrows can lead to marginal or central alopecia with widening part lines. Twisting hair into a bun on the top of the head can produce horseshoe-shaped hair loss. Rough brushing or even massaging the scalp too vigorously repeatedly can produce diffuse hair loss. Other symptoms include:

  • One side of hair is thicker than the other
  • Scalp sensitivity after undoing a hairstyle
  • Relief after untying hair
  • Itchy scalp after wearing braids or a weave
  • A headache resulting from too tight a hairstyle
  • Pustules (blisters filled with pus) or papules (little pimples) caused by tension to the hair follicles
  • Red or painful scalp (sign of inflammation)

Traction Alopecia Treatment

It is important to visit a dermatologist to ensure hair loss is not caused by a different form of alopecia. It is possible for hair to grow back if damage is not permanent, however, no further tension can be applied to the scalp or hair loss will continue. A topical preparation of high strength minoxidil is the standard treatment for traction alopecia. A dermatologist can also recommend medicated ointment if blisters are present on the scalp. Traction alopecia is often resolved within six months if it is caught and treated early. In severe cases, it can take as long as one year for a damaged scalp to regrow hair. When hair follicles are badly traumatized over a long period and scar tissue has formed, hair will not grow back by itself. A possible sign of this is shiny areas of the scalp.

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Traction alopecia

Traction alopecia is associated with sustained tension on the scalp hair. Traction causes hair to loosen from its follicular roots; however, hair loss also occurs secondary to follicular inflammation and atrophy. Sometimes also referred to as ‘cosmetic traumatic alopecia’ as it occurs when the hair has been held under tension by cosmetic practices like braiding or ponytails or the individual has slept in rollers. If tension continues to the hair roots the constantly pulling hair too tight and in the same direction can cause baldness to these specific, localized roots only. Onset is gradual and often takes 2 to 3 years to become apparent and it often occurs symmetrically around the fronto-temporal hairline, occipital scalp involvement is less common. Vellus (short, fine) hair is usually spared in the affected area.

In the initial stages, this hair loss is reversible. However, prolonged tension may induce follicular inflammatory changes with immune cell infiltrate and fibrosis which totally destroys the hair follicles and will not re-grow under any circumstances hence chronic traction alopecia occurs and can then be described as a ‘Scarring Cicatricial Alopecia’. This results in permanent localised hair loss to those specific follicles under tension. Therefore it is important to recognise this condition while it is still reversible.

Traumatic alopecia is essentially a cosmetic disorder. Rather than affecting the sufferer psychologically, therefore it should be emphasised that this condition is not a disease.

Causes

Three basic mechanisms of traction alopecia have been proposed: trichotillomania, telogen conversion, and over processing. In all cases, immediate cessation of the underlying cause can reverse the alopecia.

Over processing

  • Chemical treatment of hair with dyes, bleaches, or straighteners disrupts the keratin structure in a manner that reduces its tensile strength.
  • The hair becomes fragile and is unusually susceptible to breakage from friction or tension.
  • Normal combing can lead to the sudden loss of hair en masse.

Trichotillomania

A psychiatric disorder of compulsive behavior involving the intentional yet uncontrollable, repeated plucking of one’s own hair usually from a specific area and resulting in a patchy loss in that area.

Telogen conversion appears to be the most common cause.

  • Usually, the hair follicle can sustain trauma and still remain in the anagen growth phase.
  • Excessive traction for prolonged periods (e.g., tight braiding, wearing of ponytails) leads to conversion of the anagen phase to the telogen phase.
  • Keratin cylinders-‘hair casts’ may surround many hairs just above the scalp surface.
  • Typically, traction alopecia in the early stages involves affected hair follicles being pushed into the telogen resting state along with localized trauma to the hair follicles as a result of hair shafts being forcibly pulled.
  • In the telogen phase, the hair follicle ceases to grow and localised alopecia results.

Sub types of Telogen Conversion

Marginal

Otherwise known as Alopecia linearis frontalis, is a hair-loss pattern that usually results from the use of tight curlers, tight ponytails, or straighteners. In this condition, the distribution of hair loss follows a characteristic pattern in the temporal scalp, starting in the periauricular area and extending forward in a triangular manner. The involved area is approximately 1-3 cm in width in most cases. For example, the constant contraction of the muscles used in facial expression, in addition to the tension caused by braiding, may partially account for why this pattern is often seen in the temporal region.

Non-Marginal

Sometimes referred to as ‘chignon alopecia’ is characterized by hair loss in the occipital scalp region where the bun rests. This condition is seen in patients with a long-standing history of pulling their hair into a bun. The typical patient is a 40-year-old woman who initially complains of itching and dandruff localized to the occipital area. Similar to marginal alopecia, perifollicular erythema with occasional peripilar hair casts can be seen. The natural history of chignon alopecia mirrors that of marginal alopecia, with the eventual formation of pustules and the development of folliculitis. Permanent alopecia can also result if this condition remains undetected and the traction continues. Sometimes, the fronto-marginal part of the scalp may also be involved because the longest hair roots originate in this region, and may be subjected to traction. When an examining physician notices both chignon alopecia and marginal alopecia, the index of suspicion should be high, and the diagnosis of chignon alopecia should be considered.

Pathophysiology

Traction Alopecia is induced particularly readily in subjects with incipient common baldness, for the telogen hairs which make up a higher proportion of the total are more loosely attached and readily extracted than anagen hairs

Incidence

It is seen worldwide and for hundreds of years as cultural, religious, fashion, customs and occupations have imposed an immense variety of physical stresses on human hair, i.e.;

  • In Sikhism, a religion originating from India, men must not cut either scalp hair or beard hair. Therefore, to keep their hair from falling in front of their face, it is tightly, twisting on top of their head and pulled into a bun. This practice has led to frontal and parietal traction alopecia occurring and the tight rolling of beard hair into a pocket in the sub-mandibular region also results in a similar phenomenon.
  • The Sudanese customs of tight braiding and the use of wooden combs.
  • Frontal loss has been reported in Libyan women from tight scarves.
  • Afro- Caribbean hair styles with tight braiding of the hair into rows may cause marginal alopecia and central alopecia with widening of the partings.
  • Females from Greenland who styled their hair in a ponytail.
  • A similar pattern of hair loss was later noted in Japanese women who wear a traditional hairdo
  • The use of hair extensions, a common treatment for male or female pattern baldness, is also associated with a similar type of hair loss.
  • Nurses who secure their nurse’s caps to their scalp with hair grips and is often referred to as ‘Nurses Cap Alopecia’.
  • Ballerinas who routinely scrape their hair back into a very tight bun, has been nicknamed ‘ballerina baldness’.

In addition, modern trends have given rise to new patterns and in contemporary developed countries these are typically;

  • straightening irons,
  • massage alopecia, when excessive touching of specific area occurs,
  • Brushing too vigorously with incorrect combs or brushes.
  • Alopecia secondary to hair weaving/extensions- patchy traction alopecia has been reported to result from the cosmetic procedure of weaving additional hair into persistent terminal hair in order to camouflage common baldness.
  • Hair rollers.

Frequency

The exact frequency of traction alopecia has yet to be documented.

Symptoms

  • Often asymptomatic.
  • Hair loss.
  • Itching.
  • Dandruff.
  • Headache is possible if extensive tensile force on the hair follicle is the cause.

Diagnosis

It is sufficient to diagnose Traction alopecia without laboratory testing, but, with physical examination by a hair consultant and thorough history taking indicating repetitive use of hair styling techniques as outlined earlier and via elimination of indications for differentials for other types of alopecia.

Traction alopecia tends to follow a series of progressive events. Initially, pruritus and perifollicular erythema may be present. These may be accompanied by hyperkeratosis, creating a seborrhoeic picture. Pustules and scales may form. Eventually, an abundance of broken hairs can be detected. With persistent traction, the follicles atrophy and no longer produce the typical long and coarse hair. Instead, thinner, fine, short hair is generated.

  • When tensile forces are chronically present, an irritant type of folliculitis develops.
  • Follicular scarring and permanent alopecia may result.
  • In some cases, peripilar hair casts form. The casts are fine, yellowish white keratin cylinders smaller than 1 cm in diameter that ensheathe the hair follicle. Often, peripilar hair casts occur in isolation; however, they have also been known to occur in association with hyperkeratotic scalp disorders.
  • The hair loss pattern entirely depends on the specific grooming pattern of each patient. Marginal and Non-marginal types may be seen.
  • Patients usually have patchy areas of hair loss.
  • The hair-pulling test results in the detachment of more than 6 strands.
  • Closer inspection of the scalp reveals perifollicular erythema, scales, and pustules.
  • Hair loss may be symmetric, and marginal traction alopecia may be present in the temporal region.
  • With chignon alopecia, hair loss may be in the occipital area.
  • With corn-rowing, the area most commonly affected is that adjacent to the region that is braided.
  • The essential changes in the many variants of this syndrome are the presence of short broken hairs, folliculitis and some scarring circumscribed patches at the scalp margins.
  • Their cause is rarely recognised by the patient and is often accepted with suspicion.
  • Patients do not like to admit to cosmetic ‘abuse’ of their hair!

Prognosis

  • Traction alopecia is reversible in a few months if the hairstyling practice in question is discontinued.
  • Traction alopecia may lead to permanent hair loss if it is undetected for a protracted period.

Medical Care

The physician must identify traction alopecia early. Failure to do so places the patient at risk for irreversible alopecia.

Immediately after traction alopecia is diagnosed, any practices that exert traction on the hair must be discontinued. Discontinuing any such practices leads to complete reversal of the hair loss and regrowth within around three months.

  • Even with removal of the cause of traction alopecia it may take up to three months for the hair to recover.
  • Topical or oral antibiotics may be prescribed to aid in the reduction of inflammation and to prevent superinfection.
  • When traction alopecia is detected later in its natural course, hair loss may be irreversible. Currently, no medical treatment is available to reverse late-stage traction alopecia.

Diet

Ensuring sufficient levels of nutrients, may help promote normal hair growth, this can be assisted with diet and supplements. In my opinion the best food supplement on the market is Hair Today More Tomorrow, Multi & Omegas.

Surgical Care

The only way one can treat scarring traction alopecia is with hair transplant surgery. Follicular unit hair grafting has been identified as the only practical solution to treating traction alopecia. The number of patients with traction alopecia coming to hair transplant clinics is generally increasing and the treatment is providing them good response.

The future

The information contained in this article has been researched from the references quoted at the end. However, most other information available, but not included here is very basic and repetitive.

Therefore, as there are many unanswered questions about Traction Alopecia, it seems that the only way to attempt to answer these is by conducting further research.

Aims

To publicly, minimise incidence of Traction Alopecia. Correlate data with percentile risks that can be presented to the individual. Devise the ultimate advice for clients to minimise risks from occurring.

  • If clients insist on continuing after initial signs of Traction Alopecia develop, then what percentage does it actually occur ? Verify how long this takes. After it occurs, then how long before it becomes irreversible? Again verify how long this takes.
  • Describe what factors are more likely to precipitate Traction Alopecia i.e. scalp types and hair types and correlate if it takes some people longer for it to develop and why? Are some types totally immune? Prolonged traction causes decreased hair follicle and sebaceous gland density, which suggests it leads to dry skin conditions, therefore is a dry scalp an indicator? Is hair movement under tension more damaging?
  • Observation to clarify identification characteristics and any peculiarities in the pattern. Traction Alopecia has been documented to ooccur symmetrically around the fronto-temporal hairline, is that due to the fact that scraping the hair back off the front hairline (ballerina style) is the more common offending style or because this area is weaker? Or perhaps that the skin is more mobile there allowing more movement and increased pull back?
  • Establish how long does the tension effect last, i.e. hair grows at 1.25cm per month. Consequently, even after 1 week after application of hair attachments, it has already loosened a little, hence, maybe just short term tension doesn’t have any long term effects? Therefore, after the tightness is lessened, will risks diminish or will the weight of the extra hair still make a difference to the traction?
  • If weight is then recognised as a factor the advice will need to be given about extra care to taken when hair is wet as it will weigh more.
  • With weight issues taken into account, should there be a maximum advisable ratio of added hair to indigenous hair?
  • We know that Traction Alopecia is more likely to occur when follicles are in telogen phase. Minoxidil is thought to effect the progression of follicles to the telogen phase. Therefore, to trial use of minoxidil with hair attachment systems and observe for any noticeable difference in incidence.
  • As mentioned previously it is important to maintain ‘sufficient’ levels of iron and protein, therefore conduct a trial to obtain ‘optimum’ levels of iron stores, by placing those on supplements and also with advice about increasing protein in diet.
  • Processed hair is more likely to break, therefore establish risk and whether hair attachments should be contraindicated.
  • We know that vellus hair is spared from traction alopecia, but is that because it is too short and fine to be properly involved with the section under traction and so avoids damage?
  • Identify if there any correlation in the methodology of application of hair attachments i.e. would changing direction of the tension make a difference? Would skin glue help? Is the tension reduced if the sections under tension are larger i.e. spreading the load.

Book your consultation with Sara

Histology

Early in the condition, lymphocytes surround a lichenoid perifolliculitis with infundibula (Ackerman, 2000). Later, as the process evolves, a zone of fibroplasia separates this infiltrate.

Fully developed traction alopecia involves a mild lymphocytic perivascular infiltrate, a markedly thinned lower infundibulum, and an isthmus surrounded by a band of fibroplasia. Foreign body granuloma may be evident. The late process has a reduced number of hair follicles and thickened fibrous bands in much of the reticular dermis that extends into subcutaneous fat.

In early traction alopecia, a subacute perifollicular inflammation is accompanied by mild-to-moderate hyperkeratosis. In cases of prolonged traction, decreased hair follicle and sebaceous gland density, perifollicular fibrosis, and vertical bands of follicular scarring are seen. However, blood vessels and eccrine sweat glands remain unaffected.

It may be difficult to decide what to do with your hair, as the affected areas will require some breathing room. If you have to opt for braids or extensions, Day suggests that you “try to wear as loose as possible…be as gentle as possible with your hair.” Whether you choose to rock natural or synthetic hair, weaves or extensions, wigs or braids, the sensitive parts of your hair, especially your hairline, are just that and should be handled as such. Do the best that you can to avoid friction and try Carol’s Daughter Mimosa Hair Honey Calming Tension Spray. The creamy formula soothes when braids are tight or itchy. Celebrity hairstylist Brenton Kane Diallo, who has worked with Simone Biles, Solange Knowles, and Jourdan Dunn, advocates being vocal when expressing your needs at the salon. “Do not be afraid to communicate or confront your stylist if the styling feels too tight. I cannot stress this enough; it’s your hair scalp and health!”

Similar to other parts of your body that require extra TLC, your hair will show warning signs that things need to change. Michelle Blaisure, another accredited trichologist notes, “Once scarring occurs, no hair can grow in that area. If the scalp becomes tender or spongy in the area where hair is thinning, there may be inflammation present and should consult a dermatologist for treatment.”

The Recovery Plan and Process

It took a certain amount of time for hair follicles to deteriorate, so it will take time to rebuild those skin cells. It may take anywhere from three to nine months to see some progress. “It’s important to avoid a quick fix,” states Johnson. It’s time to pinpoint a solution and target each region with Bosley Professional Strength Healthy Hair Follicle Energizer, which was designed to stimulate growth and strengthen the hair shaft. Massage 1 or 2 drops directly into the scalp on freshly washed hair or dry hair.

It is possible to remedy existing damage and prevent further hair loss with less invasive treatments like hair transplant surgeries, so be patient. “I personally have not had any cases of alopecia that I have not been able to reverse,” says Johnson, “Maybe not 100 percent, but I have always seen growth.”

More healthy hair tips:

  • Barefoot Blonde Shares Her Tips on Caring for Your Hair Extensions This Summer
  • How to Care for a Blonde Afro
  • I Found the Best Conditioner for Platinum Blonde Hair

8 Women Who Shaved Their Heads in 2017:

The hairline has some of the finest, shortest, most fragile hairs—they don’t call them baby hairs for nothing—yet it’s also where many women do the most damaging styling. We slick our edges down with gel, braid them back, flatiron them into submission, and brush the hell out of them. All of this heavy-handed styling puts the hairline at risk for traction alopecia.

Traction alopecia is a type of hair loss where the hair thins out after prolonged stress on the hair follicle, and it’s most common around the front hairline. It’s estimated that one third of African-American women have traction alopecia, from styles and styling techniques that put a lot of pressure on the hair, like wearing tight braids or extensions, putting significant heat on the hairline, getting chemical relaxers, installing a weave, repeatedly using tight sponge rollers, and brushing already fragile hairs. However, traction alopecia isn’t just restricted to black women. Other habits that can cause it include pulling hair back tightly into updos or ponytails, and wearing headbands tightly in the same place every day.

Even if you think you have a healthy styling routine that avoids hot tools or relies on protective styles like wigs, you could still be putting your delicate, infant hairs at risk. Amy McMichael, M.D., dermatologist and chairwoman of the dermatology department at Wake Forest Baptist Medical Center, says even wearing a hair wrap every night can cause traction alopecia because it rubs against the front hairline. The key here is repetition: Traction alopecia takes hold when you repeat these tight styles and harsh hair habits without giving your hair a rest.

If you tend to do a lot of these styling sins (and, let’s be honest, we all have our ponytail weeks), there are several early warning signs to look out for, and steps that you can take to help protect your baby hairs before it’s too late.

Subtle signs of traction alopecia may appear before you notice any actual hair loss.

Traction alopecia can happen slowly, so it may take some time for you to notice that your hairline has started to recede. If you’re seeing any thinning in the frontal hairline, especially in front of the ears, this could be a red flag. Be wary of any changes to the thickness, strength, and texture of your hair, no matter how slight.

Kamilah, a braid expert and New York state–certified natural hairstylist and cosmetologist, tells SELF that, for her clients, “the warning signs of traction alopecia are something they can feel.” She can tell something is off with a client squirms or moves her head away because there is tenderness in the affected areas. Other warning signs that looks for are short or broken hairs right around a balding area and small bumps and blisters on the scalp. McMichael says to look out for small, whitehead-looking pustules that can arise at the areas of significant pulling.

If you start to see the signs of traction alopecia, you can keep it from getting worse.

First and foremost, lay off the styling habits that are causing the damage. “Braids with extensions should not be left in longer than five or six weeks max,” says Kamilah. Once removed, she recommends properly cleansing your scalp and minimizing any additional strain from weighty extensions or friction inducing accessories—especially at the hairline.

“Once the tight hair-care practices are stopped, treatment with topical minoxidil can help regrow the hair,” says McMichael. Topical minoxidil has been FDA-approved as a treatment for female pattern hair loss, and studies have shown that minoxidil 5 percent foam can effectively help promote hair regrowth in patients with androgenetic alopecia (which is a hereditary hair loss condition but causes similar effects as traction alopecia). Minoxidil is found in treatments like Women’s Rogaine, which you can get without a prescription. Another option is for a dermatologist to administer a low-dose steroid injection to take down any inflammation caused by the tight hairstyle. Once the inflammation is gone, the hair can regrow—but McMichael warns that expectations should be managed because depending on the severity of the traction alopecia, hair regrowth is not always possible.

The good news is that traction alopecia can be prevented.

If you have to pop a painkiller because of tight braids or do the head tap to soothe itching and tension from a style, you may be on the road to traction alopecia—so it’s time to change course. “If braids feel too tight, it isn’t right,” says Kamilah.

However you wear your hair, the key to preventing traction alopecia is to mix up your styling methods before long term or permanent damage is done to the follicles. If you wear braided extensions, Kamilah recommends asking for knotless braids at the salon. This method weaves hair into the braid in a way that minimizes tugging on fragile follicles.

Even though protective styles like sew-in weaves or braids are great, it’s important to give your hair a breather before going from one style to the next. “There should always be a break of at least two to four weeks in between installs,” Kamilah advises.

Can braiding make your hair fall out?

by James Harris, MD April 27, 2017 hair loss myths and facts

From 80s beauty icon Bo Derek to current basketball sensation Allen Iverson, tight braids, also known as cornrows and weaves, have been fashionable in the U.S. for decades. For years it was a common site to see legions of women disembarking from beach vacation flights sporting the tight braids, and many sports figures continue to wear elaborate braided styles to this day. Some say it’s bad for your hair. But can it really cause permanent hair loss?

Yes, tight braiding and weaves—even tight buns and ponytails—when worn over long periods of time can cause irreversible hair loss, called traction alopecia (baldness). This is because chronic pulling of the hair causes too much tension and traction on the follicles, causing them to permanently dislodge from the scalp.

In most tight weave braiding styles, the damage manifests along the front portion of the scalp, where the hair meets the forehead.

Elaborate braiding and weaves tend to be expensive and time-consuming to create, and as a result women and men tend to keep the styles for extended periods, increasing the likelihood of permanent damage. Ironically the costly styles can end up costing you your hair.

According to a study on traction alopecia at Johns Hopkins, “An estimated one-third of African-American women suffer from traction alopecia, making it the most common form of hair loss among that group.” The problem is compounded by the use of chemical straighteners and heat, which damage the hair shaft and causes breakage.

Furthermore, extensions can be damaging if they are affixed with adhesive glue to the scalp, and weight from extensions pulling on a person’s hair follicles can also cause them to rip out by the root. Model Naomi Campbell wore extensions for years, and now appears to be suffering from traction alopecia.

It will not damage your hair to wear tight braids, weaves, or hair extensions for a special occasion. The tension must be exerted over a long period of time to result in permanent hair loss.

In many instances traction alopecia can be successfully treated with a hair transplant, whereby healthy hair follicles are moved from one part of the scalp to the damaged area.

Contact my clinic for a consultation or ask me a question about your unique situation and how we might treat it.

Dr. James A. Harris is an internationally renowned hair transplant surgeon, inventor of patented follicular unit extraction technology, published author in the field of hair restoration and an advocate for patient care. Learn more about Dr. Harris or read rave reviews from his patients.

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Tight braids and hair loss (Traction Alopecia)

Posted on April 16, 2018 in Female Hair Loss

Many African American women seek our expert advice for a hair loss problem that is common to them: thinning and baldness along their entire hairline. Unlike the most common cause of thinning hair, androgenetic alopecia or genetic hair loss, this situation can be prevented. It is called traction alopecia.

Longstanding pulling on the hair destroys follicles stopping their ability to create hair shafts or fibers. This is seen most often in African American women who had tight braiding throughout their childhood and lifetime. The history of the problem is always the same: braids that were tightly knotted, which stayed in for weeks at a time. Dr. Matthew Lopresti and I always advise women of color or anyone for that matter, never to tightly braid their children’s hair for long periods of time.

There is hope to correct the baldness, which typically runs for the entire hairline and can be observed above the ears and even along the scalp neckline. If the person has realistic expectations and adequate hair to donate from the back of the head, then we can perform a hair transplant procedure to repopulate the affected areas with growing hair. However, it is best not to create the problem in the first place.

Though it is a common custom and is adorable to tightly braid young children’s hair, there is a steep price to pay if traction alopecia develops later in their lives from this braiding.

Dr. Robert Leonard

Founder of Leonard Hair Transplant Associates

Dermatology Online Journal

The “Fringe Sign” – A useful clinical finding in traction alopecia of the marginal hair line
Aman Samrao MD1, Vera H Price MD FRCPC1, Daniel Zedek MD2, Paradi Mirmirani MD1,3,4
Dermatology Online Journal 17 (11): 1

1. Department of Dermatology, University of California, San Francisco, California
2. Department of Dermatopathology, University of California, San Francisco, California
3. Department of Dermatology, Kaiser-Permanente Medical Group, Vallejo, California
4. Department of Dermatology, Case Western Reserve University, Cleveland, Ohio

Abstract

INTRODUCTION: Traction alopecia is hair loss caused by prolonged or repetitive tension on the hair. Diagnostic challenges are encountered when the clinical suspicion is not high and when a history of traction is remote or not obtained. We have made the observation that the presence of retained hairs along the frontal and/or temporal rim, which we termed the “fringe sign,” is a finding seen in both early and late traction alopecia, and may be a useful clinical marker of the condition. METHODS: This was a retrospective single-center review to determine the frequency of the fringe sign in patients with traction alopecia. RESULTS: Over a 3.5-year period the diagnosis of traction alopecia was made in 41 women. Twelve of the 41 patients were Hispanic (29%). Thirty-five (85%) of all women and 100 percent of women who had traction involving the marginal hairline had the fringe sign. Fourteen biopsies (58%) were available for review. Histopathologic findings included retained sebaceous glands (100%), an increase in vellus-sized hairs (50%), a decrease in terminal hairs (100%), fibrotic fibrous tracts (100%), and sparse lymphocytic inflammation (57%). CONCLUSIONS: The fringe sign is a sensitive and specific clinical feature of traction alopecia when it involves the marginal hairline.

Introduction

Traction alopecia (TA) is a term used to describe hair loss caused by prolonged or repetitive tension on the hair. Traction alopecia was first described in 1907 in subjects from Greenland who developed hair loss along the hairline because of the prolonged wearing of tight ponytails . Subsequently most of the literature has focused on the prevalence of TA in people of African descent . However, TA affects people of all different ethnic backgrounds and is the result of an individual’s hair care practices. It can have a large variation in its pattern of clinical presentation. Diagnostic challenges may be encountered if the clinical suspicion for traction is not high or if the history of traction is remote or not obtained. Because pathologic features are biphasic and show varying features in early and late stage disease, appropriate clinical-pathologic correlation is essential in securing a diagnosis of TA. In patients who do not give a clear history of tight hairstyles, the clinical differential diagnosis is broad and can include alopecia areata, androgenetic alopecia, telogen effluvium, trichotillomania, and primary lymphocytic cicatricial alopecias (lichen planopilaris, central centrifugal cicatricial alopecia, pseudopelade of Brocq, and frontal fibrosing alopecia). Traction alopecia of the marginal hairline may be misdiagnosed as ophiasis pattern alopecia areata or frontal fibrosing alopecia because these disorders can have a similar band-like or patchy pattern of hair loss . Thus identification of sensitive and specific clinical markers of TA would be a useful aide to clinicians and pathologists in distinguishing TA from other conditions.

Clinically, TA most often affects the frontal and temporal scalp. However, TA has been extensively reported in the literature to occur on many different regions of the scalp. The location of TA is dependent on an individual’s hair care practices, which may or may not be related to his/her racial or ethnic background. For example, frontal and parietal alopecia has been described in Sikh males as a result of twisting their uncut hair tightly on the scalp . Submandibular TA has also been reported in a Sikh male who tied his beard in a tight knot below the chin . Young and adult African American females who develop TA from braids or hair weaves, have hair loss localized to the temporal scalp as well as anterior and superior to the ears. Females who frequently wear their hair in a tight chignon or bun can develop hair loss confined to the occipital or temporal scalp. This pattern of TA has been described in European as well as Japanese women and in ballerinas . In Sudanese women tight braiding causes hair loss on the vertex of the scalp and young Zande develop TA at the frontal scalp secondary to wooden combs placed horizontally on the scalp . Traction alopecia in Amish American women is noted on the temporal scalp where the religious head dressing is pinned (personal observation PM). In addition, recent case series have reported traction alopecia from hair extensions .

It is evident that TA occurs in people of different ethnic backgrounds and is the result of an individual’s hair styling and hair care practices. It is important to note that studies in African females have shown that the likelihood of developing TA increases when traction is applied to chemically processed hair . The frequency of hair relaxing, however, does not appear to affect susceptibility of developing TA . Chemically processed hair may be less resistant to TA than natural hair. Patients who develop any symptoms with hairdressing (including pain, pimples, stinging, or crusts) have also been shown to be at increased risk of developing TA . The likelihood of developing TA also increases with age, which is likely the result of a longer history of these hair practices.

We have made the observation that the presence of retained hairs along the frontal and/or temporal rim, which we termed the “fringe sign,” is a common finding in patients with traction alopecia of the marginal hairline. In this study we sought to determine how frequently the fringe sign was noted in a series of patients with a diagnosis of traction alopecia. Also, we aimed to review the frequency of other clinical signs and histologic markers reported for these patients.

Methods

Over a 3.5-year period in a specialty hair referral clinic (Kaiser Permanente Vallejo – Northern California), the diagnosis of TA was made in 41 women. The diagnosis of TA was made based on a clinical finding of patchy non-scarring alopecia in the setting of tight hairstyles. When the clinical history of tight hairstyles was remote or not obtained, the diagnosis of TA was confirmed by scalp biopsy. The biopsy was taken from the margin of the alopecic patch. A retrospective chart review was undertaken. Photographs and histologic slides were also reviewed when available. Data was collected on whether the following clinical signs of traction were noted in the chart: the fringe sign, scalp signs of inflammation (scale, pustules, erythema, papules), and the presence of follicular markings. Histologic findings that were reviewed included: retained sebaceous glands, trichomalacia, increased catagen and telogen hairs, number of terminal hairs, vellus-sized hairs (0.03 mm), fibrotic fibrous tracts, and the presence of inflammation.

Results

Although the majority of the women were African-American, 24 (58.5%), 12 (29.2%) were of Hispanic ancestry. A summary of the demographics and clinical findings are presented (Table 1 and Table 2). The ages of the patients ranged from 15-66 years with an average age at presentation of 34 years. Ninety percent of women reported a duration of hair loss of one year or greater. All of the Hispanic women shared a history of having long thick hair and wearing their hair back in a tight ponytail for many years prior to noticing hair loss (Table 2). The majority of the women reported tight hairstyles starting in their teens or childhood.

Figure 1 Figure 2
Figure 1. Close up image of the fringe sign. Diminutive hairs (black arrows) outline the region of hair loss along the temporal scalp (white arrows).
Figure 2. Extensive late-stage traction alopecia involving the fronto-temporal scalp in a patient who wore tight ponytails and then used glued-in hairpieces to cover the bare areas, which produced more hair loss

Figure 3 Figure 4
Figure 3. Early stage traction alopecia involving the bitemporal and frontal regions. This image also highlights the long thick hair that was common to all of our Hispanic patients.
Figure 4. Traction alopecia involving the frontal and temporal scalp in an African American. This patient had concurrent trichorrhexis nodosa.

Alopecia was seen in frontal/temporal regions and less commonly the vertex and occipital scalp; the extent of alopecia varied from mild to extensive. The fringe sign was a sensitive and specific clinical finding in both mild, early and extensive, late stage traction alopecia when it involved the marginal scalp (Figures 1 through 4). It was present bilaterally and symmetrically in TA of the marginal scalp. Six African American women did not have the fringe sign on exam, but instead had patchy alopecia caused by the use of glued-in or tightly sewn-in weft-extensions that were placed at the vertex or occipital scalp. There was a decreased density of follicular markings in all of the patients. The majority of African American women (54%) compared to 17 percent of the Hispanic women had some clinical sign of scalp inflammation (most frequent finding was scalp scaling). Two of the women (5%) reported a positive history of androgenetic alopecia and showed miniaturization on exam. Almost one-third of the African American women with traction alopecia also had an additional diagnosis of central centrifugal cicatricial alopecia. In 2 patients an alternative diagnosis of alopecia areata had been made clinically. One patient was also given an alternative diagnosis of primary lymphocytic cicatricial alopecia based on histopathology . However, a review of the histopathology and correlation with the clinical findings and history confirmed the diagnosis of TA in this subject.

Discussion

History and Exam

The relatively high prevalence of Hispanic women with TA in this series may represent the geographic demographics of the referral clinic. However, a heightened awareness of the risk of TA in all Hispanic women who wear tight ponytails with long hair will likely improve early diagnosis of the disorder when hair loss is still reversible. Although diagnosis of TA is usually highly suggestive based on clinical history and presentation, the diagnosis was not readily made in our Hispanic patients. Some gave a clear history of chronic tight ponytails and had insight into the likely cause of hair loss. Others however, reported “sudden onset” hair loss and only upon specific questioning of hair care practices admitted to a history of chronic traction. It should be noted that each individual has a different tolerance to the amount of tension/traction on the hair follicle required to produce symptoms of pain or signs of TA. For instance, a patient may complain that the hairstyle is too tight and the scalp aches but will never develop TA whereas another patient may not experience pain but will still develop TA. Because the fringe sign was noted on exam in all of our patients with marginal alopecia, and in some cases was the trigger for further questioning and heightened clinical suspicion for TA, we propose that it can be used as a characteristic clinical finding that can alert the clinician to the diagnosis of TA. When combined with histopathologic examination, an accurate diagnosis of TA can be made.

Histopathology

Figure 5a Figure 5b
Figure 5. Chronic traction alopecia. Scalp biopsy from patient 1 shows (5a) retention of sebaceous glands (H&E, x40) and (5b) fibrotic fibrous tracts (H&E, x100). These findings are consistent with chronic traction alopecia.

Figure 6a Figure 6b
Figure 6. (6a) Biopsy from a patient with traction alopecia reveals a slightly reduced follicular density, follicular miniaturization, and retained sebaceous glands (H&E, x40). (6b) Follicular miniaturization and retained sebaceous glands are observed (H&E, x100). (6c) Many fibrotic fibrous tracts (lower half) are present (H&E, x200).

Figure 6c

Early, the histopathology of TA shows trichomalacia, increased numbers of telogen and catagen hairs, a normal number of terminal follicles, and preserved sebaceous glands. At some point there may be “follicular drop-out” of the terminal hairs where the follicles seem to have disappeared but the vellus-sized hairs are intact . With longstanding TA, sebaceous glands are present but may be decreased and vellus-sized hairs may be seen (Figures 6a and 6b). There is a decrease in the number of terminal follicles, which are replaced with fibrotic fibrous tracts (Figure 6c). Inflammation is little to absent in longstanding TA, but may be mild in some cases of early TA. In our 14 patients with biopsy reports (Table 3), histopathology revealed findings consistent with the diagnosis of long-standing TA (Figure 5). Indeed, only one case showed evidence of trichomalacia, a typical finding of earlier stage TA. The fact that the majority of patients in the cohort (90%) had a history of hair loss longer than one year is in keeping with the report of mostly late stage findings on biopsy specimens. An additional factor may have been a bias in the clinic to more frequently biopsy patients with late stage disease or a remote history of traction.

Clinical-pathologic Correlation and Differential Diagnosis

Clinical-pathologic correlation is key and essential for both the clinician and the histopathologist because the histopathology of TA varies with duration and has some overlapping features with other disorders commonly considered in the differential diagnosis of TA. The earliest clinical sign of traction on the scalp is perifollicular erythema, which may progress to folliculitis with continued traction. In some cases of TA, 3 mm to 7 mm fine yellow-white keratin cylinders that encircle the hair shaft may form . These are termed peri-pilar casts. The majority of African American women (54%) in the cohort compared to 17 percent of the Hispanic women had some clinical sign of scalp inflammation (most frequent finding was scalp scaling). Two of the Hispanic patients in our series were noted to have perifollicular erythema and complained of scalp discomfort. However, the majority of women had no evidence of active inflammation, suggesting the disease had progressed to the irreversible phase even though the average age at presentation was relatively young (34 years).

Clinical features that can help distinguish marginal TA from ophiasis pattern AA and frontal fibrosing alopecia are summarized in Table 4. It should be emphasized that follicular markings are maintained in AA, often decreased in TA (especially late stage), and are absent in FFA. The color of the scalp is normal in TA, can be peach colored in AA, and is pale and atrophic (with prominence veins) in FFA. Eyebrows are unaffected in TA, whereas they may be affected in AA or FFA. The presence of diminutive and broken hairs may be seen in ophiasis pattern AA, and may mimic the fringe sign. However, such hairs do not typically have the symmetric and bilateral pattern seen in TA. As stated earlier, a biopsy is crucial in definitively distinguishing these entities.

The characteristic finding of retained but diminutive/smaller caliber hairs along the frontal and/or temporal hairline may correlate with the pathologic finding of vellus-sized follicles. The cause for this finding is unclear. It has been proposed that the hairs along the border may be shorter and thus “fall out” of a tight ponytail. An alternative explanation has been that patients with androgenetic alopecia may be more susceptible to TA because of miniaturized hairs. Considering the known plasticity of the hair follicle and the fact that the size of the hair follicle changes over time and is determined by the size of the dermal papilla, it is conceivable that chronic traction may affect the dermal papilla and lead to a diminution of the hair follicle.

Histologically, in active alopecia areata, peribulbar lymphocytic inflammation and absence of fibrotic fibrous tracts distinguishes this disease from TA. The histopathologic findings of androgenetic alopecia and longstanding TA can be similar in that both can show follicular miniaturization, retained sebaceous lobules, and fibrotic fibrous tracts. However, in androgenetic alopecia follicular miniaturization is more prominent and the number of terminal follicles is greater than in longstanding TA.

In both primary lymphocytic cicatricial alopecias (PCAs) and long-standing TA, the number of terminal follicles is decreased. Both can show fibrotic fibrous tracts, but perifollicular fibrosis and inflammation are characteristic of the PCAs and not seen in TA. In PCAs the loss of sebaceous glands is an early finding, whereas in TA, both early and late, sebaceous glands are retained . This significant difference in sebaceous gland pathology highlights the likely differences in pathogenesis of these two disorders. It has recently been determined that in lichen planopilaris the underlying pathology occurs because of the loss of activity of the peroxisome proliferator activated receptor gamma (PPAR-gamma) in the sebaceous gland .

In a recent retrospective study of 15 patients, the term “cicatricial marginal alopecia” was proposed to describe a primary cicatricial hair loss that occurs at the scalp periphery sparing portions of the frontal and occipital hairlines in patients with no history of traction . Half of the patients were Hispanic and had frontal or frontal-temporal hair loss similar to that described in our patients. Histology of patients in this study also revealed decreased numbers of hair follicles, replacement of follicles by fibrous tracts, and intact sebaceous glands. The retention of the sebaceous glands in these patients argues against the diagnosis of a true primary cicatricial alopecia and points toward a likely diagnosis of late stage traction alopecia. None of the patients gave a history of chronic traction but some subjects did report wearing hair in ponytails. It is likely that these patients, who were on average older than in our series, presented during the later stages of the disease and did not recognize that certain hair care practices earlier in life could have contributed to their hair loss.

Treatment

Treatment options for TA vary depending on whether or not longstanding disease has resulted in permanent hair loss. Treatment can be divided into three stages: prevention, early TA, and long-standing TA. Prevention is key in childhood and involves educating parents on the importance of loosening the hairstyle and avoiding tenting, which occurs when the hair is pulled so tightly that the skin of the scalp is raised by the force of the pull.

In early TA in children it is important to loosen the hairstyle, and avoid chemicals or heat because hair loss is reversible at this stage. Brushing the affected area “to stimulate hair growth” should be avoided. In adults with early TA, the hairstyle should also be loosened. In those cases in which ethnic or religious practices do not permit modification of hairstyles, it is important to encourage loosening of the hairstyle. Intralesional triamcinolone, directed at the periphery of hair loss, has been reported to be beneficial in suppressing peri-follicular inflammation in adults with early TA . Oral or topical antibiotics may be used in the early stages of disease for their anti-inflammatory effect . Two percent topical minoxidil has also been reported to promote hair growth in a few patients . In our practice we frequently recommend a trial of minoxidil 5 percent solution or foam for treatment of TA.

In longstanding disease surgical options may be considered. Hair transplants, in the form of micro-grafting, mini-grafting, and follicular unit transplantation have been effective . Other options include rotation flaps and scalp reduction .

Conclusion

Traction alopecia in this cohort of women demonstrated diagnostic challenges, which were resolved after careful review of hair care practices, their duration, and correlation with clinical and histopathologic findings. Clinically, the fringe sign can be a useful guide to diagnosis in patients with marginal hair loss along with a biopsy used to confirm the diagnosis. Early intervention is vital in order to reverse hair loss in TA; the eventual outcome of hair loss frequently depends on timely diagnosis combined with appropriate counseling of patients.

1. Hjorth N. Traumatic marginal alopecia; a special type: alopecia groenlandica. Br J Dermatol. Sep 1957;69(9):319-322.
2. Khumalo NP, Jessop S, Gumedze F, Ehrlich R. Hairdressing and the prevalence of scalp disease in African adults. Br J Dermatol. Nov 2007;157(5):981-988.
3. Khumalo NP, Jessop S, Gumedze F, Ehrlich R. Hairdressing is associated with scalp disease in African schoolchildren. Br J Dermatol. Jul 2007;157(1):106-110.
4. Whiting DA, Olsen EA. Central centrifugal cicatricial alopecia. Dermatol Ther. 2008 Jul-Aug;21(4):268-78.
5. James J, Saladi RN, Fox JL. Traction alopecia in Sikh male patients. J Am Board Fam Med. Sep-Oct 2007;20(5):497-498.
6. Kanwar AJ, Kaur S, Basak P, Sharma R. Traction alopecia in Sikh males. Arch Dermatol. Nov 1989;125(11):1587.
7. Trueb RM. “Chignon alopecia”: a distinctive type of nonmarginal traction alopecia. Cutis. Mar 1995;55(3):178-179.
8. Samrao A, Chen C, Zedek D, Price VH. Traction alopecia in a ballerina: Clincopathologic features. Arch Dermatol. Aug 2010;146(8):930-1.
9. Olsen EA. Disorders of hair growth: diagnosis and treatment. New York: McGraw-Hill Companies, 2003. pp 99-100, 508-509.
10. Yang A, Iorizzo M, Vincenzi C, Tosti A. Hair extensions: a concerning cause of hair disorders. Br J Dermatol. 2009 Jan;160(1):207-9.
11. Khumalo NP, Jessop S, Gumedze F, Ehrlich R. Determinants of marginal traction alopecia in African girls and women. J Am Acad Dermatol. Sep 2008;59(3):432-438.
12. Sperling LC. Scarring alopecia and the dermatopathologist. J Cutan Pathol. Aug 2001;28(7):333-342.
13. Mirmirani P, Willey A, Headington JT, Stenn K, McCalmont TH, Price VH. Primary cicatricial alopecia: histopathologic findings do not distinguish clinical variants. J Am Acad Dermatol. Apr 2005;52(4):637-643.
14. Karnik P, Tekeste Z, McCormick TS, et al. Hair follicle stem cell-specific PPARgamma deletion causes scarring alopecia. J Invest Dermatol. May 2009;129(5):1243-1257.
15. Hantash BM, Schwartz RA. Traction alopecia in children. Cutis. Jan 2003;71(1):18-20.
16. Goldberg LJ. Cicatricial marginal alopecia: is it all traction? Br J Dermatol. Jan 2009;160(1):62-68.
17. Callender VD, McMichael AJ, Cohen GF. Medical and surgical therapies for alopecias in black women. Dermatol Ther. 2004;17(2):164-176.
18. Khumalo NP, Ngwanya RM. Traction alopecia: 2% topical minoxidil shows promise. Report of two cases. J Eur Acad Dermatol Venereol. Mar 2007;21(3):433-434.
19. Ozcelik D. Extensive traction alopecia attributable to ponytail hairstyle and its treatment with hair transplantation. Aesthetic Plast Surg. Jul-Aug 2005;29(4):325-327.

© 2011 Dermatology Online Journal

Traction Alopecia – Common Causes and Treatments

Source:

Medscape – Scarring Alopecia

Braiding, ponytails, pigtails and locs

The 2008 research into the prevalence of traction alopecia in African girls and women showed that braiding caused more problems than chemicals (although the two together were worse still).

Constant, tight braiding – or other styles like ponytails that place hair under chronic tension – can affect any ethnic group. So it’s very important to take a new approach to styling hair that doesn’t rely on placing the hair under extreme tension.

The ideal solution, of course, is to allow the hair to be completely natural, without using any kind of clips, slides or ties.

The reality, though, is that this just isn’t possible for most of us.

Our hair may either be unmanageable and wild looking when allowed to ‘do its own thing’ – or, like us, you may live in a climate where it’s simply too hot to have your hair hanging around your face all day.

The answer is that you can continue to secure back your hair, but you MUST change the way you do it from one week to the next.

Traction alopecia is usually the result of CONTINUALLY putting the hair under EXACTLY the same tension in the same place, day after day.

How to Avoid Traction Alopecia (and still have beautiful hair!)

Hold back the hair with a wide, fabric hair band.
Make sure it’s not too tight – some of the really elasticated ones can be damaging in themselves.

The key is to find one just stretchy enough to stay on, but gentle enough not to feel as if it’s squeezing your head!

Use hair slides –
either one big one at the back or smaller ones at the sides.

Change the position of the slides as often as you can. You can also try using a Flexi-8 – we find it much less ‘aggressive’ than regular hair slides.

Braid hair loosely –
you should be able to get your finger under the base of the braid.

Opt for bigger braids, rather than creating lots of little ones (which put the hair under too much tension).

After braiding or tying your hair in any way, slowly rotate your head. Do you feel any tugging/pulling anywhere? If so, loosen your hair.

Change the location of your ponytail often
Wear it high, low, on one side, then the other.

Don’t wear a ponytail at all if your hair isn’t really long enough to need one… otherwise you’ll probably be pulling your too-short hair really hard in order to secure it.

Avoid using clipped in ponytails –
the weight of them can – quite literally – tear out your hair.

Always use fabric covered hair bands –
avoid bare rubber bands like the plague!

And remove bands, clips and ponytail holders from the hair at night – this is when you may be putting your hair under tension without even realizing it.

Invest in silk or satin pillowcases.
They cause less friction on your hair than cotton or nylon ones – and, as an added bonus, they’re believed to help reduce wrinkles too!

Choose a satin wig cap –
(if you use one), rather than a nylon or cotton one. Again, this will reduce friction on your hair.

Change the location of your part as often as you can.
Even a simple part in the hair can trigger a problem when worn in the same position day after day.

Change a braided hair style after 2 to 3 months.

Don’t retwist the roots of dreadlocks
Watch this video for first-hand experience of how damaging this can be!

Remove weaves/extensions after 6 to 8 weeks –
and give the hair some time to recover before using them again.

If you use hairspray or hair gel, wash it out before you next brush your hair.
Brushing dried hairspray and gels out of your hair is damaging to the shaft and may cause further hair loss.

Make sure your hair is hydrated.
If you’re in a dry climate – or you use air conditioning or central heating – the lack of moisture in the air can make your hair brittle and more likely to break.

Traction alopecia is showing up more and more often in children.

All the recommendations here apply equally to our young daughters – it’s vital to protect their delicate scalps.

Hair loss can be particularly devastating for young girls and teens – and traction alopecia is a PREVENTABLE condition from which we need to protect them.

Healthy hair practices begin in childhood!

Other Remedies for Traction Alopecia

As described earlier, the main remedy for this condition is simply to remove the source of the tension. As long as you do this BEFORE the follicles are permanently damaged, then you should see your hair begin to grow back.

However, some women swear by the effectiveness of scalp massage to encourage regrowth and it certainly can’t do any harm to give it a try!

Popular products you can use in conjunction with scalp massage include

  • Jamaican Black Castor Oil
  • regular Castor Oil
  • olive oil
  • pure, unrefined coconut oil (has a fantastic aroma too!)
  • raw, organic apple cider vinegar (we buy Bragg Apple Cider with the ‘mother’ and dilute 1/3 cup of it in 1 quart of water, then use it as a final rinse to strengthen hair)

We’ve also received positive reports about the Shea Moisture Thickening Growth Milk line.

Although it is only indicated for treating hereditary hair loss, some women also feel they have benefited from using Rogaine. Remember, however, this can work ONLY if the follicles are still present. If you want to give Rogaine a try, use the foam, which is much easier to apply than the liquid.

One thing we DON’T recommend for encouraging regrowth is the old wives’ tale about vigorously brushing the affected area. Not only is it a myth that it makes your hair grow back – it’s actually likely to cause even MORE damage!

When Traction Alopecia Compounds Other Hair Loss Problems

If you are wearing a hairpiece – such as a clip on topper – to mask other hair problems like androgenetic alopecia, then you need to be very careful not to compound your problem with traction alopecia!

The best option is to ensure that the clips of your topper are firm, but not too tight, and that you rotate them. We also recommend undoing a couple of the clips when you’re at home – it gives your scalp a little rest from the tension.

Traction Alopecia Recovery Time

Most experts agree that your hair should recover within 6 to 9 months of your removing the cause of the problem.

If you’ve followed the guidelines given here and you are still not seeing regrowth, then it’s likely that the damage to your follicles was permanent – a fact your doctor/dermatologist can confirm. In that case, you might like to discuss the possibility of a hair transplant, which will effectively mask the problem.

Image source: naturallycurly.com

If you’ve noticed that your hair is thinning or bald in some places, you might be concerned about traction alopecia on natural hair.

Any balding or thinning can be devastating, especially if you’re female. It may seem like you’re the only one with the problem, but it is quite common.

It’s a good idea to research this type of hair loss and know the facts so you can determine whether you have this medical condition and what to do about it.

In this post, you’ll find out about traction alopecia symptoms, causes, and treatment options. If you want to know more information about this particular type of hair loss, keep reading.

What is Traction Alopecia?

Traction alopecia is a hair loss condition where the follicles have been strained from wearing tight braids, locs, weaves, wigs, and ponytails. Burning the scalp with chemical relaxers can also contribute to traction alopecia.

The condition is common in black females, occurring to almost one-third of African-American women and more than 17 percent of African-American girls ages 6-21, according to the Journal of the American Academy of Dermatology.

Traction alopecia in children is a huge concern, and it happens for the same reasons that adults get it.

It’s the constant tension that causes the kind of follicle damage that can lead to permanent hair loss. However, this type of hair loss can be reversed in some cases, especially if caught early. Read more to find out about traction alopecia treatments.

Traction Alopecia Symptoms

Use the following symptom guide to determine if you have traction alopecia:

  • Sore, Inflamed Scalp. Do some areas of your scalp feel swollen or inflamed? Prolonged inflammation and soreness can lead to hair loss.
  • Small, Pus-Filled Bumps or Blisters. If you feel several bumps along your scalp, you may have traction alopecia.
  • Itching. Wondering if traction alopecia and itchy scalp are related? If your scalp is itchy or painful in certain spots or all over, it could be folliculitis or inflamed follicles. This is a sure sign of traction alopecia.

Traction alopecia commonly affects the hairline, but it can also occur at the crown of the head, the back of the scalp, or it can cover the entire head.

Traction Alopecia and Hair Extensions

Traction alopecia from braids and other extensions is common. When all follicles are pulled tight into braids or different extension styles, eventual hair loss can occur.

Have you ever had braids that were so tight that you needed to take ibuprofen or Tylenol to ease the pain? Over-zealous hair braiders are notorious for pulling the hair too taught to do a good job.

However, the tighter the job, the more you’re at risk for thinning and bald spots. The alopecia is further worsened by placing the already tight extensions into a ponytail. This double-action often causes the follicles along the hairline edges to suffer.

This type of hair loss can be tough to reverse. Once a style like braids is installed, it’s likely that the wearer will continue with the pain, itching, and irritation, until their hair grows out and the problem lessens.

Repeated tight extension styles will likely cause permanent damage to the follicles. Try to avoid the temptation of wearing tight extensions to cover a bald spot.

Extension styles like crochet braids tend to be less damaging to follicles because the extension hair is attached to cornrows. But make sure the hair is not cornrowed too tight, as these can also be the source of traction alopecia.

Traction Alopecia from Wigs

Is it possible to get traction alopecia from wigs? Yes, wigs can cause traction alopecia if the clips are too tight, or if the wig has been glued or bonded onto the hairline.

If you need to wear a wig, be sure to avoid glue and tight clips. Also, consider purchasing silk or satin-lined wig that will be gentler on your scalp.

Prevention and Treatment of Traction Alopecia

By now, you’re probably wondering how to prevent and treat this type of hair loss. Traction alopecia does not have a quick and easy cure, but you may be able to reverse it by experimenting with different remedies.

These treatments will also help people with trichotillomania, or the hair-pulling disorder.

Significant ways of stopping and reversing traction alopecia include:

Image source: hishairclinic.com

Antibacterial and Cortisone Ointments. Traction alopecia often involves a bacterial or fungal infection that can be treated with a topical ointment. There are several products on the market you can purchase for a reasonable price that will help you manage both the infection and the accompanying inflammation.

Neosporin will fight bacteria and keep the area clean. Scalpicin or Cortizone 10 will help to treat inflammation. This combination will improve the skin and help your follicle cells perform.

Medicated Shampoos. In addition to the ointments, you can also use medicated shampoos that are formulated to stop fungus overgrowth. Most dandruff shampoos are medicated with 1% pyrithione zinc, selenium sulfide, ketoconazole 1%, or salicylic acid. You may want to try each one to see if it controls your hair loss and leads to regrowth.

However, most medicated shampoos contain sulfates, which are harmful to natural hair. If you’re looking for a sulfate-free medicated shampoo, try L’Oréal’s EverFresh Anti-Dandruff Shampoo. This shampoo contains 1% pyrithione zinc. This active ingredient is the same one that Head and Shoulders contain, but you’ll be able to avoid the sulfates.

Image source: amazon.com

If you’ve tried the medicated shampoos and haven’t had much luck, you may want to try Rogaine for Women. This product is much stronger than the conventional anti-dandruff shampoos and will require long-term use.

Rogaine is available without a prescription, but you should consult a dermatologist before going this route, because it is an expensive, long-term commitment that may have unwanted side effects. Rogaine for Women contains 2% Minoxidil. You can also purchase a generic version of this shampoo.

Surgery. Other medical treatments include hair transplants and flap surgery, but you should only consider these if you’ve tried all else.

If you’re looking for more non-invasive natural remedies you can try at home, keep reading.

How to Grow Edges Back from Traction Alopecia

Losing your edges to alopecia can be disheartening. The hairline often suffers from doing repetitive tight hairstyles like ponytails, braids, locs, and even from weaves. Chemical relaxers can also injure the scalp and cause hair strands to break.

The first step to growing your edges back is to avoid all tight hairstyles and to discontinue use of chemical relaxers.

Thinking about specific hairstyles for people with alopecia? Choose hairstyles that do not cause tension, like wash and go’s loose twists, or a low bun.

What about traction alopecia and dreadlocks? Hair loss can occur even when the hairstyle doesn’t involve added extension hair. It can happen even with natural loc styles. If the dreads are tightly formed and bound with a ponytail holder, they can still cause traction alopecia.

Massaging healing oils like castor and peppermint essential oil into your edges will help to stimulate the blood and promote hair growth. See the castor oil regimen below.

Castor Oil for Traction Alopecia

Castor oil is a remarkable oil, and you may be able to use it to heal your follicle cells. It is antifungal, antibacterial, and antiviral. It contains vitamin E, protein, fatty acids, and several minerals that treat the follicles and promote hair growth.

It is widely used by naturals as an inexpensive, effective solution for hair loss and traction alopecia regrowth. The most potent castor oil on the market is Jamaican black castor oil. In the darker Jamaican version, castor bean seeds are roasted to make the oil stronger.

To use castor oil for traction alopecia, pour a small amount onto your fingertips, and massage into the affected area.

Castor oil is best applied 1-2 times per week, the day before you wash your hair. Massaging it into the balding spot in an inverted position will help to increase blood flow to the area.

Traction Alopecia Home Remedies

Luckily, there are several home remedies you can try for your alopecia. You may want to try them before the medicated treatments, or alongside them.

Here are four remedies that will help to stop your hair loss and promote growth:

Healing Oils. Applying oils on your scalp will help to disinfect and treat the affected areas. The best carrier oils for the scalp are castor and pumpkinseed oil. The best essential oils for the scalp are tea tree, peppermint, eucalyptus, rosemary, and lavender.

Use these oils to clear bacteria and fungus, and to begin the healing process. You can use any combination of the above oils or use them all. Mix a few drops of the essential oils into the castor or pumpkinseed oil, and then massage into the affected area 1-2 times per week.

Biotin. Also known as vitamin B7, these pills will help to promote healthy follicles. Biotin takes several weeks to begin working. Take 5000 mcg per day, and be sure to drink plenty of fresh, clean water.

Onion and Garlic Juice. Onion and garlic both come from the allium family and they are high in sulfuric compounds. Our hair is made of keratin, and this protein contains sulfur. Using onion or garlic juice on your scalp helps to repair tissue and will lead to hair regrowth. An easy way to do this is to simply rub onion or garlic slices on the scalp about 20 minutes before washing your hair.

Yoga. We spend much of our lives on our feet, sitting upright, or with our head elevated on a pillow. This medicinal exercise contains several inverted positions that send blood flow to the scalp.

Adequate scalp health is the key to healthy hair growth. It’s good to practice alopecia prevention even if you haven’t suffered from traction alopecia.

The key to stopping permanent hair loss is to catch it early. Be sure to consult with a professional if you don’t notice any improvement after 2-3 months of home treatments.

If your alopecia continues for an extended period of time and doesn’t go away with home treatments, you could be at risk for permanent hair loss. Seek a dermatologist who specializes in hair loss in your city.

Do you suffer from traction alopecia on natural hair, and if so, have you tried any home treatments?

Featured image: regionalderm.com

Hey Curl Friend, I’m Patrina Haupt the creator and author of Natural Hair Queen. I hope you find my healthy hair care tips helpful in your hair journey. Healthy hair care practices are definitely, what helped me to achieve waist length hair.

Clinically, Minoxidil treatment may be combined with several other traction alopecia remedies including:

Generally, hair replacement is only considered for traction alopecia when is it too late and the hair loss is permanent.

How to prevent from traction alopecia in the future?

Braids, extensions, dreadlocks, ponytails, and the like aren’t the direct cause of traction hair loss. All these styles can be worn safely and not cause hair loss. The problem only comes if the hairstyle is so tight that it puts too much tension on your hair follicles. When that happens, the follicles get inflamed and your hair breaks.

Therefore, now that you know about traction alopecia, you don’t have to go cold turkey on your favorite hairstyle to avoid losing hair. Make small, consistent hair-friendly changes. If, for instance, you have extensions and also use hair relaxers, you could space out your chemical treatments for about three months and eventually go natural.

The following tips will also work well to keep traction alopecia away:

Bottom line

In its early stages, traction alopecia causes nonscarring hair loss, which is completely reversible. If discovered at this stage, you have the potential to get your hair back if you make positive styling changes and seek proper treatment.

However, if the hair loss is too far gone and irreversible, several hair replacement therapies may be used to help get your hair back. Either way, it’s always helpful to talk to a dermatologist or a qualified health professional if you suspect traction alopecia is creeping up on you.

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