Traction alopecia (TA) is a form of hair loss resulting from persistent pulling forces on hair follicles. It is a gradual, mechanical hair loss condition caused by prolonged tension on the hair shafts, leading to follicular damage. Unlike other forms of hair loss, such as androgenetic alopecia or alopecia areata, traction alopecia is largely preventable and, in its early stages, reversible. However, if left untreated, the damage to hair follicles can become permanent, resulting in irreversible thinning and scarring.
TA is most commonly seen in women of African descent and is thought largely to result from hair care practices causing sustained traction such as tight braids and ponytails. However, traction alopecia affects people of any ethnic background or age. This condition is common in African-American women, although it can affect people of any ethnicity. It occurs more frequently among people in professions that tend to put their hair up in a tight bun, such as ballerinas and gymnasts. Although the condition can affect people of any age, it’s more likely to happen as you get older because your hair becomes more damaged the longer you pull on it. Men get traction alopecia, too. Tight styles like buns, dreadlocks, cornrows, and even wearing hats a lot can cause it. One study showed that 2% of African American men who wear dreadlocks or cornrows have traction alopecia.
Data from South Africa indicate that traction alopecia affects both children and adults, with up to 31.7% of adult women showing hair changes. Among children aged 6 to 15, prevalence ranges from 8.6% to 21.7%. A study of African American girls aged 5.4 to 14.3 years found signs of traction alopecia in 18%. The condition is more prevalent in African schoolgirls than boys (17.1% vs. 0%) and is significantly more frequent in women than men (31.7% vs. 2.3%), with affected men more likely to wear cornrows or dreadlocks. The youngest reported case involves an 8-month-old infant. Although traction alopecia is observed in school-aged children, the prevalence increases with age, peaking in adult women.
The most common cause of traction alopecia is repetitive tension on the hair follicles, often due to certain hairstyles and grooming practices. The cause of traction alopecia is wearing your hair pulled too tight. Pulling on the hair repeatedly loosens the hair shaft in its follicle.
Any hairstyle that pulls on your scalp or hair can cause traction alopecia over time. Common causes include ponytails or certain styles like hair weaves, extensions, cornrows, and braids. Chemical relaxers can cause it, too.
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These include:
People with very long hair can also get traction alopecia due to the weight of the hair pulling on the scalp. Men can also have it in their beard if they twist it too tightly.
While traction alopecia is most commonly seen in people who frequently wear these styles, anyone can develop it if the scalp is exposed to chronic pulling and strain over time. Early on, traction alopecia might show up as little bumps on your scalp that look like pimples.
The symptoms of traction alopecia can mimic those of other conditions, so it’s important to consult your doctor. The main symptom is missing and broken hairs. The hairs along the front and sides of your scalp are most often affected. However, you may also notice hair loss on other areas of your scalp, depending on your hairstyle.
Recognizing traction alopecia in its early stages is crucial for preventing long-term damage. Some of the first warning signs include:
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In addition to hair loss, traction alopecia can cause these symptoms:
Eventually, the hair follicles can become so damaged and scarred that they can’t produce new hair. In other types, the hair loss occurs in patches all over the scalp. In traction alopecia, usually just the hair that’s been pulled is affected.
There is a large variation in the pattern of clinical presentation of traction alopecia. It there is no suspicion of traction, it can be difficult to diagnose. Traction alopecia mostly affects the front (frontal) and sides of the scalp but the location of traction alopecia wholly depends on an individual's hair care practice, which may or may not is related to their ethnic background.
Diagnosing hair loss is done by a biopsy in most cases. But other signs help doctors figure out whether you have traction alopecia or something else.
In the early stages, you might have:
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In later stages, you may see very fine, short hairs, a very oily scalp replaced by scarring, and some scalp inflammation.
The severity of traction alopecia is assessed using the M-TAS, a validated photographic scale that quantifies the severity of marginal disease. Anterior and posterior hairlines are identified using anatomic landmarks and graded on a scale of 0 to 9. Clinical studies have used this scale to correlate disease severity with potential risk factors. The M-TAS may also serve as a tool for monitoring treatment response.
Dermoscopy aids in diagnosing traction alopecia. The presence of hair casts is a characteristic finding. In patients with patchy and marginal alopecia due to traction, dermoscopy reveals reduced hair follicle density, absent follicular openings, and numerous freely mobile hair casts at the periphery of the affected area. In diffuse alopecia caused by traction, dermoscopy shows a normal hair density but an increased number of hair casts. These casts are nonadherent, white or brown, cylindrical, and encircle the proximal hair shaft.
The treatment of traction alopecia depends on disease chronicity and the presence or absence of permanent alopecia. Management is determined by the disease stage, which is classified into prevention, early traction alopecia, and longstanding traction alopecia.
The main treatment for traction alopecia is to change your hairstyle. Avoid wearing your hair in a tight style, especially overnight. You’ll know it’s too tight if it hurts. Remove braids, cornrows, or dreadlocks. Avoid pulling your hair up into a ponytail or bun, or loosen the style. If your hair is very long, cut it. Minimize the use of chemicals and heat, which can damage your hair.
Here’s what you can do:
Your doctor might prescribe one of these treatments for traction alopecia:
If hair loss is more moderate, oral therapies such as low-dose oral minoxidil and antibiotics - used for anti-inflammatory purposes - may be indicated. If severe, hair transplantation may be required. In the prevention stage, strategies focus on educating parents, children, adolescents, and young adults about hair care practices. This intervention is critical, as hair follicles are most vulnerable during this period.
In early traction alopecia, when follicular units remain intact, the primary goal is to reduce hair tension by adopting looser hairstyles. Additional strategies include avoiding chemical treatments and heat application, as well as gentle brushing of the affected area. If inflammation, characterized by scaling, erythema, or tenderness, is present, topical or intralesional corticosteroids are recommended. Intralesional triamcinolone is advised for application at the periphery of hair loss. Pustules may be treated with oral or topical antibiotics due to their anti-inflammatory effects.
In longstanding traction alopecia, surgical interventions are considered viable options. Hair transplantation techniques, including micrografting, minigrafting, and follicular unit transplantation, have shown effectiveness in restoring hair.
A novel approach involving α1-adrenergic receptor agonists has recently been explored for traction alopecia. The proposed mechanism suggests that these agents induce contraction of the arrector pili muscle, thereby increasing the force required for hair plucking. Topical phenylephrine, a selective α1-adrenergic receptor agonist, has been investigated for this purpose. In one study involving female patients, its application was associated with reduced hair loss due to traction. The study also found that the threshold of traction needed to induce epilation increased following phenylephrine application.
If you’ve lost a lot of hair and it’s not growing back, a hair replacement procedure may be an option.
The potential for regrowth depends on how early traction alopecia is identified. If hair follicles are still active, stopping the cause of traction and implementing proper care can allow hair to regrow. However, if scarring has occurred, the damage may be irreversible, and hair restoration treatments may be necessary.
If caught early enough and tight hairstyles adjusted, traction alopecia can be reversed.
Once hair follicles are destroyed, they cannot regrow. Scarring is evidence of late-stage traction alopecia. Once the hair follicles have scarred down, the hair cannot regrow as this hair loss is permanent. However, if appropriate measures for traction alopecia are taken as soon as possible, scarring can be prevented and the hair can regrow.
To prevent traction alopecia, wear your hair down. If you have to pull it up into a ponytail or bun, keep it loose and low on your head.
To decrease the risk for traction alopecia, patients should minimize hairstyles that involve prolonged tension or pulling on the scalp, such as low buns and loose ponytails. Taking breaks between tighter hairstyles and minimizing the combination of chemical straightening with extensions may also reduce the risk for traction alopecia.
Here are a few other ways to prevent this condition:
In the prevention stage, strategies focus on educating parents, children, adolescents, and young adults about hair care practices. This intervention is critical, as hair follicles are most vulnerable during this period.
Effective prevention requires collaboration between dermatology clinicians and nurses to educate patients on hairstyle modifications, as traction alopecia is largely preventable with proper awareness and intervention.
People who live with hair loss - from any cause - may feel many emotions - from anger and embarrassment to loneliness and guilt or self-blame if you feel your actions caused it. To manage life with this disease, find a support group with others living with traction alopecia. You can find groups online or ask your doctor for help. Some people use social media to find support. Consider working with a counselor or therapist to help you process the emotions that can come from living with a chronic condition. There are therapists who are trained in treating people with conditions that can be embarrassing or hard to manage due to pain or other symptoms.
Not everyone sees hair loss as a negative. Some people lose their hair and fully embrace it. But for many people - especially women - hair is part of what defines beauty and can be difficult to lose.
Losing all or some of your hair can affect your self-esteem. Talking to others with alopecia or even a therapist may help.
What are some alternative styles to tightly styled braids? You can wear a twisted chignon, two-strand twists, crochet locs, knotless braids, clip-in extensions, and braided ponytails. Contact a hair stylist - including one trained in natural hairstyles - for options.
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