Traction alopecia

The commonest cause of traction alopecia is tight hairstyles. The pattern of the hair loss will depend on the type of hairstyle and where the tension is highest. Usually, it is the longer hairs at the edge of the scalp that are pulled the most. As only longer hairs are tied up, smaller finer hairs escape being pulled and can still be seen in the balding patches.

Hairstyles often associated with traction alopecia are tight ponytails (causing hair loss at the front and side margins of the scalp), tight buns (causing hair loss at the sides and back of the scalp), as well as attachment of weaves or hair extensions. Tight braids (such as cornrows and dreadlocks) are also common causes of traction alopecia with hair loss being seen between the braids. The risk of traction alopecia is further increased if these hairstyles are combined with various chemicals used on the hair (such as chemical relaxers to straighten hair). Hair clips and tight head scarves have also been associated with traction alopecia. Excessively long hair may contribute to traction alopecia due to the weight of the hair.

Is traction alopecia hereditary? 

It is uncertain whether there is a true genetic predisposition to traction alopecia. It is mainly due to hair-styling practices. It can affect people from all ethnic backgrounds.  Traction alopecia has been seen in some people with cultural, religious and occupational hairstyles.

Traction alopecia is often seen in women and children of African descent who regularly use braids or chemicals to make it easier to manage tightly curled hair. It is possible that tightly curled Afro-textured hair may be more susceptible to breakage and traction alopecia. Traction alopecia of the scalp and beard area has also been noted in some Sikh men. 

Traction alopecia can occur anywhere on the scalp where there are mechanical forces pulling the hair. Often hair loss is seen at the front, sides or back of the scalp. Smaller hairs within the patch are often unaffected and a rim of slightly longer hairs (called the “fringe sign”) may also be seen at the edge of the patch furthest away from the traction.

Within the patches of hair loss, the skin usually looks normal. However, if tight hairstyles are still being used then sometimes redness, spots and white skin flakes attached to the hairs (called “hair casts”) may be seen at the margins of the bald patches closest to the tension.

In longstanding traction alopecia the scalp may appear smooth and shiny, where the hairs have been permanently destroyed.

What are the symptoms? 

Some people may experience itching, soreness or increased flaking of the scalp. 

Images DermNet NZ & Stocksnap.

The diagnosis is usually based on the history and pattern of the hair loss. If the diagnosis is unclear, then a scalp biopsy may be required.

Can it be cured?

Yes, depending on the stage of hair loss. If the problem is identified early, then the hair can completely regrow if the tight hairstyles are stopped. However, longstanding traction alopecia can cause permanent destruction of the hair follicle; in this situation the hair loss is permanent.

How can traction alopecia be treated?

Traction alopecia can be treated. Although, how well the hair grows will depend on whether there is any permanent damage to the hair follicle roots.

In cases of permanent hair loss:

Surgical treatments: Surgical treatment is not offered under the NHS. These can be sought privately and include:

• Consider changing hair styles, such as cutting long hair, adopting loose hair styles and avoiding high-risk hairstyles/ practices such as braiding and hair extensions.
• Avoid exposing hair to chemical relaxants and excessive heat from hair straighteners etc.
• An important function of hair is to protect the scalp from sunlight; it is therefore important to protect any bald areas of your scalp from the sun to prevent sunburn and to reduce the chances of developing long-term sun damage. You should cover any bald patches with sun block, or a hat if you are going to be exposed to sunlight.