Alopecia series - Traction

Traction alopecia

The word alopecia refers to loss of hair regardless of cause.

What is Traction Alopecia?

Traction alopecia is just one type of alopecia caused by repeated or prolonged pulling of the hair. Traction most often affects the hairline, the front and the sides being the most common. 

What causes Traction Alopecia?

The pulling of hair creates tension that extends deep to the roots of the hair. Traction creates inflammation around the root of the hair (also called hair follicle). The hair follicle is effectively the factory that produces hair. If the factory, in this case the hair follicle, is damaged, it will either produced abnormal or reduced quantities hair. In extreme cases, the damage is permanent, and that area will never grow hair again.

In the case of traction alopecia, the persistent traction results in inflammation of the hair follicle and over time the cells that invade the hair follicle to repair the damage end up causing permanent damage to the hair follicle (the hair factory), resulting in permanent hair loss. 

Who gets Traction Alopecia?

Traction alopecia is related to hair grooming practices or hairstyles as they are more commonly known. Females of African descent tend to be the most affected because of the type of hairstyles they prefer. These include braids, weaves, twisted dreadlocks, tight ponytails and hair extensions. Other less recognized causes of traction alopecia include hair pins, tight fitting headwear and heavy ornaments attached to hair. A study conducted in Langa, Cape Town by my colleagues Professor Nonhlanhla Khumalo and Doctor Sue Jessop showed that people who pulled their hair while it was relaxed, tended to have more severe traction alopecia over time. People who give a history of relaxing their hair, pain, itch, pimples and burning after one of the above-mentioned hairstyles are at a higher risk of developing traction alopecia.

How does Traction Alopecia look like?

This depends on the stage of the disease. In early stages, the hair loss may not be visible to a naked eye, only a slight reduction in hair density. What may be visible is inflammation of the hair follicle, called folliculitis, seen as redness, pimples, pustules and scale in the affected area.  Often this is associated with pain or itch. The typical picture is repeated patting of the scalp in the affected area or using cold compresses after the hairstyle to relieve the symptoms. At this stage, the alopecia is usually reversible.

With progression, the hair in the affected area progressively thins until there is complete loss. On close inspection, early on the hair follicles are still visible but with time only a shiny smooth surface results. The smooth surfaces indicates irreversible damage of the hair follicles and scarring of these follicles and surrounding tissues. There is often a fringe of fine hair that is preserved at the edge. This hair was too small to be incorporated into the hairstyle, thus it was spared the traction.  

What can you do to prevent Traction Alopecia

Change hair grooming practices to safer ones

If you still wish to have any of these hairstyles:

§  Tell your hairdresser in advance and clearly what you want

§  Make sure the pulled hair is comfortably loose enough and not too tight

§  Listen to your scalp or your child’s complaints – if it is uncomfortable, it is not good for your scalp

§  If it is uncomfortable, undo it as soon as possible regardless of cost

How do we manage Traction Alopecia

Correct diagnosis by a doctor and staging of the disease are essential before embarking on any treatment.

Available treatments include topical steroids, topical minoxidil, oral antibiotics and hair transplantation. All these become increasingly less effective with advancing Traction Alopecia. Even hair transplantation is not effective in advanced disease because of the scarring that affects the surrounding tissues. It is equivalent to planting a seed on barren rock.

Last word

The best treatment for Traction Alopecia is prevention by using correct hair grooming practices from childhood. As I often say to my patients with early disease – Listen to me now or you will forever have a bigger face to wash and a smaller head to comb.

Professor Rannakoe Lehloenya