Helping patients with traction alopecia: basics, treatment and prevention

Drug topics® spoke to 2 experts about AT: Sherry LH Maragh, MD, board-certified general, surgical, cosmetic, and laser dermatologist who practices at Advanced Dermatology and Cosmetic Surgery in Ashburn and Warrenton, Virginia , and Rockville, Md.; and Oma Agbai, MD, of the Department of Dermatology at the University of California Davis School of Medicine in Sacramento, California.

What is traction alopecia? How does he present himself?

Agbai and Maragh explained that traction alopecia (TA) is hair loss caused by repeatedly wearing very pulled hairstyles. Maragh noted that “Early on, AT can present as tiny pimple-like bumps along the hairline, with inflammation around the hair follicles which may be associated with itching, flaking and scalp pain. Hair growing in the affected area breaks and weakens. Maragh explained that over time, permanent damage to the hair follicle will occur. “There is a decrease in the rate of hair growth in the affected area, followed by thinning of hair in the area as some follicles die. This could eventually lead to permanent loss of growth in the area,” said said Maragh.

Agbai added that patches of hair loss in TA will appear where the tension on the hair causes the hair to pull out. “For example, if you wear tight ponytails, the areas around the frontal or posterior hairline could develop bald patches in a band-like distribution. Typically there is a fringe of fine hair and wispy hairline through the hairline leading to the characteristic fringe sign of traction alopecia,” she said. She explained that the use of rubber bands, weaves, braids, locks, cornrows, and other very tight styles may predispose patients to AT.

“If AT is maintained, it may progress to cicatricial (scar) alopecia,” Agbai noted.

She said the bitemporal area of ​​the scalp is most commonly affected. “The whole scalp can even be involved and that is dictated by the hairdressing technique,” ​​added Agbai. “Hair casts can be seen with severe cases of pulling,” she said.

How common is traction alopecia?

Maragh said the number of people affected by traction alopecia varies by race, gender and cultural hairdressing practices. “Although the exact percentage is unknown, traction alopecia is more common in women of African descent,” she said. She added that traction alopecia dates back centuries and has mostly affected women of various ethnicities due to traditional tight hairdressing practices.

Agbai said there was an increased prevalence among black men, women and children. “African American hair styling techniques may predispose this population to hair shaft pulling damage due to the increased use of highly pulled hairstyles. Yet individuals of any ethnicity can develop traction alopecia,” she noted. She added that many people do not seek medical care for the disease, which contributes to the difficulty in assessing its prevalence. “I found it to be a common diagnosis in my hair loss clinic though,” Agbai said.

Can patients suffer from dormant traction alopecia for years and then present?

Maragh said AT can take several years to fully present with noticeable hair loss in affected areas. “It can even show up after a person has stopped wearing tight styles if the damage has already been done in several previous years,” she said. She explained that often patients who present with TA do not have a recent history of tight, pulling or high tension hairstyles, but they have a history of these types of styles 2 or 3 years before the loss began. noticeable hair.

Agbai explained that it is possible that other forms of alopecia can be misdiagnosed as AT. “For example, I’ve had patients with biopsy-proven frontal fibrosing alopecia, lichen planopilaris, alopecia areata, and even cutaneous sarcoidosis of the scalp with a previous diagnosis of traction alopecia,” he said. she noted, adding that it was especially common among black patients. Dermatologists should be aware of the possible differential diagnosis when evaluating patients.

How is traction alopecia currently treated?

Agbai said the treatment for AT aims to reduce inflammation and promote hair growth. To do this, AT can be treated with topical antibiotics such as clindamycin and a topical corticosteroid for early papular lesions. “For more severe cases, oral antibiotics like doxycycline can reduce inflammation, especially in folliculitis,” she said, adding that foam or topical 5% minoxidil solution is also recommended. as a non-specific hair growth promoter. “I also routinely recommend intralesional triamcinolone injections every 6-8 weeks until the alopecia is stabilized and regrowth is evident. Hair transplantation can be effective once the condition is stabilized with medical therapies” , Agbai said.

Maragh added that injections of platelet-rich plasma can be used for their regenerative properties to restore damaged hair follicles in traction alopecia.

DAA recommendations to prevent AT

Dermatologists can share recommendations to help patients prevent AT. The American Academy of Dermatologists (AAD) recommends patients only wear tight styles such as buns, ponytails, pulled up buns, cornrows, dreadlocks, hair extensions, or tight weaves and braids only once in a while.1 The AAD says wearing rollers in bed most of the time can also lead to hair loss and recommends keeping this practice for special occasions.1

AAD recommends loosening braids, especially around the hairline, not wearing braids for more than 2-3 months, and choosing thicker dreadlocks or braids to avoid hair loss. Patients are also advised to change styles, such as going from cornrows to loose braids, to give the hair time to recover.1 They said the weaves should only be worn for short periods of time and removed immediately if they cause pain or irritation. AAD recommends sewn weaves over glued weaves.1

AAD says patients should watch for early hair loss, such as broken hair around the forehead, hair loss, and patches of hair loss where hair is pulled tightly.1 He urges patients to be alert for pain, tingling or crusting on the scalp, or raised sections or tentacles of the scalp.1 Patients should stop wearing tight hairstyles if they notice any of these issues and consult a dermatologist.


  1. Hairstyles that pull can lead to hair loss. American Academy of Dermatology. Accessed October 27, 2022.

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