Traction alopecia is the loss of hair from chronic tension. Young, black girls who wear tight pony tails or braids are most commonly affected. The alopecia typically starts at the edges of the section of hair involved where the traction is the greatest, e.g., at the hairline. Inflammation is usually not seen, although follicular pustules may occasionally occur. Over time, scarring occurs and the alopecia becomes permanent. Adults often show bitemporal alopecia.
A young black girl is seen to have alopecia at the margins of the gathering for the pony tail or braid. Pustules may occur. Over time, scarring occurs and the alopecia is permanent. In the older woman, frontal fibrosing alopecia (FFA) must be excluded.
The fringe sign has been coined, denoting fine, miniaturized hairs remaining along the frontal hairline [Dermatol Online J. 2011;17(11):1]. However, a "pseudo-fringe sign" may be seen in FFA.
Treatment is most successful if instituted early. Any hair style must emphasize reducing tension or weight on the hair. Ponytails and braids should be categorically avoided. Even clips at night may be too much. Chemical or heat-related hair treatments should be minimized as well.
For extensive and specific recommendations on different hair styles and practices, see JAAD 2016;75;606.
One patient of mine (African American teenager) had normal hair with braids until she started swimming in a pool 4 times a week. The chlorine seemed to weaken the hair sufficiently to precipitate traction alopecia. Stopping swimming and avoiding the braids allowed the hair to regrow.
Other interventions that have been advocated include topical and intralesional corticosteroids, oral and topical antibiotics if pustules are present, topical minoxidil, and in cases of permanent hair loss, hair transplantation, punch grafts, or flap rotation.
The fringe sign. Dermatology Online Journal 17(11)
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