A young black girl with alopecia at the margins.

TRACTION ALOPECIA

Traction Alopecia (TA) 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.

Clinical

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. However, a "pseudo-fringe sign" may be seen in FFA.

Cultural Issues

It should be noted that hair care in Black patients can be complex. Hairstyling among Black women often is a lengthy process and often results in relationship bonding with the hair care giver, in turn imparting hair care traditions to the next generation. Therefore, a well-received discussion about TA prevention not only has an impact on the patient but potentially on a multigenerational family of women and friends.

Treatment

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, barrettes and elastic hairbeads at night may be too much. Chemical or heat-related hair treatments should be minimized as well.

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 technique of "Compliment, Discuss, and Suggest" has been recommended [Cutis 2021;108;20].

For the black woman with TA:

• Compliment: "Your hair looks great. I know that you get many compliments."
• Discuss: "However, some of the styles might be increasing your risk for hair loss. Any tension or pulling can scar your hair roots. Our goal is to preserve as much of your hair as possible."
• Suggest: "Let's start by loosening your hairstyle, especially if it hurts. Pain means inflammation, which can lead to scarring and hair loss."

For the black child with TA and atopic dermatitis and her mom:

• Compliment: "You're doing a great job controlling the atopic dermatitis, which can cause Janet's scalp to be dry. Also, her hair is beautiful--it looks like you spent a lot of time on her hair. And Janet, I like the color of your barrettes."
• Discuss: "Mom, I just noticed that a few areas look tight. Let's look together." (The dermatologist points out areas where the scalp is tented upward due to traction, follicular pustules or papules, or the frontal fringe sign.)
• Suggest: "When you do Janet's hair, see if you can keep any stretching or tension to a miniumum. Remove Janet's hair ties to release tension when she is at home and while she's sleeping, if possible. Every minute that the hair is loose really helps."

RegionalDerm

Homepage | Who is Dr. White? | Privacy Policy | FAQs | Use of Images | Contact Dr. White