Traction alopecia

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Traction alopecia is a type of alopecia or hair loss caused by a chronic pulling force being applied to the hair.[1] It commonly results from a person frequently wearing their hair in a particularly tight ponytail, pigtails, or braids with increased likelihood when hair is chemically relaxed as this compromises the hair shaft's tensile strength resulting in hair breakage. Traction alopecia causes a recession of the hairline due to chronic traction, which is characterized by a fringe along the marginal hairline on physical exam.[2][3] Diagnosis is clinical and treatment directed at cessation of the chronic traction, while cosmeses, with surgical restoration is reserved for severe cases with scarring fibrosis.


Traumatic hairstyle[edit]

It is commonly seen with certain hair styles like a particularly tight ponytail, pigtails, braid or braiding pattern that pulls the hairline forcefully towards the vertex of the scalp,[4][5] and has been reported more often in African American women (as some wear their hair tightly pulled back), sometimes causing scarring.[6][7] It has also been seen in female ballerinas,[8] and seen occasionally in long-haired people who use barrettes to keep hair out of their faces and in cultural traditions where the hair is voluntarily not cut in religious obeisance, the latter caused by progressively increasing weight of the hair itself.[citation needed] Traction alopecia is mechanical in cause, rather than androgenic.[7] Traction alopecia is a substantial risk in hair weaves, which can be worn either to conceal hair loss, or purely for cosmetic purposes. The former involves creating a braid around the head below the existing hairline, to which an extended-wear hairpiece, or wig, is attached. Since the hair of the braid is still growing, it requires frequent maintenance, which involves the hairpiece being removed, the natural hair braided again, and the piece snugly reattached. The tight braiding and snug hairpiece cause tension on the hair that is already at risk for falling out. Dreadlocks and single (extension) braids can have the same effect. Men and women who have had traction alopecia have found that the hair loss occurs most at the hair line—primarily around the temples and the sides of their heads. Traction alopecia is one of the most common causes of hair loss in African American women.[9]


  • Nurses who wear caps which are tightly secured by pins at the side or back of the head can develop traction alopecia.[10]
  • Sikh men[11] and women are susceptible to traction alopecia if the hair under the turban is tied too tightly for many years.[12]
  • The way in which a hijab is worn and the hairstyle used underneath may also contribute to hair loss.[13]
  • Compressive safety helmets worn tightly and closely to the scalp are a cause of traction alopecia. The lining of tightly fitted safety helmets like those worn for activities such as motorcycling, cycling, skiing and snowboarding are responsible for the constant rubbing and tugging of localised areas of the hair and scalp. Frequent wearers or those who use such helmets for prolonged periods seem more likely to develop traction alopecia.[citation needed]


A condition known as CCCA (central cicatricial centrifugal alopecia), seen almost exclusively in African American women, can cause extensive hair loss. It is caused by a combination of too much stress (traction) on the hair and the use of harsh relaxers and dyes.[14]


Traction alopecia is characterized by a fringe along the marginal hairline on physical exam, a recession of the hairline due to chronic traction.[2]

Differential diagnosis of this type of patchy alopecia when it is in the non scarring stage includes trichotillomania and alopecia areata, in the late stage, when smooth hairless patches are present with follicular drop out, it can resemble scarring alopecias such as frontal fibrosing alopecia (FFA) and patchy central centrifugal cicatricial alopecia (CCCA).[9]

Frontal fibrosing alopecia can present with an unusual retention of the hairline (pseudo-fringe sign).[15]


Treatment is typically not pharmaceutical. Management includes cessation of the chronic traction, cosmeses, with surgical restoration reserved for more severe cases with scarring fibrosis.[7]

See also[edit]


  1. ^ Onalaja, Amanda A.; Taylor, Susan C. (2021). "1. Defining skin color". In Li, Becky S.; Maibach, Howard I. (eds.). Ethnic Skin and Hair and Other Cultural Considerations. Switzerland: Springer. p. 14. ISBN 978-3-030-64829-9.
  2. ^ a b Khumalo, N. P. (2012). "The "fringe sign" for public education on traction alopecia". Dermatology Online Journal. 18 (9): 16. doi:10.5070/D31H81C7S1. PMID 23031383.
  3. ^ Samrao, A.; Price, V. H.; Zedek, D.; Mirmirani, P. (2011). "The "Fringe Sign" - A useful clinical finding in traction alopecia of the marginal hair line". Dermatology Online Journal. 17 (11): 1. doi:10.5070/D325M840MZ. PMID 22136857.
  4. ^ Ahdout, J.; Mirmirani, P. (2012). "Weft hair extensions causing a distinctive horseshoe pattern of traction alopecia". Journal of the American Academy of Dermatology. 67 (6): e294–e295. doi:10.1016/j.jaad.2012.07.020. PMID 23158648.
  5. ^ Urbina, F.; Sudy, E.; Barrios, M. (2009). "Traction folliculitis: 6 cases caused by different types of hairstyle that pull on the hair". Actas Dermo-sifiliograficas. 100 (6): 503–506. doi:10.1016/s1578-2190(09)70108-8. PMID 19709556.
  6. ^ Borovicka, J. H.; Thomas, L.; Prince, C.; Mehregan, D. R. (2009). "Scarring alopecia: Clinical and pathologic study of 54 African-American women". International Journal of Dermatology. 48 (8): 840–845. doi:10.1111/j.1365-4632.2009.04129.x. PMID 19659862. S2CID 25927043.
  7. ^ a b c Fu, J. M.; Price, V. H. (2009). "Approach to Hair Loss in Women of Color". Seminars in Cutaneous Medicine and Surgery. 28 (2): 109–114. doi:10.1016/j.sder.2009.04.004. PMID 19608062.
  8. ^ Lillis, J. V.; Guo, C. S.; Lee, J. J.; Blauvelt, A. (2010). "Traction Alopecia in a Ballerina: Clinicopathologic Features". Archives of Dermatology. 146 (8): 918–919. doi:10.1001/archdermatol.2010.183. PMID 20713841.
  9. ^ a b Billero, Victoria; Miteva, Mariya (2018-04-06). "Traction alopecia: the root of the problem". Clinical, Cosmetic and Investigational Dermatology. 11: 149–159. doi:10.2147/CCID.S137296. PMC 5896661. PMID 29670386.
  10. ^ Hwang, Sang Min; Lee, Won Soo; Choi, Eung Ho; Lee, Seung Hun; Ahn, Sung Ku (March 1999). "Nurse's cap alopecia". International Journal of Dermatology. 38 (3): 187–191. doi:10.1046/j.1365-4362.1999.00556.x. ISSN 0011-9059. PMID 10208613. S2CID 44404854.
  11. ^ Karimian-Teherani, D.; El Shabrawi-Caelen, L.; Tanew, A. (2011). "Traction Alopecia in Two Adolescent Sikh Brothers-An Underrecognized Problem Unmasked by Migration". Pediatric Dermatology. 28 (3): 336–338. doi:10.1111/j.1525-1470.2011.01241.x. PMID 21371118. S2CID 205678095.
  12. ^ Mehta, Hitaishi; Kumar, Sheetanshu; Bishnoi, Anuradha (2021). "Turban Tribulations: Triad of Turban Ear, Traction Alopecia, and Traumatic Acne in a Sikh Patient". Indian Dermatology Online Journal. 12 (5): 770–771. doi:10.4103/idoj.IDOJ_798_20. ISSN 2229-5178. PMC 8456239. PMID 34667772.
  13. ^ Shareef, Sarah J.; Rehman, Rafey; Seale, Lauren; Mohammad, Tasneem F.; Fahs, Fatima (2022-01-30). "Hijab and hair loss: a cross-sectional analysis of information on YouTube". International Journal of Dermatology. 62 (3): e193–e194. doi:10.1111/ijd.16092. ISSN 1365-4632. PMID 35094383. S2CID 246428801.
  14. ^ Hatsbach de Paula, Joane Nathache; Basílio, Flávia Machado Alves; Mulinari-Brenner, Fabiane Andrade (2022). "Effects of chemical straighteners on the hair shaft and scalp". Anais Brasileiros de Dermatologia. 97 (2): 193–203. doi:10.1016/j.abd.2021.02.010. ISSN 1806-4841. PMC 9073307. PMID 35058079.
  15. ^ Pirmez, R.; Duque-Estrada, B.; Abraham, L.S.; Pinto, G.M.; de Farias, D.C.; Kelly, Y.; Doche, I. (July 2015). "It's not all traction: the "Pseudo-fringe sign" in frontal fibrosing alopecia". British Journal of Dermatology. 173 (5): 1336–1338. doi:10.1111/bjd.14005. PMID 26138941. S2CID 8233738.

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