What are the aims of this leaflet?

This leaflet has been written to help you understand more about traction alopecia. It will tell you what traction alopecia is, what causes it, what can be done about it, and where you can get more information about it.

What is traction alopecia? 

Alopecia is a general term for hair loss. Traction alopecia is a type of hair loss caused by constant pulling (“traction”). The pulling is usually on some hairs more than others leading to the development of bald patches. Often, this type of alopecia is due to the hairs being pulled repeatedly by  tight hairstyles.

Traction alopecia is a different condition to the one when people have the desire to actively pull their own hair (known as trichotillomania).

Traction alopecia can get better when it has only been present for a few weeks or months if the tension applied to the hair is stopped. However, if there is long-term and repetitive pulling on the hair it can lead to permanent hair loss due to damage to the hair follicles, which produce hair.

What causes traction alopecia? 

The commonest cause of traction alopecia is tight hairstyles. The pattern of the hair loss will depend on the type of hairstyle and where the tension is highest. Usually, it is the longer hairs at the edge of the scalp that are pulled the most. As only longer hairs are tied up, smaller finer hairs escape being pulled and can still be seen in the balding patches.

Hairstyles often associated with traction alopecia are tight ponytails (causing hair loss at the front and side margins of the scalp), tight buns (causing hair loss at the sides and back of the scalp), as well as attachment of weaves or hair extensions. Tight braids (such as cornrows and dreadlocks) are also common causes of traction alopecia with hair loss being seen between the braids. The risk of traction alopecia is further increased if these hairstyles are combined with various chemicals used on the hair (such as chemical relaxers to straighten hair). Hair clips and tight head scarves have also been associated with traction alopecia. Excessively long hair may contribute to traction alopecia due to the weight of the hair.

Is traction alopecia hereditary? 

It is uncertain whether there is a true genetic predisposition to traction alopecia. It is mainly due to hair-styling practices. It can affect people from all ethnic backgrounds.  Traction alopecia has been seen in some people with cultural, religious and occupational hairstyles.

Traction alopecia is often seen in women and children of African descent who regularly use braids or chemicals to make it easier to manage tightly curled hair. It is possible that tightly curled Afro-textured hair may be more susceptible to breakage and traction alopecia. Traction alopecia of the scalp and beard area has also been noted in some Sikh men. 

What are the symptoms? 

Some people may experience itching, soreness or increased flaking of the scalp. 

What does traction alopecia look like? 

Traction alopecia can occur anywhere on the scalp where there are mechanical forces pulling the hair. Often hair loss is seen at the front, sides or back of the scalp. Smaller hairs within the patch are often unaffected and a rim of slightly longer hairs (called the “fringe sign”) may also be seen at the edge of the patch furthest away from the traction.

Within the patches of hair loss, the skin usually looks normal. However, if tight hairstyles are still being used then sometimes redness, spots and white skin flakes attached to the hairs (called “hair casts”) may be seen at the margins of the bald patches closest to the tension.

In longstanding traction alopecia the scalp may appear smooth and shiny, where the hairs have been permanently destroyed.

How is traction alopecia diagnosed?

The diagnosis is usually based on the history and pattern of the hair loss. If the diagnosis is unclear, then a scalp biopsy may be required.

Can it be cured?

Yes, depending on the stage of hair loss. If the problem is identified early, then the hair can completely regrow if the tight hairstyles are stopped. However, longstanding traction alopecia can cause permanent destruction of the hair follicle; in this situation the hair loss is permanent.

How can traction alopecia be treated?

Traction alopecia can be treated. Although, how well the hair grows will depend on whether there is any permanent damage to the hair follicle roots.

Stop tight hairstyles: This is the most important step to take to prevent hair loss from worsening or becoming permanent whilst giving the best chance for the hair to recover. Hair regrowth may start around 3 months after discontinuing these hair practices, and once the hair cycle is restored.

Topical minoxidil solution or foam: Applying 2% or 5% minoxidil solution/foam to the affected areas on the scalp twice daily may stimulate hair growth. Continue treatment until you are happy with the growth and, as long as the traction has been stopped, the minoxidil can be discontinued. Minoxidil is not available on prescription but can be bought over the counter or online.  It is expensive and not always effective. Care needs to be taken to apply only to the affected areas. It can sometimes irritate the skin and accidental application to the face may increase facial hair in some women whilst being used.

Topical corticosteroids. Potent steroid based preparations (e.g. lotions, gels, or mousses) can help improve any symptoms of itch or redness of the scalp. Prolonged use of topical steroids can cause thinning or lightening of the skin.

Steroid injections (known as ‘intralesional steroids’) may be offered by your doctor to treat small area on your scalp if there is evidence of inflammation. However, these injections can be uncomfortable and may cause thinning/dimpling of the skin (atrophy) or lighter patches at the site of injection.

Wigs and hair pieces: These can either be bought privately or obtained through the support of the NHS with a consultant’s prescription (although prescription charges apply).

Cosmetic camouflage: Preparations containing small pigmented fibres or coloured sprays are available from the internet and may help to disguise the hair loss. These preparations are not waterproof and therefore may wash away if the hair gets wet (i.e. rain, swimming, perspiration), and needs reapplying between washing.

In cases of permanent hair loss:

Surgical treatments: Surgical treatment is not offered under the NHS. These can be sought privately and include:

(i) Hair transplantation. This is a procedure whereby hair follicles are taken from elsewhere on the scalp and transplanted into the bald areas. Although, the procedure does leave permanent scars; these usually look like very subtle dots scattered over a large area and therefore hardly noticeable even with short haircut.

(ii) Scalp reduction surgery. This involves the surgical removal of the bald area and stretching the remaining hair baring scalp skin to cover the defect.  This may still result in a visible scar.

Self-care (What can I do?)

• Consider changing hair styles, such as cutting long hair, adopting loose hair styles and avoiding high-risk hairstyles/ practices such as braiding and hair extensions.
• Avoid exposing hair to chemical relaxants and excessive heat from hair straighteners etc.
• An important function of hair is to protect the scalp from sunlight; it is therefore important to protect any bald areas of your scalp from the sun to prevent sunburn and to reduce the chances of developing long-term sun damage. You should cover any bald patches with sun block, or a hat if you are going to be exposed to sunlight.

Where can I get more information? 

Weblinks to patient support groups:

Alopecia UK
Web: https://www.alopecia.org.uk/
E-mail: info@alopecia.org.uk

Weblinks to detailed leaflets:

https://www.dermnetnz.org/topics/traction-alopecia/

Other websites you may find helpful:

British Hair and Nail Society: https://bhns.org.uk/

Jargon Buster: https://www.skinhealthinfo.org.uk/support-resources/jargon-buster/

Please note that the BAD provides web links to additional resources to help people access a range of information about their treatment or skin condition. The views expressed in these external resources may not be shared by the BAD or its members. The BAD has no control of and does not endorse the content of external links.

This leaflet aims to provide accurate information about the subject and is a consensus of the views held by representatives of the British Association of Dermatologists and the British Hair and Nail Society: individual patient circumstances may differ, which might alter both the advice and course of therapy given to you by your doctor.

This leaflet has been assessed for readability by the British Association of Dermatologists’ Patient Information Lay Review Panel 

BRITISH ASSOCIATION OF DERMATOLOGISTS PATIENT INFORMATION LEAFLET

PRODUCED FEBRUARY 2019

NEXT REVIEW DATE FEBRUARY 2022