Traction Alopecia (TA) – Hair Loss from Tension

Traction Alopecia is an acquired hair-loss disorder caused by prolonged or repetitive tension on the hair, leading initially to reversible hair loss and, if traction continues, to permanent scarring. It is entirely preventable and most common in women of African descent.

• Typical History: 

Gradual hair thinning along tension-bearing areas, particularly the frontal hairline, temporal, and preauricular regions ("edges").

• Causative Styles:

Tight braids, cornrows, weaves/extensions, tight ponytails, or dreadlocks.

• Symptoms:

Pain, tenderness, or headaches when hair is tied tightly; relief when loosened.

Skin of Colour (SOC) Points: 

Patients often have a long history of high-tension styling and may use combined high-risk practices (e.g., tight styles + chemical relaxers). Misdiagnosis as "genetic thinning" often delays intervention.

Distribution: Hair loss along the margins of the scalp (frontal, temporal, preauricular). The pattern is often linear, curved, or geometric based on the styling.

Key Signs:

• • Fringe Sign: A thin "fringe" of short, miniaturized hairs along the hairline is highly characteristic.

  • Hair Casts: White/brown cylindrical sleeves encircling hair shafts, indicating ongoing traction.

  • Early Disease: Perifollicular erythema, scale, and miniaturization (vellus hairs replacing terminal hairs).

  • Late Disease (Scarring): Absent follicular openings and smooth, shiny skin (irreversible damage).

SOC Notes:

• •  Erythema may be less visible; rely on follicular scale, hair casts, patient symptoms (tenderness), and broken hairs. Look for coexisting conditions like Central Centrifugal Cicatricial Alopecia (CCCA).

Management depends on whether the disease is early (reversible) or longstanding (scarring).

1. Prevention & Early Disease (Reversible)

• Lifestyle / Styling (The Core Treatment):

  • Immediately stop high-tension hairstyles.

  • Switch to looser styles (looser braids, twists, knotless braids) and avoid tight ponytails, fixed weaves, or microbraids.

  • Avoid chemical relaxers and heat styling.

  • Educate the patient that "tightness" or "headache" is a warning sign.

• Medical Therapy: Used to reduce inflammation and support regrowth:

  • Topical Corticosteroids (mild–moderate potency) or Intralesional Steroids for perifollicular inflammation.

  • Topical Minoxidil 2%–5% to support regrowth in non-scarring disease.

2. Longstanding / Chronic Disease (Scarring)

When follicular openings are absent, no regrowth is expected.

• Surgical Options:

  • Hair Transplantation (if donor hair is viable).

  • Scalp Micropigmentation for cosmetic improvement.

• SOC Note: Counsel patients about the higher tendency for hypertrophic or keloid scarring and the risk of hypopigmentation from intralesional steroids.

1. StatPearls / NCBI Bookshelf – Traction Alopecia (Syed & Kaliyadan, 2025): https://www.ncbi.nlm.nih.gov/books/NBK470434/

2. DermNet NZ – Traction Alopecia (Kapadia & Lyon, 2014): https://dermnetnz.org/topics/traction-alopecia