Traction alopecia: what it is and how to recognise it

Traction alopecia is hair loss caused by hairstyles that pull on the hair for a long time: tight braids, extensions, high ponytails and buns, turbans or caps fastened with clips. It almost always starts at the temples and the front hairline, where the hair is finer and bears more tension.

It is one of the few causes of hair loss that can be almost completely prevented. But time counts: at the start it is reversible, but if the tension continues for years, the follicles are replaced by scar tissue and the hair stops growing.

What it is and why it happens

Each hair is anchored in the follicle. When a hairstyle pulls the hair hard, the tension is transmitted to the root. If that tension is strong and repeated, for hours a day, for weeks and months, the follicle suffers micro-trauma and becomes inflamed. First, the hairs come loose or break. Then the follicles become smaller. Finally, if the damage continues, some follicles are destroyed and replaced by scar tissue.

Two phases

There is no exact time limit after which the loss becomes permanent. It depends on the force, frequency and duration of the tension, and on how fragile the hair is. So the rule is simple: the earlier it is relieved, the better.

What makes it worse

• Chemicals: relaxers, straightening and bleaching weaken the hair. The combination of relaxed hair with braids or extensions is particularly risky.
• Heat: straighteners and curling irons on hair already under tension.
• Weight: heavy extensions and long braids increase the force on the root.
• Hairstyles kept in overnight or for weeks without a break.

Who is at higher risk

Anyone who wears tight hairstyles for a long time can develop traction alopecia. The most studied groups are:

• Women and girls of African descent who wear braids, dreadlocks, extensions or hairpieces, especially on relaxed hair. It is estimated that about a third of women in these communities have some degree of traction alopecia. In a study in South African schools, the prevalence rose from 8.6% in the youngest girls to 21.7% in the final-year pupils, showing that the problem starts early and accumulates over the years (Khumalo et al., 2008).
• People who wear a high, tight ponytail or bun for years, including dancers, athletes and those who tie their hair up every day for work.
• Men who wear a bun (man bun), braids or dreadlocks, and Sikh men who wear a turban over a tight knot, or who tie their beard back hard.
• Jobs with caps, hairnets or clips fixed always in the same place.
• Women who wear very tight headscarves or turbans for many hours a day.

The review by Billero and Miteva (2018) stresses that the force and duration of tension are the key factors, and that pain during or after styling is a sign of risk: in one of the studies cited, only about 19% of people with traction alopecia said they had never had pain when having their hair styled.

How to recognise it

Where it appears

• Temples and the area above the ears: the most typical location.
• Front hairline, especially with hairstyles pulled back.
• Nape, in ponytails and buns.
• Along the parting or between the braids, where the hair is divided.
• Under the chin, in men who tie up their beard.

The first signs (reversible stage)

• Pain, burning, itching or headache after styling.
• Small spots or red dots around the follicles at the margins.
• Thinner hair and broken hairs at the temples and front hairline.
• Whitish "casts" around the hairs, near the root (a sign of active traction).

For the pain in detail, see Scalp pain from hairstyles: when to worry.

The fringe sign

A very characteristic sign is the persistence of a fine band of short, fine hairs along the front hairline, in front of the thin area. It is called the "fringe sign", described by Samrao and colleagues (2011). These hairs survive because, being very short, they are not caught by the hairstyle. The sign helps to distinguish traction alopecia from frontal fibrosing alopecia, in which this fringe usually disappears.

Advanced stage

Smooth, shiny areas with no hair, at the temples and front hairline, in a "U" or "M" shape. The recession resembles that of a man with male pattern baldness. The skin has lost its follicular openings.

How the diagnosis is made

The diagnosis is mainly clinical: the location and the history of hairstyles say almost everything. At the consultation, the doctor asks which hairstyles you use or have used, for how long, whether they hurt, whether you use chemicals or heat, and examines the margins.

Trichoscopy helps to understand which stage it is at:

• Active phase: casts around the hairs (a sign of continued traction), hairs broken at different lengths, reduced density.
• Advanced stage: absence of follicular openings, only fine (vellus) hairs in the affected area.

A biopsy is rarely needed, but it can help in doubtful cases or to assess the viability of a transplant.

What can look like traction alopecia

Treatment and prevention

The essential step: remove the tension

No treatment works if the hairstyle keeps pulling. The first step is always to relieve the tension:

• take out tight braids and extensions and give breaks between hairstyles;
• wear your hair loose or tied loosely and low, changing the position;
• avoid chemicals and heat while there is inflammation, especially combined with tight hairstyles;
• sleep with your hair loose or in a loose braid.

Medical treatments (early stage)

The evidence comes mainly from case series, without randomised trials:

• Topical or injected corticosteroids to reduce inflammation around the follicles.
• Topical or oral antibiotics when there are spots or pus.
• Topical minoxidil, with regrowth described in isolated cases; it may help the follicles that are still alive.

With the tension removed and the right treatment, many people recover within months.

Scarring stage

When the follicles have already disappeared, hair does not return with medicines. The options are:

• Hair transplant, if the condition is stable and the tension has been eliminated. Cases have been described with good graft survival, but it is essential not to return to risky hairstyles.
• Camouflage: hairstyles that cover the margins, micropigmentation, headscarves.

Prevention

The education messages proposed by specialists are simple (Mirmirani and Khumalo, 2014):

• If the hairstyle hurts, it is too tight. Pain, burning or headache are neither "normal" nor "something that will pass".
• Do not have braids or extensions on relaxed or straightened hair.
• Take breaks between tension hairstyles and alternate styles.
• Protect the margins: leave the front hairline and temples looser.
• Teach early: in children, avoid tight hairstyles and very thin braids.

For practical guidance on how to wear braids and extensions with less risk, see Braids and extensions without damaging your hair.

When you should ask for an assessment

At Luxmed, the hair medicine consultation includes a detailed history of hairstyles, examination of the hairline margins, trichoscopy to assess whether the follicles are still alive, and follow-up photographs. We agree a realistic plan with you that respects your style and your hair.

This article is for information purposes and does not replace a medical consultation. The results of any treatment vary from person to person.

Frequently asked questions