Author Sara G Allison RGN MIT.
July 2008
Research Technicians Lucinda Ellery Ltd
The information contained in this article has been researched from the references quoted at the end. However, most other information available, but not included here is very basic and repetitive.
Therefore, as there are many unanswered questions about Traction Alopecia, it seems that the only way to attempt to answer these is by conducting my own research together with Lucinda Ellery Clinic (see 'The Future').
Background
Traction alopecia is associated with sustained tension on the scalp hair. Traction causes hair to loosen from its follicular roots; however, hair loss also occurs secondary to follicular inflammation and atrophy. Sometimes also referred to as 'cosmetic traumatic alopecia' as it occurs when the hair has been held under tension by cosmetic practices like braiding or ponytails or the individual has slept in rollers. If tension continues to the hair roots the constantly pulling hair too tight and in the same direction can cause baldness to these specific, localized roots only. Onset is gradual and often takes 2 to 3 years to become apparent and it often occurs symmetrically around the fronto-temporal hairline, occipital scalp involvement is less common. Vellus (short, fine) hair is usually spared in the affected area.
In the initial stages, this hair loss is reversible. However, prolonged tension may induce follicular inflammatory changes with immune cell infiltrate and fibrosis which totally destroys the hair follicles and will not re-grow under any circumstances hence chronic traction alopecia occurs and can then be described as a 'Scarring Cicatricial Alopecia'. This results in permanent localised hair loss to those specific follicles under tension. Therefore it is important to recognise this condition while it is still reversible.
Traumatic alopecia is essentially a cosmetic disorder. Rather than affecting the sufferer psychologically, therefore it should be emphasized that this condition is not a disease.
Causes
Three basic mechanisms of traction alopecia have been proposed: trichotillomania, telogen conversion, and over processing. In all cases, immediate cessation of the underlying cause can reverse the alopecia.
Over processing
- Chemical treatment of hair with dyes, bleaches, or straighteners disrupts the keratin structure in a manner that reduces its tensile strength.
- The hair becomes fragile and is unusually susceptible to breakage from friction or tension.
- Normal combing can lead to the sudden loss of hair en masse.
Trichotillomania ,
A psychiatric disorder of compulsive behavior involving the intentional yet uncontrollable, repeated plucking of one's own hair usually from a specific area and resulting in a patchy loss in that area.
Telogen conversion appears to be the most common cause.
- Usually, the hair follicle can sustain trauma and still remain in the anagen growth phase.
- Excessive traction for prolonged periods (e.g., tight braiding, wearing of ponytails) leads to conversion of the anagen phase to the telogen phase.
- Keratin cylinders-'hair casts' may surround many hairs just above the scalp surface.
- Typically, traction alopecia in the early stages involves affected hair follicles being pushed into the telogen resting state along with localized trauma to the hair follicles as a result of hair shafts being forcibly pulled.
- In the telogen phase, the hair follicle ceases to grow and localised alopecia results.
Sub types of Telogen Conversion;
Marginal
Otherwise known as Alopecia linearis frontalis, is a hair-loss pattern that usually results from the use of tight curlers, tight ponytails, or straighteners. In this condition, the distribution of hair loss follows a characteristic pattern in the temporal scalp, starting in the periauricular area and extending forward in a triangular manner. The involved area is approximately 1-3 cm in width in most cases. For example, the constant contraction of the muscles used in facial expression, in addition to the tension caused by braiding, may partially account for why this pattern is often seen in the temporal region.
Non-Marginal
Sometimes referred to as 'chignon alopecia' is characterized by hair loss in the occipital scalp region where the bun rests. This condition is seen in patients with a long-standing history of pulling their hair into a bun. The typical patient is a 40-year-old woman who initially complains of itching and dandruff localized to the occipital area. Similar to marginal alopecia, perifollicular erythema with occasional peripilar hair casts can be seen. The natural history of chignon alopecia mirrors that of marginal alopecia, with the eventual formation of pustules and the development of folliculitis. Permanent alopecia can also result if this condition remains undetected and the traction continues. Sometimes, the fronto-marginal part of the scalp may also be involved because the longest hair roots originate in this region, and may be subjected to traction. When an examining physician notices both chignon alopecia and marginal alopecia, the index of suspicion should be high, and the diagnosis of chignon alopecia should be considered.
Pathophysiology
Traction Alopecia is induced particularly readily in subjects with incipient common baldness, for the telogen hairs which make up a higher proportion of the total are more loosely attached and readily extracted than anagen hairs
Incidence
It is seen worldwide and for hundreds of years as cultural, religious, fashion, customs and occupations have imposed an immense variety of physical stresses on human hair, i.e.;
- In Sikhism, a religion originating from India, men must not cut either scalp hair or beard hair. Therefore, to keep their hair from falling in front of their face, it is tightly, twisting on top of their head and pulled into a bun. This practice has led to frontal and parietal traction alopecia occurring and the tight rolling of beard hair into a pocket in the sub-mandibular region also results in a similar phenomenon.
- The Sudanese customs of tight braiding and the use of wooden combs.
- Frontal loss has been reported in Libyan women from tight scarves.
- Afro- Caribbean hair styles with tight braiding of the hair into rows may cause marginal alopecia and central alopecia with widening of the partings.
- Females from Greenland who styled their hair in a ponytail.
- A similar pattern of hair loss was later noted in Japanese women who wear a traditional hairdo
- The use of hair extensions, a common treatment for male or female pattern baldness, is also associated with a similar type of hair loss.
- Nurses who secure their nurse's caps to their scalp with hair grips and is often referred to as 'Nurses Cap Alopecia'.
- Ballerinas who routinely scrape their hair back into a very tight bun, has been nicknamed 'ballerina baldness'.
In addition, modern trends have given rise to new patterns and in contemporary developed countries these are typically;
- straightening irons,
- massage alopecia, when excessive touching of specific area occurs,
- Brushing too vigorously with incorrect combs or brushes.
- Alopecia secondary to hair weaving/extensions- patchy traction alopecia has been reported to result from the cosmetic procedure of weaving additional hair into persistent terminal hair in order to camouflage common baldness.
- Hair rollers.
Frequency
The exact frequency of traction alopecia has yet to be documented.
Symptoms
- Often asymptomatic.
- Hair loss.
- Itching.
- Dandruff.
- Headache is possible if extensive tensile force on the hair follicle is the cause.
Diagnosis
It is sufficient to diagnose Traction alopecia without laboratory testing, but, with physical examination by a hair consultant and thorough history taking indicating repetitive use of hair styling techniques as outlined earlier and via elimination of indications for differentials for other types of alopecia.
Traction alopecia tends to follow a series of progressive events. Initially, pruritus and perifollicular erythema may be present. These may be accompanied by hyperkeratosis, creating a seborrhoeic picture. Pustules and scales may form. Eventually, an abundance of broken hairs can be detected. With persistent traction, the follicles atrophy and no longer produce the typical long and coarse hair. Instead, thinner, fine, short hair is generated.
- When tensile forces are chronically present, an irritant type of folliculitis develops.
- Follicular scarring and permanent alopecia may result.
- In some cases, peripilar hair casts form. The casts are fine, yellowish white keratin cylinders smaller than 1 cm in diameter that ensheathe the hair follicle. Often, peripilar hair casts occur in isolation; however, they have also been known to occur in association with hyperkeratotic scalp disorders.
- The hair loss pattern entirely depends on the specific grooming pattern of each patient. Marginal and Non-marginal types may be seen.
- Patients usually have patchy areas of hair loss.
- The hair-pulling test results in the detachment of more than 6 strands.
- Closer inspection of the scalp reveals perifollicular erythema, scales, and pustules.
- Hair loss may be symmetric, and marginal traction alopecia may be present in the temporal region.
- With chignon alopecia, hair loss may be in the occipital area.
- With corn-rowing, the area most commonly affected is that adjacent to the region that is braided.
- The essential changes in the many variants of this syndrome are the presence of short broken hairs, folliculitis and some scarring circumscribed patches at the scalp margins.
- Their cause is rarely recognised by the patient and is often accepted with suspicion.
- Patients do not like to admit to cosmetic 'abuse' of their hair!
Prognosis
- Traction alopecia is reversible in a few months if the hairstyling practice in question is discontinued.
- Traction alopecia may lead to permanent hair loss if it is undetected for a protracted period.
Medical Care
The physician must identify traction alopecia early. Failure to do so places the patient at risk for irreversible alopecia.
Immediately after traction alopecia is diagnosed, any practices that exert traction on the hair must be discontinued. Discontinuing any such practices leads to complete reversal of the hair loss and regrowth within around three months.
- Even with removal of the cause of traction alopecia it may take up to three months for the hair to recover.
- Topical or oral antibiotics may be prescribed to aid in the reduction of inflammation and to prevent superinfection.
- When traction alopecia is detected later in its natural course, hair loss may be irreversible. Currently, no medical treatment is available to reverse late-stage traction alopecia.
Diet
Ensuring sufficient levels of iron and protein may help promote normal hair growth, this can be assisted with diet and supplements.
Surgical Care
The only way one can treat scarring traction alopecia is with hair transplant surgery. Follicular unit hair grafting has been identified as the only practical solution to treating traction alopecia. The number of patients with traction alopecia coming to hair transplant clinics is generally increasing and the treatment is providing them good response.
The future
The Sara Allison & Lucinda Ellery Hair Loss Consultancy Ltd Research Project
The information contained in this article has been researched from the references quoted at the end. However, most other information available, but not included here is very basic and repetitive.
Therefore, as there are many unanswered questions about Traction Alopecia, it seems that the only way to attempt to answer these is by conducting my own research together with Lucinda Ellery Clinic.
Being a busy, long established clinic, specialising in hair attachment systems, with the applications of Intralace System, Medi Connections, or Farrell Hair Replacement, Lucinda Ellery are in the best environment to be able to conduct such a detailed study of Traction Alopecia.
These systems theoretically exert tension to hair follicles; therefore they are fully aware that without meticulous care and inspection by the professionals, then potential risks of traction alopecia may occur in the long term. Naturally, if any signs of Traction Alopecia occur they recommend discontinuation of the systems, but clients are often reluctant to go back to the hair situation they had prior to hair replacement. Therefore, it becomes a quality of life assessment with risks and benefits weighed up by the client with technical judgment by the professional.
Aims
To publicly, minimise incidence of Traction Alopecia. Correlate data with percentile risks that can be presented to the individual, in order that they can make a more informed choice at The Lucinda Ellery Clinic. Devise the ultimate advice for clients to minimise risks from occurring.
- If clients insist on continuing after initial signs of Traction Alopecia develop, then what percentage does it actually occur ? Verify how long this takes. After it occurs, then how long before it becomes irreversible? Again verify how long this takes.
- Describe what factors are more likely to precipitate Traction Alopecia i.e. scalp types and hair types and correlate if it takes some people longer for it to develop and why? Are some types totally immune? Prolonged traction causes decreased hair follicle and sebaceous gland density, which suggests it leads to dry skin conditions, therefore is a dry scalp an indicator? Is hair movement under tension more damaging?
- Observation to clarify identification characteristics and any peculiarities in the pattern. Traction Alopecia has been documented to ooccur symmetrically around the fronto-temporal hairline, is that due to the fact that scraping the hair back off the front hairline (ballerina style) is the more common offending style or because this area is weaker? Or perhaps that the skin is more mobile there allowing more movement and increased pull back?
- Establish how long does the tension effect last, i.e. hair grows at 1.25cm per month. Consequently, even after 1 week after application of hair attachments, it has already loosened a little, hence, maybe just short term tension doesn't have any long term effects? Therefore, after the tightness is lessened, will risks diminish or will the weight of the extra hair still make a difference to the traction?
- If weight is then recognised as a factor the advice will need to be given about extra care to taken when hair is wet as it will weigh more.
- With weight issues taken into account, should there be a maximum advisable ratio of added hair to indigenous hair?
- We know that Traction Alopecia is more likely to occur when follicles are in telogen phase. Minoxidil is thought to effect the progression of follicles to the telogen phase. Therefore, to trial use of minoxidil with hair attachment systems and observe for any noticeable difference in incidence.
- As mentioned previously it is important to maintain 'sufficient' levels of iron and protein, therefore conduct a trial to obtain 'optimum' levels of iron stores, by placing those on supplements and also with advice about increasing protein in diet.
- Processed hair is more likely to break, therefore establish risk and whether hair attachments should be contraindicated.
- We know that vellus hair is spared from traction alopecia, but is that because it is too short and fine to be properly involved with the section under traction and so avoids damage?
- Identify if there any correlation in the methodology of application of hair attachments i.e. would changing direction of the tension make a difference? Would skin glue help? Is the tension reduced if the sections under tension are larger i.e. spreading the load.
Findings will be published at the end of the research project.
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Histology
Early in the condition, lymphocytes surround a lichenoid perifolliculitis with infundibula (Ackerman, 2000). Later, as the process evolves, a zone of fibroplasia separates this infiltrate.
Fully developed traction alopecia involves a mild lymphocytic perivascular infiltrate, a markedly thinned lower infundibulum, and an isthmus surrounded by a band of fibroplasia. Foreign body granuloma may be evident. The late process has a reduced number of hair follicles and thickened fibrous bands in much of the reticular dermis that extends into subcutaneous fat.
In early traction alopecia, a subacute perifollicular inflammation is accompanied by mild-to-moderate hyperkeratosis. In cases of prolonged traction, decreased hair follicle and sebaceous gland density, perifollicular fibrosis, and vertical bands of follicular scarring are seen. However, blood vessels and eccrine sweat glands remain unaffected.
References 