Traction Alopecia Research Articles

Central centrifugal cicatricial alopecia: possible familial aetiology in two African families from South Africa

Central centrifugal cicatricial alopecia: possible familial aetiology in two African families from South Africa

The “fringe sign” for public education on traction alopecia

The "fringe sign" introduced by Samrao and co-authors is a phenomenally descriptive catch phrase for translating study data for public education in the prevention of traction alopecia.

‘A detective look’ at hair biopsies from African-American patients

A patient's ethnicity can be an important clue in the diagnosis of scarring alopecia as some disorders such as traction alopecia (TA) and central centrifugal cicatricial alopecia (CCCA) are more prevalent in or exclusive to African-Americans. To perform a retrospective review of 60 scalp biopsies from African-American patients including 25 cases of CCCA, 22 cases of TA, five cases of frontal fibrosing alopecia, three cases of discoid lupus erythematosus, three cases of hair breakage and two cases of alopecia areata. Serial horizontal and vertical sections were examined. Features characteristic of the African-American scalp include: golf club-shaped bulb, elliptical shape of the hair shaft, asymmetrical outer root sheath and paired grouping of hair follicles. Clues to the diagnosis of CCCA include: premature desquamation of the inner root sheath, goggles and naked hair shafts in fibrous streamers. Diagnosis of TA is suggested by preserved sebaceous glands along with follicular miniaturization and drop-out. The clues reported here aim to help the dermatopathologists to: recognize at a glance that they are dealing with a scalp biopsy from an African-American patient; make the most probable diagnosis by connecting the clues (even if only vertical sections are present); and understand the morphological basis for the susceptibility of the African hair to damage.

Habit reversal training for trichotillomania

Trichotillomania is characterized by the repeated urge to pull out hair, leading to noticeable hair loss, distress, and social or functional impairment. Most of the cases present initially to dermatologists with complaints of loss of hair and is often confused with other dermatological conditions like alopecia areata, tinea capitis, traction alopecia, and loose anagen syndrome. It is a chronic condition and difficult to treat. No formal treatment algorithm is present for trichotillomania and no drug has been found to be universally effective. We present a case report of a 22-year-old single female diagnosed with trichotillomania, with complaints of recurrent hair pulling resulting in noticeable hair loss since the age of 8 years. She was treated with Habit Reversal Training with Stimulus Control over a period of 12 weeks and attained complete remission. The effectiveness of HRT plus for the treatment of Trichotillomania is ascertained.

Hair loss and its management in children

Hair loss in children can cause psychological stress to the parent and patient alike. Alopecia can be classified into congenital and acquired. Commonly encountered causes of pediatric alopecia (tinea capitis, alopecia areata, traction alopecia and trichotillomania) are reversible if diagnosed early. Special note should be made of the extent and type of alopecia (scarring or nonscarring), any hair shaft anomalies and signs of inflammation. Diagnostic evaluation includes a bewildering array of age-old simple bedside tests (e.g., potassium hydroxide preparation) to state-of-the art accurate instruments (e.g., trichoscan). Systemic antifungal therapy is required for tinea capitis. Topical and systemic immunomodulators are currently being employed for treating alopecia areata. A holistic approach would include not just therapeutic intervention but also an active search for associated nutritional deficits, underlying psychosocial disturbances and behavioral problems, the latter two requiring counseling and beha...

The “Fringe Sign” - A useful clinical finding in traction alopecia of the marginal hair line

Traction alopecia is hair loss caused by prolonged or repetitive tension on the hair. Diagnostic challenges are encountered when the clinical suspicion is not high and when a history of traction is remote or not obtained. We have made the observation that the presence of retained hairs along the frontal and/or temporal rim, which we termed the "fringe sign," is a finding seen in both early and late traction alopecia, and may be a useful clinical marker of the condition. This was a retrospective single-center review to determine the frequency of the fringe sign in patients with traction alopecia. Over a 3.5-year period the diagnosis of traction alopecia was made in 41 women. Twelve of the 41 patients were Hispanic (29%). Thirty-five (85%) of all women and 100 percent of women who had traction involving the marginal hairline had the fringe sign. Fourteen biopsies (58%) were available for review. Histopathologic findings included retained sebaceous glands (100%), an increase in vellus-sized hairs (50%), a decrease in terminal hairs (100%), fibrotic fibrous tracts (100%), and sparse lymphocytic inflammation (57%). The fringe sign is a sensitive and specific clinical feature of traction alopecia when it involves the marginal hairline.

A retrospective study of thyroid structural abnormalities in alopecia patients

Thyroid dysfunction is classically associated with alopecia. Studies focusing on manual thyroid examinations, with ultrasonography of palpable abnormalities, in alopecia patients are lacking. To examine the clinical utility of manual and sonographic evaluation of the thyroid in alopecia patients. A retrospective chart review was performed among patients diagnosed with alopecia. We found that 20.2% (74/367) of manual thyroid exams performed were deemed abnormal and 78.8% (41/52) of patients who had an ultrasound had an abnormal finding. Twenty two of the 74 patients did not obtain the requested ultrasound. Non-scarring alopecia was associated with 36 of 41 patients with abnormal ultrasounds (Telogen effluvium 29.3%, Androgenetic alopecia 27.8%, Alopecia areata 24.4%, and Traction alopecia 9.8%). No one specific structural abnormality was associated with a specific hair loss type. Of note, 78% (32/41) of patients with an abnormal ultrasound exam had normal thyroid function tests and only 9/41 (22%) patients had both. THESE INCLUDE: a retrospective study design, small sample size, use of multiple sites for laboratory and sonographic thyroid evaluation, and a high attrition rate for ultrasound evaluation. This study revealed that the manual examination of the thyroid in alopecia patients may identify additional thyroid abnormalities not detected with serologic evaluation alone. Further prospective studies are required to evaluate the necessity and significance of manual thyroid palpation and subsequent ultrasound studies in this patient population.

Comparison Between Langerhans Cell Concentration in Lichen Planopilaris and Traction Alopecia With Possible Immunologic Implications

Lichen planopilaris and long-standing traction alopecia are both traditionally classified as scarring alopecias. The etiology of lichen planopilaris has not been fully elucidated, although an autoimmune mechanism is generally accepted with Langerhans cell involvement implicated in previous studies. The etiology of traction alopecia is generally considered to be the result of mechanical force with subsequent inflammation without an autoimmune component. Langerhans cells in pure traction alopecia have not been previously evaluated nor have Langerhans cell concentrations been compared among the scarring alopecias. We performed double immunostaining with CD1a and CD3 to assess the ratio of Langerhans cells to T lymphocytes in lichen planopilaris and traction alopecia. Sixteen biopsies were evaluated including 9 biopsies of lichen planopilaris and 7 biopsies of traction alopecia. The mean ratio of the concentration of Langerhans cells to T lymphocytes was 1.28 for the lichen planopilaris group and 0.59 for the traction alopecia group. There is a significantly higher ratio of Langerhans cells to T lymphocytes in lichen planopilaris compared with that seen in traction alopecia. This supports previous data recognizing an immune component in lichen planopilaris mediated by Langerhans cells while emphasizing that most traction alopecias are not primarily immune related. Thus, the traditional classification systems for alopecia may need review and revision, especially when looking at etiopathogenesis. However, rare cases of traction alopecia demonstrated ratios similar to those seen in lichen planopilaris. These cases may represent the recently described "traction alopecia" condition, cicatricial marginal alopecia or changes seen in long-standing lesions, emphasizing the need for inclusion of distribution and duration within the clinical information.

Traction Alopecia in Two Adolescent Sikh Brothers—An Underrecognized Problem Unmasked by Migration

Traction alopecia denotes an often permanent hair loss resulting from prolonged physical damage to the hair shaft. We report on two adolescent Sikh brothers who wore a turban since early childhood and developed a band-like scarring alopecia at the frontal hairline. Awareness of this condition may help in preventing irreversible hair loss by early modification of the daily hair care routine.

The “Fringe Sign” A Useful Clinical Finding in Traction Alopecia of the Marginal Hair Line

Background: Traction alopecia is hair loss due to prolonged or repetitive tension on the hair. Diagnostic challenges may be encountered if the clinical suspicion for traction is not high, or if the history of traction is remote or not obtained. Since pathologic features can vary dramatically with the stage of the disorder clinico-pathologic correlation is essential. We have made the observation that the presence of retained hairs along the frontal and/or temporal rim, which we termed the sign, is a finding that can be see in both early and late traction alopecia, and thus may be a useful clinical marker of the condition. Objective: To determine the frequency of the fringe sign in a series of patients with a diagnosis of traction alopecia. Methods: This was a retrospective single-center review. Results: Over a 3.5 year period the diagnosis of traction alopecia was made in 41women. Twelve of the 41 patients were Hispanic (29%). The average age of our cohort was 34. Thirty-five (85%) of all women and 100% of women who had traction involving the marginal hair line had the fringe sign. The majority of African American women (54%) compared to 17% of the Hispanic women had some clinical sign of scalp inflammation(most frequently scalp scaling). Fourteen biopsies(58%) were available for review. Histopathologic findings included retained sebaceous glands (100%) and an increase in vellus-sized hairs (50%), a decrease in terminal hairs (100%), fibrotic fibrous tracts (100%), and sparse lyphocytic inflammation (57%). Trichomalacia was only noted in only one of the biopsies. Limitations: Retrospective analysis, uncontrolled study. Conclusions: Hispanic women as well as African American women are at high risk for traction alopecia. The fringe sign was a sensitive and specific clinical feature of traction alopecia when it involved the marginal hair line. Retained sebaceous glands, decreased terminal hairs, and fibrotic fibrous tracts were noted in all histopathologic specimens.

The “Fringe Sign” for Public Education on Marginal Traction Alopecia

The “Fringe Sign” for Public Education on Marginal Traction Alopecia

Hair casts are a dermoscopic clue for the diagnosis of traction alopecia

Hair casts are a dermoscopic clue for the diagnosis of traction alopecia

Hair care practices and their association with scalp and hair disorders in African American girls

Few studies have extensively examined the prevalence of hair care practices and their association with scalp and hair conditions in African American girls. We sought to determine the prevalence of hair care practices and their association with traction alopecia, seborrheic dermatitis (SD), and tinea capitis (TC). A questionnaire was administered to caregivers of African American girls aged 1 to 15 years. Multivariate analyses were performed to determine the association of hair care practices with reported disorders. A total of 201 surveys were completed from dermatology (n= 98) and nondermatology (n= 103) clinics. Mean patient age was 9.8± 4.4 years. Essentially all respondents reported use of hair oils/grease (99%). Ponytails, braids, and cornrows were worn by 81%, 67%, and 49% of girls, respectively, within the past 12 months. In all, 61% reported hair washing every 2 weeks; 80% used hot combs; and 42% used chemical relaxers. Cornrows were significantly related to traction alopecia among respondents from nondermatology clinics only: adjusted odds ratio= 5.79 (95% CI 1.35-24.8, P= .018). Hair extensions and infrequent hair oil use were significantly related to SD: adjusted odds ratio= 2.37 (95% CI 1.03-5.47, P= .04) and 3.69 (95% CI 1.07-12.7, P= .039), respectively. No significant associations were observed for TC. Small sample size and disorders reported by caregivers were limitations. Certain hair care practices were strongly associated with development of traction alopecia and SD. No association was found between hair washing frequency and SD or TC, or between hair grease use and TC. These results can be used to inform practitioners, advise parents, and adapt treatment regimens to accommodate cultural preferences.

Histopathology of alopecia: a clinicopathological approach to diagnosis

Interpretation of the histopathological findings of primary scarring and non-scarring alopecias may prove daunting. This is especially true if the biopsy specimen is inadequate, and the clinical history and pattern of the alopecia are not known. Common forms of scarring alopecias discussed here are the lymphocytic (discoid lupus erythematosus, lichen planopilaris, central centrifugal cicatricial alopecia, pseudopelade of Brocq), the neutrophilic (folliculitis decalvans, dissecting folliculitis), and the mixed (acne keloidalis) entities. The non-scarring alopecias reviewed are androgenic alopecia, telogen effluvium, alopecia areata, trichotillomania and traction alopecia. In all cases of primary alopecia, adequate tissue sampling and appropriate laboratory processing, in combination with pertinent clinical information, provide the key to diagnosis.

Foliculitis por tracción: seis casos producidos por diferentes tipos de peinado tirante

Excessive hair traction caused by hairstyles that pull the hair too tightly may cause noninfectious mechanical and irritant folliculitis known as traction folliculitis. We present a series of 6 cases of traction folliculitis caused by different hairstyles. All patients were women aged between 12 and 26 years old. Their hairstyles were braids, ponytails, pigtails, cornrows, and hair extensions in 2 patients. The lesions consisted of small, slightly painful, follicular pustules confined to the sites of maximum hair traction and surrounded by erythema. Only in 1 case were the lesions associated with traction alopecia. In 2 cases in which bacterial cultures were done, Staphylococcus aureus was isolated. All patients improved after undoing their hairstyle and treatment with oral flucloxacillin. We assume that the role of S aureus is secondary and opportunistic, given that only follicles subject to traction and not the adjacent ones were affected.

Approach to Hair Loss in Women of Color

Hair loss in women of color represents a unique diagnostic challenge that requires a systematic approach. In women of color, clinical examination of the hair and scalp is most helpful when performed first and used to guide subsequent history-taking to arrive at a clinical assessment. The most common hair problems in women of color are hair breakage, traction alopecia, and central centrifugal cicatricial alopecia. A careful detailed clinical examination and history will guide the clinician to appropriate counseling and management. It is important to recognize that a patient may have more than one of these 3 diagnoses and each requires separate attention. Traction alopecia is completely preventable with appropriate education of the public and medical establishment.

Literature: Dermatology

1. Marc Avram, MD 1. New York, New York 2. Nicole Rogers, MD 1. New Orleans, Louisiana ### Citation Khumalo, N.P., et al. Determinants of marginal traction alopecia in African girls and women. J Am Acad Dermatol. 2008; 59:432-438. Many African American women apply relaxers (sodium

Cicatricial marginal alopecia: is it all traction?

In a specialized hair loss clinic, a group of patients was identified with focal or complete hair loss at the scalp periphery, with a normal scalp surface. Biopsy revealed complete loss of individual hair follicles, indicative of scarring alopecia. Not all patients had a history supportive of a diagnosis of traction alopecia. To identify and characterize further patients with scarring alopecia of the scalp margin using a retrospective review. All biopsies of scarring alopecia carried out by a single clinician between 1 January 1999 and 29 September 2006 were reviewed. Patients in whom the hair loss was located at the periphery of the scalp were selected for retrospective chart review. A total of 15 patients met the study criteria, which included histological scarring alopecia and hair loss of the scalp margin. Six of the patients gave a history of relaxing or straightening their hair. Six denied hair care practices sufficient to cause traction alopecia. In three patients, the hair care history was unknown. Occipital hair loss was a common clinical finding, mimicking alopecia areata. The presence of scarring was often subtle histologically. A group of patients with moderate to severe cicatricial alopecia of the scalp margin is described. The presence of scarring is difficult to diagnose both clinically and histologically. The lack of a history of severe traction or harsh styling practices in half the patients casts doubt on whether or not traction is the only pathogenic factor.

Determinants of marginal traction alopecia in African girls and women

Our recent population studies reported a prevalence of traction alopecia (TA) of 17.1% in African schoolgirls (6-21 years) and of 31.7% in women (18-86 years). More schoolgirls had chemically treated hair than women and disease presence was associated with hairstyles. The aim of this study was to investigate determinants of TA presence and severity in girls and women using data from both studies. Clinical assessment and a Marginal TA Severity score were used for diagnosis and disease severity, respectively. The data used included 574 schoolgirls and 604 women. The first analysis was multiple logistic regression for disease presence. Exploratory associations for disease severity were assessed using the Spearman rank correlation test. Adults were defined as age 18 years or older, irrespective of study. The odds ratio for TA was higher in adults than in children (<18 years) (1.87 [P < .001, 95% confidence interval 1.28-2.72]) and was higher with braiding-related than chemical-related symptoms. The highest risk of TA, compared with natural hair, occurred when traction was added to relaxed hair (odds ratio 3.47 [P < .001, 95% confidence interval 1.94-6.20]). Only 18.9% of patients with TA had never had symptoms related to hairdressing. TA severity was associated with age group, current hairstyle, and hairdressing symptoms. Participants with severe disease were too few to estimate determinants. There is a need for the validation of the Marginal TA Severity score with larger numbers and for future studies to include more participants with severe disease. Our findings suggest that avoiding both hairdressing symptoms and the addition of traction, especially to chemically processed hair, may reduce the risk of developing TA.

Expert Stresses Prevention of Traction Alopecia in Children

Expert Stresses Prevention of Traction Alopecia in Children