Crutchfield Dermatology Case-of-the-month header image

Case of the Month

A 38-year-old woman presents with multiple round patches of hair loss that are in a strikingly regular/geometric pattern?

Traction marks on head in hair loss
Traction marks on head in hair loss

What's Your Diagnosis?

Diagnosis: Traction Alopecia

microscopic skin
Women with Dreadlocks
skin under microscope
Traction Alopecia example 2

Traction Alopecia

She had worn her hair in the style known as “Dreadlocks” for almost 3 years. (See picture of woman wearing dreadlocks).

When she took them out and cut her hair, this is what she saw. Although this is not an uncommon finding after wearing dreadlocks for an extended period, this case still represents a very impressive case of traction alopecia.

Additional information:

Traction alopecia (TA) is a condition of the scalp secondary to trauma of the hair shaft. The hair shaft is weakened by various hair grooming practices including chemical hair relaxers, braiding, and tight ponytails. (see picture of the traction alopecia from tight braiding) It presents initially as a nonscarring alopecia that can result in permanent hair loss if not treated or if the insult persists.

TA is caused by frequent tight braiding, use of elastic bands and tight rollers, decorative cornrows, and excessive brushing or heat at the roots. Chemically relaxed hair with these styles is more susceptible to traction alopecia.

TA is more common in women and girls, particularly of African descent. This is attributed to the unique mechanical features of African hair and the type of hair grooming that is practiced in certain cultures. African hair is drier, asymmetrical, and helical in shape, which lead to points of weaknesses along the hair shaft. This makes it more susceptible to breakage during combing and to TA when hair is worn in tight styles for prolonged periods. TA is worsened if the hair is chemically relaxed because relaxers weaken the tight disulfide bonds, rendering the hair shaft thinner and drier.

TA is seen in indigenous populations in Western Greenland, young Danish girls with ponytails, ballet dancers, and any ethnic group that styles hair with tension to the frontal region of the scalp. TA also occurs with work-related gear such as helmets, hair caps, headbands, and nurses' caps. It is also seen in religious gear, eg, nuns' coifs and Sikh men who wear turbans.

TA usually involves the temporal region bilaterally, but the condition can be found on any area of the scalp where hair is pulled tightly in various hairstyles, eg, braids, weaves, ponytails, and dreadlocks. Symptoms of a tender, itchy scalp and headaches may be reported.

If TA is recognized early on, such as during childhood or adolescence, and practices that place tension on hair are stopped, then full recovery and hair regrowth can be achieved. However, if the patient presents as an adult and reports years of hair thinning on temporal and frontal margins, it most likely that hair follicles have undergone years of inflammation and scar tissue has formed, making the hair loss permanent.


Contributors: Zamambo Mkhize MBChB, FCDerm, Anisa Mosam MBChB, MMed, FCDerm, PhD, Ncoza C. Dlova MBChB, FCDerm, PhD, Belinda Tan MD, PhD, Susan Burgin MD

Charles Crutchfield III M.D. Eagan Dermatologist

For more dermatology cases-of-the-month visit Dr. Crutchfield's Case of the Month Archive

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