Traction alopecia is mostly seen in black females. It is associated with tight braiding or cornrow hairstyles. Hair loss is generally noted along the hairline and in the temporal areas. Trichotilomania is a traction alopecia related to a compulsive disorder. Patients pull on or pluck their hairs resulting in bizarre patterns of hair loss. Patients require medication for this Impulse Control Disorder and Counseling. N-Acetyl Cysteine (NAC) has been used with reasonable efficacy in treating Trichotillomania medically in the past. Often the peripheral hairline is spared. In chronic cases the hair loss may resemble Androgenetic Alopecia or an inflammatory scarring alopecia. Areas such as the eyebrows and eyelashes may also be affected.

Traction Alopecia can occur in young women as well as older women and also in men. In the long run it may result in permanent hair loss. Triangular Alopecia (congenital hair loss in the temporal area) may enter the same differential diagnosis as Traction Alopecia . In the early stages regrowth of hair is possible, with only mild inflammation present. In chronic cases permanent hair loss occurs and there is evidence of microcapillary inflammation, but less than is seen in scarring alopecias. A clinical clue of Traction Alopecia is the “Fringe Sign” because of retained hair follicles in the hair margin (peripheral hairline). The differential diagnosis includes Alopecia Areata; Androgenetic Alopecia; Frontal Fibrosing Alopecia and Triangular Alopecia.

It is often necessary to tease the history from the patient as they are not always forthcoming about specific hair styles and practices. Blunt ended hair breakage is often a sign of use of Heat Devices, eg Hot Combs.

Biopsy specimens from acute lesions of trichotillomania may show peri-follicular bleeding and fractured hair shafts. In later stages we see normal hair follicles surrounded by areas of empty follicles without signs of inflammation present. Less commonly we may see corkscrew like hairs (wavy amorphous type hairs), despite being highly characteristic of Trichotillomania. In chronic cases scarring may be present in the dermis.

As stated above, the treatment of Trichotillomania includes medication and counselling for this Impulse Control Disorder. Hair transplant surgery is not an option for Trichotillomania until the Impulse Control Disorder has been under control for many years.

Traction Alopecia due to styling preferences such as when using Hot Combs; or braides and weaves or cornrows and dreadlocks can be treated with hair restoration surgery provided the patient has adequate donor hair and discontinues the destructive hair styling practices.

– Disorders of Hair Growth, Diagnosis and Treatment, Elise A. Olsen
– ISHRS Basics Course Lecture on, “Identification of Non Androgenetic Pathological Hair Loss”, by Dr. Bernard Nussbaum
– Dr. Andre Nel Hair Restoration practice experience.

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