Managing Traction Alopecia in Black Women

Black women are more likely than other populations to experience traction alopecia due to a higher prevalence of high-tension hair styling practices and intrinsic hair qualities, including hair with lower density and tensile strength, less moisture, and slower growth rates.¹ Although findings on the prevalence of traction alopecia among Black women are mixed, it is estimated that approximately one-third of this population are affected.²

Although traction alopecia can “occur in any race and gender with hairstyles that pull the hair and induce traction, it is very common in [Black] women because African hair is fragile and more susceptible to breakage,” explained Antonella Tosti, MD, a Fredric Brandt Endowed Professor in the Dr Phillip Frost Department of Dermatology and Cutaneous Surgery at the University of Miami in Florida.

In addition to contributing to traction alopecia, some study results indicate a link between the long-term use of traction hairstyles and increased risk for central centrifugal cicatricial alopecia,³ which almost exclusively affects Black women aged between 30 and 55 years.⁴ Such findings further underscore the need to minimize or eliminate the frequency of such hairstyling practices.³

To discuss the mechanisms of traction alopecia and optimal treatment strategies, we spoke with Oma Agbai, MD, Director of the Multicultural Dermatology and Hair Loss Disorders Clinic at the University of California Davis Medical Center in Sacramento, California; and Lisa Akintilo, MD, MPH, FAAD, Cosmetic Dermatologic Surgery Fellow at Skin Associates of South Florida in Coral Gables.

Women of African descent are at increased risk for traction alopecia, and this risk is exacerbated by the use of high-tension hairstyles and duration for which these hairstyles are worn. Can you describe the mechanisms by which these hairstyles contribute to traction alopecia?

Dr Agbai: Forcibly pulling on the hair due to tight hairstyling is thought to induce folliculitis with nonscarring alopecia in the early stages of traction alopecia, which is followed by longer-lasting follicular damage that may lead to scarring alopecia if traction is sustained.

Dr Akintilo: Any hairstyle that induces prolonged scalp tension, hair shaft trauma, or sustained pulling can lead to traction alopecia. Although most commonly seen in Black women, traction alopecia has also been reported in Black men, Hispanic women, Japanese women, Sikh men, and ballet dancers.⁵

Certain styles such as high buns, tight ponytails, braided extensions, locs, weaves, cornrows, and even wigs and hair prostheses can potentially be placed with unwanted tension and pull on the scalp — particularly the temples — which, over time, can distress the hair follicles and cause alopecia. 

Can you describe the current treatment landscape of traction alopecia? How does decision-making in prescribing practices differ between women of color and those of other racial and ethnic groups?

Dr Agbai: One key component in the management of traction alopecia is advising the patient to stop use of any tightly pulled hairstyles to minimize further hair follicle damage.    

Treatment approaches that focus on decreasing inflammation² include the use of intralesional triamcinolone; topical steroids, such as clobetasol ointment; and topical calcineurin inhibitors, such as tacrolimus ointment. In addition, the promotion of hair growth can be achieved by the use of topical 5% minoxidil solution once daily.

Treatments for traction alopecia are similar across ethnicities. However, patients with European or Asian hair types should receive topical solutions, such as clobetasol or fluocinonide solution, rather than ointments, as is common in patients with African hair types. This is based on patient preference and the experience of ointments weighing the hair down for patients with European or Asian hair textures.    

Dr Akintilo: Current treatments for traction alopecia include hairstyling modifications, topical therapies, intralesional treatments, systemic treatments, and surgery.⁵ These treatments include topical steroids, topical minoxidil, topical antibiotics, intralesional steroids, oral antibiotics, low-dose oral minoxidil, and hair transplantation.

Decision-making in prescribing practices for traction alopecia does not substantially differ between patients with differing ethnic backgrounds. What is more important is the patient’s individual curl pattern and how that may affect the formulation of a specific medication. Patients with tighter curl patterns tend to be more amenable to thicker topicals such as ointments, which can be easily blended with routine hair care products, as opposed to creams and lotions, which can be drying to the hair.

Some patients prefer oral medications to topical medications, and some may wish to avoid surgery. Deciding what therapy to pursue depends on shared decision-making between the patient and clinician. There also is ongoing research assessing platelet-rich plasma, topical alpha-1 agonists, and laser/device-assisted drug delivery with growth factors as potential treatments for traction alopecia.⁵ 

What initial therapies are recommended for women of color with traction alopecia? If response to first-line treatment is inadequate, what other options can be considered and which patient factors might be considered in making that decision?

Dr Agbai: When diagnosed early, the first-line therapies previously described have led to hair loss stabilization and partial regrowth or better in the majority of patients I have treated. When these modalities are ineffective, clinicians should consider adding a systemic anti-inflammatory agent, such as oral doxycycline, especially if there are visible pustules signifying signs of perifollicular inflammation.    

Dr Akintilo: My choice in first-line therapy for women of color with traction alopecia depends on the severity of hair loss upon presentation. If very mild, making modifications to hairstyling practices may be enough, or perhaps the addition of topical steroids and/or topical minoxidil.

If hair loss is more moderate, oral therapies such as low-dose oral minoxidil and antibiotics — used for anti-inflammatory purposes — may be indicated. If severe, hair transplantation may be required. Patient input and physician-patient collaboration is required for optimal and satisfactory treatment results. 

Some diagnoses of traction alopecia can be partially attributed genetic predisposition toward hair loss, but preventive measures may lower the risk for predisposed patients. Can you elaborate on lifestyle modifications or other counseling points that may be beneficial for clinicians to share with patients?

Dr Agbai: One thing to avoid is painful hairstyles, as pain may signify excessive traction on the hair follicle in a patient with traction alopecia.⁶

Dr Akintilo: To decrease the risk for traction alopecia, patients should minimize hairstyles that involve prolonged tension or pulling on the scalp, such as low buns and loose ponytails. If a particular hairstyle is painful or causes redness or bumps, it likely is too tight and should be loosened if possible.

Taking breaks between tighter hairstyles and minimizing the combination of chemical straightening with extensions may also reduce the risk for traction alopecia. Collaboration with hair care professionals and stylists can be immensely helpful in mitigating the risk for traction alopecia.

What treatment options are available for patients who experience scarring as a result of traction alopecia?

Dr Agbai: There is perifollicular scarring that is histologically demonstrated in the later stages of traction alopecia. The destroyed hair follicles cannot be regenerated to grow hair again. In these circumstances, hair transplantation or cosmetic camouflage of the scalp may be the best management options. Even in these cases, topical anti-inflammatory therapy and topical minoxidil should be continued in an effort to salvage any viable hair follicles and promote hair growth.    

Dr Akintilo: Scarring is evidence of late-stage traction alopecia. Once the hair follicles have scarred down, the hair cannot regrow as this hair loss is permanent. However, if appropriate measures for traction alopecia are taken as soon as possible, scarring can be prevented and the hair can regrow. For this reason, seeking medical care as soon as possible is key for identifying traction alopecia early and situating patients for treatment success.