An Uncommon Phenomenon: Traction Alopecia Causing Ulceration

Ulceration as a Complication of Traction Alopecia in a Nine Year Old Girl

Traction alopecia is a form of hair loss whereby pulling forces on the hair cause hair loss. Patients with traction alopecia often develop redness around the hairs (perifollicular erythema) and tingling, itching or ternderness and headaches in the earliest stages followed by papules and pustules as the pulling continues. Tenting can also be seen and this is a phenomenon whereby the skin is raises around the hair in patients who pull the hair tight. Khumalo showed in 2008 that 81.1% of patients with traction alopecia TA had a history of symptoms during hairdressing.

If traction alopecia is immediately recognized and the pulling forces stopped, hair can recover and permanent hair loss becomes less likely. However, if the traumatic hairstyling is not stopped, inflammation in the scalp facilitates the devlopment of fibrosis (scar tissue) within the dermis and permanent destruction of hairs.

Traction alopecia can occur in many different racial backgrounds. Black patients are at high risk due and it has been estimated that one third of black women experience traction alopecia.

A Unique Case of Ulceration after Synthetic Extension Placed into Lemonade Braids

A recent report in the journal Pediatric Dermatology described a 9-year-old African American girl who developed a scarring alopecia after a challenging situation. She first styled her hair with synthetic extensions into “lemonade braids” If you are not familiar with lemonade braids, they are side swept cornrows. The hair style received its name from Beyonce's 2016 album “Lemonade” in which she herself had a side cornrow style. To review in detail the Lemonade braiding style, please see this helpful video

The girl denied pain during braid placement but described the braids as “tight” once finished.

Three days later, the patient complained of headache with scalp pruritus and pain.

The patient’s mother noted that the braid on the crown of the head seemed tighter than the surrounding braids, with associated swelling at its base. Upon removal, the her mother noticed “blisters and sores” on the vertex of the patient's scalp. The hair in that area fell out over the following days.

The patient saw her primary care physician recommended washing her hair with Dawn dish soap twice weekly and prescribed an oral antibiotic, ketoconazole shampoo, and a topical antibiotic ointment twice daily. Despite the adherence to this treatment regimen, the patient's conditioned worsened and she was brought to the emergency department. This was 11 days after putting in the Lemonade braids.

In the emergency room, the patient was found to have no fever. She was seen by the dermatology service. It was noted that she did have irregularly shaped ulcerations within a large patch of hair loss on the vertex scalp. Bacterial cultures came back with only normal flora.

All in all, the final diagnosis was the skin necrosis and ulceration due to trauma from traction of the braid. The authors considered other diagnoses but nothing fit. Contact dermatitis was not likely give that the ulcers occurred on only one area and the synthetic hair was placed all over. There were no glues or known irritants/allergens were used during the braiding process.

The patient was sent home with recommendation to stop the oral antibiotic and stop ketoconazole shampoo. She was advised to wash the scalp with a mild cleanser twice daily, and then apply mupirocin ointment and a petrolatum-soaked dressing. She was followed closely by the dermatology team for several months for monitoring of healing. After 11 weeks of treatment, the ulcer had resolved but there were residual left over areas of scarring alopecia. At the 6-month follow-up visit, the young girl did have a large amount of regrowth but there were small areas of permanent hair loss.

Comment

This was an interesting case given just how uncommon it is to have ulcers with traction alopecia. The authors felt the weight of the synthetic extensions together with the tightness of the braids and then swellign that it also generated created ischemia. What was important to note here is just how quickly the hair loss occurred. Typical traction alopecia areata creates issues over many weeks. Here is was just a matter of days after synthetic hair placement before issues developed.

The authors of this study remind us that most of the cases of significant scalp ulceration with hairstyling have been reported in African American patients. The authors propose that black individuals may not only be at increased risk for traction alopecia but also acute traction induced scalp ulceration.

Traction alopecia is an important issue in pediatric patients. It is common and often misdiagnosed. Many children and adolescents use hairstyles that cause traction. The early intervention is key and this really comes from early recognition. We really do need to be comfortable advising parents about traction in a respectful manner. It’s not so much a discussion with parents that hairstyles need to be completely stopped but rather modified to reduce the risk of traction. Completely stopping certain practices may be viewed as unrealistic, impractical and lead to loss of trust between parents and the provider if it comes to be felt that providers don’t understand the importance of certain practices. One must never shame parents and patients. Parents can be encouraged to avoid tight pulling of hair and to take breaks every few weeks to let hair down.

Hairstyles are important so it’s not so much a discussion about what hairstyles to use or not to use but rather an understanding of the possibility of permanent hair loss if traction does occur. Headaches, tingling, redness, bumps and pustules are all signs that traction alopecia could be present. As mentioned, Khumalo et al showed in 2008 that 81.1% of patients with traction alopecia TA had a history of symptoms during hairdressing. Pain that occurs after hairstyling is one of the earliest symptoms of traction alopecia and must be given a lot of attention. It does not occur in all patients with traction but it extremeley improtant to take note of. Some parents and patients have come to learn that these symptoms are just a normal expected part of having certain hairstyles. Education is therefore needed to clarify these types of long held views. This is important information to share with parents. Symptoms are the body’s way of saying that the hairstyle is too tight. Khumalo et al also showed that patients with tight painful braids or pimples developing at the base of hairs have a nearly two fold increased risk of traction.

Traction alopecia can occur in children and adults of all racial and ethnic backgrounds. However, the risks are increased in black patients with tight curl patterns. We know that the risks of traction are even further increased if traction hairstyles are applied to thermally or chemically relaxed hair. This seems to compound the risk.

Traction alopecia can happen anywhere on the scalp. TA affecting black patients may be categorized into three main subtypes: anterior hairline, ophiasis pattern, and patchy. It often occurs in the frontal scalp but it can occur in other areas where pulling of hairs is occurring. Glued and sewn in weaves increase the risk for a variety of patterns affecting the back of the scalp.

REFERENCE

Johns HR et al. Acute onset traction-associated ulceration and alopecia.  Pediatr Dermatol 2021 Nov;38 Suppl 2:103-105.

Khumalo NP et al. Determinants of marginal traction alopecia in African girls and women. J Am Acad Dermatol. 2008;59:432-438.