Traction Alopecia — SAQ

Stem

A 28-year-old Black woman presents with a 5-year history of progressive frontal and temporal hairline recession. She has worn tight braids with glued-in extensions for 12 years and chemical-relaxes her hair every 6 weeks. On examination, the frontal and temporal hairline is receded with a smooth, shiny, atrophic appearance. There is a retained band of fine, short hairs along the very rim. No active erythema or pustules are seen. The occipital donor area is dense and uninvolved. A pull test is negative.

Questions

a) What is the most likely diagnosis, and which clinical sign confirms it? (2 marks)

• Diagnosis: Late-stage (irreversible) marginal traction alopecia (biphasic mechanical → scarring hair loss from sustained tension).

• The confirming clinical sign is the fringe sign (Samrao 2011) — a retained band of fine, short (vellus) hairs along the very frontal and/or temporal rim, with thinning immediately behind it. It is considered sensitive and specific for marginal traction alopecia and indicates that the marginal follicles are miniaturised but not yet destroyed.

^[5]b) What are the key features in the history that establish the aetiology, and what risk factors are present? (2 marks)

• Tight braids with glued-in extensions for 12 years; chemical relaxer every 6 weeks; high frequency of re-tightening; combined chemical + mechanical injury (the highest-risk pattern for traction alopecia and CCCA in women of African descent).
• Establish the absence of pulling (to distinguish from trichotillomania), the hairstyle history, frequency, weight, pain on styling (Khumalo's warning sign), heat use, and family history of CCCA.

^[2][4]c) What is the differential diagnosis, and how is this distinguished from frontal fibrosing alopecia (FFA) and trichotillomania? (3 marks)

^[3]- Differential diagnosis includes alopecia areata, trichotillomania, telogen effluvium, frontal fibrosing alopecia, lichen planopilaris, androgenetic alopecia, and central centrifugal cicatricial alopecia (CCCA) on the traction spectrum.

• Vs FFA: FFA is a lymphocytic cicatricial alopecia of POST-MENOPAUSAL women, with PERIFOLLICULAR ERYTHEMA, EYEBROW loss, and NO hairstyle history. Biopsy shows a lichenoid infiltrate at the isthmus. Traction alopecia is hairstyle-related, often in younger women, and retains the fringe.
• Vs trichotillomania: Trichotillomania presents with IRREGULAR patches of BROKEN HAIRS OF VARYING LENGTHS ('Friar Tuck' or 'tonsure' sign), psychiatric comorbidity, and a history of PULLING rather than tight styling. The patch is not distributed along the vector of force.

^[2]d) Outline your stepwise management plan, and state the single most important intervention. (2 marks)

• The single most important intervention is to DISCONTINUE the traction-inducing hairstyle (and the chemical relaxer) and adopt loose, natural styles. In late-stage scarring disease this will not regrow hair but it will prevent further loss and is a pre-requisite for any future transplantation.
• Adjuncts (layered on top of hairstyle change):
  • Topical minoxidil 2% (or 5%) twice daily to the affected margin for ≥ 6–12 months.
  • Topical corticosteroid lotion (mometasone furoate 0.1% or betamethasone dipropionate 0.05%) for any residual inflammation.
  • Cosmetic camouflage (wigs, hairpieces, scalp micropigmentation) for immediate psychosocial relief.
  • Hair transplantation (FUE or FUT) for definitive restoration, BUT only when the disease is BURNT-OUT (no active inflammation for ≥ 12 months), the occipital donor is intact (no CCCA), and the patient has realistic expectations (1–3 sessions over 18–24 months; 70–90% graft survival at 12 months in experienced hands).
• Prevention: looser hairstyles, no chemicals on fragile hair, ≥ 4–6 weeks per year without traction, satin or silk sleep cap, no pain on styling.

^[1]e) What is the prognosis, and what determines the outcome? (1 mark)

• The disease is irreversible in its current state; follicles cannot regrow.
• Outcome is determined by duration of traction, severity at presentation, adherence to hairstyle change, donor density, surgical expertise, and psychosocial support.
• A full cosmetic result is achievable with FUE/FUT in 2–3 sessions in an experienced centre; without transplantation, the patient is left with permanent scarring alopecia, which can be camouflaged with wigs, hairpieces, or scalp micropigmentation.