Introduction

What is traction alopecia?

Alopecia simply refers to hair loss, which may be partial or complete, and can occur in one or multiple areas of the scalp. Hair loss may be gradual or sudden, and its progression can vary.¹

Traction alopecia is a type of hair loss caused by continuous and repetitive pulling on the hair. It typically affects the anterior (frontal) and lateral (side) regions of the scalp. In its early stages, traction alopecia is reversible; however, if the pulling continues, it can become irreversible.

How traction alopecia specifically affects children: an overview

Traction alopecia in children is commonly associated with hairstyles that exert tension on the hair. The extent of hair loss depends on both the intensity of the pulling and the duration for which the hairstyle is worn. The pattern of alopecia depends on the type of hairstyle used.

A study of 200 African girls (aged one to 15 years) who wore braids, cornrows, or ponytails revealed that prolonged use, especially of cornrows for over 12 months, led to hair thinning. In many cases, chemical relaxers used to straighten the hair for these styles further contributed to hair fragility and loss.²

Some children of African descent add beads or barrettes (bar-shaped clips) to their braids, which worsens the situation and adds more traction.

Traction alopecia is most prevalent in children of African descent but is not exclusive to them. For example:

• Hispanic girls often wear tight ponytails, which may lead to hair loss over time
• Sikh boys may wear turbans tied tightly, causing frontal alopecia
• Similar effects are seen in children from other backgrounds due to cultural or religious hairstyling practices²

Importance of early diagnosis and treatment

Hair loss in children under the age of 12 can indicate the presence of various underlying conditions, including:³

• Fungal or bacterial infections (e.g. tinea capitis, folliculitis, head lice)
• Inherited forms of alopecia
• Structural hair shaft abnormalities
• Traction alopecia 

Early diagnosis is essential to identify the exact cause, begin treatment promptly, and prevent permanent hair loss. It is crucial that parents consult a paediatrician as soon as signs of hair loss are observed to minimise potential psychological impacts such as low self-esteem, bullying, depression, and social withdrawal.³

Causes of traction alopecia in children

Traction alopecia is primarily caused by excessive and repeated pulling on the hair, which damages the hair follicles. This repeated tension can lead to inflammation, manifested by redness and papules (raised lesions) on the scalp. Over time, this damage can become permanent, leading to irreversible hair loss.² 

Tight hairstyles

Wearing tight hairstyles such as braids, cornrows, ponytails, weaves, deadlocks, and buns for a long period of time throughout an individual’s lifetime can result in hair thinning, receding hairline, and hair loss.² A study found that people with tight hairstyles developed “tenting" in their scalps, which is raised scalp or bumps in the scalps due to the hair pulled into a tight twisted hairstyle, like a braid.⁴

Cultural hair practices

Hairstyles are a form of self-expression. People from different cultures, religions, and professions often have distinct ways of styling their hair or wearing head coverings to reflect their identities. For example:² 

• Individuals of African descent often wear tight braids, weaves, or cornrows
• Sikh person assigned male at birth (AMAB) typically tie their hair tightly under a turban
• Muslim person assigned female at birth (AFAB) may wear hijabs (head covers) wrapped tightly around the scalp
• Rastafarians wear tightly twisted dreadlocks
• AFAB athletes, dancers, and healthcare professionals often wear tight buns or caps

All these are examples of how people express themselves through hairstyles, but these hairstyles, after a long period of time, can cause traction alopecia and hair loss.

Environmental factors

One of the environmental factors is the use of chemical relaxers (straighteners), particularly among individuals with Afro-textured hair.⁴ These chemical relaxers break the chemical bonds naturally found in the hair strand, making it fragile and easily broken. A study found that:

• 59% of South African girls who used chemical relaxers developed traction alopecia
• 80% of African American girls who used relaxers experienced similar hair loss⁴

Risk factors

Age

Traction alopecia is a progressive condition; thus, adults are generally more affected than children. A study found that 31.7% of adults AFAB, had traction alopecia, compared to 9.4% of children. Similarly, another study showed that 8.6% of female children aged 6–7 years had traction alopecia, while 21.7% of AFAB aged 17–21 had it. However, some researchers argue that children may be more susceptible due to the delicacy of their hair follicles. A Nigerian study supported this, finding traction alopecia in 18.4% of female children aged 1–15, compared to 7.7% of adult AFAB.⁴

Hair type

African hair types are more vulnerable to traction damage due to their structure. African hair strands are asymmetrical and helical, with a kidney-shaped cross-section. This irregular shape creates weak points along the hair shaft, making it more prone to breakage compared to the rounder strands seen in Asian and European hair types.²

Symptoms and early warning signs

Thinning hair along the hairline 

Hair thinning is one of the early signs of traction alopecia, and it starts in the place where traction is exerted the most. Usually it is the frontal and side parts of the scalp, depending on the hairstyle.²

Redness, tenderness, or scalp irritation

The alarming signs that can help with early diagnosis and treating alopecia, while still reversible, are redness of the scalp and presence of papules and pustules in the scalp.²

Gradual hair loss in patches

After the initial signs of traction alopecia, the actual hair loss starts gradually in two different patterns:

Marginal hair loss

Marginal hair loss is the common hair loss pattern. It happens in the frontal and side parts of the scalp and is associated with the “fringe sign”, which means that there is hair thinning around the patch where the hair is lost.²

Non-marginal hair loss

Non-marginal hair loss is less common, and its pattern depends on the hairstyles causing the hair loss. The hair loss is usually in places other than the frontal and side parts of the scalp.²

Prevention strategies

Avoid tight hairstyles

Avoid tight hairstyles or at least avoid wearing them all day to prevent traction alopecia.⁴ If you decide to wear a braid, a bun, or a ponytail, make sure the frontal part is loose and not pulled tight.⁵

Alternating hairstyles

If you want or have to wear a tight hairstyle, then make sure that you give your hair a break from it. For example if you wear a tight ponytail in the day make sure that at night you wear a loose and relaxed hairstyle

Try to alternate constantly between tight hairstyles and relaxed hairstyles to give your scalp and hair a chance to relax from the mechanical damage tight hairstyles cause.⁵

Hair care education 

Parents and carers should be educated about the importance of avoiding tight hairstyles to avoid traction alopecia in children.⁴ Children should also be taught to express themselves whenever they feel pain or discomfort (pulling or irritation) from the hairstyle so that the carer can avoid it.⁵

Psychological and social impact

Self-esteem and emotional well-being

When dealing with a child with traction alopecia, we must consider their feelings and the condition’s psychological impact on them. Children with traction alopecia may suffer from low self-esteem and depression that can lead to self-isolation.

They might as well face bullying in school, which can worsen the situation. Children with severe hair loss might need wigs or hair extensions to help them with how they feel towards the condition.³

Summary 

Traction alopecia is a condition of hair loss due to hair pulling in tight hairstyles. Many cultures and religions include different hairstyles or head coverings that, with time, can cause hair loss due to constant hair pulling. Lots of children, especially female children, suffer from traction alopecia due to these tight hairstyles, which can immensely affect their self-esteem and self-confidence. People of African descent are more prone to this condition due to hair texture and traditional styling practices. Early detection and intervention are crucial to prevent permanent damage. Education and awareness among carers, combined with psychological support for affected children, are essential in managing this condition.