Trichoscopic evaluation of non-marginal traction alopecia: A case series

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Here, we report ten cases of non-marginal traction alopecia. All female patients presented with asymptomatic focal hair loss on the scalp. A patch of hair loss in the middle of the scalp and otherwise very long, normal-looking hair was seen on examination. The patch was irregular, linear, variable in length, and extended from the frontal line to the vertex through the middle of the scalp. No other patches of hair loss were observed on the scalp or any other body part. On further inquiry, patients denied any history of pulling their hair, tying their hair tightly, or using any hot combs, relaxers, tight extensions, or weaves. On trichoscopy, flambeau sign (multiple linear white tracks at the base of the shaft of the terminal hair posterior to the formed fringe), empty hair follicles, hair shafts of different diameters, single follicular units, and peripilar cylindrical cast areas were seen [Table 1] [Figures 1 and 2].

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Figure 1(a):

(inset clinical image) Peripilar whitish scales (black arrows), single follicular units, and Flambeau sign (black circle). (Dermlite DL5, 10x); (b) (inset clinical image) Peripilar whitish scales (black arrows), hair shafts of different diameters, vellus hair, background erythema, empty hair follicles, single follicular units and Flambeau sign (black circle). (Dermlite DL5, 10x); (c) (inset clinical image) Peripilar whitish scales (black arrows), hair shafts of different diameters, single follicular units, vellus hairs and Flambeau sign (black circle) (Dermlite DL5, 10x); (d) (inset clinical image) Peripilar whitish scales (black arrows), vellus hair, empty hair follicles, single follicular units and Flambeau sign (black circle). (Dermlite DL5, 10x).

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Figure 2(a):

(inset clinical image) Peripilar whitish scales (black arrows), empty hair follicles, hair shafts of different diameters, single follicular units, and Flambeau sign (black circle). (Dermlite DL5, 10x); (b) Peripilar whitish scales (black arrows) Flambeau sign (black circle). Enhanced ultraviolet (UV) dermoscopy; (c) (inset clinical image) Peripilar whitish scales (black arrows), empty hair follicles, hair shafts of different diameters, single follicular units, and Flambeau sign (black circle). (Dermlite DL5, ×10); (d) (inset clinical image) Peripilar whitish scales (black arrows) Flambeau sign (black circle) enhanced on UV dermoscopy.

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Scalp biopsy for histopathology was suggestive of traction alopecia [Figures 3a and b]. Eight of ten patients provided consent for scalp biopsy. The most prevalent histological findings were catagen/telogen follicles, empty hair follicles, sebaceous gland preservation, minor perifollicular fibrosis, and mild perifollicular inflammatory infiltration. These findings confirmed our diagnosis of non-marginal traction alopecia. They were advised to cut their hair to a shorter length and apply a topical 2% minoxidil solution twice a day, which improved their alopecia within a few months.

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Figure 3(a):

Catagen/telogen hair follicles, mild perifollicular fibrosis, empty hair follicles, and the presence of normal sebaceous glands (H&E, 10x); (b) No evidence of perifollicular inflammatory infiltrate (H&E, 40x). H&E: Hematoxylin and eosin stain.

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Traction alopecia is a type of patchy alopecia that occurs as a result of chronic tensile forces on the hair. It results from prolonged traction on the scalp due to physical pressure, due to different hairstyles such as tight braids, tight ponytails, cornrows, dreadlocks, or due to hair treatment with rollers or extensions.^[1] Traction alopecia is of two types: Marginal and non-marginal.^[2] Marginal traction alopecia is the more frequent type, typically involving the frontoparietal scalp, while non-marginal traction alopecia can affect any part of the scalp.^[2] Recently, it has been noted that non-marginal traction alopecia can be caused by the excessive weight of very long, non-manipulated hair. Alejandro et al., called this type of non-marginal traction alopecia Rapunzel alopecia.^[1]

Traction alopecia often produces a recognizable pattern of hair loss, typically presenting as marginal alopecia, but it can involve any area of the scalp, depending on the hairstyling practice undertaken. Marginal traction alopecia affects patients whose hair is drawn firmly back. The “fringe sign” is characteristic of this type of alopecia - the hair along the frontal hairline is retained. Still, it is attenuated or finer in caliber, and the area of alopecia is present behind this “fringe”.^[1,2] Non-marginal traction can involve any area of the scalp. One such type is chignon alopecia, reported by Trueb as localized alopecia of the occipital scalp, wearing of a bun (chignon).^[3] In addition, in a report by Hwang et al., seven South Korean nurses developed localized parieto-occipital alopecia at the site where the cap was attached to the scalp by two bobby pins.^[4] Submandibular alopecia can also occur as the Sikh men tie their beards into tight knots that sit on the chin. Non-marginal traction alopecia should be ruled out in cases of persistent alopecia areata.^[2] The earliest clinical sign of traction alopecia is perifollicular erythema, which may lead to the development of pustules and papules. Eventually, hair loss may become persistent if the traction is continuous and may lead to scarring.^[1,2]

Differentials include alopecia areata, female pattern hair loss (FPHL), and tinea capitis. Alopecia areata shows yellow dots, exclamation mark hairs on trichoscopy, and characteristic peribulbar lymphocytic infiltrates on histopathology; tinea capitis is distinguished by broken hairs and perifollicular scaling with fungal elements; and FPHL is distinguished by diffuse mid-frontal thinning with a higher proportion of miniaturized hairs and an increased hair-diameter diversity with preserved follicular openings but an increased vellus ratio. It is critical to separate non-marginal traction alopecia from these causes of localized alopecia. Because traction alopecia and FPHL may be found to overlap in a single patient, we recommend close monitoring and, if the diagnosis is clinically equivocal, repeated trichoscopy or scalp biopsy to confirm the diagnosis [Table 2]. Flambeau sign present on dermoscopy could be correlated to the hyperkeratosis, collagen homogenization in the papillary dermis, perivascular infiltration of lymphocytes and histiocytes in the upper and mid dermis, mild perifollicular fibrosis, and reduced terminal hair density on HPE.^[5,6]

Treatment of traction alopecia in the early stages, include measures aimed at reducing tension on hair follicles, including avoidance of hairstyles that increase tension on the hair, such as tight ponytails and braids.^[2] Other strategies include complete avoidance of chemicals or heat and brushing the affected area. If signs of inflammation are present, such as scaling, erythema, or tenderness, topical or intralesional corticosteroids are recommended. Pustules may be treated with oral or topical antibiotics. In advanced stages, promising results have been shown by topical 2% minoxidil.^[2,5] In cases where scarring has occurred, surgical options such as hair transplant using techniques such as micro-grafting, mini-grafting, and follicular unit transplantation are effective. Recently, alpha-1 adrenergic receptor agonists, such as topical phenylephrine, have been advocated.^[6]