Nocturnal Traction: Techniques Used for Hair Style Maintenance while Sleeping May Be a Risk Factor for Traction Alopecia

Abstract

Background

Traction alopecia (TA) is a preventable form of hair loss that most commonly affects women. It is the result of chronic use of hairstyles that put tension on hair. Public health efforts to increase awareness of this condition are critical. Early recognition by health care providers, along with counseling and cessation of offending hair care practices can impact severity of hair loss.

Objectives

In a patient with patchy hair loss, having a high index of suspicion for TA and looking for clues in the history and exam, can help establish an accurate diagnosis.

Methods

Patients with afro-textured or curly hair may use various techniques to maintain their hairstyles while sleeping in order to avoid time-consuming and/or expensive hair care. This behavior is not commonly recognized or addressed.

Results and Conclusions

Increased awareness of “nocturnal traction” and asking patients “How do you wear your hair when you sleep?” may help identify at-risk patients.

Established Facts

• Traction alopecia (TA) is a nonscarring alopecia that primarily affects women.

• TA is the result of ­chronic use of hairstyles that cause prolonged tension on the hair follicle.

Novel Insights

• History of hairstyles worn at night may aid in determining the etiology and diagnosis of traction ­alopecia.

• Awareness of nocturnal hairstyles will aid in appropriate counseling regarding hair care ­practices to prevent progression of TA.

Introduction

Traction alopecia (TA) is a form of hair loss that results from prolonged or repetitive tension on hair. Making the diagnosis often requires a high clinical suspicion, a detailed history of current and past hair care practices, and histologic evaluation. Early recognition and cessation of the offending hair care practice are critical because sustained traction can lead to permanent hair loss. Diagnostic pitfalls are particularly common in TA since the clinical presentation can vary widely depending on the hairstyle, hair type, and duration of tension. Further obscuring the diagnosis is the biphasic nature of the histologic findings.

Additionally, certain hairstyles are more likely than others to place tension on the hair. High-risk hair hairstyles include braids, weaves, extensions, buns, and ponytails among others [1, 2]. Asking detailed questions about type and duration of hairstyles over time is essential. In addition to hairstyles that may place tension, the concomitant use of chemicals and/or heat may increase the risk of TA [3]. In this article, we propose that it is helpful to inquire about nocturnal hair care practices as part of the hair history. Asking patients “How do you wear your hair when you sleep?” is helpful in the identification and diagnosis of additional at-risk patients.

Case Presentations

Patient 1 is a 54-year-old African American woman with a history of hair loss of many years. She first noted thinning along her hairline when she was 18. Though her hair regrew, she again developed hair loss in her 20s along her “edges” which never fully regrew. Her hair loss had been progressive over the years to the point where she now wore a wig. Upon questioning, she reported styling her hair in a “press and curl” style for most of her life. She denied ever using braids or weaves. Upon further questioning, she admitted to often wearing her hair in tight curlers overnight to maintain her style and did report itch and irritation of her scalp on a regular basis. On exam, she had short afro-textured hair with patchy alopecia along the temporal scalp bilaterally (Fig. 1). A fringe sign was noted, as were 3 triangular or “pie slice” patches of alopecia along the temporal scalp which the patient confirmed corresponded to where she would typically place her rollers. On dermatoscopic exam, follicular markings were diminished, and no evidence of scalp inflammation was noted. A 4 mm scalp biopsy was performed and was consistent with a diagnosis of TA showing a decreased terminal hair count with follicular dropout and miniaturization of hair follicles.

Fig. 1.

Patient 1 with patchy alopecia along the temporal scalp bilaterally. A “fringe sign” was noted, as were 3 triangular/“pie slice” patches of alopecia along the temporal scalp which corresponded to where patient placed rollers at night.

Patient 2 is 23-year-old woman of Middle Eastern descent who was seen in the dermatology clinic for hand dermatitis. She was incidentally noted to have a high, tight, ponytail with some thinning along the temporal edges. She had been wearing that hairstyle since high school. Since her hair was long, thick, and curly, she typically only let her hair down in the shower when she was washing it, but otherwise kept it tied up, even at night when she was sleeping, for ease of manageability. She did have some occasional scalp tenderness. On exam, she had decreased hair density bilaterally along the temporal scalp with a fringe sign (Fig. 2). Her follicular markings were noted to be intact on dermatoscopic exam, and she had no signs of scalp inflammation. A clinical diagnosis of early TA was made, and the patient was counseled on gentle hair care techniques.

Fig. 2.

Patient 2 with decreased hair density along the temporal scalp bilaterally. A fringe sign was noted.

Discussion

TA most commonly affects adult women but can occur at any age [2, 4]. In early stages of TA, hair loss may be absent or be limited to minimally decreased hair density. Perifollicular papules, erythema, or sterile pustules can be seen in some cases. It is difficult to quantify tension from hairstyles, and each individual will have a different threshold at which damage may occur. However, patients who develop symptoms with hairdressing (including pain, pimples, stinging, or crusts) have been shown to be at increased risk of developing TA [3, 4, 5].

Marginal TA, one of the most common patterns of hair loss, affects the frontal and temporal scalp above the ears. This pattern is seen most often with hairstyles that pull the hair away from the face such ponytails, buns, or braids. Nonmarginal TA can occur as a result of various other hair care practices such as pins used to secure hats [6], or other regular use of hair accessories [7, 8]. Linear, horseshoe, or stippled patterns of hair loss can occur when hair is styled with hair extensions or weaves [8, 9]. The fringe sign, which is defined as fine or miniaturized hairs retained at the hairline, can be a helpful clue in identification of marginal TA [1, 10]. It can also be helpful in differentiating TA from other types of hair loss that can affect the hairline such as frontal fibrosing alopecia or ophiasis pattern alopecia areata [2]. Dermatoscopic examination can be a useful tool in the diagnosis of TA. In addition to more readily identifying casts, dermoscopy may be helpful in visualizing whether follicular ostia (pinpoint white dots) are present, which can be diminished in persistent TA [11, 12].

The 2 patients presented here illustrate the importance of having a high index of suspicion for TA in patients with patchy alopecia as well as the need for a detailed history of hair care. Patient 1 did not have a usual hairstyle thought of as high risk for TA; however, questioning her about her night-time hair care uncovered the use of curlers which were the likely culprits in causing hair loss. Patient 2 had a typical hairstyle that prompted concern for TA; the additional information that she maintained the high, tight, ponytail at night helped confirm the diagnosis and assisted in appropriate counseling.

These patients with “nocturnal” traction highlight another issue which is not commonly discussed or addressed: those with afro-textured or curly hair may use various techniques to maintain their hairstyles while sleeping in order to avoid time-consuming (and sometimes expensive) hair care. Hairstyles such as braids, locks, weaves, and extensions that are kept for many weeks are considered to be high risk for TA and are by nature unchanged at night. However, braids and locks can be pulled up or twisted either for styling or for maintenance, so a discussion of avoidance of further traction at night is still relevant. Other hairstyles that rely on intermittent application of heat may be maintained in a way that places tension on the hair such as with curlers or ponytails. Prior studies have shown that the combined use of heat or chemicals with traction may be particularly damaging [3]. Additionally, the duration, length, and weight of hair or hair extensions may contribute to TA, as may the duration of wearing a certain hairstyle [3]. Although there is no evidence-based data, the use of silk scarves, bonnets, and pillows at night has been advocated to help with hair maintenance and to avoid hair breakage. However, use of tight-fitting head wraps at night can themselves contribute to TA in patients who have other risk factors for TA (AM personal observation).

An increased awareness of techniques used for hair maintenance and hairstyling, while sleeping may help identify patients at risk for TA. Early identification coupled with appropriate counseling and education can be critical in reversing hair loss in its early stages and preventing permanent follicular damage.

Statement of Ethics

Subjects have given their written informed consent to publish photos and details of the case.

Conflict of Interest Statement

The authors have no conflicts of interest to declare.

Funding Sources

The authors did not receive any funding.

Author Contributions

Paradi Mirmirani, MD contributed to the study design and drafting of the manuscript. Aman Samrao, MD contributed to drafting of the manuscript. Amy McMichael, MD contributed to clinical observations and editing of the manuscript.