Turban Tribulations: Triad of Turban Ear, Traction Alopecia, and Traumatic Acne in a Sikh Patient

Sir,

A teenage girl presented to the dermatology outpatient department with a 3-year history of painful, nonhealing lesions over her ears. She also had several acne lesions over her forehead along with alopecia involving her frontal scalp. Examination revealed several areas of erythematous thickened skin over antihelix and retro auricular folds, approximately at the junction of upper two-thirds and lower one-third on both the ears [Figure 1]. The lesions were mildly tender on palpation. She had several comedones and inflammatory papules over her forehead, while the rest of her face was relatively uninvolved [Figure 2]. Scalp examination demonstrated symmetrical areas of alopecia along the frontotemporal areas along with the presence of short hair scattered along the frontotemporal line (fringe sign), suggestive of traction alopecia [Figure 2]. The three seemingly unrelated complaints could all be explained by the turban headgear that she had been wearing regularly for the last 5 years. She was diagnosed with a turban ear, acne mechanica, and traction alopecia, all stemming from tightly wrapping the turban around her head.

Figure 1.

(a) Erythematous plaque over antihelix with central vertical fissuring, (b) Similar lesions were present in retroauricular folds as well

Figure 2.

Comedones and inflammatory papules over the forehead and symmetrical alopecia along the frontotemporal line, Fringe sign +

Sikhism is a religion that originated in the Punjab region of the Indian subcontinent. Cutting scalp hair is forbidden in Sikhism. The scalp hair is tied up tightly in a plaid, knotted, and covered with a turban. Turban is a long scarf wrapped around the head for protecting the hair and to preserve Sikh identity. Most Sikhs wear it the entire day, removing it only while washing and combing the hair. The lesions on our patient's ear corresponded to the site of maximal contact with her turban [Figure 3] and it was postulated that repeated friction from the garment instigated these lesions. Turban ear has been described previously in the literature[1] and has been compared to acanthoma fissuratum in spectacle wearers, representing a similar response of facial skin to repeated trauma and friction. Acne mechanica is a term used to describe the presence of inflammatory papules and pustules caused by friction from the repetitive rubbing of the skin accompanied by pressure and occlusion. The most common causes of acne mechanica are sports equipment (helmets with chin straps, shoulder pads) and tight garments. In this patient, damage to follicular ostia of the forehead by repeated rubbing due to turban might be the primary event, while continuous occlusion would have hyperhydrated the skin, causing problems in resisting shear force. Traction alopecia is a non-scarring alopecia caused by tight hairstyles and is a common disorder among Sikh patients.[2] Since the hair is knotted in the frontal region, this region experiences the brunt of the trauma. The submandibular region is affected in men who similarly tie their beards.[3]

Figure 3.

Lesions of acne on the forehead (a) and those on the ear (b) coincide with sites of maximum friction with the turban

Management of this condition poses a challenge as the cutting of hair or removing turban is forbidden by the religion. We prescribed the patient a combination of topical benzoyl peroxide and clindamycin for her acne lesions, mild topical steroids (fluticasone propionate 0.05%) to reduce inflammation of lesions over the ears, and topical minoxidil for traction alopecia. She was explained that wearing a turban was the inciting factor of her complaints and only a limited response to treatment could be expected. Since our patient was a female she agreed to trade her turban for a dupatta, a long garment that covers the head but drapes around the shoulders instead of being wrapped around the head. However, this may not be an option in Sikh males. These patients can be advised to tie their hair loosely in the turban, to wrap the turban loosely at base keeping it from creating any pressure points, to use a softer, non-starched garment for the turban, wrapping the ear with cotton wool, and to avoid wearing a turban at night. This case highlights the role of cultural factors in certain skin diseases, which may be important to identify to avoid unnecessary investigations and treatment while facilitating preventive action. Inquiring about the cultural background might be prudent in certain cases to ascertain the origin of the skin complaint.

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Conflicts of interest

There are no conflicts of interest.