Knowledge of Traction Alopecia and Hair Care Practices among Adolescents in Keffi, North-Central Nigeria

Abstract

Background

Traction alopecia (TA) is the commonest cause of hair loss among women, with a prevalence of 46.2% in Nigeria. Adequate knowledge and good hair care practices can assist in its prevention.

Objective

The aim of this study was to determine knowledge of both TA and hair care practices among adolescents in Keffi, Nigeria.

Methods

This was a cross-sectional survey conducted among 333 female adolescents in 3 senior secondary schools between November 2019 and February 2020. The participants were randomly selected and interviewed using a questionnaire which sought information about the knowledge of TA and hair care practices. The data were analysed using SPSS 25 statistical software.

Results

Overall, the knowledge score was poor in 61.4% of the adolescents. Hair plaiting 86.8% (289/333), use of chemical relaxers 68.8% (229/333), and use of hair covers 88.3% (294/333) were the predominant hair care practices. In total, 90.8% had concurrently relaxed and plaited their hair. Cornrows with own hair were the commonest hair grooming style. The use of hair attachments was believed to be the commonest cause of TA. The use of hijab was the commonest form of hair cover used.

Conclusions

The knowledge of TA is poor among female adolescents. A large number engaged in risky hair care practices. Interventions to reduce the knowledge gap will reduce the prevalence of TA.

Key Message

The knowledge of traction alopecia is poor among female adolescents in Keffi who engage in traumatic hair practices.

Introduction

Traction alopecia (TA) is hair loss resulting from sustained pulling of the hair due to hairstyle or hair care practices [1]. It is characterized by a temporary loss of marginal terminal hair which can progress to permanent hair loss. It occurs in all races but more common among women of African descent [2, 3, 4].

There is limited information about the knowledge of TA among the younger population. Among South Africans, Khumalo et al. [4, 5] reported that 31.7% of women and 9.4% of children had TA. A community-based study among young women in southern Nigeria reported that TA was the commonest cause of hair loss, with a prevalence of 46.2% [6]. Among the adolescents, the prevalence of TA was 35.6%. In these reports, the knowledge of TA among the participants was not studied.

Multiple factors including individual hairstyles have been implicated in the development of TA. Frequent wearing of tight buns and braids with hair extension is known to increase the risk of TA [4, 5]. The act of chemical relaxation of the hair also adds to the risk [7]. Cultural, religious, and occupational practices that increase the tension across the hair also increase the risk of TA [2, 8]. TA is commoner among older women [5, 6].

TA is characterized by loss of marginal terminal hairs with fringe sign (rim of hair at the hairline), predominance of vellus hair, occasional papules, redness and inflammation at the base of the hair (folliculitis), irreversible alopecia, and perifollicular casts on trichoscopy [9, 10, 11, 12, 13]. Various reports had described 5 patterns of TA linked to the hairstyles among different groups [1, 14, 15, 16, 17]. Early identification of hair care practices that predispose to TA is crucial.

There are reports of preferred hair care practices among young women in various countries in Africa. In southern Nigeria, more women prefer natural hair than the relaxed hair [6]. However, in South Africa, the majority of young women had relaxed their hair and styled as ponytails or tight buns [5]. These practices continue into adulthood and could contribute to the observed rising frequency of TA among older women. Hence, determination of effective intervention programmes to reduce the prevalence of TA in the adult population is important.

Materials and Methods

This was a cross-sectional survey carried out among adolescents (10–19 years) selected from 3 senior secondary schools in Keffi, Keffi LGA, Nasarawa state, Nigeria, from 4 November 2019 to 26 February 2020. Ethical approval was obtained from the Health Ethics Research Committee of the Federal Medical Centre, Keffi, Nasarawa state. Permission was obtained from the Keffi Zonal Inspectorate of Education and the principals of the schools. Students from private schools were not recruited for the study because their principals declined participation in the study. Informed consent was obtained from both parents or guardians and students. A total of 333 female adolescents were randomly selected from 3 public senior secondary schools which were randomly selected from the list of public senior secondary schools obtained from the Keffi Inspectorate of Education. The students were interviewed using a structured questionnaire which sought information regarding their demographic details, knowledge of TA, and common hair care practices.

Data Analysis

Data were analysed using SPSS 25 statistical software. The age was represented as mean with standard deviation and was subsequently grouped into early adolescence (10–14 years) and late adolescence (15–19 years). Categorical variables were represented as proportions. To assess the knowledge of TA, each of the 5 questions was scored one for every positive response. The score for each participant was calculated as the sum of the positive answers. The overall score was graded as poor if the score is <3 but as good if it is 3 and above.

Result

The data from 333 female adolescents were analysed. The mean age of the participants was 16.11 ± 1.57 years. The other demographic variables are shown in Figure 1.

Fig. 1.

Demographic features of the participants.

Knowledge of TA

There was poor knowledge of TA as only 27.3% (91/333) were aware of TA (shown in Fig. 2). The overall score of their knowledge about TA was poor in 61.3% (204/333) of the respondents. The other details of the knowledge of TA are shown in Figure 2. Participants were aware that different styles could lead to TA (shown in Table 1), but the use of attachments for hair extension was considered as the most likely cause of hair loss by 28.2% (96/333) of the respondents. Cornrows with own hair which was the commonest hairstyle among this age group were not considered as a cause of hair loss.

Fig. 2.

Knowledge of TA among female adolescents in Keffi, north-central Nigeria. TA, traction alopecia.

Table 1.

Distribution of common hairstyles and risk of alopecia

Usual hairstyle of participant	Frequency	Percentage
Braids with attachment*	44	13.2
Weaves attachment*	27	8.1
Tight buns*	16	4.8
Ponytails*	5	1.5
Threading*	24	7.2
Cornrows with own hair	138	41.4
Natural	79	23.7

^*Hairstyles that can cause alopecia according to the participants.

Hair Care Practices among Adolescents

The respondents engaged in various hair care practices. The acts of hair plaiting 86.8% (289/333), relaxing the hair 68.8% (229/333), and covering the hair 88.3% (294/333) were the common ones. Making cornrows (shown in Fig. 3a) with own hair 44.1% (138/333) was the commonest hairstyle. The distribution of usual hairstyles is shown in Table 1. A large number, 79.6% (230/289), experienced discomfort after plaiting hair, with 76.1% experiencing pain, while the rest experienced rashes and itching.

Fig. 3.

Common hairstyles among adolescents in Keffi, north-central Nigeria; cornrows (a), tight buns (b), braids with attachment (c), and threading (d).

Among those with relaxed hair, 63.8% (146/229) relaxed their hair > once per year. A wide range of relaxers were used in this age group, but the Ozone brand was the commonest one used by 39.3% (90/229). Majority, 59.6% (137/229), applied the relaxer to the whole hair, while others applied to the undergrowth only. Only 28% (64/229) visited hairstylists to relax their hair, while the rest engaged friends or relatives. In 40.2% (92/229), the relaxer was washed off following painful sensation, 29.3% (67/229) left it for >20 min, while 20.5% (47/229) washed it off in <20 min. Overall, 90.8% (208/229) of the participants who relaxed their hair also plaited it, while the rest wore tight buns or ponytails (shown in Fig. 3b).

The practice of covering hair involved the use of scarf (26.2%), hijab (44.6%), and cap (28.6%) in most cases. More participants, 51.4% (151/294), used hair cover for >6 h a day, while the others used hair cover for <6 h a day. The details of other hair care practices are shown in Table 2.

Table 2.

Hair care practices among adolescents in Keffi, Nigeria

Hair care practice	Frequency	Percentage
Hairstyle holiday
Yes	86	25.8
No	247	74.2
Barb hair
Yes	95	28.5
No	238	71.5
Use of hair glues/bond
Yes	107	32.1
No	226	67.9
Use of hot combs or tongs
Yes	143	42.9
No	190	56.3
Plaiting hair
Yes	289	86.8
No	44	13.2
Relaxing hair
Yes	229	68.8
No	104	31.2
Using hair cover
Yes	294	88.3
No	39	11.7
Hair care products
Yes	282	84.7
No	51	15.3
Which hair care product you use
Oils	150	53.1
Ointments	37	13.1
Creams	95	33.7
Frequency of washing the hair
Daily	54	16.2
Twice weekly	113	33.9
Once weekly	128	38.4
Fortnightly	8	2.4
Others	30	9.1
What you use for washing hair
Only water	21	6.3
Shampoo	261	78.4
Regular bathing soap	48	14.4
Sponge	3	0.9

Those who had natural hair were 31.2% (104/333). Out of these, 81 (77.9%) usually plait their hair, while the rest did not.

There was no practice of colouring or dying of the hair reported among the participants. The poor knowledge about TA cuts across all the participants as there was no significant association between the knowledge of TA and demographic factors like the age group, tribe, religion, and family economic status.

Discussion

This is the first study to assess the knowledge of TA and hair care practices among adolescents in north-central Nigeria. There was poor knowledge of TA among the study group. Hair care practices among adolescents were characterized by mainly hair plaiting, use of chemical relaxers, and hair covers.

There were no previous assessments of knowledge of TA among adolescents in Nigeria. However, TA has been reported among adolescents in Nigeria [6]. Similarly, TA has been reported in similar age group in other African countries and African Americans [5, 18]. However, there are no reports on knowledge of TA among this age group. The poor knowledge about TA among the participants could be related to low public awareness of TA among adolescents and the fact that TA is of gradual onset and becomes prominent only later in life.

The predominant hair care practices among the adolescents were plaiting of different styles, relaxing the hair, and the use of hair covers. A large number of the participants plaited their hair with various braiding and threading patterns. Different braiding styles have been reported among Africans [19]. Cornrows with own hair were the commonest hairstyle among the participants. Cornrows have been reported as one of the common hairstyles among young women of African descent [18]. In addition, TA has been reported among young girls of African descent wearing cornrows [18]. Other plaiting styles among the participants were braiding with attachment (shown in Fig. 3c) and threading (shown in Fig. 3d). The use of attachments was reported as the commonest hairstyle associated with TA by the participants. Attachments increase traction along the hair because of the increased weight and have been reported as one of the risk factors for TA [19].

Straightening of the hair using chemicals (relaxing the hair) was common among the participants. This is a known hair care practice among Africans [6, 20]. Relaxed hairs are believed to be easier to manage and more beautiful than the natural hair. However, this practice has been reported as one of the risk factors for TA [20, 21]. In our study, majority of those that relaxed their hair also plaited, thus further increasing the risk of TA. Few numbers of the participants with relaxed hair wore tight buns and ponytails. According to Sani et al. [6], majority of young women from southern Nigeria kept natural hair. This may be related to cultural differences between the 2 regions. The women from the north tend to routinely beautify their skin with Henna paintings and other beauty practices which may include straightening the hair during marriages and other special celebrations [22]. In addition, Khumalo et al. [5] reported a high frequency of relaxing hair among young women in South Africa with a significant number of them wearing tight buns and ponytails. Similarly, among young African-American girls, wearing ponytails was the predominant hairstyle [18]. The duration of applying the relaxer varies among the adolescents, with more of them washing off the relaxer when they start experiencing pains. This lack of uniformity was also reported by Sani et al. [6] among the young females in southern Nigeria. Few of them visited professional hairstylists, leading to the reported variation in the duration of applying the relaxer.

Many of the participants use hair covers like scarf, hijab, or cap. This is related to religious/cultural identity of the community. Islam and Christianity were the predominant religions of the respondents. The use of hijab is mandatory for young female Muslims, while their Christian counterparts are at liberty to wear scarf and cap or go without hair covers. Interestingly, a little more than half of them use the hair covers for >6 h in a day. Similarly, the use of head tie was reported in >80% of the young women seen in southern Nigeria, but the duration of the use of the head ties was not reported [6]. The use of these hair covers has been reported among various cultural/religious groups. Such practices have been associated with TA, especially when they are tight on the scalp [2, 23]. Hair covers can protect the scalp from damaging effects of ultraviolet rays and other environmental factors. However, the total effect of these hair covers on the hair requires further investigation.

Other hair care practices observed among the participants were the use of hot combs/tongs to straighten the hair (thermal hair straightening), use of hair glues/bonds to attach extensions, and poor practice of resting the hair from hairstyling (hair holiday). These have been reported as risk factors for some types of alopecia in adult women [20]. Thermal straightening weakens the disulphide bonds in hair, thereby increasing the risk of hair breakages [20]. The use of bonding glues increases the risk of hair breakage due to the effects of the glue and weight of the weaves. In addition, allergic contact dermatitis can result from the components of the glues [24]. Among our participants, the practice of hair holiday is poor as many of them were not aware of such practice. Such holidays have been advocated to reduce the frequency of braiding and risk of TA.

The frequency of washing hair varied among our participants, with majority washing their hair once every week. This is more frequent than in adult females [25]. Most of the participants change their hairstyle frequently because the styles were done by friends and relatives at little or no cost. A practice of more frequent washing of the hair was reported among young Asian females [26]. The use of shampoo was reported in majority of the participants, while few use regular bathing soap and only water for washing the hair. Frequent use of shampoo has been proposed as a cause of hair damage due to loss of hair lipids [27]. The effects of these methods of washing the hair will require further evaluation. Various hair oils were the predominant hair care products used by the participants. Such oils like those containing coconut oil have been reported to be protective against hair breakages.

Conclusion

The knowledge about TA among adolescents in northern Nigeria is poor. The adolescents engaged in various hair care practices like chemical straightening of hair, frequent plaiting, and lack of hairstyle holidays. The use of hair covers which is one of the predominant practices among adolescents of certain religious dominations will require further study to determine how it affects the hair. We recommend a school-based health education programme focused on reducing the knowledge gap about TA and modifying the risky hair care practices among female adolescents. Such a programme will lead to the emergence of adolescent female hair care ambassadors through an inter-school quiz competition on hair care and TA. The hair care ambassadors will be engaged in promoting good hair care practices among their peers.

Limitations of the Study

Some of the participants could not recall some of the details of their hair care practices. In addition, the terminologies for some of the different local hairstyles were difficult to clarify and were lumped as braiding.

Statement of Ethics

The study was conducted in line with the Declaration of Helsinki. The study protocol was reviewed and approved by Health Research Ethic Committee of Federal Medical Centre, Keffi, with approval No. FMC/KF/HREC/335/19. A written informed consent was obtained from the participants who are >18 years and parents/legal guardian of those <18 years. All the students gave assent before participating in the study.

Conflict of Interest Statement

We declare no conflict of interest.

Funding Sources

This study was supported financially by L'Oreal Research and Innovation.

Author Contributions

O.E. Okoro conceptualized the study, collected data, and wrote the manuscript. A. Imam analysed data and wrote the manuscript. R. Barminas collected data and wrote the manuscript.

Data Availability

All data generated or analysed during this study are included in this article. Further enquiries can be directed to the corresponding author.