Cicatricial Marginal Alopecia: Your traction alopecia patients will thank you!

Not all ‘Traction Alopecia’ is Actually Traction Alopecia

Traction alopecia is a form of hair loss that occurs due to pulling of hair. Diagnosing traction alopecia sounds easy but surprisingly there are a great number of mimicking conditions that can fool the hair specialist.

Frontal traction alopecia refers to hair loss in the frontal hairline that is due to traction. Often the temples are affected but any part of the frontal hairline, temples and area around the ears can be affected. Often the hairs in the very frontal hairline are unaffected leading to the appearance of a so called “fringe” sign:

Classic ‘fringe’ sign in a patient with traction alopecia. The fringe refers to the fringe of hair in the frontal hairline.

Cicatricial Marginal Alopecia (CMA)

There are times when patients who present with what seems to be traction alopecia tell us that they couldn’t possibly have traction alopecia. These are the patients who tell us that they have worn their hair fairly natural for years and that a diagnosis of traction alopecia just makes no sense to them. These are the patients that politely stare at us when we tell them to be careful how they style their hair and to be carefully to avoid heat or chemicals. When a hair specialist wants to make a diagnosis of traction alopecia but realizes the patient’s story just does not add up to give a convincing story of traction alopecia - the diagnosis of cicatricial marginal alopecia (CMA) must be considered.

The Differential Diagnosis of Frontal Hair Loss: What’s a specialist to consider anyways?

Of course, the diligent hair specialist considers many things in the differential of frontal traction alopecia like presentations including

1. Traction alopecia

2. Cicatricial Marginal Alopecia

3. Frontal fibrosing alopecia

4. Discoid lupus

5. Androgenetic alopecia

6. Telogen effluvium

7. Alopecia Areata

8. Trichotillomania

Cicatricial Marginal Alopecia: A Traction Alopecia Like Alopecia Without A Traction History

It was Dr Lynn Goldberg in Boston who put forth the notion of cicatricial marginal alopecia. She described 15 patients who presented with hair loss in a typical traction alopecia like pattern. Information pertaining to whether or not the patient relaxed or straightened the hair was available In 12 patients. 6 of the 12 patients gave a history of relaxing the hair or straightening the hair. For the other 6 other patients there was no such history. In other words, in 50 % of patients with frontal 'traction alopecia-like” hair loss a history of true traction styling practices were not present. These patients still had some degree of scarring on their biopsies indicating that this too could be a scarring type of hair loss. 

Treatment of CMA involves topical or oral minoxidil combined with topical and/or intralesional steroids. In some patients use of agents like oral doxycycline or topical tacrolimus can be helpful.

Summary and Key Lessons

As soon as we let open our mouths to pronounce the words traction alopecia, we must say in the same breath “or a traction alopecia like mimickers.” Could my patient have traction alopecia or a “traction alopecia like mimicker.”

Cicatricial Marginal Alopecia is one of these closely related mimickers. I like to refer to it as cicatrical marginal alopecia to honour my great colleague Dr Goldberg and so this is what I write in all my letters and consultation notes to other physicians. In my mind, I say the patient has a Traction Alopecia Like Alopecia Without a Traction History because it helps me remember the key elements of this presentation.

Reference

Goldberg L. Cicatricial Marginal Alopecia: Is It All Traction? Br J Dermatol 2009 Jan;160(1):62-8.

Traction Alopecia: How long is too long?

Early Traction Alopecia: Regrowth is Possible

Traction alopecia is a form of hair loss that comes from the tight pulling of hair.  Braids, weaves cornrows, ponytails, man buns, and other hair styles all can contribute to traction alopecia. The most important thing one can do in cases of suspected traction alopecia - is to stop the hair care practice that was likely responsible as soon as possible.

In general, cessation of hair care practices in early traction alopecia is associated with a high chance of regrowth.  However, cessation of hair care practices in long standing traction alopecia is associated with a much lower chance of regrowth.  There are no definitive guidelines for what constitutes early and what constitutes late. In general though, traction hair styles that have gone on for less than a few weeks are often highly regrowable. 

Work up/Evaluation for Traction Alopecia

Diagnosing traction alopecia is said to be a 'clinical diagnosis' - meaning that special tests are usually not needed. For example, a biopsy is seldom needed in cases of traction alopecia. However, a biopsy can be helpful if there is any other diagnosis that is being considered such as a scarring alopecia. Blood tests are advisable for many patients with traction. I advise blood tests for iron, thyroid, vitamin D, and zinc as starting points. Other blood tests could be important depending on the patient's history.  

 

Treatment of Traction Alopecia

As mentioned above, the most important step is simply stopping the hair care practice that caused the pulling in the first place. A physician can help determine whether treatments such as minoxidil, or use of corticosteroids for a short period of time could also be helpful. Taking vitamin or mineral supplements will potentially help if a patient has a particular deficiency. Otherwise, they are likely not going to be helpful.  

My hair was ripped off: Will it grow back?

Traumatic Hair Pulling:  Full Regrowth May or May Not Occur

I am often asked if hair that is pulled out forcefully will regrow. Examples of this are the pulling of hair by children on the playground, hair getting caught in doors, machines etc or cases of hair pulling during assault or abuse-related situations (for example domestic abuse).

Without actually seeing the scalp, and knowing details of the patient's story, it is impossible to determine if hair will or will not grow back in any particular case. This requires an in person examination so that the scalp can be properly examined.

Hair regrowth is not a guarantee

There is no guarantee that hair regrowth will occur. One will know in 6-9 months if they will acheive full regrowth or not because that is how long it takes for hair to grow back following any type of injury.

It is certainly possible for repeated pulling to give permanent hair loss. However, in the vast majority of cases where hair is pulled from the scalp, hair grows back.  If you or I were to reach up a pluck a hair, it will grow back. However, if pulling is repeated many times or is excessive with bleeding a greater chance exists for scarring to develop. Hair pulling that is accompanied by injury to the skin layers (i.e. that creates an actual wound) has a markedly increased chance of being associated with permanent scarring.  It is such scarring that blocks the regrowth of hair.  Scar tissue is permanent and, if present,  generally destroys stems cells. 

Anyone with concerns about incomplete growth after episodes of hair pulling should see a physician who specializes in hair loss for consideration of a scalp biopsy.

Hair Loss at the Nape of the Neck: What are the main causes?

Losing Hair at the Nape: What are the main Causes?

Hair loss can either be localized (meaning one area of the scalp) or diffuse (meaning all over the scalp). There are many causes of hair loss at nape of the neck and the back of the scalp. 

1. Traction alopecia (photo 1)

Traction alopecia refers to a type of hair loss due to the tight pulling of hair. The back of the scalp is particularly susceptible to loss of hair.  Hair styling practices can frequently lead to traction including braids and weaves and pony tail.  If traction alopecia is of recent onset, hair regrowth can occur even without treatment. If traction is longer standing, the hair loss can often be permanent.  Some women with hair loss that looks like traction actually have a scarring alopecia known as cicatricial marginal alopecia. 

PHOTO 1: Traction alopecia presenting as hair loss in the nape

2. Alopecia Areata (photo 2)

Alopecia areata is an autoimmune disease that affects about 2 % of the world. Hair loss can occur anywhere. Alopecia areata can frequently cause hair loss specifically at the nape in some patients. The particular form that causes loss at a the back of the scalp is the 'ophiasis' form. The ophiasis form is frequently resistant to standard treatments although topical steroids, steroid injections and diphencyprone are typically first line. 

PHOTO 2: Alopecia areata presenting as hair loss in the nape

 3. Androgenetic Alopecia (photo 3)

Androgenetic alopecia (male and female thinning) typically causes hair loss at the top of the scalp. In men, the temples and crown are most often affected. In women, the mid-scalp region is generally affect first. The back of the scalp can also be affected although this is not typically thought of. Hair thinking along the nape is not uncommon in advancing balding in men and women. 

PHOTO 3: Androgenetic alopecia (AGA) presenting as thinning in the nape

 

4. Frontal Fibrosing Alopecia (photo 4)

Frontal fibrosing alopecia (FFA) is a type of scarring alopecia. FFA typically affects women between 45-70. Most often hair is lost along the frontal hairline and eyebrow. However the back of the scalp (at the nape) and frequently be affected. The hair loss in the nape typically starts at the sides (left side and right side) just behind the ears. Treatments for FFA include topical steroids steroid injections, topical calcineurin inhibitors. Oral drugs include finasteride, doxycycline and hydroxychloroquine at the top of the list.

PHOTO 4: Frontal fibrosing alopecia (FFA) presenting as hair loss in the nape

5.  Heat and Chemicals

Heat and chemical treatments can lead to hair shaft damage and hair loss at the nape. Frequently, heat and chemical overuse leads to an increased tendency to develop traction alopecia which si discussed above. 

6. Acne keloidalis nuchae

Acne keloidalis nuchae (AKN) is a condition that can affect both men and women. Small papule or bumps develop along the posterior scalp and are accompanied by hair loss in the region as well.  The hair loss in AKN is often permanent and can lead to thicken and thicker scars some of which are disfiguring. 

7. Hair shaft disorders

Some individuals are born with abnormalities in how the hair shaft is produced. This frequently leads to hair breakage. Monilethrix is one of the hair shaft disorders that frequently leads to hair loss along the nape. 

Are my hair extensions safe?

I frequently get asked if wearing hair extensions is okay. Often it is fine, but one needs to monitor over time if any hair damage is occurring. Individuals feeling pain, "pins and needles" should consider loosening the extensions or changing the method of application. Individuals showing clinical signs in the office of hair damage may also consider changing the method of application.

Consider the patient shown in this picture. She has been using extensions for some time now. She has a few broken hairs (labelled B) and several miniaturized hairs (labelled V for vellus) in any area that did not previously show miniaturization. These two signs are evidence of hair damage. A recommendation was made to change the extension in this case and treatment with a corticosteroid was given to reduce inflammation that is common in such cases of early traction alopecia.
 

If hair extensions are causing hair loss, do they need to be removed?

Hair extensions can sometimes cause hair loss. Whether to remove the extensions or change the type of extension is a decision made on a case by case basis. This is not always a simple answer. Sometimes the improvements that come with the patient using the extensions supercedes a small amount of hair loss that might come with wearing them. This makes removing the extensions less relevant - especially if this is a more permanent type of camouflaging option for the patient. If, however, the hair extensions are causing significant hair loss and the use of the extension is only temporary (and the long term goal is to improve the patient's hair), then the extensions should likely be removed or changed to reduce the chance of long term damage to the hair follicle and the scalp.

Who said miniaturization only happens in AGA?

Miniaturization of Hairs

It is often said that the "miniaturization" of hairs (ie the progressive thinning of hairs) is a key feature specific to men and women with androgenetic alopecia. However, this is not accurate.

Miniaturization can be seen in many conditions including traction alopecia, alopecia areata (shown here) as well as androgenetic alopecia.