Traction alopecia (TA) represents a pattern of traumatic hair loss caused by a pulling force applied to the hair shaft over time. This excessive tensile force results from hair styling practices such as tight ponytails, braids, cornrows, chingons, or religious head coverings. TA has traditionally been categorized into marginal alopecia (occurring behind the frontal hairline or along the temporoparietal margin) or non-marginal alopecia. In the US, traction alopecia is most common in African American women due to their hair styling practices.1 It is also common in Sikh men of India and Japanese women whose traditional hair styles result in excessive tension on the hair. The presence of retained hairs along the frontal and/or temporal hairline, termed the “fringe sign,” is a common finding in patients with traction alopecia of the marginal hairline and can help in making a clinical diagnosis of TA.2 The histopathology of TA in early stages shows trichomalacia, a normal number of terminal follicles, and preserved sebaceous glands. At some point there may be “follicular drop-out” of the terminal hairs where the follicles seem to have disappeared but the vellus-sized hairs are intact. With longstanding TA, there is a decrease in the number of terminal follicles, which may be progressively replaced with concentric fibrosis. Inflammation is little-to-absent in longstanding TA but may be mild in some cases of early TA.2

Diagnostic challenges may be encountered if the clinical suspicion for traction is not high, if the history of traction is remote or not obtained or if the pattern of alopecia is atypical. Herein, we report two patients with an unusual variant of TA resulting from use of hair wefts, which we termed “horseshoe” pattern traction alopecia (Figure 1). Wefted hair extensions consist of multiple strands of hair held together by a band of fine threads (Figure 2). These extended-wear hairpieces are attached directly to the hairline by being sewn, bonded, glued, or clipped and are used to conceal existing hair loss or for cosmetic purposes. Repeated application of wefts or longstanding use may mimic scarring alopecia, however a detailed history will often reveal the cause of hair loss.3

It is important to recognize various patterns of TA at early stages into order to cease traction and prevent progression to permanent alopecia. Although the pathogenesis of TA remains to be fully elucidated, it may follow three stages, including a reversible, pre-alopecia stage, a reversible stage with associated alopecia, and finally an irreversible stage with permanent alopecia. The mainstay of treatment for early disease is to discontinue hair styling practices that generate traction. For late stage TA associated with scarring, the optimal treatment is hair transplantation.4

Dr. Jennifer Ahdout and Dr. Mirmirani have no financial interests to disclose.

Dr. Ahdout is with the department of Dermatology, University of California, Irvine, CA.

Dr. Paradi Mirmirani is with the department of Dermatology, University of California, San Francisco CA, the Department of Dermatology, Case Western Reserve University, Cleveland OH, and the Department of Dermatology, The Permanente Medical Group Vallejo, CA.

  1. Fu JM, Price VH. Approach to hair loss in women of color. Semin Cutan Med Surg. 2009;28(2):109-114.
  2. Samrao A, Price VH, Zedek D, Mirmirani P. The “Fringe Sign” - a useful clinical finding in traction alopecia of the marginal hair line. Dermatol Online J. 2011;17(11):1.
  3. Hair extensions: a concerning cause of hair disorders. Br J Dermatol. 2009;160(1);197-228.
  4. Ozcelik D. Extensive traction alopecia attributable to ponytail hairstyle and its treatment with hair transplantation. Aesthetic Plast Surg. 2005;29(4):325-327.