Scalp-pulling hairstyles can lead to a form of gradual hair loss, caused by prolonged or repeated tension on the hair root, an analysis shows.
Traction alopecia is the most common form of hair loss among African-American women. An estimated one-third suffer from the condition.
The researchers urge dermatologists to better educate themselves about the damaging hairstyles—such as tight ponytails, braids, knots, and buns—and to advise patients of risks and alternatives.
“Hair is a cornerstone of self-esteem and identity for many people,” says Crystal Aguh, assistant professor of dermatology at the Johns Hopkins University School of Medicine, “but ironically, some hairstyles meant to improve our self-confidence actually lead to hair and scalp damage.”
Aguh led a review of 19 previous studies; the results are published online by the Journal of the American Academy of Dermatology. Traction alopecia, she says, is entirely preventable, and early intervention can stop or reverse it.
“We have to do better as care providers to offer our patients proper guidance to keep them healthy from head to toe,” she says.
Aguh’s team categorized hairstyling practices into low-, moderate- and high-risk groups, based on the degree to which follicles—the cavities in skin from which hairs develop—are exposed to tension, weight, heat, and hair-altering chemicals.
Some high-risk styles can be reclassified as only moderately risky when used on natural unprocessed hair. Low-risk styles generally included low-tension styles, such as loose buns, and loose-hanging styles, such as wearing the hair down. Decreasing friction on the hair and scalp and avoiding chemical relaxers also reduces risk, the researchers say.
Aguh says the highest-risk styles include braids, dreadlocks, weaves, and extensions, especially when applied to chemically straightened hair. These styles are popular among African-Americans, she says, because they are low-maintenance, but the constant pulling of the hair in one direction, the tight-locking patterns and added weight can result in significant breakage and, eventually, in traction alopecia.
Damage can also be done if extensions are affixed with adhesive glue put directly on the scalp, especially when the glued-on hair is removed. Chemical straightening weakens the hair shaft, causing breakage.
More moderately risky are thermal straightening, permanent waving and use of wigs. Temporary thermal or heat-related hair straightening, such as the use of flat irons and blow drying—while not by themselves significantly associated with traction alopecia—can weaken shafts, leading to “significant” hair loss when traction is later applied, the researchers say. Permanent waves made with ammonium thioglycolate to create or alter curl pattern, together with added tension from chemical treatment, do the same. Wigs attached with clips and adhesives can cause significant breakage.
Aguh also notes that cotton and nylon wig caps that rub the hairline may also weaken hair shafts; satin ones are less likely to do so.
Untreated and unprocessed hair, she says, can withstand greater traction, pulling, and brushing, and overall decreases the risk of traction alopecia, regardless of styling.
The investigators offered guidelines for dermatologists to prevent and manage hair loss from traction alopecia. The first line of therapy, they say, is to loosen braids and other high-tension styles, as well as weight on the follicle, permanently or periodically. Braided hairstyles should be in place no longer than two to three months, they say, and weaves and extensions should also be removed for a time after six to eight weeks.
The investigators also recommend people alternate styles to allow follicles to recover from stress.
“Dermatologists need to be conscious of the fact that many high- and moderate-risk hairstyles greatly improve hair manageability, and simply telling patients to abandon them won’t work for everyone,” Aguh says. “Instead, physicians can educate themselves to speak with patients about making the best hairstyling choices to minimize preventable hair loss.”