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A 38-year-old woman was found to have hair thinning on the anterior scalp. She had long thick heavy hair that she always styled in a bun on the top of her head. She was concerned about the slow, steady loss of hair that she was experiencing. Figure 188-1 shows the appearance of the thinned hair as a result of chronic traction. A 4-mm punch biopsy was performed to confirm the clinical impression and the histology was supportive of this diagnosis.

Figure 188-1

Traction alopecia from pulling the hair up in a tight bun. (Courtesy of Richard P. Usatine, MD.)

Traction alopecia is hair loss caused by damage to the dermal papilla and hair follicle by constant pulling or tension over a long period. It often occurs in persons who wear tight braids, especially “cornrows” that lead to high tension, pulling, and breakage of hair. Trichotillomania (Greek for “hair-pulling madness”) is a traction alopecia related to a compulsive disorder caused when patients pull on and pluck hairs, often creating bizarre patterns of hair loss.

  • The prevalence of traction alopecia (Figures 188-1 and 188-2) is unknown and varies by cultural hairstyle practices. It is most commonly seen in females and children.1
  • The prevalence of trichotillomania (Figures 188-3, 188-4, 188-5, and 188-6) is also difficult to determine, but is estimated to be approximately 1.5% of males and 3.4% of females in the United States. The mean age of onset of trichotillomania is 8 years in boys and 12 years in girls, and it is the most common cause of childhood alopecia.2

Figure 188-2

Traction alopecia in a young African American girl whose mom braids her hair tightly. (Courtesy of Richard P. Usatine, MD.)

Figure 188-3

Trichotillomania in an 11-year-old boy. Note the incomplete hair loss and unusual geometric pattern. He was receiving help and the hair is now growing in. (Courtesy of Richard P. Usatine, MD.)

Figure 188-4

Chronic hair loss in a 39-year-old woman with trichotillomania. (Courtesy of E.J. Mayeaux, Jr., MD.)

Figure 188-5

Trichotillomania in his 17-year-old honors student who is currently taking four Advanced Placement courses simultaneously. (Courtesy of Richard P. Usatine, MD.)

Figure 188-6

A. Trichotillomania in a 12-year-old girl undergoing much stress because of conflict in her family. B. Close-up of trichotillomania showing broken hairs, black ...

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