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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 196-1 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 196-1

Traction alopecia from pulling the hair up in a tight bun. (Reproduced with permission from 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.


Traumatic alopecia, hair pulling.


  • Epidemiologic information on traction alopecia is limited (Figures 196-1 and 196-2) and varies by cultural hairstyle practices. It is most commonly seen in females and children of African descent.

  • The prevalence of trichotillomania (Figures 196-3, 196-4, 196-5, 196-6) 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.1

FIGURE 196-2

Traction alopecia in a young African-American girl whose mom braids her hair tightly. (Reproduced with permission from Richard P. Usatine, MD.)

FIGURE 196-3

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. (Reproduced with permission from Richard P. Usatine, MD.)

FIGURE 196-4

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

FIGURE 196-5

Trichotillomania in a 17-year-old honors student who is currently taking four Advanced Placement courses simultaneously. (Reproduced with permission from Richard P. Usatine, MD.)

FIGURE 196-6

A. Trichotillomania in a 12-year-old girl undergoing significant ...

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