I first experimented with wearing braids as a protective style during the pandemic. The style helped me maintain my thick, coily hair when I could not get my bi-weekly salon blowouts during the lockdown. I opted for long box braids—sleek, thick in width, and rope-like—similar to the version Janet Jackson wore in Poetic Justice.
Besides helping me look and feel more put together with minimal effort, the ease box braids afforded me could not be discounted. The no-fuss style was the perfect choice for me, a low-maintenance woman who wanted an effortless style that looked polished. I loved the freedom they gave me. I no longer had to invest 20 minutes daily carefully detangling and styling my multi-textured hair. Instead, I could get up and go about my business quickly, savoring the precious time saved instead of being beholden to my hair.
Thus, it was a no-brainer when I chose to keep the braided hairstyle even when hair salons were allowed to open again. I had my box braids professionally redone every eight to ten weeks. However, after 18 months of getting braids consistently, I noticed that my edges were thinning. “That looks like traction alopecia to me,” a pro hairstylist told me as he inspected my fragile hairline during an appointment, finally making me question whether my chosen protective style was “protective” at all. The reality is that any hairstyle that creates tension at the root of your hair (think braids, buns, ponytails, tight headbands, etc) can put you at risk of hair loss, shedding, or traction alopecia in more severe cases.
To help me sort out if traction alopecia was the cause of my thinning edges, I reached out to Carl Truesdale, MD, a board-certified facial plastic surgeon and hair transplant surgeon; Hadley King, MD, a board-certified dermatologist; and trichologists Bridgette Hill and Sophia Emmanuel to discuss all there is to know about traction alopecia, including how to recognize it, how to prevent it, and how you can grow hair after shedding.
What is traction alopecia?
Traction alopecia is hair loss caused by repeated pulling or tension on the scalp. According to Dr. Truesdale, excessive stress on hair follicles is extremely common due to the rise in popularity of braids, extensions, wigs, and snatched-back hairstyles like buns and ponytails. While anyone can experience traction alopecia, the condition is common in Black women, affecting one third of them, according to research. “Traction alopecia can affect any area of the scalp that is pulled tightly, but it primarily affects the hairline, the crown, and the nape,” Emmanuel tells us. “Over time, prolonged use of high-tension hairstyles can result in permanent hair loss due to irreversible damage to hair follicles.”
Dr. Truesdale says that the culprit behind traction alopecia is usually chronic inflammation that occurs at the hair follicles when hair is pulled too taut. “The constant inflammation can lead to thinning, breakage, and ultimately, balding of the affected area,” he says.
What causes traction alopecia?
Traction alopecia can be caused by any hairstyle that excessively pulls or places tension on the scalp. These styles can also include what some refer to as “protective styles,” including braids, twists, locs, weaves, extensions, buns, and ponytails when done too tight. “They are no longer deemed protective when done improperly,” Hill says. “They’re more so ‘styles of convenience’ as they can cause more harm than good when done tightly.” Hill also says that using bulky extensions in some protective styles can cause physical stress to your strands by weighing them down and eventually yanking them out. “Be mindful when adding hair to your style that it isn’t heavy or carries significant weight,” she warns.
Emmanuel also says that clip-in hair extensions can cause traction alopecia by repeatedly pulling and pressing on the scalp, which, when done repeatedly, can weaken hair follicles over time. Similarly, improper-fitting wigs—”whether too small or too loose”—can cause friction to your edges, contributing to hair loss,” she adds, noting that the glue used for securing wigs may also assist in thinning your natural hairline. Another contributing factor that may cause the weakening of the hair follicle is the use of taut hair accessories, like tightly wound rubber bands, ponytail holders, and snug headbands.
What are the signs of traction alopecia?
Dr. Truesdale says early signs of traction alopecia include an itchy, tender, or red scalp, small pimple-like bumps along the hairline and temples from the pulling tension, and hair breakage. “As the condition progresses, hair thinning becomes noticeable, and in severe cases, hair follicles are permanently damaged,” he says. Usually, injury to the follicle is visually evident when diagnosing traction alopecia, says Dr. King; however, a doctor can conduct a biopsy to rule out other hair loss possibilities.
How to treat traction alopecia?
“If you suspect you may be experiencing traction alopecia, it’s essential to consult with a healthcare professional or a dermatologist,” says Dr. Truesdale. “Early diagnosis and treatment can help minimize hair loss and improve your overall hair health.”
First up—loosen your tight style
Hill says the first step to recovery is to stop wearing compromising hairstyles or using harmful techniques that pull your hair tightly or cause excessive friction so that you can relieve any tension in your follicles. This doesn’t mean never to wear a ponytail or get box braids again, but stop and take a minute to loosen your hair tie if it’s tugging at your roots (or take it out before bed) and definitely communicate with braiders and hairstylists if your style feels too tight.
Adopting practices like sleeping on a silk pillowcase to minimize additional friction or ensuring that the band on your bonnet isn’t too snug—along with using gentle, nourishing haircare products can also help. “Hair loss doesn’t happen the first time you wear a tight hairstyle. It happens over time. So if you can keep the scalp healthy going forward, you can get your hair back on track,” Dr. King explains. For more advanced cases, medical interventions may be necessary, Dr. Truesdale says, with treatments depending on the severity of the hair loss.
Discuss medication options with your doctor
The FDA-approved topical medication minoxidil can help stimulate hair growth if no follicle scarring is involved. Minoxidil works by improving blood flow to the scalp, which in turn helps keep hair in its anagen phase—the growing phase of hair—longer—some dermatologists like to compound minoxidil with tretinoin to improve its efficacy and scalp absorbency. Additionally, doctors can inject topical corticosteroids (like the FDA-approved injection Kenalog) into the affected areas to reduce inflammation caused by the condition.
In conjunction with the previously mentioned scalp therapies, Dr. Truesdale also likes treating the compromised area with red light therapy, platelet-rich plasma therapy (also known as PRP), or exosome injections to foster scalp health and hair follicle recovery. Red light therapy works by exposing areas of hair loss to red LED light to boost dormant hair follicles into the growth stage.
PRP involves drawing blood from a patient and separating the enriched cells, then injecting them back into the scalp to feed the damaged follicles and stimulate their stem cells for hair growth. On the other hand, exosome therapy is a newer scalp procedure that helps snap dormant hair follicles out of rest. Exosomes contain growth factors, various proteins, and activated stem cell signals, which can communicate with impaired follicle cells to spur hair regeneration.
However, if the damage to the follicles is severe and results in scarring, the resulting hair loss will be permanent, explains Dr. King. “There is nothing you can do to reverse it at that stage,” she tells us. Hence, a hair transplant may be your only viable option if that is the case. The procedure involves transferring healthy hair follicles from areas from the back or sides of the scalp—where hair is not normally susceptible to balding—to fill in the spots that experienced irreversible hair loss by replacing them with new ones, explains Dr. Truesdale.
What can we do to prevent traction alopecia?
The best way to avoid traction alopecia is to avoid tight hairdos altogether, advises Dr. Truesdale. Opt for looser styles to reduce tension on the hair instead, suggests Hill. If you wear hair extensions, braids, wigs, clip-ins, locs, or twists, ensure they aren’t so tight, wear them in moderation, and switch up your hairstyle often to give your hair follicles a rest in between.
And remember, when selecting a braiding expert, seek a licensed hairstylist or an experienced artist with a technique that minimizes scalp irritation. Most importantly, don’t be afraid to speak up if you experience discomfort, and have them immediately undo the style if it’s painful, says Hill. We know it can be a bit awkward to push back in the salon chair, but using your voice at the first sign of discomfort can save you lots of stress and pain in the long run.
Final takeaway
Armed with the above info, I paused on frequently getting braids and started sporting a lower-tension hairstyle, pronto. I also sought the professional aid of a dermatologist to assess my hair and scalp and help determine my best course of action. Thankfully, traction alopecia is preventable and reversible in many cases, especially if you act fast. Luckily, the damage to my hairline was superficial, and the dermatologist was able to bolster it to its original thickness with a combination of Kenalog shots and a minoxidil compound prescription.
Will I ever cop back to the convenience of “protective styling” again? Most likely, yes. I’m actually considering braids for my next week-long vacation (which is totally fine), but now, I am well-equipped with the knowledge on how to wear and care for them properly so my hair and scalp can thrive and flourish to the fullest.
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