Counseling About Traction Alopecia

A "Compliment, Discuss, and Suggest" Method

Ciara Grayson, MD; Candrice R. Heath, MD


Cutis. 2021;108(1):20-22. 

In This Article

Abstract and Introduction


Traction alopecia (TA) remains a common concern for Black women visiting a dermatologist. Understanding cultural hair care practices, timely diagnosis, and discontinuation of high-risk hairstyles are essential for preventing TA from progressing to scarring alopecia. This dialogue might be difficult for hair-discordant physicians and patients because of a lack of training and shared experiences. We present an empathetic and culturally sensitive method for discussing TA with patients.


Traction alopecia (TA)—one of the most common types of hair loss in Black women (although not exclusive to Black women)—is reversible when early corrective measures are taken; if chronic tension continues, however, permanent scarring alopecia ensues. Dermatologists can prevent worsening of this distressing hair loss. Due to a dearth of training among dermatologists in conditions occurring in patients with tightly coiled hair, it is imperative to add practical methods to the body of dermatology literature, with the goal of enhancing cultural humility.

Hairstyling among Black women often is a lengthy process and often results in relationship bonding with the hair care giver, in turn imparting hair care traditions to the next generation. Therefore, a well-received discussion about TA prevention not only has an impact on the patient but potentially on a multigenerational family of women and friends. We present a memory aid for discussing TA, with a focus on cultural humility and patientcentered communication.

Factors contributing to the risk of TA are hairstyles and hair care practices commonly used in Black individuals, including braids, locs, weaves, wigs, and chemical straightening.[1] These styles often are worn to increase hair manageability or as a creative expression of beauty.

Discussing TA can be distressing for physicians and patients, especially in the setting of hair texture discordance. In a study that surveyed Black patients’ perception of their dermatologic care both in and outside of a skin of color clinic, 71% of respondents (12/17) said that they prefer a race-concordant dermatologist. Some respondents reported that non–skin of color clinic dermatologists examined their hair with the end of a pencil or not at all; patients interpreted these interactions as disrespectful and racially insensitive.[2] Another study found that only 30.2% (19/63) of dermatology chief residents and 12.2% (5/41) of program directors reported a specific rotation during which residents gained experience treating skin of color patients.[3]

Due to a paucity of training in diagnosing and treating patients with tightly coiled hair who experience hair loss, some physicians might feel uncomfortable caring for patients who have tightly coiled hair. Although many Black patients prefer to see a race-concordant dermatologist because of their perceived cultural competence and shared experience, there is a paucity of Black dermatologists to see all patients who have tightly coiled hair.[4] Therefore, all dermatologists should become skilled and comfortable discussing and treating TA in patients with all hair types.