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The “fringe sign” for public education on traction alopecia

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The “fringe sign” for public education on traction alopecia
Nonhlanhla P Khumalo FCDerm PhD
Dermatology Online Journal 18 (9): 16

Division of Dermatology, Red Cross Children's and Groote Schuur Hospitals, University of Cape Town Cape Town, Western Province, South Africa


The “fringe sign” introduced by Samrao and co-authors is a phenomenally descriptive catch phrase for translating study data for public education in the prevention of traction alopecia.

The manuscript by Samrao et al introduces a fantastically memorable clinical sign, the “fringe sign,” that’s likely to improve the recognition of traction alopecia (TA) [1]. General population data on disease prevalence outside Africa have not yet been published, but clinic data have been reported [2]. In our population mild-to-moderate TA is somewhat ubiquitous in females. The prevalence is higher in African schoolgirls than boys (17.1% vs. 0%); increases with age in girls [8.6% (6-7 years), 15.6% (10-15 years), to 21.7% (17-21 years)]; is higher in girls with relaxed vs. natural hair (22% vs. 5.2%) [3]; and is highest in adults (31.7% in women vs. 2.3% in men; with affected males more likely to wear cornrows and dreadlocks) [4]. The risk of TA increases with symptomatic traction (pain, pimples, crusts) [odds ratio 1.98 (p: <0.022, CI 1.10 – 3.57)] and is highest in combined hairstyles i.e. traction (braids/weaves/locks) done on relaxed hair [odds ratio 3.47 (p: <0.001, CI 1.94 – 6.20)] [5]. Rucker Wright et al [2] reported a high prevalence in a clinic population of African American girls (18% aged 5.4 – 14.3 years) as well as a TA risk that increased with traction and a history of relaxers (OR 5.27, CI 1.5 – 18.32, P = 0.009). Relaxers weaken hair by breaking down disulphide bonds significantly reducing hair strength [6] and hair length [7]. Relaxer-induced hair damage is most notable in the hair furthest from the scalp. Protection of previously relaxed hair during repeat chemical processing may limit damage and warrants study. This hair breakage, a feature of trichorrhexic nodosa is worsened by hair dyes and heat [8] and improved by conditioning or appropriate moisturizers [9].

Although TA is most common in people with afro-textured hair, all hair phenotypes can be affected as demonstrated in this study in which 29 percent of patients were Hispanic. Two thirds of subjects in this study had histological examination; Samrao et al are to be commended because this contributes to understanding disease pathogenesis. The sequence is likely to be firstly traction folliculitis (not always clinically apparent) [10]. In addition to retention of sebaceous glands [11] and increased catagen hair [1, 12], both decreased and increased telogen hairs have been reported as well as miniaturized follicles [1, 11, 13]. However, cases reported from dermatology clinics are likely to have more severe disease and there is as yet no published data on the histopathological spectrum of clinically graded mild to severe TA.

From examining large numbers of participants, TA appears to start with gradual but significant shortening of marginal hair (i.e. an early “fringe” without bald patches) equivalent to Marginal Traction Alopecia Severity Score (M–TAS) Grade 1–2 [5]. This may suggest that traction initially induces follicular miniaturization. With progression bald patches appear but hair persists on the hairline as a separate “fringe” [1] equivalent to M–TAS 3–4 [5]. The end stage on histopathology is progressive fibrosis. Longstanding TA is thought to be irreversible, although anecdotal regrowth has been reported [14]. It would be useful to identify histological features that predict both the onset of permanent hair loss and response to treatment, which could start with controlled trials of topical minoxidil.

Data suggest that the pre-teen years are an ideal public education target for TA prevention. Although more research is required there is evidence for clear public health messages.

To avoid developing the “fringe sign”:

  1. Traction-based hairstyles should be painless – pain is an indication to undo the hair, not for damp scarves or aspirin.
  2. Traction hairstyles on relaxed hair should be avoided or done at least two weeks after processing – relaxed hair is weak and prone to breakage.
  3. Relaxers should be avoided especially in children – hair damage increases with exposure duration
  4. If used, relaxers should be applied according to package instructions, taking care to only process the new growth or “virgin hair” – no “smoothing” of the cream through previously relaxed hair. In addition, the hair should be thoroughly rinsed and neutralized after processing or immediately if scalp tingling or burning occurs.
  5. Using both relaxers and dyes compound hair damage; it should be avoided or done at least two weeks apart.
  6. Heat on relaxed hair should be avoided – air dry or use low-heat hairdryer settings. Hot combs and flat irons should be avoided or limited; their very high temperatures can cause significant hair damage.
  7. Conditioners and the use of non-occlusive petroleum-free moisturizers for dry hair may reduce the risk of hair breakage during grooming.

In spite of quantum leaps in many technologies, the active ingredients of relaxers have changed little since their legendary chance discovery a century ago by people such as Garrett Morgan [15]. Further, available combs break afro-textured hair and induce “steady state” lengths [16]. Not all traction is harmful; braids are a beautiful cultural art form that, with care, can be maintained without damage. As we spread the message of “no, to pain” and “no, to combined hairstyles” perhaps it is also time to call for the paradigm to shift out of the “relaxer box” – at least in its present form. There is a need for innovative development of “high-tech” combs and “novel products.” This could herald a new generation of Afro-textured hair care, without (or very limited) breakage of disulphide bonds that are so crucial for hair strength. With collaborative systematic effort, TA is a condition we certainly can eradicate.


1. Samrao A, Price VH, Zedek D, Mirmirani P: The "Fringe Sign" – A useful clinical finding in traction alopecia of the marginal hair line. Dermatology Online Journal 2011, 17(11):1. [PubMed]

2. Rucker Wright D, Gathers R, Kapke A, Johnson D, Joseph CL: Hair care practices and their association with scalp and hair disorders in African American girls. Journal of the American Academy of Dermatology. 2011, 64(2):253-262. [PubMed]

3. Khumalo NP, Jessop S, Gumedze F, Ehrlich R: Hairdressing is associated with scalp disease in African schoolchildren. Br J Dermatol. 2007, 157(1):106-110. [PubMed]

4. Khumalo NP, Jessop S, Gumedze F, Ehrlich R: Hairdressing and the prevalence of scalp disease in African adults. Br J Dermatol. 2007, 157(5):981-988. [PubMed]

5. Khumalo NP, Jessop S, Gumedze F, Ehrlich R: Determinants of marginal traction alopecia in African girls and women. J Am Acad Dermatol. 2008, 59(3):432-438. [PubMed]

6. Khumalo NP, Stone J, Gumedze F, McGrath E, Ngwanya MR, de Berker D: 'Relaxers' damage hair: evidence from amino acid analysis. Journal of the American Academy of Dermatology. 2010, 62(3):402-408. [PubMed]

7. Khumalo NP, Gumedze F: African hair length in a school population: a clue to disease pathogenesis? J Cosmet Dermatol. 2007, 6(3):144-151. [PubMed]

8. Mirmirani P: Ceramic flat irons: improper use leading to acquired trichorrhexis nodosa. Journal of the American Academy of Dermatology. 2010, 62(1):145-147. [PubMed]

9. Rele AS, Mohile RB: Effect of mineral oil, sunflower oil, and coconut oil on prevention of hair damage. J Cosmet Sci. 2003, 54(2):175-192. [PubMed]

10. Fox GN, Stausmire JM, Mehregan DR: Traction folliculitis: an underreported entity. Cutis; cutaneous medicine for the practitioner 2007, 79(1):26-30. [PubMed]

11. Miteva M, Tosti A: "A detective look" at hair biopsies from African American patients. The British Journal of Dermatology. 2012. [PubMed]

12. Sperling LC, Lupton GP: Histopathology of non-scarring alopecia. J Cutan Pathol. 1995, 22(2):97-114. [PubMed]

13. Sperling LC, Cowper SE: The histopathology of primary cicatricial alopecia. Semin Cutan Med Surg. 2006, 25(1):41-50. [PubMed]

14. Khumalo NP, Ngwanya RM: Traction alopecia: 2% topical minoxidil shows promise. Report of two cases. J Eur Acad Dermatol Venereol. 2007, 21(3):433-434. [PubMed]

15. The Black Inventor Online Museum. Biography on Garrett A. Morgan.

16. Khumalo NP: African hair length: the picture is clearer. J Am Acad Dermatol. 2006, 54(5):886-888. [PubMed]

© 2012 Dermatology Online Journal