HIGHLIGHTING SKIN OF COLOR Traction Folliculitis: An Underreported Entity Gary N. Fox, MD; Julie M. Stausmire, MSN, CNS; Darius R. Mehregan, MD Traction folliculitis is a component of traction air and scalp diseases induced by traumatic alopecia syndrome and has received minimal hairstyling techniques, including the use of attention in primary source medical literature. Hchemical relaxers and permanent solutions, The popularity of hairstyles that produce hair hot combs, braids, hair extensions, and pomades, tend traction and the knowledge that early interven- to be underappreciated.1-4 The practice of these tech- tion improves prognosis amplify the importance niques and their sequelae are most common in black of recognizing this entity. Traction folliculitis individuals.1 We present an illustrative scenario of presents as perifollicular erythema and pustules trauma caused by hairstyling techniques in an infant on the scalp in areas where hairstyles produce and review the literature on traction folliculitis. We traction on the hair shaft. In addition to the trac- found no prior reports of traction folliculitis in infants tion, concurrent hair care practices may play a and no prior images of traction folliculitis in the facilitatory role in the development of traction primary source medical literature. folliculitis. Treatment involves immediate removal of traction on hair and temporary alteration of the Case Report facilitatory hair care practices. In more severe An 8-month-old black infant was brought in by his cases, topical or systemic antibacterial therapy mother for evaluation of “pus bumps” on the scalp and, occasionally, topical corticosteroid therapy of several weeks’ duration. The infant was otherwise may be necessary. Failure to discontinue traction- healthy with an unremarkable past medical history. producing hairstyles can lead to traction alopecia On examination, the infant’s vital signs, growth, and irreversible hair loss. Cultural considerations and development were appropriate for his age; the often are paramount in hairstyle choices and hair infant was playful and healthy in appearance; and care practices that cause predisposition to trac- skin examination was unremarkable, except for the tion disorders. Thus, culturally competent coun- scalp and scalp margins. The infant had a geometric seling requires understanding the significance of hairstyle with the hair sectioned into squares. The the hairstyle and hair care practices to the patient hair in each square was pulled tightly to the center (or caregivers), discussing the recommendations and then secured with a hair band. This hairstyle pro- in a culturally sensitive manner, and negotiating duced maximum traction around the outer edges of the mutually acceptable alternative practices. square with less traction centrally. It produced a lat- Cutis. 2007;79:26-30. ticework of sharply defined parts on the scalp between the squares. Follicle-based papules and pustules were evident within these parts (Figure, A–C) and along the frontotemporal margins (Figure, A). When the hair bands were released, the scalp in the central Accepted for publication April 4, 2006. area within each square, which had experienced less Dr. Fox is from the Medical University of Ohio, Toledo. Ms. Stausmire tension, was unaffected (Figure, C). Hair loss was is from Mercy Health Partners Family Practice Residency Program, evident in a typical traction alopecia distribution, Toledo. Dr. Mehregan is from Wayne State University, Detroit, especially along the frontal scalp margin (Figure, A). Michigan, and the Medical University of Ohio. The authors report no conflict of interest. The patient did not exhibit notable peripilar Reprints: Gary N. Fox, MD, Charter One Bank Bldg, 3130 Executive hair casts. The hair and scalp appeared greasy from Pkwy, 5th Floor, Toledo, OH 43606 (e-mail: [email protected]). application of pomade. 26 CUTIS® Highlighting Skin of Color A B Frontotemporal area illustrating degree of tension pro- duced by the hairstyle, traction alopecia, and traction folliculitis along the frontotemporal margins and hair parts (A). Parietal area illustrating extent of traction folliculitis in the hair parts (B). Lower tension in central C areas of the hairstyle; no folliculitis present (C). (The sheen observed is from the use of direct flash.) Treatment of this patient’s traction folliculitis yielded only 2 citations2,5 dating back to 1961 included a discussion with caregivers about the and 1983, though others can be located by cross- condition and its etiology. Elements of the patient’s referencing citations.6 Commonly used general der- care, worked out collaboratively with the patient’s matology textbooks neither list traction folliculitis caregivers included elimination of traction on the in their indexes nor specifically refer to traction fol- hair, temporary institution of a topical antibacte- liculitis when discussing traction alopecia.7,8 In fact, rial shampoo, and temporary avoidance of pomade. both of these texts devote only 2 sentences each to Additionally, cephalexin 50 mg/kg per day in traction alopecia9,10 despite the near epidemic fre- 4 divided doses for 10 days was prescribed. At a visit quency of the latter in black women.11,12 Moreover, 17 days later, the scalp had completely cleared. some textbooks devoted entirely to hair and scalp disorders failed to index, discuss, or display images of Comment traction folliculitis,13 while others indexed the disor- Although the pathogenesis of many conditions der but devoted only a few sentences to it.14 Although is multifactorial, we believe our patient exhibited traction folliculitis is mentioned in reviews of hair dis- traction-induced folliculitis. The distribution of the orders, especially reviews specific to these disorders in folliculitis was localized exclusively to the areas of black individuals, most discussions are limited to 1 or maximal traction; there was no evidence of bacterial 2 sentences3,15,16 or a mention in a table.4,15 An infection elsewhere; and there were no other signs of Internet search for “traction folliculitis” produced pomade-induced dermatitis, such as on the face. some additional links relevant to the topic, including Traction folliculitis rarely is reported in the references containing continuing medical education primary source medical literature. A search of course descriptions mentioning traction folliculitis,17 the PubMed database (US National Library of US Food and Drug Administration committee hear- Medicine) for “traction folliculitis” in humans ings,18 and information for healthcare professionals.11 VOLUME 79, JANUARY 2007 27 Highlighting Skin of Color A search of dermatology photographic resources on follicles, which causes folliculitis and may create the Internet showed a few patients with traction fol- visible perifollicular erythema (perifolliculitis).16,28,29 liculitis not reported in the traditional literature.19-21 Mild erythema on the scalp in individuals of color A review of all sources suggests that traction follicu- may escape detection30; therefore, papulopustular litis is more common than its minimal representation folliculitis may be the first observed manifesta- in the indexed primary source medical literature tion.1,4 If the traction continues, chronic inflamma- would suggest. tion ensues, which may lead to follicular atrophy We believe that our 8-month-old patient is the with thinner shorter hair; then reversible traction youngest reported patient with traction folliculitis. alopecia; followed by follicular destruction, scar- Slepyan6 reported 24 patients with traction syn- ring, and permanent alopecia.1,16,29 Other clinical dromes (not all patients had folliculitis) but did manifestations of traction folliculitis may include a not specify their ages; none appeared to be infants. seborrhealike hyperkeratosis and posterior cervical Rollins5 reported 3 girls, aged 9, 10, and 16 years, lymphadenopathy from the inflammation.28 with traction folliculitis. The patients reported in Sustained traction, probably through injury of Internet sources were aged 2 years (1 patient)19 and the hair follicle, seems to predispose patients to sec- 4 years (2 patients).20,21 Therefore, the youngest ondary staphylococcal infection of the scalp, leading prior patient we were able to locate was 2 years old.19 to the development of purulent pustule formation We also did not locate case reports or photographs of as a component of traction-induced disease.1,6,16,28,29 traction folliculitis in black patients in the primary It has been suggested that these patients also are at source medical literature, though a review article of increased risk for fungal scalp infection.19 cosmetics did include one photograph of traction Pomades commonly are used to condition, lubri- folliculitis in a black patient.15 cate, and aid in manageability of thick spiraling hair The origin of the current concepts regarding trac- frequently found in black children. These prepara- tion folliculitis can be traced to Slepyan.6 In 1958, tions often contain mineral oil, petroleum, and par- he reported “alopecia of the scalp occurring in young affin, which can occlude hair follicles and predispose girls wearing the pony tail.” He noted that “the to or exacerbate folliculitis induced by traction or earliest manifestation is a mild erythema about the superinfection.4,15,28 follicles receiving the greatest amount of traction. Specific hairstyles that can lead to traction Occasionally some scaling is noted and not infre- syndromes