Intralesional Triamcinolone Acetonide in the Treatment of Traction Alopecia

February 2020 | Volume 19 | Issue 2 | Case Reports | 4 | Copyright © February 2020

Laura N. Uwakwe MD,a Brianna De Souza MD,b Andrea Tovar-Garza MD,b Amy J. McMichael MDb

aDepartment of Dermatology, Columbia University Irving Medical Center, New York, NY bDepartment of Dermatology, University of Texas Southwestern Medical Center, Dallas, TX

Abstract
Traction alopecia (TA) is a form of hair loss caused by continuous and prolonged tension to the hair, most commonly seen in Black/African American women and children who wear hairstyles that pull excessively at the frontotemporal hairline. Dermatologists have recommended the use of intralesional triamcinolone acetonide injections (ILK) to decrease the inflammatory process, however, evidence-based proof is lacking in the literature. In this case series, we evaluate the effectiveness and safety of ILK in the TA management of 6 African American women. A retrospective chart review was done of patients with a diagnosis of TA, who were treated with ILK at an academic dermatology clinic, yielding 6 patients. Management of TA was assessed by comparing the photographs for changes in hair density along the frontotemporal hairline. ILK with a concentration of 5 mg/mL, was administered in areas of low hair density along the frontotemporal hairline at 6 to 8-week intervals, for 3 successive visits. All subjects demonstrated visible increase in hair density along the frontotemporal hairline following their first or second treatment, and no severe adverse effects were observed or reported. The use of ILK is currently an effective and safe method of treating TA, particularly in the early to mid-stages. Common adverse effects are pain, and subsequent transient atrophy at the injection site. The transient atrophy is not an indication to stop treatment. Avoidance of treating dented areas is sufficient to allow it to revert. Patient education is pivotal in the prevention and management of TA. It is imperative that dermatologists caution against grooming practices that exert tension on the hairline.

J Drugs Dermatol. 2020;19(2) doi:10.36849/JDD.2020.4635

Published online January 9, 2020.

BACKGROUND

Traction alopecia (TA) is a form of hair loss secondary to repetitive and/or prolonged tension to a hair follicle over an extended period of time. This typically results from wearing tight hairstyles, or an acute traumatic event.1,2 As the etiology is mechanical trauma of the hair follicle, it can occur in any ethnic/racial demographic or gender. It has been observed in ballerinas, as well as Sikh Indian males, all of whom wear hairstyles that exert tension on the frontotemporal hairline. However, most cases of TA occur in women of African descent.1,3

The diagnosis of TA can be made clinically, as well as through the histological examination of a scalp biopsy. The earliest signs of TA are perifollicular erythema and pruritus with or without surrounding papules and pustules.4 The fringe sign of TA is a clinical finding characterized by the presence of retained hair along the frontal and/or temporal hairline, and it has been shown to have high sensitivity for detecting early and late disease of TA.5 On dermoscopy, one may observe reduced hair density with an absence of follicular openings in late stages, and in earlier stages an absence of hairs with preserved follicular openings outlined in brown, particularly at the periphery of the patch of affected scalp, corresponding to the pigmented basal cell layer of the follicular infundibulum that can be seen on histology.6,7 The histological findings can also vary depending on the stage of the disease. Early findings on histology include trichomalacia, normal number of terminal hairs, preserved sebaceous glands, and increased number of telogen and catagen hairs.8 Late disease findings include a decreased number of terminal hair follicles which have been replaced by fibrous tracts, vellus hairs, and retained sebaceous glands.8

Recommended treatment for TA includes the use of minoxidil and intralesional steroid injections. However, evidence-based proof of the efficacy of ILK in the improvement of TA has not been reported in the literature. In this case series, we evaluate the efficacy and safety of intralesional triamcinolone acetonide injections (ILK) when used with topical minoxidil in the management of TA in 6 African American women.

METHODS

A retrospective chart review was performed in patients carrying a diagnosis of TA, who were seen at an active hair disorder clinic between January 2016 and December 2017. All patients who were treated with ILK, and whose treatment progress were recorded with photographs were included. Those who used minoxidil as an adjunct treatment were also noted. The management of TA was assessed by comparing the changes in hair