Topical and intralesional corticosteroids, typically triamcinolone acetonide (ILTAC), are the most common TA treatment, although evidence is mixed. At our institution, topical fluocinolone 0.01% oil and fluocinonide 0.05% solution are prescribed once to twice daily. Oil is preferred for curlier hair, as desiccating solutions can lead to fragility and breakage. Intralesional corticosteroids dosages used for TA have not been well documented in the literature. Higher concentrations have a risk of dyschromia and hypopigmentation. Typically, a maximum dose of 20mg per month is preferred to limit local and potentially systemic side effects.4 Concentration, ranging from 2.5 to 5 mg/cc, and volume vary depending on the surface area involved.
Few publications describe the use of topical or oral antibiotics in TA management. The mechanism of action is thought to be similar to that of intralesional corticosteroids by decreasing hair follicle inflammation. At our institution topical 1% clindamycin or oral tetracyclines such as doxycycline or minocycline are often used starting at 100mg BID, and antibiotic therapy is reassessed after 3–4 months to avoid antimicrobial resistance.5 Doxycycline is preferred due to its better side effect profile.
To date, there is only one publication describing the use of topical minoxidil for TA. Khumalo et al presented two cases of South African women with clinically diagnosed TA who had significant regrowth with 2% topical minoxidil lotion.6 At our institution, we utilize 5% topical minoxidil solution applied to affected areas twice daily.
Surgery can be effective for late-stage TA. Punch grafting and micro- or mini-grafting can be performed successfully.7 Despite the risk of keloids or koebnerization in the setting of concomitant scarring alopecia, surgery should certainly be considered in patients with quiescent cicatricial alopecia and minimal response to medical therapies.
Novel therapies have been recently investigated in the medical literature. Goren et al proposed that topical alpha1 agonists may be a convenient preventative approach to stimulate piloerection and resist pulling forces in high tension hair styling practices.8
In summary, there are limited effective treatment options for TA. Future directions in TA management include heightened public awareness to mitigate risks of high-tension hairstyles in partnership with community hair care professionals. More research is required to investigate new potential TA treatments including oral minoxidil, platelet-rich plasma, and laser assisted drug delivery with growth factors. Further studies are needed to determine the effectiveness of these treatment options.
Few publications describe the use of topical or oral antibiotics in TA management. The mechanism of action is thought to be similar to that of intralesional corticosteroids by decreasing hair follicle inflammation. At our institution topical 1% clindamycin or oral tetracyclines such as doxycycline or minocycline are often used starting at 100mg BID, and antibiotic therapy is reassessed after 3–4 months to avoid antimicrobial resistance.5 Doxycycline is preferred due to its better side effect profile.
To date, there is only one publication describing the use of topical minoxidil for TA. Khumalo et al presented two cases of South African women with clinically diagnosed TA who had significant regrowth with 2% topical minoxidil lotion.6 At our institution, we utilize 5% topical minoxidil solution applied to affected areas twice daily.
Surgery can be effective for late-stage TA. Punch grafting and micro- or mini-grafting can be performed successfully.7 Despite the risk of keloids or koebnerization in the setting of concomitant scarring alopecia, surgery should certainly be considered in patients with quiescent cicatricial alopecia and minimal response to medical therapies.
Novel therapies have been recently investigated in the medical literature. Goren et al proposed that topical alpha1 agonists may be a convenient preventative approach to stimulate piloerection and resist pulling forces in high tension hair styling practices.8
In summary, there are limited effective treatment options for TA. Future directions in TA management include heightened public awareness to mitigate risks of high-tension hairstyles in partnership with community hair care professionals. More research is required to investigate new potential TA treatments including oral minoxidil, platelet-rich plasma, and laser assisted drug delivery with growth factors. Further studies are needed to determine the effectiveness of these treatment options.
DISCLOSURES
The authors have no conflict of interest.
REFERENCES
1. Okereke UR, Simmons A, Callender VD. Current and emerging treatment strategies for hair loss in women of color. Int J Womens Dermatol. 2019;5(1):37-45.
2. Madu P, Kundu RV. Follicular and scarring disorders in skin of color: presentation and management. Am J Clin Dermatol. 2014;15(4):307-21.
3. Karimian-Teherani D, El Shabrawi-Caelen L, Tanew A. Traction alopecia in two adolescent Sikh brothers-an underrecognized problem unmasked by migration. Pediatr Dermatol. 2011;28(3):336-8.
4. Chu TW, AlJasser M, Alharbi A, Abahussein O, McElwee K, Shapiro J. Benefit of different concentrations of intralesional triamcinolone acetonide in alopecia areata: An intrasubject pilot study. J Am Acad Dermatol. 2015;73(2):338-40.
5. Zaenglein AL, Pathy AL, Schlosser BJ, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2016;74(5):945-73.e33.
6. Khumalo NP, Ngwanya RM. Traction alopecia: 2% topical minoxidil shows promise. Report of two cases. J Eur Acad Dermatol Venereol. 2007;21(3):433-4.
7. Billero V, Miteva M. Traction alopecia: the root of the problem. Clin Cosmet Investig Dermatol. 2018;11:149-59.
8. Goren A, Shapiro J, Sinclair R, Kovacevic M, McCoy J. α1 -AR agonist induced piloerection protects against the development of traction alopecia. Dermatol Ther. 2016;29(3):160-3.
2. Madu P, Kundu RV. Follicular and scarring disorders in skin of color: presentation and management. Am J Clin Dermatol. 2014;15(4):307-21.
3. Karimian-Teherani D, El Shabrawi-Caelen L, Tanew A. Traction alopecia in two adolescent Sikh brothers-an underrecognized problem unmasked by migration. Pediatr Dermatol. 2011;28(3):336-8.
4. Chu TW, AlJasser M, Alharbi A, Abahussein O, McElwee K, Shapiro J. Benefit of different concentrations of intralesional triamcinolone acetonide in alopecia areata: An intrasubject pilot study. J Am Acad Dermatol. 2015;73(2):338-40.
5. Zaenglein AL, Pathy AL, Schlosser BJ, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2016;74(5):945-73.e33.
6. Khumalo NP, Ngwanya RM. Traction alopecia: 2% topical minoxidil shows promise. Report of two cases. J Eur Acad Dermatol Venereol. 2007;21(3):433-4.
7. Billero V, Miteva M. Traction alopecia: the root of the problem. Clin Cosmet Investig Dermatol. 2018;11:149-59.
8. Goren A, Shapiro J, Sinclair R, Kovacevic M, McCoy J. α1 -AR agonist induced piloerection protects against the development of traction alopecia. Dermatol Ther. 2016;29(3):160-3.
AUTHOR CORRESPONDENCE
Kristen Lo Sicco MD Kristen.Losicco@nyulangone.org
