Wearing wigs for vigorous Irish dancing was the source of traction alopecia in several young girls, according to a recently published case series, highlighting another cause of hair loss that has also been associated with tight braids, ponytails, and buns.

Traction alopecia associated with high-tension hairstyles is a known cause of hair loss in adults but is not widely reported in children, especially as a result of wig-wearing, wrote Sara N. Bilimoria, MD, a dermatology resident at the Medical College of Wisconsin in Milwaukee, and coauthors. Traction alopecia can occur following repetitive or prolonged tension on hair follicles; is commonly associated with tight braids, ponytails, or hair extensions; and can lead to permanent scarring hair loss if not recognized, they noted.

“The reassuring part is that traction alopecia can be reversible when it is recognized early and the source of tension is removed,” senior author Katherine Kondratuk, MD, assistant professor of pediatric dermatology at the Medical College of Wisconsin, told Medscape Medical News.

“In our patients, we saw partial or complete hair regrowth after avoiding or limiting wig use,” she said.

In the report, published in Pediatric Dermatology, Kondratuk and her coauthors described three cases of girls aged 7-8 years who developed patchy hair loss soon after extended periods of performing Irish dance while wearing traditional, elaborate wigs secured to the vertex scalp. The wigs were attached with combinations of wig clips, hairpins, elastic bands, and styling products, according to the patients and their families.

Each patient presented with an alopecic patch on the vertex scalp (one patient had two alopecic patches) and had unevenly broken hairs on examination.

After the recommended treatment — wig avoidance — one patient had full hair regrowth at a 6-month follow-up visit, and the other two showed partial regrowth after 6 months.

“Once we understood how these wigs were being secured and worn, the mechanism for hair loss associated with wig-donning in Irish dancers made sense,” Kondratuk said, noting that the manner in which the wigs are secured can concentrate tension on a relatively small area of the scalp. “When you combine that tension with the weight of the wig and the vigorous, repetitive movement of dancing, there is a plausible mechanism for significant mechanical stress on the hair follicles,” she explained.

Implications and Advice

“Rather than being an entirely different type of hair loss, we think this may represent a unique setting in which several sources of traction and mechanical stress occur simultaneously,” said Kondratuk. Any potential individual characteristics, such as hair type, that might increase a child’s susceptibility to this type of traction alopecia are unknown, but from a mechanical standpoint, she noted that any factors that increase the concentration of traction on the scalp should be considered.

“One of the practical messages from our report is to focus on modifiable sources of tension rather than assuming that a particular hair type is inherently at risk,” said Kondratuk. “Using a lighter or smaller wig, distributing its weight more evenly, avoiding excessive tension during attachment, and limiting wig use when possible (such as for competition only) are reasonable strategies to reduce mechanical stress on the hair,” she said.

The authors referred to a report published in 2018 in Pediatric Dermatology describing cases of localized alopecia in two girls aged 4 and 5 years who received elaborate hairstyles involving tight buns and hair extensions as part of a princess-themed boutique package at a popular theme park. These cases did not involve repeated styling and vigorous activity but provide additional examples of the potential for traction alopecia in children related to hairstyling techniques. Both children were treated with topical steroids, and the 5-year-old used topical minoxidil for several months; both experienced hair regrowth in the areas of hair loss.

Traction alopecia classically develops from repetitive or prolonged tension on the hair follicles, so a hairstyle or wig that is worn repeatedly over a competitive season is of greater concern than a wig worn once for a special event, said Kondratuk. “For something like a Halloween costume worn once, I would expect the risk to be considerably lower than with repeated wig use, assuming the wig is not excessively heavy or tightly secured,” she said.

The studies received no outside funding. The researchers disclosed having no financial conflicts of interest related to these studies.