Acute onset traction‐associated ulceration and alopecia

Abstract

A 9-year-old African American girl presented to the Emergency Department (ED) for blisters on her scalp. Her hair was styled with synthetic extensions into "lemonade braids" (side swept cornrows) 11 days prior to presentation. The mother stated that the patient had her hair braided in the past with no issues, and denied use of any chemicals, hair relaxers or new products during the braiding process.The patient denied pain during braid placement but described the braids as "tight" once finished. Three days later, the patient complained of headache with scalp pruritus and pain. The mother noted that the braid on the crown of the head appeared tighter than the surrounding braids, with associated swelling at its base. Upon removal, the her mother noticed "blisters and sores" on the vertex of the patient's scalp. The hair in that area fell out over the following days. The patient's primary care physician recommended washing her hair with Dawn™ dish soap twice weekly and prescribed oral cefdinir, ketoconazole shampoo, and a compound of polymyxin B sulfate and bacitracin zinc ointment twice daily. Despite the adherence to this treatment regimen, the patient's conditioned worsened, and she subsequently presented to the ED. The patient had no systemic symptoms. On clinical exam in the ED, there were irregularly shaped ulcerations within a large patch of alopecia on the vertex scalp with no notable erythema or crusting (Figure 1). A bacterial culture was obtained which grew normal flora. Due to the temporal association