The “Fringe Sign” A Useful Clinical Finding in Traction Alopecia of the Marginal Hair Line

Abstract

Background: Traction alopecia is hair loss due to prolonged or repetitive tension on the hair. Diagnostic challenges may be encountered if the clinical suspicion for traction is not high, or if the history of traction is remote or not obtained. Since pathologic features can vary dramatically with the stage of the disorder clinico-pathologic correlation is essential. We have made the observation that the presence of retained hairs along the frontal and/or temporal rim, which we termed the "fringe sign", is a finding that can be see in both early and late traction alopecia, and thus may be a useful clinical marker of the condition. Objective: To determine the frequency of the fringe sign in a series of patients with a diagnosis of traction alopecia. Methods: This was a retrospective single-center review. Results: Over a 3.5 year period the diagnosis of traction alopecia was made in 41women. Twelve of the 41 patients were Hispanic (29%). The average age of our cohort was 34. Thirty-five (85%) of all women and 100% of women who had traction involving the marginal hair line had the fringe sign. The majority of African American women (54%) compared to 17% of the Hispanic women had some clinical sign of scalp inflammation(most frequently scalp scaling). Fourteen biopsies(58%) were available for review. Histopathologic findings included retained sebaceous glands (100%) and an increase in vellus-sized hairs (50%), a decrease in terminal hairs (100%), fibrotic fibrous tracts (100%), and sparse lyphocytic inflammation (57%). Trichomalacia was only noted in only one of the biopsies. Limitations: Retrospective analysis, uncontrolled study. Conclusions: Hispanic women as well as African American women are at high risk for traction alopecia. The fringe sign was a sensitive and specific clinical feature of traction alopecia when it involved the marginal hair line. Retained sebaceous glands, decreased terminal hairs, and fibrotic fibrous tracts were noted in all histopathologic specimens.

Trichotillomania and Traction Alopecia

“…An important clinical caveat in the diagnosis of TA is the "fringe sign," defined as the presence of retained hairs along the frontal and/or temporal margin. This useful finding was observed in early and late stages of TA alike (Figure 2) [43].…”

“…As noted earlier, the alopecia is typically nonscarring in the early stages, but may become irreversible later during the disease course, following a "biphasic" course [27]. Correspondingly, follicular markings tend to be decreased in the late stages of TA [27,31,43]. An important clinical caveat in the diagnosis of TA is the "fringe sign," defined as the presence of retained hairs along the frontal and/or temporal margin.…”

“…It is well recognized that traction causes an inflammatory, sometimes subclinical, folliculitis. The exact pathomechanism leading from follicular inflammation to follicle damage and hair loss remains to be elucidated; however, follicular miniaturization is considered to play a possible role [28,[42][43][44].…”

“…Importantly, hairdressing practices causing symptoms such as stinging, pain, or crusting are associated with an increased risk of TA [37,39]. "Tenting" of the hair follicle, which manifests as elevation of the scalp skin due to tight pulling, has been interpreted as a sign of excessive tension [27,39,43]. A more recent literature review classified hairstyles into low risk, moderate risk and high-risk [39].…”

A Dermoscopic Clue for the Diagnosis of Traction Alopecia: Peripilar Keratin Casts: Case Report

“…8 Traksiyon alopesi tanısı koymak genellikle kolay olmakla birlikte, traksiyon hikâyesi net olarak alınamıyor ve alopesinin dağılımı atipik ise tanısal zorluk ortaya çıkabilmektedir. 10 Traksiyon alopesi erken dönemde en sık alopesi areata ile karışmaktadır. Bunun yanında telogen effluvium, androgenik alopesi, trikotillomani, tinea kapitis, alopesi sifilitika, anagen effluvium ile ayırıcı tanısının yapılması gerekmektedir.…”