An Approach to Hair Loss in Hijab-Wearing Individuals in Primary Care

To the Editor: While traction alopecia (TA) is a common and well-known etiology of hair loss,¹ we believe it is important to highlight the potential for TA in individuals who wear hijab and how to approach removal of the hijab for a physical exam.

A hijab is a cloth worn by Muslim women to cover their hair and preserve their modesty.² Approximately 43% of Muslim women in the United States reported always or usually wearing hijab.³ The earliest description of hair loss in individuals who wear hijab was in 1980. It was reported that continuous strong traction on the hairline in Libyan woman who wore hijab resulted in TA corresponding with the placement of the scarf.⁴ More recently, TA was described in Iraqi women who wear hijab.⁵

Although hair loss is typically distressing to patients, there is a potential for delayed diagnosis in individuals who wear hijab due to feelings of embarrassment and/or fear for violation of modesty. It is important for providers to be aware of this risk of hair loss and to recognize exam findings of TA.

Stress on the hair root, either continuous or intermittent, can lead to TA. The typical presentation is symmetrical and variegated hair loss at the frontal hairline.⁶ However, early TA may induce an inflammatory response with initial signs of perifollicular erythema and pustules.^1,7 Without appropriate treatment, this initially reversible hair loss may cause permanent scarring with little to no follicular markings present.⁷ While there are a wide array of etiologies of hair loss,¹ if present, one reported marker of TA is the “fringe sign.”⁸ This refers to when there are intact hairs at the anterior fronto-temporal rim of patients with loss noted posteriorly to this “fringe” of hair.⁸

When evaluating the patient with hair loss, a thorough history is necessary. Of note, while the focus of this article is on TA, individuals who wear hijab may also have other or a combination of etiologies of hair loss and being familiar with other forms of hair loss is necessary.

Examining an individual who wears hijab may create hesitancy in the practitioner. It is important to approach the exam with cultural humility. In 2021, Rehman et al, published recommendations surrounding hijab etiquette for dermatology clinics, which is a useful guide for all practitioners.² A summary of recommendations for caring for hijab-wearing patients can be found in Table 1.

When focusing on treatment, primary prevention is important. In order to avoid initiating or exacerbating TA, we would advise the patient to avoid placing hair in tight hairstyles under the hijab that may lead to a further propensity for traction.^9,10 As the hijab itself can lead to TA, avoiding confounding causes of TA is likely beneficial. Additionally, when placing hair in an updo under the hijab, it is recommended to loosen the proximal ends of the frontal hairline to decrease tension.^9,10 Finally, when patients are in a location where they can remove the hijab, encourage them to remove any traction.

In addition to modifying hair style practices, topical minoxidil may be beneficial. Furthermore, if there are signs of inflammation, anti-inflammatory medications or intralesional corticosteroids may be necessary. However, as aforementioned with longstanding TA, irreversible hair loss may occur and hair transplantation may be the only restorative treatment option.^1,10 For patients with long-standing TA or signs of inflammation or scarring (perifollicular erythema and/or follicular dropout), we recommend referral to dermatology.¹⁰

In summary, TA in patients who wear hijab is an important entity for practitioners to be aware of and having a systematic approach to examining and treating these patients is likely beneficial.