Localised Alopecia Associated with Hairstyling Accessories: A Multicentre Case Series with Clinical, Trichoscopic, and Histopathological Evidence of Mixed Mechanical Injury

Mechanical forces generated by hairstyling practices are recognised causes of hair and scalp disorders, particularly traction alopecia, but the effects of prolonged, localised exposure to hairstyling accessories remain poorly characterised. We conducted a multicentre retrospective study of 10 women evaluated at five centres with chronic localised alopecia anatomically corresponding to the site of repeated accessory contact, analysing clinical, trichoscopic, histopathological and outcome data. Mean age was 51.3 years and mean disease duration 5.8 years; nine patients had vertex involvement, and one had an interparietal patch. Trichoscopy showed vellus hairs, with variable broken hairs, black and yellow dots, dystrophic, bent and coiled hairs, perifollicular casts and loss of follicular openings. Histopathology, available in seven patients, showed scarring alopecia in four and non-scarring alopecia in three. Implicated exposures included hairpins, clips, buns, rollers and a hair prosthesis. After accessory removal and variable treatment, four patients showed partial regrowth, four remained stable, one worsened, and follow-up was unavailable for one. The anatomical correspondence between alopecic patches and accessory exposure, with overlapping pressure, traction and friction-related features, is consistent with a proposed mixed mechanical injury from chronic low-intensity stress. Recognising hairstyling accessories as a potential cause of localised alopecia may facilitate diagnosis and prevent progression to irreversible damage.