In short: Traction alopecia is hair loss caused by years of pulling — tight buns, braids, ponytails, extensions, and in Sikh men the joora tied above the forehead under a turban. Caught early, it can reverse once the tension stops. Left long enough, the follicles scar and die, and the only fix is a hair transplant. Before surgery, though, you need to know whether ordinary male pattern hair loss is hiding underneath — it often is — because that changes the medication, the timing, and the plan. This article walks through a real case of a 23-year-old Sikh man to show how I'd approach it.
This is a case I get asked about far more than the amount of information online would suggest, which is exactly why the patient wrote to me. His photos, at first glance, look like an ordinary Norwood 3A pattern of hair loss. They aren't. Here's his email, lightly trimmed.
"I'm a Sikh male, age 23, and I've suffered from traction alopecia. It's extremely common amongst the community but the content and information out there regarding this specific issue is extremely rare. Sikh males keep their hair long and typically keep it in a bun, which tends to be tied on the top of the frontal hairline area. The tight keeping of this bun means the hairs in that area are being pulled, so they are damaged quite badly. I know many friends and relatives who have suffered the same problem. With the extent it gets to after childhood and teenage years, there is nothing that can be done to repair the damaged areas apart from surgical intervention."
He's right on every point. I saw a lot of Sikh men at the clinic where I used to work, and I've had many more cases submitted online since. What follows is what I told him, and what I'd tell anyone with the same problem.
What is traction alopecia?
Traction alopecia is hair loss caused by prolonged, repeated tension on the follicle — mechanical damage rather than hormones. Any hairstyle that pulls can cause it: tight ponytails and buns, braids, cornrows, weaves and extensions, and religious head coverings that require the hair to be tied tightly. It typically shows up first where the pull is greatest, which for most styles means the frontal hairline and the temples.
Among Sikh men it is common enough to have its own medical literature. The hair is never cut, it's tied in a knot (the joora) on top of the head, and the turban sits low and tight across the forehead. Years of that, starting in childhood, produce a very recognisable pattern: the temple points and the hair above the sideburns are wiped out, often on both sides, while the hair behind them can be perfectly normal.
Can traction alopecia be reversed?
Early on, yes. In the first stage the follicles are inflamed and miniaturised but alive, and if the tension is removed — looser styles, no more tight tying — hair can regrow over months. Minoxidil can help it along. The problem is that people rarely notice, or rarely can change the style, until it's too late. Once the follicles have been pulled for long enough they scar over and are gone for good, and no medication brings them back. At that point the only way to put hair in the area is to transplant it there from the donor zone.
How do you tell traction alopecia from male pattern baldness?
This is where the case gets interesting, and it's the part almost nobody talks about. The patient had seen a trichologist, who confirmed traction alopecia — and then added a note: microscopic examination showed some hair miniaturisation, possibly from telogen effluvium, to be monitored before recommending treatment.
Miniaturisation is the signature of DHT. Traction alopecia doesn't miniaturise hair in a diffuse pattern; it destroys it where the pull is. So when I looked past the obvious temple damage — which is the telltale sign, the entire area above the sideburn obliterated on both sides, with a few barely-alive hairs clinging on in the traction zone — I went looking at the mid-scalp and behind the temples. And there's a thin spot there I wouldn't expect to see in someone with no androgenetic loss at all. It isn't measured, it isn't scientific, and his photos made it hard: his hair is very long, he hadn't parted it, and I couldn't see the donor area or the top properly. But after thousands of photos over the years, my gut said his hair is being affected by DHT at least to some degree. The trichologist's note points the same way.
Patients often tell me "I don't have male pattern baldness, it's just X." Sometimes that's true. Often I look at the photos and it isn't. It matters enormously here, because a transplant into a scalp that's also losing hair to DHT — in a 23-year-old, no less — is a transplant into a moving target.
What should you do before considering a hair transplant?
Get on the medication first. I'm sorry, but you have to at least give it a shot. If the trichologist sees miniaturisation and the surgeon agrees there's pattern loss at play, then finasteride is step one, and you give it six months to see what it does against a proper baseline. He wasn't in a huge rush — he said "this year," not "as soon as possible" — so there was time to do this properly. Oral minoxidil, PRP and other non-surgical options are worth discussing with the doctor as well, but start with the basics.
This isn't just about protecting future hair. At 23, with damage this extensive, fixing the traction zones is not a few grafts. It's a big procedure, and realistically two passes to get density that blends with the rest of his hair. Going in with the pattern loss under control means the surgeon is designing for a stable scalp, not guessing at what will still be there in ten years.
What does surgical repair of traction alopecia look like?
He asked me to draw a hairline showing what a sensible, realistic design might be — not what he might wish for. I did: not too low, not too aggressive on the temples and temple points, but enough to restore him to a look of normality. The surgeon he was considering is conservative by nature and produces a natural result every time, so I'd expect something close to it. It's a rough approximation of hairline height, not a surgical plan.
On method: he was talking about FUT, and I think that's the right call for him. He will never shave his head — long hair for life is the whole point — so FUE harvesting, which needs the donor area shaved, is off the table. A strip procedure leaves a linear scar hidden under long hair and lets him keep the hair he has throughout.
And I'd do it in two stages rather than one. First pass, let it grow out — he can keep covering with a bandana or do-rag exactly as he does now — then go back, assess with the doctor, and add density where it needs it so the final result blends. He's not in a position to risk a single big shot at it. You can hide poor growth under a head covering, but if that's the plan, why have surgery at all?
What should anyone with traction alopecia take from this?
Stop the tension as early as you can — it's the only thing that gives the follicles a chance. Get an honest assessment of whether pattern hair loss is also present, because it changes everything. If it is, treat it before you transplant. If you need surgery, choose a harvest method that fits how you'll wear your hair for the rest of your life, and plan for more than one session. And remember that this is elective surgery with real risk and no guarantees — for this patient, and for everyone reading. If you're weighing this decision and want a second opinion on your photos before you talk to a clinic, that's what a strategy session is for; part your hair and show me the donor area when you send them.
The full consultation on video:
Sources
- Billero V, Miteva M. Traction alopecia: the root of the problem. Clin Cosmet Investig Dermatol. 2018;11:149-159. PubMed
- James J, Saladi RN, Fox JL. Traction alopecia in Sikh male patients. J Am Board Fam Med. 2007;20(5):497-498. PubMed
Further reading
This article is educational and reflects my experience as a patient, a former clinic insider and a patient advocate. It is not medical advice. Finasteride and minoxidil are medications; discuss them, and any surgery, with a qualified physician.
First published January 2021. Last reviewed and updated by Joe Tillman, September 2026.