Religious headwear and alopecia: considerations for dermatologists.

An estimated 84% of the global population identifies with a religious group.1 Wearing religious headwear has been associated with alopecia, most notably traction alopecia (Fig. 1). Traction alopecia can result from how the headwear is secured and styled, or other practices that may lead to tension on the hair and scalp. Individuals with alopecia who observe religious head coverings may struggle to conform to practices regarding headwear styling. As this topic is scarcely reported in the scientific literature, the authors relied on their personal experiences and expertise in treating hair and scalp disorders to provide recommendations for mitigating alopecia risk. Although no published clinical study directly implicates religious headwear in alopecia presentation, there is a strong discourse on headwear and hair loss. For example, Shareef et al.2 analyzed self-reported hijab-related alopecia content on YouTube and found 27 videos with a total of 17,158,078 views. Traction is a likely contributor to hijab-related alopecia, owing to the consistent and tight wrapping of the hijab around the head and hair, which can lead to continuous pull on the hair roots. This is a particularly important consideration for certain subgroups, such as women with afro-textured hair who have fewer elastic fibers attaching hair follicles to the dermis compared to Caucasians.3 In the Jewish tradition, wigs, known as sheitels, worn by Orthodox women may cause traction alopecia if they create tension on the scalp, particularly from wig attachment techniques. Wig placement often requires natural hair to be styled in a sleek, compact manner, promoting tight hair styling techniques such as buns and braids that can lead to alopecia. A case series on dermatologic considerations in ultra-Orthodox Jews reported a woman who presented with an alopecic patch in the frontal scalp where the sheitel clip was consistently placed.4 Hair regrew in the region after the patient transitioned to a clipless wig. Similarly, a study of 37 men with localized alopecic patches in the region of the pins used to secure their kippah showed that 58.8% of the patients who changed to a different type of pin fastener exhibited hair regrowth.5 Traction alopecia related to the turban or dastar, worn by Sikh men, has been reported in the scientific literature and is referred to as turban alopecia.1 This condition results from the tension caused by hairstyling and/or headwear styling. Sikh men generally style the hair in a bun or knot that is wrapped tightly with a cloth or scarf around the head. Tension can result from the bun itself, or from the turban being worn too tightly. The Rastafarian tradition encourages the growth of dreadlocks, which are considered a symbol of the Lion of Judah and a mark of African identity. The risk of traction alopecia can be influenced by the weight and length of dreadlocks as well as the tightness with which they are tied or wrapped under a headwrap. Recommendations for preventing and treating religious headwear-associated alopecia are outlined in Table 1. Alopecia related to religious headwear is a significant concern affecting a large population in the United States and globally. Dermatologists should be aware of risks and cultural nuances when treating patients from diverse religious backgrounds. By incorporating culturally competent care, dermatologists can effectively address and prevent headwear-associated alopecia, fostering patient trust and well-being.