Trichorrhexis nodosa

Trichorrhexis nodosa

Description, Causes and Risk Factors:

Abbreviation: TN.

Trichorrhexis nodosa is a common disorder characterized by hair breakage due to weak points in the hair. Though there are inherited forms, the most common type of TN is due to physical or chemical trauma to the hair. It occurs more frequently in individuals of African origin with very curly hair. The spiral shape of the hair follicle and hair shaft predispose African hair to breakage. African hair naturally is less dense and grows slower than hair types of other ethnic groups and it is at increased risk for significant damage when exposed to cosmetic treatments.

Your genes may play a role in whether or not you develop trichorrhexis nodosa. Certain things you do to your hair -- such as blow-drying, over-brushing, perming, or excessive chemical use -- appear to trigger the condition.

In some cases, trichorrhexis nodosa may be caused be an underlying disorder such as hypothyroidism, argininosuccinicaciduria, Menkes' kinky hair syndrome, ectodermal dyspalsia, Netherton syndrome, or trichothiodystrophy.

The more common acquired form results from excessive or repeated trauma caused by frequent application of hair-permanent liquid, hair dyes, frequent brushing, scalp massage, and lengthy and repeated ultraviolet exposure, a reflection of the amount of trauma inflicted on the hair shafts rather than by some inherent or structural defect. Trichorrhexis nodosa may also be due to malnutrition or endocrinopathy, especially iron deficiency and hypothyroidism.

Seasonal recurrence of trichorrhexis nodosa has been reported as the result of the cumulative effect of diverse insults to the hair. The manifestations appear each summer when repeated soaking in salt water and exposure to ultraviolet light were superimposed on the traumas of shampooing and hair brushing. Trichorrhexis nodosa has also resulted from the use of chemical hair straighteners and selenium shampoo and from trauma induced by infestation with trichomycosis axillaris. Numerous studies have reproduced trichorrhexis nodosa in both normal and affected hairs by exposing them to simulated physical and chemical trauma.

Trichorrhexis nodosa may also occur as part of the trichohepatoenteric syndrome (THES), an autosomal recessive syndrome also characterized by life-threatening diarrhea in infancy, immunodeficiency, liver disease, facial dysmorphism, hypopigmentation, cardiac defects, and possibly platelet abnormalities (eg, reduced platelet alpha-granules, unusual stimulated alpha granule content release, abnormal lipid inclusions, abnormal platelet canalicular system, and reduced number of microtubules). It has been linked to mutations in TTC37.


Symptoms may include:

    Lack of apparent hair growth.

  • Hair appears patchy.

  • Hair breaks easily close to scalp.

  • Hair may have thickenings or nodes in the shaft.

  • Ends of hair thinned or split.

  • Whitish discoloration of hair tips.

  • Hair breaks easily at tips.

Your hair may appear patchy or like it's not growing.In African-Americans, looking at the scalp area using a microscope shows that the hair breaks off at the scalp area before it grows long.In Caucasians, the problem often appears at the end of a hair shaft in the form of split ends, thinning hair, and hair tips that look white.


All patients should be questioned about their routine hair care habits and environmental or chemical exposures to determine the source of physical or chemical trauma.

Light and electron microscopy of the affected areas reveal a decreased or absent cuticular cell layer and the characteristic paintbrush bristle appearance of trichorrhexis nodosa. More precisely, it resembles a crushed paint brush and is called a "paint brush fracture."In patients with underlying trichothiodystrophy, polarized light shows the typical appearance of alternating light and dark bands on the shaft, the so-called tiger-tail pattern.Fungal microscopy and culture may be performed if necessary. Patients suspected of having an underlying congenital disorder because of a young age at onset and because of the presence of associated symptoms warrant further investigation.

Analysis of the hair shaft may reveal a chemical deficiency caused by a metabolic disorder (eg, low sulfur level in trichothiodystrophy). Serum and urine amino acid levels should be investigated.

Other blood tests may include copper level tests, iron studies, blood cell counts, and liver and thyroid function tests.


Improving environmental factors will reduce damage to the hair. Gentle brushing with a soft brush should replace more aggressive brushing, ratting, or other procedures. Harsh chemicals such as hair straightening compounds and permanents should be avoided. The hair should not be ironed. Excessively harsh shampoo should be avoided. Hair conditioners should be used.

Once hairs are broken, they cannot be mended so prevention is key. Limit physical stress to the hair (e.g., combing, scratching, etc.). If your scalp itches, anti-dandruff shampoos may be helpful, but these may also dry out African hair.

Consider wearing hair in its natural state as avoidance of heat and chemicals is optimal to allow your hair to recover. However, if relaxers are desired, apply a protective ointment such as petrolatum to the scalp prior to application (i.e., base), and only apply the chemicals to new hair growth to avoid further damage to previously relaxed hair. Consider ammonium bisulfite cream relaxers, which are the least damaging; but keep in mind that these are not permanent. If a permanent relaxer is desired, have it professionally applied no more than every eight weeks. Relaxers should be followed by thorough rinsing with neutralizing shampoo. Wait at least two weeks after relaxing/waving to permanently color hair. An alternative is to use temporary colorants or semi-permanent hair dyes, which are less damaging and can be used the same day as chemical straighteners.

Limit use of heat on the hair as much as possible, using heat once weekly at the most. Use hot comb/curling iron/flat iron only on clean dry hair.

Use conditioning shampoos and moisturizing conditioners with ingredients that will protect the hair. Such moisture-binding ingredients include sodium PCA, glycerine, panthenol, chitosan, dimethicone and/or silicone. Silicone or dimethicone can also be found in moisturizing shampoos. Use of leave-in conditioners or weekly heated deep conditioning treatments containing such ingredients may also be helpful as prolonged application helps to coat and protect the hair.

If braiding, extensions, or weaving are used, a “tight pull” should be avoided. No hair style should ever be painful. Braided styles should be removed every 6-8 weeks to avoid accumulation of debris and locking which, when removed, can contribute to breakage.

Avoid use of hair products containing alcohol. Limit grooming of hair when it is styled with hair products. Wash or rinse products from hair prior to restyling. Have damaged ends regularly trimmed.

A visit to a dermatologist may be necessary to tailor the treatment regimen and possibly rule out underlying fungal infection in cases that are refractory to the above measures.

NOTE: The above information is for processing purpose. The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition.

DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.


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