Marginal traction alopecia severity score: development and test of reliability

Traction alopecia (TA) is common in African females. Although hairstyles are thought to be causal, the contribution of individual hairstyling variables to TA severity has not been quantified. The aim of the current study was to develop a severity scoring system (M-TAS score) for marginal TA, the commonest form of this disorder, and to test its reliability.

The margins of the scalp were divided into anterior and posterior with an imaginary line joining the tips of both ears. The anterior and posterior hairlines were further divided into three using the temporalis muscles and mastoid processes at the hairline as landmarks, respectively. Each examiner assessed each of the six areas. If any were found to have TA, the severity was scored using an examiner assessed system (tested once) or a picture matched score (tested twice). Ten and eight female patients with TA of varying severity were assessed by 11 and 9 examiners (dermatologists, dermatology trainees, and nurses), respectively.

The intraclass correlation coefficient (ICC) for interobserver agreement was larger with photograph-matched scores than with examiner estimated scores reaching substantial (0.61-0.80) and excellent (0.81-100) agreement for both anterior and posterior scores irrespective of level of skill of examiner. The ICC for intraobserver agreement with the photograph matched scores was 0.99.

The diagnosis of normal margin was excellent for the anterior yet poor for the posterior margin with photograph scores. The M-TAS score is not for diagnosis but to assess severity.

The photograph-based M-TAS score requires validation with larger samples but could be a useful research tool for elucidating disease prevalence and determinants of TA as well for monitoring response to treatment.