Central Centrifugal Cicatricial Alopecia

What it is

Central centrifugal cicatricial alopecia, usually shortened to CCCA, is a type of hair loss in which inflammation destroys hair follicles and leaves scar tissue where they were. Because the follicle is gone rather than resting, the loss can be permanent [1].

Why this guide is written for Black patients

CCCA is seen more commonly in Black women, and it is the most common type of scarring hair loss in women of African descent [1]. It is the most frequent cause of scarring hair loss in African American women and usually begins during middle age [1].

How common it is depends on which study you read. Two 2011 studies came out very differently, one reporting a prevalence of 5.6 percent among 529 African American women and another about 28 percent in a cohort of 326 women [4]. That spread is a real gap in the research rather than a disagreement about the disease.

Two things are worth knowing about cause. Hair styling and grooming may play a role, but this has yet to be proven, and the American Academy of Dermatology notes that some women who develop CCCA have never used relaxers while most women who use relaxers never develop it [2]. Genes are likely partly responsible, and one gene called PADI3 may be involved [2]. There is also an association with type 2 diabetes: in the research the AAD cites, 37 percent of Black women living with CCCA had type 2 diabetes compared with 12 percent of Black women who did not [2].

What to ask a clinician

• Is this scarring or non-scarring hair loss, and how are you telling the difference?
• Will you do a scalp biopsy, and what will it change about the plan [3]?
• What is the plan to stop the spreading, separately from the plan to regrow hair?
• Should I be screened for type 2 diabetes given the association [2]?
• What can I do with my hair in the meantime that will not set this back?

What good care looks like

Diagnosis is made with a scalp biopsy: a dermatologist numbs part of the scalp and removes a small piece of skin to examine under a microscope, which confirms CCCA and rules out other causes of hair loss [3]. In practice a 4mm punch biopsy is taken from an actively inflamed area and needs to include the fat beneath the skin [4].

Treatment aims at the inflammation first. Dermatologists use corticosteroids, antibiotics such as doxycycline or minocycline, calcineurin inhibitors and minoxidil [3]. Minoxidil is always used alongside other medications, and using only minoxidil cannot treat CCCA effectively [3]. Treating CCCA at home with minoxidil alone cannot prevent further hair loss, because halting the loss requires prescription medicine that reduces inflammation [3].

Timelines are long. Corticosteroids may be applied daily for two to four weeks at first, antibiotics run two to six months, and injections are usually monthly for six to eight months [3]. Intralesional triamcinolone is commonly given every four to six weeks [4].

Early treatment is the whole game. Caught early, treatment may help you regrow some hair, while late stage care is aimed at relieving symptoms and preventing further loss [3].

When it is urgent

CCCA is not an emergency, but it is time sensitive in a way most hair loss is not, because delaying treatment gives it time to spread outward and cause more permanent loss [1]. The first sign is often noticeable hair loss at the crown of the scalp, a small round bald patch that grows over time [1]. Some people feel small raised bumps, and many people with untreated CCCA say the scalp burns, stings or itches [1]. Any of those is a reason to book now rather than after the next appointment with your stylist.

What to do next

Book with a dermatologist and ask specifically whether they treat scarring alopecia in Black hair. You cannot effectively treat CCCA with hair loss products bought online or in stores, because it needs prescription medication [1].

Start with Black dermatologists, take photographs of the crown in good light before the appointment, and bring the names of everything that touches your scalp.