Central centrifugal cicatricial alopecia

Overview

Central centrifugal cicatricial alopecia (CCCA) is a type of scarring hair loss that primarily affects women of African descent. It typically begins at the crown or center of the scalp and gradually spreads outward in a circular pattern. CCCA leads to permanent hair loss due to destruction of hair follicles and replacement by scar tissue. Early recognition and treatment are critical to slowing progression and preserving existing hair.

Causes

The exact cause of CCCA is not fully understood, but it is believed to result from a combination of genetic, inflammatory, and possibly environmental factors. Contributing causes may include:

• Genetic predisposition: A family history of CCCA increases risk, suggesting a hereditary component

• Inflammation: Chronic inflammation around hair follicles leads to follicular destruction and scarring

• Hair grooming practices: Frequent use of chemical relaxers, hot combs, tight braids, or weaves may contribute to or worsen the condition

• Hormonal and immune factors: Under investigation as potential contributors to disease onset

Symptoms

Symptoms of CCCA often develop gradually and may not be immediately noticeable. Common signs include:

• Progressive hair thinning: Starting at the crown (vertex) and moving outward

• Scalp tenderness or discomfort: Including burning, itching, or soreness

• Scalp inflammation: Redness or scaling may be seen in early stages

• Smooth, shiny scalp: In areas of scarring where follicles have been destroyed

• Broken hairs or pustules: Sometimes present around the affected area

Without treatment, the condition can lead to irreversible hair loss and permanent scarring of the scalp.

Diagnosis

Diagnosing CCCA involves a detailed history, clinical examination, and often additional testing:

• Medical and hair care history: To assess risk factors such as family history or hair practices

• Scalp examination: Dermoscopy can help identify signs of follicular dropout and scarring

• Scalp biopsy: A small sample of scalp skin may be taken and examined under a microscope to confirm inflammation, scarring, and follicular destruction

• Photography and mapping: To monitor progression over time

Treatment

While there is no cure for CCCA, early treatment can reduce inflammation, halt progression, and potentially stimulate regrowth in areas not yet scarred. Treatment options include:

• Topical corticosteroids: To reduce inflammation and suppress immune activity

• Intralesional corticosteroid injections: Delivered directly into the scalp for more aggressive inflammation control

• Topical calcineurin inhibitors (e.g., tacrolimus): For patients who cannot tolerate steroids long term

• Oral antibiotics (e.g., doxycycline): With anti-inflammatory properties

• Minoxidil (topical): To support hair growth in salvageable areas

• Hair care modifications: Discontinuation of damaging hairstyles, chemical treatments, and heat styling

• Oral anti-inflammatory or immunomodulating drugs: Used in resistant or advanced cases under specialist guidance

Prognosis

The prognosis of CCCA depends on how early the condition is diagnosed and treated. In early stages, inflammation can be controlled and hair regrowth may occur in non-scarred areas. However, once follicles are destroyed and replaced with scar tissue, the hair loss is permanent. Ongoing medical treatment and careful hair care practices are essential to preserving remaining hair. Regular follow-up with a dermatologist familiar with scarring alopecias improves long-term outcomes.