Central centrifugal scarring alopecia
Central centrifugal cicatricial alopecia (CCCA) is a form of scarring hair loss. Read more...
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What is central centrifugal cicatricial alopecia?
Central centrifugal cicatricial alopecia (CCCA) is a form of scarring hair loss. It is poorly understood in terms of etiology. It is characterized by inflammation at the base of the hair follicle that ultimately leads to hair loss and scarring of the follicle. Numerous possible causes have been attributed to CCCA, all with limited supporting evidence. Triggers ranging from hair care products or practices to autoimmune to genetic and, potentially, idiopathic have been implicated.
How does central centrifugal cicatricial alopecia present?
Inflammation and irritation around the hair follicles begin initially at the vertex of the scalp. This proceeds centrifugally and symmetrically outwards leaving a path of thinned hair or hair loss. It has been described as predominantly presenting in middle-aged African American women, however, the process likely begins earlier than this and is likely underdiagnosed.
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How is central centrifugal cicatricial alopecia diagnosed?
Often women come in well after their hair loss has progressed substantially. There is usually a patch of little to no hair growth at the vertex of the scalp when patients present. At times there can be tenderness, burning, or itching associated with the scalp, however, these symptoms are not always present. The vertex is smooth or soft to the touch with little to no appreciable hair growth. Although a biopsy can be performed to confirm the diagnosis, the presentation is classic and does not always require a biopsy to confirm.
How is it central centrifugal cicatricial alopecia treated?
The first step towards managing CCCA is the use of anti-inflammatory agents. Either topical or intralesional steroid injections can help reduce inflammation at the base of the hair follicles. Topical calcineurin inhibitors can also be used.
Oral therapy with doxycycline can be considered for its anti-inflammatory benefits. This has the potential to at least reduce further hair loss and potentially trigger hair to resume growth.
I often recommend the use of minoxidil, topical and also now oral, to promote hair growth as well.
There was a recent report of patients responding to topical metformin. Given the paucity of agents available to address CCCA and the significant number of patients I manage with this condition, I was quick to add this to the regimen for a number of my patients. Fortunately, I have seen some encouraging results in the first few months of adding this in.
Is it possible to avoid permanent hair loss?
The most important step to take to avoid permanent hair loss is early diagnosis and early intervention. Building recognition of this condition, identifying it at earlier stages, and implementing therapeutic interventions prior to the onset of scarring hair loss is key to success. Treatments tend to do best at reducing further loss but often fall short of actually adding more hair growth.
Practically speaking this outcome is the result of scarring or permanent loss of the hair follicle due to the chronic nature of the inflammation present. I encourage those that carry this diagnosis to ask their younger family members to be evaluated early to potentially implement preventative strategies. For example, the early addition of a topical calcineurin inhibitor is relatively safe to use and can potentially reduce the inflammation associated with permanent hair loss.