Central centrifugal cicatricial alopecia
- Leonard C Sperling, MD
Leonard C Sperling, MD
- Professor of Dermatology and Pathology
- Uniformed Services University
Central centrifugal cicatricial alopecia (CCCA) is a type of cicatricial (scarring) alopecia that presents as an area of permanent hair loss on the crown or vertex of the scalp that expands centrifugally (picture 1A-D). Clinical signs of inflammation (eg, inflamed papules, pustules, erythema, or scale) or symptoms (eg, scalp pain, tenderness, or itching) may accompany the hair loss. Women of African descent represent the most common population affected.
Data on the treatments for CCCA are limited, and treatment of the condition is largely guided by expert opinion. Local corticosteroid therapy and oral tetracyclines are well-accepted pharmacologic interventions for CCCA. Although uncertainty remains about the role of hair care practices in the development of CCCA, minimization of practices that can be damaging to the hair and scalp often is recommended.
The clinical manifestations and diagnosis of CCCA will be reviewed here. Other forms of cicatricial and noncicatricial alopecia are reviewed separately. (See "Evaluation and diagnosis of hair loss", section on 'Classification'.)
The terminology for the condition characterized by central scalp hair loss that is now called “central centrifugal cicatricial alopecia” (CCCA) has evolved over time:
●1968 – The term “hot comb alopecia” is proposed by the authors of a published series of 51 African-American women with scarring alopecia involving the central scalp based upon a theory that permanent hair loss resulted from thermal damage to the scalp during use of a hot comb (a specialized metal comb that is heated and used to straighten hair) .
- LoPresti P, Papa CM, Kligman AM. Hot comb alopecia. Arch Dermatol 1968; 98:234.
- Sperling LC, Sau P. The follicular degeneration syndrome in black patients. 'Hot comb alopecia' revisited and revised. Arch Dermatol 1992; 128:68.
- Nicholson AG, Harland CC, Bull RH, et al. Chemically induced cosmetic alopecia. Br J Dermatol 1993; 128:537.
- Sperling LC, Solomon AR, Whiting DA. A new look at scarring alopecia. Arch Dermatol 2000; 136:235.
- Olsen EA, Bergfeld WF, Cotsarelis G, et al. Summary of North American Hair Research Society (NAHRS)-sponsored Workshop on Cicatricial Alopecia, Duke University Medical Center, February 10 and 11, 2001. J Am Acad Dermatol 2003; 48:103.
- Powell J, Dawber RP. Folliculitis decalvans and tufted folliculitis are specific infective diseases that may lead to scarring, but are not a subset of central centrifugal scarring alopecia. Arch Dermatol 2001; 137:373.
- Callender VD, Onwudiwe O. Prevalence and etiology of central centrifugal cicatricial alopecia. Arch Dermatol 2011; 147:972.
- Olsen EA, Callender V, McMichael A, et al. Central hair loss in African American women: incidence and potential risk factors. J Am Acad Dermatol 2011; 64:245.
- Khumalo NP, Jessop S, Gumedze F, Ehrlich R. Hairdressing and the prevalence of scalp disease in African adults. Br J Dermatol 2007; 157:981.
- Khumalo NP, Jessop S, Gumedze F, Ehrlich R. Hairdressing is associated with scalp disease in African schoolchildren. Br J Dermatol 2007; 157:106.
- Kyei A, Bergfeld WF, Piliang M, Summers P. Medical and environmental risk factors for the development of central centrifugal cicatricial alopecia: a population study. Arch Dermatol 2011; 147:909.
- Sperling LC, Skelton HG 3rd, Smith KJ, et al. Follicular degeneration syndrome in men. Arch Dermatol 1994; 130:763.
- Rondina A, Gathers RC. A case of central centrifugal cicatricial alopecia in an African American man. J Am Acad Dermatol 2009; 60:AB102.
- Davis EC, Reid SD, Callender VD, Sperling LC. Differentiating central centrifugal cicatricial alopecia and androgenetic alopecia in african american men: report of three cases. J Clin Aesthet Dermatol 2012; 5:37.
- Gathers RC, Jankowski M, Eide M, Lim HW. Hair grooming practices and central centrifugal cicatricial alopecia. J Am Acad Dermatol 2009; 60:574.
- Nnoruka EN. Hair loss: is there a relationship with hair care practices in Nigeria? Int J Dermatol 2005; 44 Suppl 1:13.
- Khumalo NP, Pillay K, Ngwanya RM. Acute 'relaxer'-associated scarring alopecia: a report of five cases. Br J Dermatol 2007; 156:1394.
- Dlova NC, Forder M. Central centrifugal cicatricial alopecia: possible familial aetiology in two African families from South Africa. Int J Dermatol 2012; 51 Suppl 1:17.
- Dlova NC, Jordaan FH, Sarig O, Sprecher E. Autosomal dominant inheritance of central centrifugal cicatricial alopecia in black South Africans. J Am Acad Dermatol 2014; 70:679.
- Suchonwanit P, Hector CE, Bin Saif GA, McMichael AJ. Factors affecting the severity of central centrifugal cicatricial alopecia. Int J Dermatol 2016; 55:e338.
- Miteva M, Tosti A. Central Centrifugal Cicatricial Alopecia Presenting with Irregular Patchy Alopecia on the Lateral and Posterior Scalp. Skin Appendage Disord 2015; 1:1.
- Shah SK, Alexis AF. Central centrifugal cicatricial alopecia: retrospective chart review. J Cutan Med Surg 2010; 14:212.
- Callender VD, Wright DR, Davis EC, Sperling LC. Hair breakage as a presenting sign of early or occult central centrifugal cicatricial alopecia: clinicopathologic findings in 9 patients. Arch Dermatol 2012; 148:1047.
- Horenstein MG, Simon J. Investigation of the hair follicle inner root sheath in scarring and non-scarring alopecia. J Cutan Pathol 2007; 34:762.
- Sperling LC. Premature desquamation of the inner root sheath is still a useful concept! J Cutan Pathol 2007; 34:809.
- Wohltmann WE, Sperling L. Histopathologic diagnosis of multifactorial alopecia. J Cutan Pathol 2016; 43:483.
- Miteva M, Tosti A. Dermatoscopic features of central centrifugal cicatricial alopecia. J Am Acad Dermatol 2014; 71:443.
- Fu JM, Price VH. Approach to hair loss in women of color. Semin Cutan Med Surg 2009; 28:109.
- Gathers RC, Lim HW. Central centrifugal cicatricial alopecia: past, present, and future. J Am Acad Dermatol 2009; 60:660.
- Callender VD, McMichael AJ, Cohen GF. Medical and surgical therapies for alopecias in black women. Dermatol Ther 2004; 17:164.
- Rodney IJ, Onwudiwe OC, Callender VD, Halder RM. Hair and scalp disorders in ethnic populations. J Drugs Dermatol 2013; 12:420.
- Smith K, Leyden JJ. Safety of doxycycline and minocycline: a systematic review. Clin Ther 2005; 27:1329.
- Chiang C, Sah D, Cho BK, et al. Hydroxychloroquine and lichen planopilaris: efficacy and introduction of Lichen Planopilaris Activity Index scoring system. J Am Acad Dermatol 2010; 62:387.
- Sperling LC, Nguyen JV. Commentary: treatment of lichen planopilaris: some progress, but a long way to go. J Am Acad Dermatol 2010; 62:398.
- Donati A, Assouly P, Matard B, et al. Clinical and photographic assessment of lichen planopilaris treatment efficacy. J Am Acad Dermatol 2011; 64:597.
- Price VH. The medical treatment of cicatricial alopecia. Semin Cutan Med Surg 2006; 25:56.
- Powell JJ, Dawber RP, Gatter K. Folliculitis decalvans including tufted folliculitis: clinical, histological and therapeutic findings. Br J Dermatol 1999; 140:328.
- Summers P, Kyei A, Bergfeld W. Central centrifugal cicatricial alopecia - an approach to diagnosis and management. Int J Dermatol 2011; 50:1457.
- Donovan JC, Shapiro RL, Shapiro P, et al. A review of scalp camouflaging agents and prostheses for individuals with hair loss. Dermatol Online J 2012; 18:1.
- Callender VD, Lawson CN, Onwudiwe OC. Hair transplantation in the surgical treatment of central centrifugal cicatricial alopecia. Dermatol Surg 2014; 40:1125.
- Hair care practices
- CLINICAL MANIFESTATIONS
- Patient history and physical examination
- DIFFERENTIAL DIAGNOSIS
- Patient selection
- First-line therapy
- - Local corticosteroids
- - Oral tetracyclines
- - Behavioral interventions
- Refractory disease
- Other therapies
- Cosmetic interventions
- CLINICIAN AND PATIENT SUPPORT
- SUMMARY AND RECOMMENDATIONS