Central Centrifugal Cicatricial Alopecia

Central centrifugal cicatricial alopecia (CCCA) is the most common scarring alopecia in women of African descent, causing slowly progressive centrifugal hair loss from the crown with permanent follicular destruction.

• Prevalence is about 2 to 6% of Black women. Onset in the third to fourth decade.
• Causes: genetic (PADI3 mutations), plus traction, hot combs, relaxers, tight braids, and inflammation. Associated with uterine fibroids and type 2 diabetes in some studies.
• Considered a fibroproliferative disorder with premature desquamation of the inner root sheath.

• Hair loss beginning at the vertex and expanding centrifugally, with a smooth, shiny scalp with reduced follicular ostia.
• Often asymptomatic, but sometimes itching, tenderness, burning, or tingling; hair "breakage" and thinning.
• Early disease shows perifollicular erythema, scale, and pustules, with "peripilar casts".
• Late disease is a shiny, atrophic, scarred scalp.

• Clinical and trichoscopy: white dots, peripilar white grey halos, honeycomb pigmentation pattern, and loss of follicular openings.
• Scalp biopsy (4 mm punch, horizontal sectioning) from active margin: premature desquamation of inner root sheath, perifollicular lymphocytic infiltrate, concentric lamellar fibroplasia, and fibrosis.
• Exclude traction alopecia, lichen planopilaris, folliculitis decalvans, discoid lupus, and AGA.
• Screen glucose and thyroid function; ask about hair styling practices.

• Stop traction and heat: avoid tight braids, hot combs, and chemical relaxers; gentle low tension styles.
• Anti-inflammatory therapy to halt progression:
  • Topical clobetasol 0.05% or fluocinonide solution daily or several times weekly; tacrolimus 0.1%.
  • Intralesional triamcinolone 10 mg/mL every 4 to 6 weeks.
  • Doxycycline 100 mg twice daily for 3 to 6 months or minocycline 100 mg twice daily.
  • Hydroxychloroquine 200 mg twice daily, mycophenolate 1 g twice daily, or methotrexate 15 to 20 mg weekly for refractory disease.
  • Oral minoxidil 0.25 to 2.5 mg daily and topical minoxidil 5% are adjuncts.
• Newer options: JAK inhibitors, PRP, and metformin trials.
• Hair transplantation can be considered in stable, quiescent disease (at least 12 months), with test grafts.
• Early diagnosis is key; counselling on realistic goals and psychological support.