Central centrifugal cicatricial alopecia - an approach to diagnosis and management

Central centrifugal cicatricial alopecia: a deeper insight into the disease

Central centrifugal cicatricial alopecia (CCCA) is a scarring alopecia of multifactorial etiology that presents on the vertex as patchy areas of hair loss, spreading centrifugally over the scalp. It most commonly affects women of African descent, but cases among other ethnicities have also been reported. CCCA typically starts with thinning and breaking of the hair as the first sign of presentation, which eventually progresses to hair loss over the central part of the scalp, spreading symmetrically outwards to involve a larger area. Currently, there is no definitive cure for the disease; however, multiple management options are available, which should aim to be tailored to the individual patient. Owing to its cosmetic outcomes, the quality of life (QoL) of patients with central centrifugal cicatricial alopecia is also disturbed, as patients may face psychological and social stress due to their permanent hair loss. This article focuses on various aspects of the pathogenesis, clinical trials, quality of life, barriers faced by patients, and treatment of central centrifugal cicatricial alopecia.

Clinical factors and hair care practices influencing outcomes in central centrifugal cicatricial alopecia

Central centrifugal cicatricial alopecia (CCCA) is the most common form of primary scarring alopecia in women of African descent, negatively impacting their quality of life. Treatment is often challenging, and we usually direct therapy to suppress and prevent the inflammation. However, factors affecting clinical outcomes are still unknown. To characterize medical features, concurrent medical conditions, hair care practices, and treatments used for patients with CCCA and assess their relationship with treatment outcomes. We analyzed data from a retrospective chart review of 100 patients diagnosed with CCCA who received treatment for at least one year. Treatment outcomes were compared with patient characteristics to determine any relationships. P-values were calculated using logistic regression and univariate analysis with 95% CI P < 0.05 was considered significant. After one year of treatment, 50% of patients were stable, 36% improved, and 14% worsened. Patients without a history of thyroid disease (P = 0.0422), using metformin for diabetes control (P = 0.0255), using hooded dryers (P = 0.0062), wearing natural hairstyles (P = 0.0103), and having no other physical signs besides cicatricial alopecia (P = 0.0228), had higher odds of improvement after treatment. Patients with scaling (P = 0.0095) or pustules (P = 0.0325) had higher odds of worsening. Patients with a history of thyroid disease (P = 0.0188), not using hooded dryers (0.0438), or not wearing natural hairstyles (P = 0.0098) had higher odds of remaining stable. Clinical characteristics, concurrent medical conditions, and hair care practices may affect clinical outcomes after treatment. With this information, providers can adjust proper therapies and evaluations for patients with Central centrifugal cicatricial alopecia.

Beyond the Hot Comb: Updates in Epidemiology, Pathogenesis, and Treatment of Central Centrifugal Cicatricial Alopecia from 2011 to 2021

Central centrifugal cicatricial alopecia (CCCA) is a form of scarring alopecia that predominantly affects middle-aged women of African descent. Recent data suggest a multifactorial etiology of CCCA that is influenced by environmental and genetic factors. Emerging evidence regarding the genetic basis of the condition may elucidate new therapies. While topical and intralesional steroids and tetracycline antibiotics are the mainstay of treatment, refractory cases may be considered for hair transplantation. Emerging therapies using platelet-rich plasma, botanical formulas, and cosmetic procedures have shown promising results for the future management of CCA. As recent notable advances in CCCA have been achieved, this review provides an update on the epidemiology, pathophysiology, and management of CCCA.

Scarring Alopecia: Diagnosis and New Treatment Options

This article focuses on the assessment and treatment of patients with primary cicatricial alopecia and provides new information regarding the genetics and pathophysiology of this group of diseases.

Central Centrifugal Cicatricial Alopecia: Challenges and Treatments

Central centrifugal cicatricial alopecia (CCCA) is the most common form of primary scarring alopecia diagnosed in women of African descent. Although the etiology was originally attributed exclusively to hairstyling practices common among women of African descent, more recent research on CCCA supports the concept that there are several contributing factors, including variants in gene expression, hair grooming practices that increase fragility on the hair follicle, and associations with other systemic conditions. Treatment of CCCA involves a combination of patient counseling and education on alternative hairstyles, medical therapies, and procedural methods when necessary.

New pattern hair loss in young Turkish women; What's wrong in their daily life?

BACKGROUND

The application of heat, used to straighten the typically coiled hair, has long been hypothesized to play a role in the etiologic factor for central centrifugal cicatricial alopecia (CCCA). The aim of this study was to evaluate the effect of thermal hair straightening on hair loss pattern in Asian women exist.

MATERIALS AND METHODS

Thirty-five patients with hair loss who have been using hair straightening devices and 25 patients with telogen effluvium were enrolled in this prospective study. Laboratory analysis and dermatoscopic findings were used to compare these groups.

RESULTS

The peripilar white halo around hairs, peripilar dark/gray halo around follicular orifices, the predominance of a single hair perifollicular unit (FU), hair diameter diversity, the thin miniaturized hair, interfollicular pinpoint white dots, and white patches were statistically higher in hair straightener group (P < 0.001). White patches of the scalp increased by the time of the application of these devices (P < 0.01). White patches of vertex region were significantly higher than the midfrontal region (P < 0.01).

CONCLUSION

The common side effects of thermal hot comb strengtheners' were summarized as damage to the hair shaft; decreasing in the brightness of the hair, burns, and scars on the scalp; and lastly CCCA-like hair loss.

The new paradigm for androgenetic alopecia and plant-based folk remedies: 5α-reductase inhibition, reversal of secondary microinflammation and improving insulin resistance

ETHNOPHARMACOLOGICAL RELEVANCE

Research in the past half a century has gradually sketched the biological mechanism leading to androgenetic alopecia (AGA). Until recently the aetiological paradigm has been too limited to enable intelligent commentary on the use of folk remedies to treat or reduce the expression of this condition. However, our understanding is now at a point where we can describe how some folk remedies work, predict how effective they will be or why they fail.

RESULTS

The new paradigm of AGA is that inheritance and androgens (dihydrotestosterone) are the primary contributors and a secondary pathology, microinflammation, reinforces the process at more advanced stages of follicular miniaturisation. The main protagonist to microinflammation is believed to be microbial or Demodex over-colonisation of the infundibulum of the pilosebaceous unit, which can be ameliorated by antimicrobial/acaricidal or anti-inflammatory therapies that are used as adjuvants to androgen dependent treatments (either synthetic or natural). Furthermore, studies reveal that suboptimal androgen metabolism occurs in both AGA and insulin resistance (low SHBG or high DHT), suggesting comorbidity. Both can be ameliorated by dietary phytochemicals, such as specific classes of phenols (isoflavones, phenolic methoxy abietanes, hydroxylated anthraquinones) or polycyclic triterpenes (sterols, lupanes), by dual inhibition of key enzymes in AGA (5α-reductase) and insulin resistance (ie., DPP-4 or PTP1B) or agonism of nuclear receptors (PPARγ). Evidence strongly indicates that some plant-based folk remedies can ameliorate both primary and secondary aetiological factors in AGA and improve insulin resistance, or act merely as successful adjuvants to mainstream androgen dependent therapies.

CONCLUSION

Thus, if AGA is viewed as an outcome of primary and secondary factors, then it is better that a 'multimodal' or 'umbrella' approach, to achieve cessation and/or reversal, is put into practice, using complementation of chemical species (isoflavones, anthraquinones, procyanidins, triterpenes, saponins and hydrogen sulphide prodrugs), thereby targeting multiple 'factors'.

Primary scarring alopecia: A retrospective study of 89 patients in Taiwan

Primary scarring alopecia (PSA) is caused by irreversible damage to the hair epithelial stem cells that reside in hair follicles. There is limited published work regarding PSA amongst the Asian population. The aim of this study was to evaluate the clinical features and to characterize the subtypes of PSA in southern Taiwan. In this retrospective case series, we reviewed 89 patients with pathology-confirmed PSA. The data was collected from National Cheng Kung University Hospital between 1988 through 2016. The clinical and histological data were reviewed, and the patients were characterized into different subtypes of PSA based on the clinical features and histological findings. We noted seven different subtypes of PSA. The most common type was dissecting cellulitis (DC) (30.3%), followed by lichen planopilaris (LPP) (23.5%), central centrifugal cicatricial alopecia (CCCA) (12.4%) and acne keloidalis nuchae (AKN) (12.4%). The other subtypes include folliculitis decalvans (FD), discoid lupus erythematosus (DLE) and pseudopelade of Brocq (PPB). Interestingly, FD, DC and AKN were more common in males, while CCCA, LPP, DLE and PPB had a female predominance. The mean age of patients with DLE, DC and AKN were younger, while patients with CCCA, LPP, PPB and FD tend to be older. The pattern of hair loss was more likely to be unifocal-ragged border in CCCA and DLE, multifocal-interconnected in LPP and FD, and multifocal-separated in DC. The pathogenesis of PSA may be influenced by sex, age and genetic background. It is important to identify the hair loss pattern to differentiate the subtypes of PSA.

Primary cicatricial alopecia: Lymphocytic primary cicatricial alopecias, including chronic cutaneous lupus erythematosus, lichen planopilaris, frontal fibrosing alopecia, and Graham-Little syndrome

Both primary and secondary forms of cicatricial alopecia have been described. The hair follicles are the specific target of inflammation in primary cicatricial alopecias. Hair follicles are destroyed randomly with surrounding structures in secondary cicatricial alopecia. This 2-part continuing medical education article will review primary cicatricial alopecias according to the working classification suggested by the North American Hair Research Society. In this classification, the different entities are classified into 3 different groups according to their prominent inflammatory infiltrate (ie, lymphocytic, neutrophilic, and mixed). Part I discusses the following lymphocytic primary cicatricial alopecias: chronic cutaneous lupus erythematosus, lichen planopilaris, frontal fibrosing alopecia, and Graham-Little syndrome.

Primary cicatricial alopecia: Other lymphocytic primary cicatricial alopecias and neutrophilic and mixed primary cicatricial alopecias

Primary cicatricial alopecias can be frustrating for both patients and physicians. Proper diagnosis guides more successful management of these challenging conditions. Part II will cover the remaining lymphocytic primary cicatricial alopecias, which include pseudopelade of Brocq, central centrifugal cicatricial alopecia, alopecia mucinosa, and keratosis follicularis spinulosa decalvans. It will also discuss the neutrophilic and mixed primary cicatricial alopecias, namely folliculitis decalvans, dissecting cellulitis, folliculitis keloidalis, folliculitis (acne) necrotica, and erosive pustular dermatosis.

Updates in the understanding and treatments of skin & hair disorders in women of color

Skin of color comprises a diverse and expanding population of individuals. In particular, women of color represent an increasing subset of patients who frequently seek dermatologic care. Acne, melasma, and alopecia are among the most common skin disorders seen in this patient population. Understanding the differences in the basic science of skin and hair is imperative in addressing their unique needs. Despite the paucity of conclusive data on racial and ethnic differences in skin of color, certain biologic differences do exist, which affect the disease presentations of several cutaneous disorders in pigmented skin. While the overall pathogenesis and treatments for acne in women of color are similar to Caucasian men and women, individuals with darker skin types present more frequently with dyschromias from acne, which can be difficult to manage. Melasma is an acquired pigmentary disorder seen commonly in women with darker skin types and is strongly associated with ultraviolet (UV) radiation, genetic factors, and hormonal influences. Lastly, certain hair care practices and hairstyles are unique among women of African descent, which may contribute to specific types of hair loss seen in this population, such as traction alopecia, trichorrhexis nodosa and central centrifugal cicatricial alopecia (CCCA).

Hair care practices and structural evaluation of scalp and hair shaft parameters in African American and Caucasian women

How African American hair fragility relates to hair care practices and biologic differences between races is not well understood. To assess the differences between perceptions of hair health, hair care practices, and several biologic hair parameters between Caucasian and African American women. A questionnaire on perceptions of hair health and hair care practices was administered. Biological and structural parameters of hair shaft and scalp, including growth, density, diameter, cycle, breakage, and scalp blood flow were also assessed in this case-control study. Significant differences between the Caucasian and African American women were observed in the questionnaire and biologic study data. Regarding self-reported perceptions of hair health, there were differences in the following: hair shaft type (P < 0.001), hair breakage (P = 0.040), and desire to change hair (P = 0.001). Regarding self-reported hair care practices, there were differences in the following: location of haircutting (P = 0.002) and washing (P = 0.010), washing frequency (P < 0.001), chemical relaxer use (P < 0.001), hooded hair dryer use (P < 0.001), and hair shaft conditioner use (P = 0.005). The two groups had similar practices in regard to the use of hair color, frequency of hair color use, chemical curling agents, and handheld blow dryer use. Regarding biological and structural parameters, there were differences in the following: hair growth rate (P < 0.001), density (P = 0.0016), diameter (P = 0.01), number of broken hairs (P < 0.001), and blood flow (P = 0.03). There was no significant difference in hair cycle parameters.The differences in hair care practices and hair fiber morphology among African American women may contribute to clinically observed variation in hair fragility and growth.

Black women's hair: the main scalp dermatoses and aesthetic practices in women of African ethnicity

Afro-ethnic hair is different from Caucasian and Asian hair and has unique features. Ethnic hair is more prone to certain conditions or diseases. Such diseases are not only related to the fragile inner structure of the hair, but also to the cultural habits of hairstyles that often exert traction forces upon the pilosebaceous follicle. Women with African hair subject their hair to chemical treatments such as hair straightening and relaxing, and thus modify the structure of their hair shaft, making it more susceptible to damage. For this reason, hair complaints are common among black women and represent a diagnostic challenge to the dermatologist, requiring a thorough clinical examination of the hair and scalp, and a detailed medical history of the patient. The purpose of this review is to warn of the potential side effects and sequelae related to hairstyles and hair treatments used by black women, and to highlight the major diseases that affect this ethnicity.

Updates in the understanding and treatments of skin & hair disorders in women of color

Skin of color comprises a diverse and expanding population of individuals. In particular, women of color represent an increasing subset of patients who frequently seek dermatologic care. Acne, melasma, and alopecia are among the most common skin disorders seen in this patient population. Understanding the differences in the basic science of skin and hair is imperative in addressing their unique needs. Despite the paucity of conclusive data on racial and ethnic differences in skin of color, certain biologic differences do exist, which affect the disease presentations of several cutaneous disorders in pigmented skin. While the overall pathogenesis and treatments for acne in women of color are similar to Caucasian men and women, individuals with darker skin types present more frequently with dyschromias from acne, which can be difficult to manage. Melasma is an acquired pigmentary disorder seen commonly in women with darker skin types and is strongly associated with ultraviolet (UV) radiation, genetic factors, and hormonal influences. Lastly, certain hair care practices and hairstyles are unique among women of African descent, which may contribute to specific types of hair loss seen in this population, such as traction alopecia, trichorrhexis nodosa and central centrifugal cicatricial alopecia (CCCA).

Central centrifugal cicatricial alopecia severity is associated with cowhage-induced itch

BACKGROUND

Patients with central centrifugal cicatricial alopecia (CCCA) often suffer from varying degrees of itch, pain and burning sensations. However, the neural component of these skin sensations has not been assessed.

OBJECTIVE

To conduct a comprehensive analysis of C nerve fibre function relating to itch and pain perception in patients with CCCA using thermosensory testing and experimental itch models.

METHODS

Fifteen healthy African-American women and 16 African-American female patients with CCCA participated in the study and underwent quantitative computerized thermosensory testing to assess warmth and heat pain thresholds. Itch was induced using histamine iontophoresis and application of cowhage spicules, and the intensity of each itch was assessed. The association between itch intensity and CCCA severity score was examined.

RESULTS

A positive correlation between CCCA severity score and peak itch ratings of cowhage on the lesional scalp (crown) was observed (P = 0·023, r = 0·562). Notably, the histamine peak itch rating was not found to have a significant correlation with CCCA severity score (P = 0·913). The crown also had significantly higher warmth and pain thresholds than the occiput in both healthy subjects and patients with CCCA.

CONCLUSIONS

Our results suggest a putative role for the protease-activated receptor (PAR)-2, which is activated by cowhage, in the pathogenesis of CCCA. Future studies should examine PAR-2-directed therapeutics for patients with CCCA. Examining for itch and other dysaesthesias in patients with CCCA is of vital importance to dermatologists in assessing disease severity.

Central centrifugal cicatricial alopecia

Central centrifugal cicatricial alopecia is a common cause of progressive permanent apical alopecia. This unique form of alopecia includes entities previously know as "hot comb alopecia," "follicular degeneration syndrome," "pseudopelade" in African Americans and "central elliptical pseudopelade" in Caucasians. The etiology appears to be multifactorial and the condition occurs in all races.