CENTRAL CENTRIFUGAL CICATRICIAL ALOPECIA

CCCA is mainly a condition in women of African descent. I don’t feel that the statement regarding Asian population is really correct. Yes, it has been reported in adolescents but we need to be careful if it’s truly CCCA or simply a CCCA-like condition. There are many types of CCCA in women so it’s not truly one standard condition! There is a form that starts more like folliculitis decalvans (with redness and pustules) and a form that starts more asymptomatic with breakage. Whether the forms in adolescents are truly the same needs more study. The reality is that there is only so much hair can do when it is subjected to insults (lose sebaceous glands, induce fibrosis, trigger inflammation). We really need more study.

No, I don’t think that CCCA is a condition that is likely to develop in white patients living in Africa. We have no evidence for this. Fundamentally, it appears that there is a GENETIC predisposition of some kind that presents the increased risk. Then as step 2, there is some kind of hair related trauma that incites inflammation. The genetics has not been fully worked out but PADI3 genes play a role in about 1/3 of women. What about the other 2/3 of women with CCCA? Well, we have no idea really.

One must not forget the overall importance of the hair curl and the chemistry of the hair itself. Afro-textured hair is more likely to be damaged with routine haircare and this may set up a microinflammation that drives CCCA. Women who do not wear braids, weaves or extensions before age 18 have a reduced risk of developing CCCA later in life. So there is something important about the microinflammation/microtrauma that is occurring over time.

Overall, there is no evidence that white individuals living in Africa or moving to African have an increased risk of CCCA.

Generally speaking, 6 months is reasonable. But it depends a bit on what sort of “endpoint” the clinician has in mind. In a case of very advanced CCCA, I might be trying to make sure it does not get worse, but I’m not really watching for dramatic improvements. In early CCCA, I’m really hoping for growth and an improvement in density (at least to some degree). I’ll give it 4-6 months. If things are worse, I might first ask myself if other factors are causing it to be worse (low iron, low vitamin D, traction, etc) or really and truly it’s worse because my therapies are not helping. If I feel my treatments are the reason things are not better, I’ll probably change things by 6 months and maybe sooner if there is significant loss or ongoing symptoms. But if there is a hint that something is better, I might keep going. If one is impatient and just keeps throwing up there hands (Ahh, this is not working, or ahh that is not working), you’ll soon run out of treatments. 6 months is more or less a reasonable time point, but it can be 4 months if things are clearly worsening and 9 months if there are some signs of hope. Finally, if a patient has tried 15 treatments, and you are on your last few treatment, you are quite likely to give it a bit longer because you have not much else to turn to. In general, we tend to not be patient enough when treating scarring alopecia.