Review
Central centrifugal cicatricial alopecia: Past, present, and future

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Clinical scarring alopecia in African American women has been recognized for years. The classification of this unique form of alopecia dates back to Lopresti, who first described the entity called “hot comb alopecia.” More recently, the term “central centrifugal cicatricial alopecia” has been adopted to describe a progressive vertex-centered alopecia most common in women of African descent. While this form of hair loss is widely recognized, and may even be on the rise, the causes of central centrifugal cicatricial alopecia are a constant source of debate and remain to be elucidated. This review outlines the descriptive evolution of central centrifugal cicatricial alopecia and the historical controversies ascribed to its pathoetiology; it also examines African hair structure and discusses how hair structure along with common physical and chemical implements utilized by individuals with African hair type may play a causal role in the development of central centrifugal cicatricial alopecia.

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CCCA: An evolving nomenclature and description

The nomenclature and classification schemes describing clinical cicatricial alopecia in African American women has been a source of some debate, and has varied fairly widely over the years (Fig 2). LoPresti, Papa, and Kligman11 in 1968, first described an “irreversible alopecia of the scalp” occurring in 51 African American women who straightened their hair using a hot comb. They described an “absolutely characteristic” course and configuration of alopecia beginning on the crown, which, given

Epidemiology of CCCA

While there are sparse epidemiologic data on the racial and sex distribution of CCCA, the vast majority of reports describe women of African ancestry. LoPresti, Papa, and Kligman11 described 51 African American women in their description of hot comb alopecia, but also reported one Caucasian woman with an “identical clinical state.” In their 1992 description of FDS, Sperling and Sau6 described 10 black women. In their review of chemically induced cosmetic alopecia from Europe, Nicholson et al14

Histology of CCCA

In their landmark 1968 description of “hot comb” alopecia, LoPresti, Papa, and Kligman11 described ORS degeneration in association with superficial perifollicular lymphocytic infiltrate and epidermal atrophy with elongated rete ridges and hypogranulosis, with ultimate replacement of the follicular unit, save the arrector pili muscle, with dense bands of eosinophilic collagen.7, 11 Later, Sperling and Sau6 described two histologic features as being unique in what they had termed FDS: (1)

African hair structure

As it appears clear that CCCA disproportionately affects those of African descent, the unique structural properties of African hair must be considered. In general, hair in people of African descent is elliptical in cross section, with the physical shape resembling a twisted oval rod.19, 20 By contrast, the hair of Asians demonstrates a round hair shaft with a very large diameter. Caucasian hair generally appears structurally between the two. While Asian hair has a circular geometry, African

African American hair care

Just as its tight curl pattern may make African textured hair more likely to break and fracture, and may arguably make it more susceptible to disorders not largely seen in individuals with differing hair types, the culturally unique grooming patterns and practices among those with African textured hair may also make them uniquely susceptible to a myriad of dermatologic quandaries (Table I).

Thermal hair straightening relaxes the tight coils of African textured hair by temporarily rearranging

Etiology: A quandary

The etiology of CCCA remains controversial (Table II). Sperling, in his description of FDS, has hypothesized that the condition results from early degeneration of the IRS which allows the hair shaft to impinge upon the exposed soft ORS and subsequently precipitate a chain of histopathologic events which result in scarring.6, 10 Ackerman et al10, 33 have described what is now termed CCCA as a form of traction alopecia, while Headington postulates that follicular stem cells are repeatedly injured

Treatment of CCCA

To date, there are no published case-controlled prospective studies documenting effective treatment of CCCA. In fact, as CCCA is an ultimately scarring process, at its very late stages there is likely to be no treatment at all, save the possibility of hair transplants for some patients.3 However, it is important to note that in its early stages, CCCA can be treated, perhaps halted, and a significant amount of hair saved. As such, early identification and treatment of these patients is crucial.

CCCA: Controversies and unanswered questions

Whether or not the unique hair care practices of those with African textured hair influences the pathogenesis of CCCA remains a source of ongoing debate, and to date there are few published retrospective studies regarding CCCA and grooming practices. Could chemical relaxers, traction, glues, or heat, or their chronicity of usage, predispose users to CCCA? Are those with CCCA exposed to the deleterious insult early in life, when scalp and follicular morphology is nascent? As Headington15

The future

Hair loss has a significant impact upon life quality and is commonly associated with loss of self-confidence and self-esteem.20 The patient with CCCA must be approached from a standpoint of cultural understanding and competence, which are imperative if therapeutic regimens and counseling are to be successful. There is a wealth of anecdotal knowledge where the pathogenesis and therapy of CCCA is concerned. Now, it is incumbent upon the dermatologic research community—clinical, epidemiological,

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    Funding sources: None.

    Conflicts of interest: None declared.

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