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Cases from Ackerman Academy

Central centrifugal cicatricial alopecia

Blattner, Collin; Polley, Dennis C.1; Ferritto, Frank1; Elston, Dirk M.

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Indian Dermatology Online Journal: Jan–Mar 2013 - Volume 4 - Issue 1 - p 50-51
doi: 10.4103/2229-5178.105484
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Central centrifugal cicatricial alopecia (CCCA) is the term adopted by the North American Hair Research Society (NAHRS) to encompass the previous terms of “hot comb alopecia,” “follicular degeneration syndrome,” “pseudopelade” in African Americans and “central elliptical pseudopelade” in Caucasians.[1] CCCA is a subcategory of primary, inflammatory cicatricial alopecia, and is the most common form of scarring alopecia in many populations.[2] CCCA presents as progressive apical alopecia.[3] Certain hair care practices have been associated with increased risk for developing CCCA; in a review of 44 patients by McMichael,[4] more women with scarring alopecia had a history of hair weaving and long duration of chemical relaxer usage as compared to those unaffected by scarring alopecia.[5] However, there is developing evidence that the etiology of CCCA may be multifactorial, occurs in all races, and does not always relate to obvious hair care practices.[6]


The clinical presentation of CCCA appears to be similar between men and women.[5] However, clinically diagnosing CCCA may be challenging because it can resemble female pattern hair loss, alopecia areata, lichen planopilaris, or telogen effluvium.[7] A biopsy is often necessary to confirm the diagnosis. CCCA typically begins and remains most severe on the crown or vertex of the scalp, gradually expanding in a centrifugal fashion [Figure 1].[8] The affected scalp is in parts smooth and shiny and illustrates massive follicular dropout. Typically, a few short, brittle hairs remain within the scarred expanse.[9] Patients commonly complain of mild dysesthesia (pruritus, tenderness) in the affected area.[710] The disease generally progresses slowly, but longstanding or severe disease can result in hair loss covering the entire crown of the scalp.[11] This is in contrast to nonscarring (non-cicatricial) alopecia, which is reversible as the follicular epithelium remains intact.[9] CCCA, at its end stages, is irreversible, as the follicular epithelium has been replaced by connective tissues.[12] Additionally, pustules and crusting may be found in patients with superimposed folliculitis decalvans.

Figure 1:
Central centrifugal cicatricial alopecia presents with progressive permanent apical alopecia


CCCA, in both men and women, will display similar histopathological features[6] including contraction of dermal collagen with loss of space between collagen bundles and broad hyalinized fibrous tracts that may contain naked hair shafts [Figure 2].[13] Premature desquamation of the inner root sheath has also been described as a characteristic feature, but is also present in lichen planopilaris and other forms of scarring alopecia. In elastic Van Geison-stained sections, thickened dermal elastic fibers are present.[14] The elastic sheath surrounding the fibrous tract is preserved [Figure 3] and often duplicated in contrast to lupus erythematosus, lichen planopilaris, and folliculitis decalvans, where there is loss of the elastic sheath.[15] Additionally, CCCA may demonstrate perifollicular mucinous fibrosis and sparse lymphocytic perifollicular inflammation, which primarily occurs at the level of the upper isthmus and lower infundibulum.[2] In advanced lesions, total destruction of the follicular epithelium with retained hair shaft fragments and granulomatous inflammation will be seen.

Figure 2:
Central centrifugal cicatricial alopecia is characterized by hyalinization of dermal collagen with broad tree trunk-like fibrous tracts (H and E, ×20)
Figure 3:
Central centrifugal cicatricial alopecia is characterized by preservation of the elastic sheath surrounding the fibrous tracts (H and E, ×100)


Therapeutic options are limited. Hair styles that require heat treatment or produce traction should be avoided. Ceasing the use of relaxers is also suggested, as this practice correlates with increased incidence of disease.[1] For those patients who have crops of pustules, suggesting superimposed folliculitis decalvans, topical corticosteroids, and oral tetracyclines can be of benefit. Hair transplantation can be useful in patients with advanced disease; however, CCCA presents a unique challenge for hair transplantation as the presence of scarring can decrease the transplanted graft survival rate.[4]


1. Olsen EA, Callender V, McMichael A, Sperling L, Anstrom KJ, Shapiro J, et al Central hair loss in African American women: Incidence and potential risk factors J Am Acad Dermatol. 2011;64:245–52
2. Jean B, Jorizzo JL, Rapini RP Dermatology. 2003 London Mosby
3. 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;147:909–14
4. McMichael AJ. Ethnic hair update: Past and present J Am Acad Dermatol. 2003;48:S127–33
5. 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;5:37–40
6. Summers P, Kyei A, Bergfeld W. Central centrifugal cicatricial alopecia – an approach to diagnosis and management Int J Dermatol. 2011;50:1457–64
7. Sperling LC, Sau P. The Follicular degeneration syndrome in black patients. ‘Hot comb alopecia’ revisited and revised Arch Dermatol. 1992;128:68–74
8. Callender VD, McMichael AJ, Cohen GF. Medical and surgical therapies for alopecias in black women Dermatol Ther. 2004;17:164–76
9. Gathers RC, Jankowski M, Eide M, Lim HW. Hair grooming practices and central centrifugal cicatricial alopecia J Am Acad Dermatol. 2009;60:574–8
10. Sperling LC, Sau P. The follicular degeneration syndrome in black patients Arch Dermatol. 1992;128:68–74
11. Whiting DA, Olsen EA. Central centrifugal cicatricial alopecia Dermatol Ther. 2008;21:268–78
12. Sperling LC, Cowper SE. The histopathology of primary cicatricial alopecia Semin Cutan Med Surg. 2006;25:41–50
13. Miteva M, Tosti A. ‘A detective look’ at hair biopsies from African-American patients Br J Dermatol. 2012;166:1289–94 Available from: Academic Search Elite, Ipswich, MA
14. Ross EK, Tan E, Shapiro J. Update on primary cicatricial alopecias J Am Acad Dermatol. 2005;53:1–37
15. Elston DM, McCollugh ML, Warschaw KE, Bergfeld WF. Elastic tissue in scars and alopecia J Cutan Pathol. 2000;27:147–52

Source of Support: Nil

Conflict of Interest: None declared


Alopecia; central; centrifugal; cicatricial; pseudopelade

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