Central centrifugal cicatricial alopecia

Central centrifugal cicatricial alopecia (CCCA) is a primary inflammatory condition that previously held the names of “hot comb alopecia,” “follicular degeneration syndrome,” “pseudopelade” and “central elliptical pseudopelade.” CCCA primarily affects the vertex/crown scalp and progressively spreads down the top of the scalp over time.

The causes of CCCA have been speculated but not proven.  One study performed by Dr. McMichael1 showed patients affected by CCCA had a history of hair weaving and a long duration of chemical relaxer usage compared to unaffected individuals.  However, a more recent study in 2011 by Olsen et al showed no obvious association of general central hair loss with relaxer or hot comb use, history of seborrheic dermatitis (dandruff article) or a reaction to a hair care product, bacterial infection, or male pattern hair loss in fathers of those affected2.

CCCA can mimic other hair loss disorders including female pattern hair loss and requires definitive diagnosis and medical intervention.  CCCA typically affects women but also men of primarily African descent. Patients present with an itchy, tender, and scaly scalp with areas of tight shiny skin where hair follicles have been destroyed and replaced with scar tissue. The condition is slowly progressive and severe cases can progress to involve the entire scalp. Awareness of this condition is important due to symptoms going unnoticed for a long time.  The most common early signs are hair breakage, itching, scalp tenderness in the affected area.

If diagnosed early, medical intervention can stop the progression of the condition. Topical steroids, antibiotics and other anti-inflammatory medications are used to calm down the inflammation targeting the follicles and the sebaceous glands (anatomy of a follicular unit).


  1. Review Ethnic hair update: past and present. McMichael AJ. J Am Acad Dermatol. 2003 Jun; 48(6 Suppl):S127-33.
  2. 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.


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Alopecia is not a diagnosis



Alopecia, latin for partial or complete absence of hair from an area which normally grows hair, is a diagnosis term but is not a final diagnosis. It is an umbrella term under which there are numerous subsets and reasons for hair loss. I often hear people tell me they were told by physicians and stylists that they have alopecia. This is a broad term similar to saying, “you would like a beverage.” There are many types of beverages of all variations, flavors, consistency, and contents. This also pertains to alopecia. Having a specific diagnosis is important for not only knowing the prognosis of your hair loss but also tailoring treatment towards the pathology, or reason, for the hair loss. For example, if you have hair loss secondary to an auto immune condition, treating with oral supplements and stopping all of your medications is not targeting the reason for the hair loss.

A large part of treating hair loss is education and increasing awareness so individuals present to a dermatologist earlier in their course with hopes to stop the progression and if possibly restore the hair. When I speak at salons and cosmetology schools I explain the umbrella term of alopecia. I also categorize hair loss into different types to show that not all hair loss is the same and should not be treated the same.

There are primary inflammatory conditions where the immune system is the initial cause of inflammation attacking the follicles/sebaceous glands (anatomy of hair follicle unit) causing permanent destruction.  Then there are secondary inflammatory conditions which there is an inciting trigger to cause inflammation, such as traction, chemicals, heat, and trauma. Another way to categorize hair loss is by scarring and non-scarring which helps with prognosis.  Scarring hair loss definitely requires medical intervention to stop the inflammatory process and to prevent progression of further follicle damage and hair loss.  Non-scarring conditions are usually environmental or changes in the body- hormones, stress, medications, infections, etc and are reversible sometimes on their own and sometimes with medical intervention.

In this series I will explain the following types of hair loss and the natural progression of each condition if it isn’t diagnosed and treated earlier in its course.


Scarring hair loss:

  1. Frontal fibrosing alopecia:
  2. Central centrifugal cicatricial alopecia:
  3. Lichen planopilaris
  4. Pseudopelade (Brocq)
  5. Discoid lupus erythematosus
  6. Dissecting cellulitis
  7. Acne keloidalis nuchae
  8. Folliculitis decalvans
  9. Traction alopecia


Non-Scarring hair loss:

  1. Alopecia areata
  2. Telogen effluvium
  3. Trichorrhexis nodosa
  4. Seborrheic dermatitis
  5. Lipedematous alopecia