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).
- Review Ethnic hair update: past and present. McMichael AJ. J Am Acad Dermatol. 2003 Jun; 48(6 Suppl):S127-33.
- 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.
Frontal Fibrosing Alopecia (FFA) is a primary inflammatory condition where lymphocytes (a type of white blood cells) target and destroy fine and vellus hairs on the scalp, face, and less commonly, the body.
FFA is common amongst postmenopausal women with early symptoms presenting around 50-60 years of age. Initially this condition was only seen in Caucasian women but over the past few years cases have emerged amongst African American and Hispanic women.
FFA presents as a band of hairline recession along the scalp. Itching may or may not be present. The skin on the forehead and temples is thinner and blood vessels appear prominent in fairer skin. With the use of a dermatoscope, one can appreciate fine bumps around hair follicles. In areas of long-term or permanent hair loss, the follicles scar over and the follicular openings cannot be visualized.
Women suffering from FFA also notice thinning or complete loss of facial and body hair including eyebrows, sideburns, eyelashes, arms, legs, and underarm hair. The skin surrounding eyebrow hairs may also be affected and can appear red and inflamed.
The cause of FFA is still unknown. FFA is responsive to topical anti-inflammatories and medications that block androgens prompting speculation that there may be a hormonal influence to this condition. The inflammation destroys the stem cells located near the sebaceous glands (article on anatomy of hair follicle) which are needed to regenerate hair. Early diagnosis and treatment is important to halt the progression and if caught early enough, can salvage follicles not yet destroyed by the lymphocytes.
FFA requires a detailed history from the patient, a thorough exam, and if warranted, a biopsy. The work up for FFA is necessary because other hair loss conditions such as traction alopecia and lichen planopilaris can look similar to FFA but require different treatments. It is also important to know that more than one hair disorder can present in the same individual.
Below are photos of individuals with FFA involving the scalp and/or eyebrows.
Tinea capitis, commonly known as Ringworm, is a type of fungal infection involving the skin and the follicles. Fungal infections can occur anywhere on the body, but we will focus on the condition it involves the scalp (tinea capitis), beard (tinea barbae) and other facial hair.
Despite the name, ringworm has nothing to do with a worm or insect. It is a fungus, commonly Trichophyton tonsurans or Microsporum canis, and is contagious between humans by direct skin to skin contact, sharing infected brushes, combs, clippers, towels, hats, and other hygienic and clothing items, and direct contact with infected animal skin. It is mostly common in kids but can occur in adults and those with immune suppression.
If left untreated, the patches of scale can enlarge or spread to form new lesions on the scalp, beard, eyebrows, or skin. The fungus can be incorporated into the hairs, causing the hairs to become fragile and break off at the skin level. this gives the appearance of black dots on the skin and “moth-eaten” patchy hair loss. One can also develop pus bumps in the affected area and swollen lymph nodes at the back of the scalp. An inflammatory reaction to the fungus may result in the formation of a kerion, a large pus-filled abscess.
Tinea capitis can be diagnosed in a clinic by fungal cultures, biopsies, or using a wood’s lamp which fluoresces the fungal byproducts a yellow-green color.
Tinea capitis must be treated medically because the follicles and the hair fibers are involved. The good news is that the hair loss is reversible if treated early. A course or oral medications for 6-8 weeks is needed. The medicine not only helps kill the fungus on the skin but is incorporated into the hair, preventing the fungus from growing inside the hair fiber. Medicated shampoos can also help with treating the skin lesions.
It is generally a good idea to not have any hair cuts until you have undergone treatment. Using clippers or a razor can spread the fungus to other hair-barren body parts you may shave. Discard razors and clean clippers with antiseptic prior to reusing them after a fungal infection.
We are born with roughly 100,000 follicles on our scalp. We cannot regrow or generate new follicles after birth so what we are born with is what we have. Follicles create hair from stem cells that sit near the follicle and produce a new hair bulb (the white part located at the root end of a shed hair and is released with the hair). Over time, we lose follicles through factors such as age, hormone, or genetic follicular miniaturization or scarring disorders that destroy the abovementioned stem cells.
Blondes have roughly 20% more follicles than brunettes and redheads have about 20% fewer follicles. Asians and African Americans have fewer follicles and lower hair density than Caucasians. The follicles on the scalps of Caucasians and Asians are straight. The follicles curl and are on a greater angle on African American scalps. This curled follicle is the reason follicles are more difficult to harvest for hair transplants in African American patients.
Follicles cycle through three natural cycles, a growth phase, a rest phase, and a fall out phase, medically referred to as anagen, catagen, and telogen phases, respectively. Each follicle individually cycles through these three phases independently of each other. Of those ~100 000 follicles, 85-90% are in anagen, <1% are in catagen, and 10-15% are in the natural fall out phase, telogen. Follicles stay in the anagen growth phase for 2-6 years, catagen for 2-3 weeks, and telogen for 3 months before the hair is released from the follicle. Applying these numbers, you will shed on average 100-200 hairs/day. If these hairs are collected, it can appear as a large amount of hair but be reassured that a fresh new anagen hair helps to push out that old telogen hair and a new follicle cycle begins.
Anagen follicles grow scalp hairs at a rate of 0.35cm/day or roughly 1cm/month. This rate may increase with medications or pregnancy and decrease with age, nutrition, medications, and illnesses. Follicles only create hair in anagen growth phases. Therefore, hairs only grow in anagen phase, so follicles in the catagen and telogen phase only rest and fall out, respectively. The maximum length is greatest at the end of anagen phase with the exception of breakage which can shorten hairs. Proper hair care can help maintain length retention. Moisture regimens can be found at http://www.DrHillHairLoss.com/?p=73.
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