Central centrifugal cicatricial alopecia

Central centrifugal cicatricial alopecia (CCCA) is a scarring hair loss condition first observed in African Americans during the 1950s and documented by LoPresti and colleagues in 1968. Initially, it was thought to result from applying petrolatum followed by a stove-heated iron comb; the theory held that hot petrolatum traveled to the hair root, burned the follicle, and caused scarring after repeated injury. Later, it became clear that CCCA also occurs in men and women without a history of such styling practices. This led to updated names: follicular degeneration syndrome (coined by Sperling and Sau in 1992) and then CCCA (introduced by Olsen and colleagues in 2003). Other possible contributing factors include African American styling techniques such as relaxers, tight braids, heavy extensions, and certain oils, gels, or pomades. CCCA typically begins at the central midline of the scalp, is symmetrical, and involves scarring, as its name indicates. It may be limited to the top of the scalp or spread outward in a centrifugal pattern. Early symptoms can include itching, abnormal sensations, and tenderness. On examination, the skin appears thin with few visible hair follicle openings; later, the scalp may look shiny. The exact mechanism of CCCA remains unknown, so causes are only hypothesized, not proven. It is thought to have multiple contributing factors. One theory involves pressure on the internal root sheath, leading to damage that recruits inflammatory cells and results in scarring. African Americans are at increased risk. Historically, some proposed that CCCA is an end stage of traction alopecia, but this theory is considered unlikely because many patients with CCCA have not used traction hairstyles. Under the microscope, CCCA shows a lymphocytic infiltrate around hair follicles, concentric layers of fibroblasts in the papillary dermis (lamellar fibrosis), loss of sebaceous glands, and early breakdown of the internal root sheath. Granulomatous inflammation from follicular rupture may also be seen. Perifollicular redness and follicular keratosis are usually absent. Treatments for CCCA remain experimental. Changing hair care practices has not been shown to help regrow hair.