Navigating Central Centrifugal Cicatricial Alopecia in Adolescents

Original Article: Central Centrifugal Cicatricial Alopecia in the Adolescent

Population: An Overview of Available Literature

What are the key takeaways of this article?

Central Centrifugal Cicatricial Alopecia (CCCA) is a unique subtype of scarring alopecia characterized by symptoms such as scalp pruritus, scaling, and tender papules or pustules, although it can also be asymptomatic. The distinctive distribution of this lymphocytic scarring occurs primarily at the vertex, frontal, or parietal areas, expanding centrifugally, meaning radially spreading outwards from the centre. In their study, Palmer and Valdebran specifically focus on adolescents, recognizing the importance of understanding CCCA in this developmental stage.

The authors conducted a literature review using keywords such as "central centrifugal cicatricial alopecia," "scarring hair loss," "hot comb alopecia," "pediatric," and "adolescent" yielding three articles addressing CCCA in the adolescent population.

The authors highlight the epidemiology of CCCA by reporting an estimated incidence of 5.6% in the United States. Notably, the condition exhibits a higher prevalence among adults of African descent, particularly females (3:1 ratio). The onset of symptoms typically occurs around the age of 14, and one study indicated a common association with both anxiety and depression, each with a prevalence of 22.2%. The authors also discuss the genetic basis of CCCA, revealing an autosomal dominant pattern with partial/variable penetrance in familial cases. Moreover, individuals with Fitzpatrick phototypes 4 to 6 demonstrate an increased proportion of fibroblasts relative to their White counterparts. In fact, scalp biopsies of CCCA show upregulation of genes related to fibroblast proliferation, collagen formation, and wound healing, including the potentially relevant PADI3 gene involved in lipid metabolism and hair shaft formation. CCCA is also proposed as a potential marker for metabolic dysregulation, as evidenced by increased risks of diabetes mellitus type 2, breast cancer, and uterine leiomyomas in affected individuals. Further research is required to inform a standard screening approach for associated biomarkers and genetic markers in the younger population.

Of note, the authors explore the debated association between CCCA and ethnic hair care practices, such as chemical relaxers, braids, and weaves. While previous studies link traumatic hairstyling practices with CCCA, the prevalence of these practices among Black patients complicates the interpretation of findings. Chemical relaxers have not consistently shown statistical associations, and further histopathological studies are recommended to elucidate clearer connections. Despite these debates, traction and chemical damage which may arise from such practices underscore the importance of educating patients and caregivers on modified grooming practices to prevent further hair loss.

Distinguishing CCCA from other diagnoses requires a nuanced understanding of the clinical presentation, particularly given potential complicating factors such as long-standing tinea capitis and similar presentations with conditions such as folliculitis decalvans, and lichen planopilaris. In terms of therapeutic approaches, primary interventions for CCCA involve the use of topical corticosteroids to reduce inflammation and halt disease progression. First line therapies include gentle hair styling, anti-dandruff shampoo used at every wash, high potency topical corticosteroids, intralesional corticosteroid injections, oral tetracyclines and topical metformin if associated with metabolic syndrome. Second line therapies include hydroxychloroquine, oral immunomodulators, and oral/topical minoxidil and platelet-rich plasma therapy. For overlap between CCCA and lichen planopilaris or folliculitis decalvans, immunosuppressive medications such as cyclosporine and JAK inhibitors can be used. Surgery may be offered for patients with end-stage biopsy-proven CCCA.

Ultimately, the authors advocate for a multidisciplinary approach to CCCA management, involving dermatologists, hair stylists, and mental health professionals. They emphasize the need for education and awareness campaigns to empower healthcare providers and affected individuals, promoting early detection and intervention. Additionally, a low threshold to biopsy as well as entire families to be screened if patients present with CCCA is suggested. This can serve as a method of decreasing morbidity due to the possible association with not only anxiety and depression, but also breast cancer and diabetes. Overall, they stress the ongoing importance of research into the types of breast cancer associated with CCCA in combination with increasing awareness of the condition and possible biomarkers to enhance care and well-being for those dealing with this distinctive form of hair loss.

Publication Date: February 4th, 2024

Reference: Palmer, V., & Valdebran, M. (2023). Central Centrifugal Cicatricial Alopecia in the Adolescent Population: An Overview of Available Literature. Life (Basel, Switzerland), 13(4), 1022-. https://doi.org/10.3390/life13041022

Summary By: Jaycie Dalson