The patient is a 48-year-old black woman with marked alopecia of her midscalp that has progressed over several years. Medical history is positive for adult-onset diabetes and hypertension, and she is currently taking several oral medications. In the past she used hot combs and braided her hair. She denies itching and burning. Surrounding hairs reveal evidence of breakage, and the vertex scalp is devoid of follicular openings and is shiny.
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Central centrifugal cicatricial alopecia, formerly referred to as hot comb alopecia, is a scarring type of hair loss that occurs primarily in black females and may be engendered by traumatic hair practices such as chemical relaxation and thermal straightening,1,2 although such an association is not invariable.3 Central centrifugal cicatricial alopecia is one of the most common forms of alopecia in this population, with a prevalence that exceeds 3%.4 Hair loss commences at the vertex or midscalp and extends outward in a centrifugal pattern. The loss occurs in a gradual but progressive fashion and is infrequently accompanied by burning or itching. Hair breakage may be apparent at the periphery, and loss of follicles often gives rise to a shiny appearance.5
Diagnosis is based on clinical appearance and is supported by history of prior hair and scalp manipulations. A scalp biopsy, best taken from the periphery, is warranted when the etiology is in question. Histopathology may reveal hair breakage, a lymphocytic inflammatory infiltrate around the base of the hair follicle, and fibrosis.6
When correlated with grooming practices, early recognition and counseling are important to help prevent extension.7,8 A variety of therapies have been reported to slow progression, ranging from topical and intralesional steroids to hydroxychloroquine and cyclosporine.9 Some patients benefit from hair transplantation, although the presence of scarring decreases the transplanted graft survival rate.
- Shah SK, Alexis AF. Central centrifugal cicatricial alopecia: retrospective chart review.J Cutan Med Surg. 2010;14:212-222.
- 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;147:909-914.
- Nnoruka EN. Hair loss: is there a relationship with hair care practices in Nigeria? Int J Dermatol. 2005;44:13-17.
- Olsen EA, Callender V, McMichael A, et al. Central hair loss in African American women: incidence and potential risk factors. J Am Acad Dermatol. 2011;64:245-252.
- Callender VD, Wright DR, Davis EC, Sperling LC. Hair breakage as a presenting sign of early or occult central centrifugal cicatricial alopecia: clinicopathologic findings in 9 patients. Arch Dermatol. 2012;148(9):1047-1052.
- Uhlenhake EE, Mehregan DM. Prospective histologic examinations in patients who practice traumatic hairstyling. Int J Dermatol. 2013;52:1506-1512.
- McMichael AJ. Ethnic hair update: past and present. J Am Acad Dermatol. 2003;48:S127-S133.
- Gathers RC, Lim HW. Central centrifugal cicatricial alopecia: past, present, and future. J Am Acad Dermatol. 2009;60:660-668.
- Callender VD, McMichael AJ, Cohen GF. Medical and surgical therapies for alopecias in black women. Dermatol Ther. 2004;17:164-176.