A Retrospective Review of Treatment Results for Patients With Central Centrifugal Cicatrical Alopecia

April 2017 | Volume 16 | Issue 4 | Original Article | 317 | Copyright © April 2017

Ariana Eginli BA, Emily Dothard MD, Courtney W. Bagayoko MD, Karen Huang MS, Alyssa Daniel MD, and Amy J. McMichael MD

Wake Forest Baptist Health, Winston-Salem, NC


INTRODUCTION: Central centrifugal cicatricial alopecia (CCCA) is a form of scarring alopecia primarily affecting women of African descent on the crown of the scalp. Limited data exists regarding evidence-based treatment for CCCA.

OBJECTIVE: To examine photos of subjects with CCCA before and after treatment in order to evaluate results of treatment and compare results of different treatment regimens.

METHODS: Photographs of 15 subjects with CCCA before and after treatment were evaluated by two blinded investigators who assigned disease severity scores to photographs based on a published scale: Central Scalp Alopecia Photographic Scale in African American Women.

RESULTS: Median change in severity score (post-treatment severity score – pre-treatment severity score) was 0.5 (P = 0.58) for all 15 subjects receiving a series of 7 to 8 intralesional steroid injections along with topical steroids (Class I/II) +/- minoxidil and +/- anti-dandruff shampoo, indicating worsening of disease after treatment. Subjects receiving minoxidil versus those who did not (0.25 vs 0.5; P = 0.38) and subjects receiving anti-dandruff shampoo versus those who did not (0.0 vs 0.5; P = 0.42) demonstrated no statistically significant difference in pre- and post-treatment severity scores. Of 15 subjects, 5/15 (33.3%) had decreased severity scores, 8/15 (53.3%) had increased severity scores, and 2/15 (13.3%) had no change in severity scores.

CONCLUSIONS: Although no statistically significant difference was found in pre- versus post-treatment disease severity, this may indicate intralesional steroid injections and topical steroids +/- minoxidil and +/- anti-dandruff shampoo halt disease progression.

J Drugs Dermatol. 2017;16(4):317-320.


Central centrifugal cicatricial alopecia (CCCA) is a form of scarring alopecia primarily affecting women of African decent.1 The etiology still remains unknown; however, inflammatory mediated destruction of the hair follicles is involved in the pathogenesis.2 Clinically, the natural progression of CCCA starts at the crown as roughly circular scarred patches, which evolve into scarred areas increasing in size circumferentially.3 Affected individuals may complain of pruritus, pain, or tenderness. CCCA can cause permanent hair loss, dysesthesias, and psychological distress and can affect overall quality of life.4 Despite the substantial burden, evidence-based treatment guidelines are lacking. The primary goal of treatment of CCCA is to halt disease progression early and provide symptomatic relief rather than regrowth of hair.5 To relieve inflammation and decrease pruritus, intralesional steroids, topical steroids, increasing the frequency of hair washing, and anti-dandruff shampoos are commonly used as treatments.5-6 Though the etiology of CCCA is unknown, potentially damaging hair care practices such as the use of hardening gels and sprays, and tight hair styles are discouraged.7 Additionally the application of excessive heat to the scalp is not recommended, especially in chemically processed hair.3 Ultimately, there is a paucity of data pertaining to CCCA treatment and a lack of studies analyzing the efficacy of these commonly used treatments.


Medical records of patients seen at the Hair Disorders Clinic at Wake Forest Baptist Health Department of Dermatology with a diagnosis of CCCA were carefully reviewed after receiving institutional review board approval. Approximately 75 medical records were reviewed to identify 15 patients who met inclusion criteria. The inclusion criteria for the study were patients with biopsy-proven CCCA, who had treatment initiated at Wake Forest Baptist Health for a 1-1.5 year time frame, and had scalp photographs taken before and after treatment documented in their medical records. Post-treatment photos were taken after subjects completed standard treatment for CCCA, including intralesional corticosteroids, topical corticosteroids, anti-dandruff shampoo and topical minoxidil. All patients included in this study received intralesional triamcinolone acetonide injections to the affected area of the scalp at 7.5 mg/mL administered every 4-6 weeks for a total of 7-8 rounds. Two blinded investigators (two trained dermatologists) evaluated the before and after treatment photos, which were presented to the physicians for assessment in random order (Figure 1-2). Investigators assigned disease severity scores to photographs, based on the published scale: Central Scalp Alopecia Photo- graphic Scale in African American Women8 (Figure 3). Subtypes