Trichoscopy of Central Centrifugal Cicatricial Alopecia

CCCA: Trichoscopy

Central centrifugal cicatricial alopecia (CCCA) is a scarring alopecia that commonly affects women with afrotextured hair.  It has a genetic basis in some women. The condition starts with central hair loss in most affected women and this is followed by expansion of the hair loss outwards. There may be symptoms such as itching, or pins and needles, but many women are asymptomatic. 

In an article earlier this year, I discussed some very interesting studies which showed a five fold increased risk of uterine fibroids among women diagnosed with CCCA.   

 

Dermatoscopic Features of CCCA
 

It is critically important to identify CCCA in the early stages in order to try to stop hair loss. Today I'd like to focus on the up close features of CCCA using a handheld dermatoscope.  We refer to this as trichoscopy. 

The trichoscopic features of CCCA are few. Miteva and Tosti in 2014 published the first real compressive overview of the trichoscopic features of CCCA. They retrospectively images obtained from 51 women with histologically proven CCCA and  compared to controls (which included 30 dermatoscopic images from histologically proven cases of scarring traction alopecia and discoid lupus erythematous).   

 

The Peripilar White Gray Halo

The so called "peripilar white gray halo" was found in 94% of patients and was highly specific and sensitive for CCCA. This halo was seen around the emergence of hair follicles.

The halo was shown to correspond on pathology to the lamellar fibrosis surrounding the hair follicle outer root sheath.

Reference

Miteva and Tosti. Dermatoscopic features of central centrifugal cicatricial alopecia. J Am Acad Dermatol. 2014.

Hair transplantation in black men: Can we do FUE?

Choosing between FUE and FUSS in hair transplant surgery

There are two ways that a hair transplant can be done nowadays: FUSS and FUE. With FUSS (follicular unit strip surgery), a strip of skin is removed from the back of the scalp and then the area is stitched up. The result is a linear scar or line. With FUE, the back of the scalp is shaved and hairs are removed from the area "one by one." The results is small tiny circular 'microscars in the area where the hairs were taken. the advantage with FUE is patients can wear their hair short in the future without worrying about seeing the scar.

FUE in black men: What the are the main considerations?

Most of my male patients with afro-textured hair want to wear their hair very short. Having a linear scar is not practical. Therefore, the decision on having FUE rather than FUSS is very important. 

Performing FUE on afro-textured hair requires much more skill than caucasian hair. The photo in the top panel on the right shows the typical curved hair follicles in afro textured hair and the photo on the bottom shows the relatively straight hair from a caucasian patient. It's easy to see why removing these hairs with a small punch would be more difficult in the top panel. 

Ensuring healthy grafts: how do I perform FUE in afro-textured hair?

In performing FUE, I focus on being flexible in the instruments I use. I don't start the day thinking that I'm going to use one sized punch over another, or do the procedure one way instead of another. One must be flexible. I generally start with a 1.17 mm punch and then move to 1 mm and then 1.3 mm and see what produced the best grafts. I move from manual punches (that I direct myself) to 'motorized' punches that drill with the help of a motor.  I go from minimal depth punches to deeper punches into the skin. All while looking at the grafts that are coming out to ensure they are healthy. 

Our hair transplant program for afro-textured is consistently able to offer FUE as a good option for hair transplantation. In fact, for most of my black male patients we are nearly routinely doing FUE rather than FUSS - a big change from just 3-4 years ago.

Hair transplantation for central centrifugal cicatricial alopecia (CCCA)

Scarring Hair Loss Conditions in Black Women : Is hair transplantation an option?

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**CLICK TO ENLARGE ** Photo of top of scalp in woman with CCCA

Diagnosing hair loss in women with afro-textured hair requires special expertise. Many hair loss conditions are possible and they tend to look similar. Central centrifugal cicatricial alopecia (CCCA) can look similar to genetic hair loss and so can some types of traction alopecia. Our program for women with afro-textured hair addresses some of the unique aspects of hair loss and hair care in black women. 

Hair transplantation in CCCA

Central centrifugal cicatricial alopecia (or "CCCA" for short) is a type of scarring hair loss condition in black women. Hair loss starts in the centre of the scalp and spreads outwards over time. If treated early, the condition may be halted - at least for some women. Hair transplants are possible in CCCA once the condition becomes “quiet.” By quiet, we mean that there has been no further hair loss for a period of 1-2 years. 

Are hair transplants possible for CCCA?

Surgery is sometimes an option for a group of conditions known as scarring alopecias. These conditions are frequently autoimmune in nature and have names like lichen planopilaris, frontal fibrosing alopecia, central centrifugal cicatricial alopecia. 

When can a hair transplant be done in CCCA ?

A hair transplant is not possible for many patients with these conditions because the condition is "active." However, once the condition becomes "quiet" - a hair transplant can be considered. 

By 'quiet', several conditions must be met. These are summarized in the CCCA Hair Transplant Criteria.

DONOVAN CCCA HAIR TRANSPLANT CANDIDACY CRITERIA 

In order for patients with CCCA to be a candidate for hair transplant surgery ,  ALL FIVE of the following criteria must be met:

1.  The PATIENT should be off medications.

Ideally the patient should be off all topical,  oral and injection medications to truly know that the disease is "burned out (burnt out)". However, in some cases, it may be possible to perform a transplant in someone with CCCA who is using medications AND who meets criteria 2, 3 and 4 below.  This should only be done on a case by case basis and in rare circumstances. It is a last resort in a very well-informed patient. 

2. The PATIENT must not report symptoms related to the CCCA in the past 12 months, (and ideally 24 months) .

The patient must have no significant itching, burning or pain. One must always keep in mind that the absence of symptoms does NOT prove the disease is quiet but the presence of symptoms certainly raises suspicion the disease could be active.  Even the periodic development of itching or burning from time to time could indicate the disease has triggers that cause a flare and that the patient is not a candidate for surgery. The patient who dabs a bit of clobetasol now and then on the scalp to control a bit of itching may also have disease that is not completely quiet. 

3. The PHYSICIAN must make note of no clinical evidence of active CCCA in the past 12 months, (and ideally 24 months).

There must be no scalp clinical evidence of active CCCA such as hair fragility or scalp erythema. . This assessment is best done with a patient who has not washed his or her hair for 48 hours. Some scalp redness may be persistent in patients with scarring alopecia even when the disease is quiet. Therefore scalp redness alone does not necessarily equate to a concerning finding. Perifollicular redness however is more concerning for disease activity.  In addition, the pull test must be completely negative for anagen hairs and less than 4 for telogen hairs.  A positive pull test for anagen hairs indicates an active scarring alopecia regardless of any other criteria.

4. Both the PATIENT and PHYSICIAN must show no evidence of ongoing hair loss over the past 12 months (and ideally 24 months). 

There must be no further hair loss over a period of 24 months of monitoring OFF the previous hair loss treatment medications. This general includes the patient and physician's perception that there has been no further loss as well as serial photographs every 6-12 months showing no changes. 

5. The patient must have sufficient donor hair for the transplant. 

Not all patients with CCCA maintain sufficient donor hair even if the disease has become quiet. But this is an important and final criteria.

 

Follicular Unit Extraction in Black Men and Women

Follicular Unit Extraction in Black Men and Women

I few weeks ago I wrote a blog about considerations when performing follicular unit extraction (FUE) in black men and women.  Because hair in black men and women tends to be curlier than caucasian hair, there are several considerations that need to be carefully addressed before performing surgery.  Unless such care is taken, precious follicular units may be cut or 'transected.' Today, I read a great article in the journal Dermatologic Surgery by New York hair transplant surgeons Drs Singh and Avram. They outlined some practical points when performing FUE.

Key Aspects of Follicular Unit Extraction

The authors outlined four points, which I have summarized here:

1. Maximal sized punch. It's important to choose a big enough punch to accomodate hairs. 1.3 mm sized punch may be acceptable depending on the patient. 

2. Minimal depth. It's important not to go to deep to limit the chance of transection

3. Manual punches instead of motorized. The authors proposed that manual punches give better control for some patients. 

4. Meticulous attention to following the angle the hairs emerge from the scalp. This ensures that transection is limited. 

On account of the greater curl, follicular unit extraction is black men and women presents several differences compared to caucasian or asian hair. However, with carefully attention to fundamental principles outstanding results can be acheived. 

Reference

Singh MK and Avram MR. Technical Considerations for Follicular Unit Extraction in African American Hair. Dermatol Surg 2013; May 13

 

Follicular Unit Extraction (FUE) in Black Men and Women

Follicular Unit Extraction (FUE) in Black Men and Women

In a hair transplant, there are two main ways of removing hairs from the back of the scalp or 'donor area' :

1. Follicular unit extraction (FUE) 

2. Follicular unit strip harvesting (FUSS)

Both methods can give great results and there are advantages and disadvantages of each. Men who plan to shave their scalp in the future (or wear their hair very short) prefer the FUE method because the linear scar is not seen.  

FUE Techniques in Black Men and Women

There are several factors that influence whether someone is a candidate for FUE.  One of these is the shape and curl of the patient's hair follicles.  It is much easier to extract hairs by FUE in men and women with straight hair than men and women with curly hair.   The structure of hair in black men and women is such that it is curlier than caucasian and asian hair.  The curlier the hair, the more difficult it is to predict the path that the hair follows under the scalp and the more likley these hairs are to be damaged by FUE.  We call this damaged 'transection.' Curlier hair is much more likely to be transected during FUE. It's for this reason that a proportion of black men and women are not good candidates for FUE.  

Compare the photos below of follicular units in a caucasian hair (above):

 with photos of follicular units from a black hair (below):

You'll note the hairs are much curlier in black hair.

Conclusion 

I often recommend performing a short 'test session' prior to hair transplant surgery to ensure 100 % that hair follicles will be easy to harvest on the day of surgery and to ensure that the follicles will not be subjected to excessive damage.  Indeed a 30 minute test procedure for the patient in photo 2 peformed 4 weeks before a scheduled hair transplant confirmed that it was still possible to extract follicle by FUE with minimal damage (transection).  

This blog has been filed into the following folders:

Hair Loss in Black Women: CCCA

Hair Loss in Black Women: CCCA

Central Centrifugal Ccatricial Alopecia (or 'CCCA' for short) is a common cause of hair loss in black women. Some estimates suggest that up to 30% of black women have CCCA. Unfortunately, the condition is very much underrecognized and underdiagnosed. Too often women with CCCA are misdiagnosed as having genetic hair loss - both conditions lead to hair loss in the central scalp.

CCCA causes permanent hair loss in the central scalp.  Individuals affected by the condition sometimes have scalp itching, burning or pain but very often have no symptoms.  This make it difficult to catch the diagnosis in early stages.  Hair loss gets worse over time. The cause is not known at present although hair styling practices and the use of of chemicals and relaxers continue to be explored as causes.

How can we improve our ability to diagnose CCCA?

CCCA is underrecognized in the medical community and underdiagnosed.  How can we train more physicians to recognize this common condition? Certainly training others  to recognize this condition is the first step. There is a suprisingly easy rule I teach doctors who work with me in my clinics:

Any black women with hair loss in the middle of the scalp needs evaluation (& possibly scalp biopsy) to rule out the diagnosis of CCCA.

Hair loss from CCCA is permanent. In most cases regrowth is not possible. Treatments help stop further hair loss but are not always 100 % effective. Treatment for CCCA includes topical steroid medications and steroid injections. Oral medications including tetracycline based antiinflammatory drugs can also be used. Hair transplantation can be successfully used to restore hair density once the condition becomes quiet.

Is there an Increased Risk of Diabetes in Patients with Central Centrifugal Cicatricial Alopecia?

Central Centrifugal Cicatricial Alopecia: Risk of Diabetes

Hair Loss in Patient with CCCA Central centrifugal cicatricial alopecia or "CCCA" is the most common cause of scarring alopecia. Scarring alopecia refers to hair loss conditions where scarring develops around the hair follicles and leads to permanent hair loss. "CCCA" predominantly affects black women where up to 30 percent of women are affected.

Last year, an interesting paper was published in the journal Archives of Dermatology by researchers at the Cleveland Clinic. The authors handed out a survey to African American women at 2 churches as well to African American women attending a health fair. The survey allowed the collection of information about basic medical history as well as information about hair styling practices. In total, 326 women participated in the study.

8% of Women with CCCA Had Diabetes

About 8 percent of women in the study had type 2 diabetes. However, the researchers found an increased prevalance of diabetes in women with centrifugal cicatricial alopecia. Women with CCCA were more likely to used braids and weaves than women without CCCA.  The vast majority of women who participated in the study used releaxers. However it did not appear that the use of relaxers was associated with the development of CCCA in this particular study.

Although there are many limitations to this study, I particularly like the study. First, it reminds us the CCCA is a common reason for hair loss in black women. Second, this study provides new information that CCCA may be asociated with an increased risk of diabetes. Although more research is needed to confirm this, these findings open many new avenues for research.

Reference

Kyei et al. Medical and Environmental Risk Factors For the Development of Central Centrifugal Cicatricial Alopecia. Arch Dermatol 2011; 147: 909-14