CCCA Is the Most Common Scarring Alopecia in Women of African Descent
Central Centrifugal Cicatricial Alopecia (CCCA) is a form of scarring alopecia that affects up to 17% of women of African descent. It begins at or near the crown of the scalp and spreads outward in a centrifugal (expanding circle) pattern. Unlike androgenetic alopecia, which shrinks follicles but leaves them alive, CCCA permanently destroys follicles through inflammation and fibrosis.
Early detection and monitoring are the most important factors in preserving hair. Once follicles are scarred, they cannot be recovered by any current treatment.
What CCCA Looks Like
Early Signs
CCCA often begins subtly, which is why it goes undiagnosed for years in many patients:
- Central scalp tenderness or discomfort: Many patients report a "tingling," "crawling," or tender sensation at the crown before visible hair loss begins
- Breakage at the crown: Hair in the affected area may break easily or feel brittle
- Mild thinning at the vertex: The very center of the scalp begins to thin, sometimes mistaken for normal aging or traction alopecia
Progressive Signs
As CCCA advances, the pattern becomes more distinctive:
- Smooth, shiny scalp at the center where follicles have been replaced by scar tissue
- Loss of follicular ostia (the tiny openings where hairs emerge), visible under magnification
- Expanding circular border as inflammation moves outward from the center
- Single hairs remaining in the affected zone (polytrichia, or multiple hairs per follicle, is lost as scarring separates follicular units)
What Distinguishes CCCA from AGA
| Feature | CCCA | AGA |
|---|---|---|
| Starting point | Crown center | Temples (men) or part line (women) |
| Spread pattern | Centrifugal (outward from center) | Follows Norwood/Ludwig pattern |
| Scarring | Yes (follicle destruction) | No (follicle miniaturization) |
| Follicular ostia | Lost in affected area | Preserved |
| Reversibility | Destroyed follicles cannot recover | Miniaturized follicles can improve with treatment |
| Symptoms | Tenderness, itching at active border | Usually asymptomatic |
| Biopsy findings | Perifollicular fibrosis, inflammation | Miniaturized follicles, no scarring |
Risk Factors
Established Risk Factors
- Genetics: CCCA has a strong familial component. Variants in the PADI3 gene (involved in hair shaft formation) have been identified in some families with CCCA
- Hair care practices: While not the sole cause, certain practices may contribute to or worsen CCCA. These include chemical relaxers, high-heat styling, and tight braiding or extensions that place stress on the central scalp
- Traction: Chronic tension on the hair (tight ponytails, braids, weaves) can compound CCCA damage
Important Context
CCCA is not caused solely by hair care practices. The genetic and autoimmune components are primary. Many women who use relaxers or heat styling never develop CCCA, and some women who use gentle, natural styling methods still develop the condition. Hair care practices are a modifiable risk factor, not the root cause.
How to Track CCCA Progression
Tracking Protocol
Because CCCA is a scarring condition where lost territory cannot be regained, tracking serves a different purpose than in AGA. The goal is to monitor whether the active border is expanding and whether treatment is controlling the inflammatory process.
Monthly tracking should include:
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Crown/vertex photos: Standardized overhead photos showing the full extent of the affected area. Use the same angle, distance, and lighting every time.
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Border zone measurement: Focus on the boundary between the smooth, scarred center and the surrounding hair. Is this boundary moving outward? AI density tracking can measure the zone just outside the scar border where density may be declining.
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Symptom logging: Record any tenderness, itching, or discomfort at the active edge. Increasing symptoms may indicate active inflammation before visible expansion.
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Close-up photos of the border zone: This area is where active disease occurs. Look for redness, scaling, or perifollicular inflammation around individual hairs at the periphery.
For specific guidance on photographing afro-textured hair for tracking, see our guide on hair loss assessment for afro-textured hair.
What to Watch for in Your Data
Positive signs (treatment working):
- Stable border position over 3-6 months
- Reduced symptoms (less tenderness, less itching)
- No new hair loss at the periphery
- Inflammation markers improving on follow-up trichoscopy
Concerning signs (disease may be active):
- Border expanding (even slightly) between monthly photos
- New symptoms or worsening tenderness
- Hair breakage or shedding near the border zone
- New areas of follicular redness or scaling
Treatment Options
Anti-Inflammatory Medications (First-Line)
The primary treatment goal is suppressing the inflammation that destroys follicles.
- Topical corticosteroids: High-potency steroids (clobetasol) applied to the active border zone
- Intralesional corticosteroid injections: Triamcinolone acetonide injected directly into the active border, typically every 4-6 weeks
- Doxycycline: 100mg twice daily, used for its anti-inflammatory (not antibiotic) properties
- Hydroxychloroquine: 200-400mg daily, an immunomodulator that reduces the inflammatory process
Hair Care Modifications
While hair care is not the primary cause, reducing additional stress on affected areas is prudent:
- Minimize or eliminate chemical relaxer use
- Avoid high-heat styling on or near the affected zone
- Use low-tension hairstyles
- Gentle handling of the border zone area
Surgical Options
Hair transplantation into CCCA-affected areas is generally not recommended during active disease because transplanted follicles can be destroyed by the same inflammatory process. In cases where CCCA has been completely inactive (burned out) for 1-2+ years, some specialists cautiously attempt transplantation, but results are less predictable than in AGA.
Why Early Detection Matters
Every month of uncontrolled CCCA means additional permanent follicle loss. The difference between catching CCCA at 2 cm diameter versus 6 cm diameter represents a significant area of irreversible hair loss. This is why consistent tracking and prompt dermatological evaluation are critical.
Understanding the difference between miniaturization (AGA) and scarring (CCCA) helps you recognize which process is occurring in your tracking data.
When to See a Dermatologist
If you notice thinning at the crown with any of the following, schedule a dermatology appointment as soon as possible:
- Scalp tenderness or itching at or near the crown
- Smooth, shiny areas where hair used to grow
- Loss of visible follicle openings in the affected zone
- Family history of CCCA or scarring alopecia
- Hair loss that does not match typical AGA patterns
A scalp biopsy is the gold standard for confirming CCCA. It reveals the characteristic perifollicular inflammation and fibrosis that distinguish CCCA from non-scarring conditions.
Start Monitoring Your Crown Density
Whether you are concerned about early CCCA or monitoring an existing diagnosis, consistent tracking provides the objective data needed for treatment decisions. AI-powered density analysis can detect changes at the active border zone that are not yet visible to the eye.
Begin your crown density analysis at myhairline.ai/analyze and establish the baseline data you and your dermatologist need.
Medical disclaimer: This article is for informational purposes only and does not constitute medical advice. CCCA is a complex condition that requires diagnosis by a board-certified dermatologist, ideally one experienced in scarring alopecias. A scalp biopsy is necessary for definitive diagnosis. Do not delay seeking clinical evaluation if you suspect CCCA.