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Chapter 81: Central Centrifugal Cicatricial Alopecia

Taylor A. Jamerson; Taylor Dyson; Crystal Aguh

CENTRAL CENTRIFUGAL CICATRICIAL ALOPECIA

Therapeutic Approach

Central centrifugal cicatricial alopecia (CCCA) is a primary, progressive scarring alopecia almost exclusively presenting in women of African descent. Unlike other forms of cicatricial alopecia where clinical signs of inflammation can be used to guide therapeutic approach, the inflammation in CCCA is often subclinical and warrants aggressive treatment to slow or halt disease progression. The treatment of CCCA can be thought of in 2 phases: anti-inflammatory (aimed at controlling inflammatory infiltrate) and maintenance (aimed at sustaining disease stability). In some cases, early initiation of treatment can save hair follicles that have not fully succumbed to fibrosis. As a result, patients may experience increased follicular density and hair regrowth in areas previously thought to represent end-stage scarring. In the authors’ experience, initiating treatment with high-potency topical steroids 3-5 times per week + intralesional triamcinolone acetonide is effective at halting disease progression. Oral doxycycline or minocycline can be effective in patients with more symptomatic disease. See Table 81-1.

Table 81-1CCCA Treatment Table
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Table 81-1 CCCA Treatment Table
MEDICATION NAME INDICATION MECHANISM OF ACTION DOSING ADVERSE EFFECTS SUGGESTED MONITORING LEVEL OF EVIDENCE (REFERENCE)
Topical Therapy
Clobetasol propionate Inflammatory phase, maintenance Anti-inflammatory 0.05% ointment; apply QD for up to 14 consecutive days, 2-3 times qwk for maintenance Atrophy, striae, skin discoloration, telangiectasias None III1
Betamethasone dipropionate Inflammatory phase, maintenance Anti-inflammatory 0.05% ointment; apply QD for up to 14 consecutive days; 2-3 times qwk for maintenance Atrophy, striae, skin discoloration, telangiectasias None IV2-4
Fluocinonide Inflammatory phase Anti-inflammatory 0.05% ointment; apply QD Atrophy, striae, skin discoloration, telangiectasias None IV2-4
Fluocinolone acetonide Inflammatory phase Anti-inflammatory, antimicrobial 0.01% scalp oil; apply QD Atrophy, striae, skin discoloration, telangiectasias None IV2
Antifungal shampoo (eg, ketoconazole, zinc pyrithione, ciclopirox) Inflammatory phase, maintenance Anti-inflammatory Apply q1-2wk Irritation, dryness of hair/scalp None III5
Tacrolimus Inflammatory phase Immunomodulator 0.01% ointment; apply BID Myalgias, stinging/burning, headache None IV3,6
Pimecrolimus Inflammatory phase Immunomodulator 1% cream; apply BID Myalgias, stinging/burning, headache None IV3,6
Minoxidil Maintenance Reverses follicular miniaturization and lengthens anagen phase of hair cycle

1 mL 2% or 5% foam/solution; apply BID

Note: solution vehicle is preferred for tightly curled/coiled hair

 Hypertrichosis, irritant contact dermatitis, pruritus None IV2,3,7
Metformin Maintenance Adenosine monophosphate-activated protein kinase (AMPK) activation 10% compounded in lipoderm Irritation, dryness None III8
Systemic Therapy
Doxycycline Inflammatory phase Anti-inflammatory, antimicrobial 100 mg BID × 3 mo Contraindicated in pregnancy, <8 y of age; GI upset, headache, photosensitivity, esophagitis None IV9,10
Minocycline Inflammatory phase Anti-inflammatory, antimicrobial 100 mg BID × 3 mo Contraindicated in pregnancy, <8 y of age; GI upset, headache, photosensitivity, esophagitis None IV9,10
Hydroxychloroquine Inflammatory phase Anti-inflammatory, antimalarial 200 mg BID or 7.5 mg/kg QD Abdominal pain, anorexia, hematologic changes, skin hyperpigmentation, retinopathy Baseline ophthalmic examination within ...

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