Central centrifugal cicatricial alopecia: why acting early protects your hair
Dr Sharon Belmo, Consultant Dermatologist
Central centrifugal cicatricial alopecia, usually shortened to CCCA, is the most common cause of permanent hair loss in women of African descent, and it often goes unrecognised until a significant amount of hair has already been lost. How early it is diagnosed makes a considerable difference to the outcome, because treatment works mainly to protect the hair you still have rather than to restore what has been lost. Recognising the early signs gives you the best possible chance of keeping your hair.
What is Central centrifugal cicatricial alopecia?
CCCA is a scarring form of hair loss. Inflammation develops around the hair follicles, the small structures in the scalp that produce each hair, and over time this inflammation destroys them and replaces them with scar tissue. Once a follicle has scarred, it can no longer grow hair, so any loss in that area is permanent. The thinning usually begins as a small patch at the crown, the area at the top of the scalp, and spreads slowly outwards in a circular pattern. This gradual, outward spread is what the word "centrifugal" in the name describes.
Why CCCA is often diagnosed late
In the early stages, many people have no symptoms at all, so the condition can progress for some time before it is noticed. Others experience burning, tingling, itching or tenderness of the scalp. Hair breakage at the crown can be an early clue, appearing before any obvious patch of thinning develops. Early CCCA can also be mistaken for other causes of hair loss, such as female pattern hair loss (androgenetic alopecia), which adds to the delay.
The scale of that delay is clear from recent research. A 2025 study published in JAAD International, involving more than 1,000 patients with scarring hair loss, found that these conditions were diagnosed on average around three and a half years after symptoms first began. For CCCA, the delay was longer still, at almost six years, and CCCA was the strongest predictor of a late diagnosis. The authors concluded that greater awareness among both patients and clinicians is needed to speed up referral to a dermatologist.
What causes CCCA?
The exact cause of CCCA is not yet fully understood, and it is likely that several factors act together rather than any single one being responsible. Genetics plays an important role, and CCCA often runs in families. In 2019, a landmark study published in the New England Journal of Medicine identified variants in a gene called PADI3 in around a quarter of the women with CCCA who were studied. PADI3 is involved in forming the hair shaft, and these variants are thought to weaken its structure, leaving the hair and follicle more vulnerable.
CCCA has also been linked with other health conditions. Women with CCCA are more likely to have uterine fibroids, which, like CCCA, involve excessive formation of fibrous tissue and may share some underlying biological pathways. Associations with type 2 diabetes and insulin resistance have also been reported, suggesting that wider metabolic factors may contribute to the inflammation in some people.
Hair care practices are frequently, and often unfairly, blamed for CCCA. The condition was once even called "hot comb alopecia", a name that has long been abandoned because the evidence did not support heat or hot combs as the cause. No hair care practice has been shown to cause CCCA. It is important to be clear that CCCA is not the result of how someone has chosen to wear or care for their hair. Many women who develop it have cared for their hair in exactly the same way as those around them, and genetic and inflammatory factors appear to play the central role.
Why early treatment matters
There is currently no cure for CCCA, but it can be controlled, which is why early diagnosis and treatment are so important. The aim of treatment is to calm the inflammation that damages the follicles and to halt the progression of the condition, preserving the hair you still have. Follicles that have already scarred cannot regrow hair, whatever treatment is used, so the sooner the inflammation is controlled, the more hair can be saved.
Treatment also requires patience. The response is gradual, and it usually takes at least six months before the effect can be properly assessed. CCCA is a long-term condition, and regular review remains important even once it has settled, as it can become active again.
What treatment involves
Treatment is tailored to each patient, depending on how active the condition is and how much of the scalp is affected. In most cases it combines medicines taken by mouth with treatments applied to, or injected into, the scalp:
Oral anti-inflammatory treatment is a mainstay of managing active disease. Tetracycline-class antibiotics, such as doxycycline, are commonly used, not to treat infection but for their anti-inflammatory effect. Other oral medicines, such as hydroxychloroquine, may be used depending on the clinical picture
Steroid injections into the affected scalp settle active inflammation directly around the follicles
Topical treatments, including potent steroid lotions and steroid-sparing treatments such as calcineurin inhibitors, help to control inflammation and itching at the scalp surface
Minoxidil, either applied to the scalp or taken in low doses by mouth, may be added to support growth from follicles that are still viable
Newer approaches, including metformin and targeted anti-inflammatory medicines such as JAK inhibitors, are being studied in CCCA and show early promise, although the evidence is still emerging
Hair transplantation can be an option for some patients, but only once the condition has been inactive for a sustained period, which should be confirmed on examination and often on biopsy. Scarred scalp has a reduced blood supply, so grafts may not survive as well as they would in healthy scalp, and surgery carries a risk of reactivating the condition. Careful assessment by a dermatologist experienced in CCCA is essential before this is considered.
When to see a dermatologist
If you notice thinning at the crown, or hair that keeps breaking in the same area, particularly alongside itching, burning or tenderness of the scalp, it is worth seeing a dermatologist promptly rather than waiting to see whether it settles on its own. A specialist can examine the scalp closely with a dermatoscope and, where needed, take a small scalp biopsy to confirm the diagnosis and assess how active the condition is.
CCCA is a central focus of my work. As a consultant dermatologist specialising in hair loss in Afro-textured hair, I diagnose and treat CCCA at every stage, and I understand how distressing it can be, particularly when it has gone unrecognised for some time. The earlier it is identified, the more hair can be preserved. If you have noticed any of the signs described here, I would encourage you to book a consultation at my Harley Street clinic, where I can confirm the diagnosis and put a treatment plan in place to protect your hair.
About the author
Dr Sharon Belmo is a Consultant Dermatologist and the founder of a private dermatology practice dedicated to Black skin and hair. She has particular expertise in hair loss in Afro-textured hair, and sees patients at 152 Harley Street, London.
