Recently there has been debate in the media about the visibility of black women’s hair in its natural form. This follows Lupita Nyongo1 the famous black African actress getting Grazia magazine to apologize for removing her natural African textured pony tail from the front cover of its November 2017 edition. This followed her commentary on Instagram that her image had been altered to a more euro centric hair style without her consent.
This episode was a reminder of the societal pressures that black women are under to alter the texture of their hair. The application of heat, hairstyles that pull too tightly on the scalp and harsh chemical treatments that damage the hair shaft are associated with the pathogenesis of central centrifugal cicatrizing alopecia (CCCA), which is classified as a lymphocytic primary scarring alopecia that primarily affects women of African descent. It has been shown in a small series that CCCA can be inherited in an autosomal dominant fashion, with a partial penetrance and a strong modifying effect of hairstyling and sex.2 A US based cross sectional study in 2013 indicated that the duration of hair loss is positively associated with severity of disease and androgen related conditions are prevalent in those affected with CCCA3
Clinically CCCA presents with scarring at the vertex or crown of the scalp that tends to spread centrifugally. Cosmetically it can be extremely disfiguring, impacting significantly on quality of life. 4 This year Dlova et al issued a call for action on this condition inviting dermatologists who see patients with this condition to reach out to hair salons to help raise awareness of this condition.5 It has been reported that CCCA patients are among the top five reasons why African- Americans seek dermatological evaluation.5

Early identification is crucial because of the progressive nature of the condition. The aim of treatment is to alleviate symptoms, halt disease progression6 and possibly stimulate regrowth of viable hair follicles.7 However current treatment recommendations are largely based on mainly anecdotal evidence. Well designed randomized controlled trials are needed to discover optimal management.2

April 2017’s retrospective review of 15 subjects with CCCA supported some of the current recommendations. 8 The authors concluded that intralesional steroid injections and topical steroid +/- minoxidil and +/- anti-dandruff shampoo halt disease progression.8

Dermatologist input is crucial for scalp biopsy to confirm the diagnosis and to offer early treatment with intra and peri-lesional steroids. As a referring GP, I would also perform mycology to exclude tinea capitis, counsel the suspected CCCA patient on hair care practices and consider starting the patient on a systemic anti-inflammatory agent such as doxycycline 40mg daily modified release preparation, plus topical clobetasol proprionate (once per day to 3x per week usage), 5% minoxidil daily, and advise the patient to use an anti-dandruff shampoo.
The most exciting CCCA development this year was published in the Journal of Investigative Dermatology.9 It supported the hypothesis that follicular regeneration in CCCA may occur in response to wounding with a CO2 laser, with the most significant change in hair count noted at the peripheral sites at the highest setting. It would be good to know whether any BHNS members intend to explore this hypothesis further.

Dr Ingrid Wilson MBChB BSc(Hons) DRCOG DFSRH LoCIUT MPH FFPH MTTS

The Trichological Society