Derm Appeal Blog

Alopecia in Women of Color: What is CCCA?

Alopecia is the abnormal loss of hair on the scalp, face, or body thought to be the result of both genetic and environmental factors. Although people from any race can develop the condition, there is a specific type of hair loss that is especially common among Black women. Even celebrities can develop this condition; Jada Pinkett Smith has gone public with her experience with hair loss, and recent events have put her struggle with alopecia in the spotlight.

Autoimmunity in alopecia

Although researchers do not fully understand what causes the autoimmune response in alopecia, they believe that genetic and environmental factors play a role. It is thought that the immune system mistakenly attacks hair follicles and causes inflammation that leads to the destruction of the follicle and the formation of scar tissue, preventing the nutrients and blood flow necessary for new hair to grow. Another hypothesized cause of alopecia is that rogue white blood cells erroneously stop hair growth in the anagen (formation) phase, which prevents new hair from growing after the typical shedding of 50 to 100 strands of hair each day.

External factors in alopecia

Alopecia may also be triggered by environmental factors such as extreme stress, hair care and styling practices, pollution, poor lifestyle or diet, and type 2 diabetes and other health conditions. In Black women with alopecia-related hair loss, the practice of using hot combs, relaxers, tight extensions, wigs, weaves, or braids were often blamed for the condition. However, new research suggests that the reasons are multifactorial and cannot be attributed only to external factors.

 Central centrifugal cicatricial alopecia

A type of hair loss known as central centrifugal cicatricial alopecia (CCCA) is the most common form of scarring alopecia in women of color. Although it is seen across all ages and races, middle-aged Black women are most affected. The same genetic and environmental factors in other types of alopecia are likely present, but researchers have observed a specific mutation in the PAD13 gene that could be linked to CCCA. Peptidyl arginine deiminase, type III (PADI3), is an enzyme responsible for modifying the proteins essential to hair formation. A team of scientists at the University of KwaZulu Natal found distinct variants in the PAD13 gene on several patients with CCCA that were of African descent. This research suggests that PAD13 mutations predispose individuals to CCCA, and then environmental factors such as damaging styling practices may be what trigger the disorder.

Clinical implications of CCCA

In CCCA, hair loss usually begins at the mid-scalp (vertex) and extends in an outward (centrifugal) manner. Other than hair loss, symptoms include burning, itching, tenderness, and a shiny appearance to the scalp that indicates follicular scarring (fibrosis). Early diagnosis of CCCA based on observed clinical features and a possible scalp biopsy is essential to prevent the condition from progressing. Unfortunately, therapy is focused on halting progression, as there is no effective targeted treatment yet than can regrow hair from a follicle with fibrosis.

Skin of Color Society and CCCA

In a video released by the Skin of Color Society (SOCS) in 2019, several Black women share stories of how CCCA has affected their lives, self-view, and identity. Many of them mention at first seeking the counsel of their stylist after noticing hair loss, not realizing CCCA was a medical condition. The dermatologists in the SOCS video explain that hair loss of all causes can be traumatic for people, especially women who have come to know and appreciate their hair as a part of their identity. Experts explain another critical factor that can contribute to a higher burden of CCCA in Black women; the condition may go undiagnosed and untreated for longer because of barriers to accessing care that pertain specifically to people of color.

Key takeaway

Although alopecia can affect individuals of all races, ethnicities, genders, and ages, a type of hair loss known as CCCA is most common in middle-aged Black women. This form of alopecia presents in a characteristic pattern of hair loss that extends from mid-scalp outward and may result from the interplay between a mutation of the PAD13 gene and styling practices that stress hair follicles.

 

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