An Update on Medical and Surgical Treatment Options for Hair Loss

Central centrifugal cicatricial alopecia (CCCA) and frontal fibrosing alopecia are two very common hair diseases in our skin of color patients. Often these conditions are challenging to diagnose and even more problematic to treat and control. Expert Dr. Valerie Callender spoke during the Skin of Color Seminar Series (now Skin of Color Update https://skinofcolorupdate.com)in New York City on May 5th, 2018 on these conditions—giving us all valuable insight into her current treatment regimen for patients and what’s new on the treatment horizon.

Central centrifugal cicatricial alopecia (CCCA) is a progressive inflammatory scarring alopecia, seen in both men and women, often beginning in the vertex of the scalp and expanding peripherally. CCCA can be severe, leading to permanent destruction of the pilosebaceous unit and can progress to involve the entire scalp in some cases. While CCCA used to be called “hot comb” alopecia, it is now known to be a multifactorial disease—likely some combination of a genetically predisposed individual with an environmental insult.

CCCA has been associated with many factors including hot combs, chemical relaxers, tinea capitus, hirsutism, diabetes mellitus, bacterial skin infections and even uterine leiomyomas. Of course, a family history is always important to ascertain! Typically beginning in the mid-thirties, many patients with CCCA are asymptomatic. Symptomatic patients will often complain of tenderness, pruritus or a burning sensation on the scalp. Before starting treatment, it is important to discuss with patients the scarring nature of the hair loss and reinforce that the goal of treatment is to minimize progression of the disease.

Treatment is often divided into an active phase and a maintenance phase. Dr. Callender’s “active” phase treatment includes oral doxycycline combined with intralesional steroid injections every 4 weeks and an anti-seborrheic shampoo treatment once weekly. When her patients are in the “maintenance” phase, she recommends topical minoxidil, topical steroid solutions 3 days per week, and continued use of the weekly anti-seborrheic shampoo. If the hair loss is severe, hair transplantation can be considered, but should be done by an expert in the procedure to minimize any risk of adverse effects and have the best possible graft survival. It is critical for dermatologists to be aware of a new clinical variant of CCCA, called Patchy CCCA, often involving lateral and posterior scalp in addition to the more classic central scalp location.

Frontal fibrosing alopecia (FFA), a variant of lichen planopilaris, is another cause of hair loss in our skin of color patients. Frontal fibrosing alopecia is a scarring alopecia of the eyebrows, anterior hairline, axillary, and pubic hair. FFA has been associated with vitiligo, thyroid disease, and lichen planus pigmentosus.  While it has also been associated with use of sunscreen and positive patch testing to fragrances, there are currently larger ongoing studies testing these associations. Clues to the diagnosis may include loss of eyebrows and hypopigmentation on the anterior hairline, with loss of follicular ostia. Use caution when assessing patients with facial hyperpigmentation as lichen planus pigmentosus can be the initial presenting sign of FFA.

Treatment of FFA can be challenging and includes many different options such as doxycycline, hydroxychloroquine, topical, intralesional steroids, and more recently finasteride. There have been newer reports of isotretinoin as a potential treatment option. Stay tuned for more information on this in the coming months!

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