Central Centrifugal Cicatricial Alopecia (CCCA)


Last updated: December 2023

Also known as: Hot comb alopecia, follicular degeneration syndrome, pseudopelade of the central scalp, pseudopelade in African Americans

What is central centrifugal cicatricial alopecia?

Central centrifugal cicatricial alopecia (CCCA) is a chronic and progressive type of scarring alopecia that results in permanent hair loss. CCCA most commonly starts in the centre of the scalp and, without treatment, expands over time causing an irreversible area of baldness.

Who gets central centrifugal cicatricial alopecia?

CCCA is most commonly seen in middle-aged African women.

What causes central centrifugal cicatricial alopecia?

The cause of CCCA is unknown, but it is likely that genetic factors and several hair care practices may cause CCCA, such as:

  • excessive heat (hot combs/hair straighteners, hair dryers and curling irons)
  • traction (tight braids/cornrows, weaves, tight ponytails or hair extensions that pull on the hair)
  • chemical relaxers (especially lye relaxers).

Mutations in PAD13 gene, which encodes a hair protein has been associated with CCCA.1

What does central centrifugal cicatricial alopecia look like?

CCCA only affects the scalp. The bald patch starts in the central part of the scalp (vertex or crown) and gradually expands outwards symmetrically (centrifugal). It may progress slowly (over decades) or rapidly (over years) resulting in patches of permanent hair loss (baldness). There is often a bald patch with shiny skin (scarring) seen in the centre of the scalp. Traction alopecia (loss of hair in areas of high tension) or hair breakage is also a feature.

Individuals with CCCA may also experience tenderness, pain, tingling, burning, “pins and needles” or itching of the scalp.  In some cases, crusts, pimples and scale may also be present and the scalp may feel soft or ‘boggy’ when touched.

However, sometimes there are no symptoms other than an area of hair loss present.

How is central centrifugal cicatricial alopecia diagnosed?

Early diagnosis is important so that treatment can be started to prevent further permanent hair loss. CCCA is diagnosed clinically. A skin biopsy of the affected area of scalp should be taken to understand the presence of inflammatory cells around the hair follicles, loss of the sebaceous glands (oil glands) and premature damage of the hair follicle.

Skin scrapings and swabs may also be required if scale, crust and/or pimples are present to exclude the possibility of fungal or bacterial infections.

How is central centrifugal cicatricial alopecia treated?

Treatment options will vary depending on the individual and their needs. The aim of treatment is to improve symptoms and stop further hair loss.

Treatment of CCCA involves changing haircare practices and avoiding:

  • Excessive heat (hot combs/hair straighteners, hair dryers and curling irons)
  • Traction (tight braids/cornrows, weaves, ponytails, hair extensions)
  • Chemical relaxers (especially lye relaxers).

Anti-inflammatory agents may also be used such as:

  • Strong topical steroids or intralesional steroids
  • Calcineurin inhibitors
  • Tetracyclines
  • Hydroxychloroquine
  • Ciclosporin

Cosmetic camouflage (e.g. wigs) and hair transplantation may be an option for individuals who have significant bald patches seen in the advanced stages of CCCA.

What is the likely outcome of central centrifugal cicatricial alopecia?

Without early treatment, CCCA is likely to progress over years eventually causing severe, non-reversible scarring and permanent hair loss (bald patches).

  1. Malk L, Sarig O, Romano MT, et al. Variant PADI3 in Central Centrifungal Cicatricial Alopecia. N Engl J Med 2019; 380(9):833-841. 
Dr Michelle RodriguesDecember 2023
Dr Michelle Rodrigues2020


2019 © Australasian College of Dermatologists.

You may use for personal use only. Please refer to our disclaimer.