Central centrifugal cicatricial alopecia (CCCA) on Black skin

Key cue: Slowly expanding hair loss from the crown outward, with smooth shiny scalp. Primarily affects Black women; early dermatology care preserves follicles.

Central centrifugal cicatricial alopecia (CCCA) is the most common form of scarring alopecia in Black women, affecting an estimated 6-15% of Black adult women in US community studies (Olsen EA., Arch Dermatol 2011). It begins at the crown/vertex and spreads centrifugally. Because it is scarring, early diagnosis is the difference between preserving and permanently losing hair.

What it actually looks like

Textbook says

Textbook: central/vertex scarring alopecia with smooth, shiny scalp, loss of follicular openings, and gradual centrifugal expansion. Patients often report mild tenderness, itch, or burning in the affected area early on. Histology: premature desquamation of the inner root sheath, perifollicular inflammation, eventual follicular destruction and fibrosis.

On Black skin

CCCA is a primarily Black-women's disease; the skin-of-colour literature is where most of the evidence comes from:

Early CCCA shows widening of the part at the crown, shorter/broken hairs in the central scalp, and subtle scalp changes — often before obvious hair loss. This is the window for effective treatment.
Loss of follicular openings (a smooth, shiny scalp where follicles should be) is a late and irreversible sign. On Black skin this can be subtle — compare affected area to the occipital scalp (normal follicles visible).
Tenderness, itch, or burning of the crown/vertex is common and often the chief complaint — don't dismiss 'tender scalp' in a Black woman as just haircare irritation.
Tight hairstyles (braids, weaves, relaxers) were historically implicated but are no longer believed to be the primary cause — CCCA has genetic components (PADI3 gene variants, Malki et al. NEJM 2019) and an inflammatory pathophysiology. Avoiding extreme traction remains reasonable.
Treatment: first-line topical and intralesional corticosteroids, oral doxycycline or minocycline (anti-inflammatory effect), minoxidil (topical or oral), and — in refractory cases — hydroxychloroquine or methotrexate. Hair transplant is possible only once disease is quiescent and requires an experienced SOC surgeon.
Traction alopecia — a related but distinct hairline-retraction pattern from tight hairstyles — can coexist and is reversible if caught early.

What to look for

Widening of the part at the crown or visible scalp on top of the head where there used to be full hair.
Tender, itchy, or burning scalp at the vertex/crown.
Short, broken hairs, or hairs that are thinner than surrounding hair.
Shiny, smooth-looking skin on the scalp where follicles should be visible.
Gradual spread over months to years from the crown outward.

When to seek care

See a dermatologist with expertise in hair disorders and Black scalp as soon as possible. A scalp biopsy confirms CCCA and rules out other scarring alopecias (discoid lupus, lichen planopilaris, frontal fibrosing alopecia). Early treatment preserves remaining follicles. Skin of Color Society maintains a referral list; the NAHRS also lists qualified dermatologists.

Common misdiagnosis

Early CCCA is frequently misdiagnosed as seborrheic dermatitis, traction alopecia, androgenetic alopecia, or 'breakage from relaxers'. Each of these has different treatment. A scalp biopsy (small 4 mm punch) is the gold-standard differentiator and should not be delayed; untreated CCCA is irreversible.

See it for yourself — curated external imagery

We don't host clinical photos here. The links below go to peer-reviewed or open-access sources (Mind the Gap, DermNet NZ, PubMed Central, and similar). Each opens in a new tab.

DermNet NZ — Central centrifugal cicatricial alopecia — image set including early and late disease.
Skin of Color Society — CCCA — patient-facing education.
PMC — CCCA clinical review (open access).
Skin of Color Society directory for finding a qualified dermatologist.

References

Olsen EA, Callender V, McMichael A, et al. Central hair loss in African American women: incidence and potential risk factors. J Am Acad Dermatol. 2011;64(2):245-52. PMID: 21030101.
Malki L, Sarig O, Romano MT, et al. Variant PADI3 in central centrifugal cicatricial alopecia. N Engl J Med. 2019;380(9):833-841. PMID: 30763140.
Callender VD, McMichael AJ, Cohen GF. Medical and surgical therapies for alopecias in Black women. Dermatol Ther. 2004;17(2):164-76. PMID: 15113284.
Olsen EA, Bergfeld WF, Cotsarelis G, et al. Summary of North American Hair Research Society (NAHRS)-sponsored Workshop on Cicatricial Alopecia. J Am Acad Dermatol. 2003;48(1):103-10. PMID: 12522380.

Medical disclaimer

Educational content only. This is not a substitute for in-person evaluation. If you are worried about yourself or someone you love, see a clinician — and if you are concerned about an emergency sign described here, call 911 or your local emergency number. We do not host clinical imagery; the external references are for reader self-education and are not owned by or affiliated with Black Health.