Clinical Challenge: Mid-Scalp Alopecia in a Woman - MPR

Clinical Challenge: Mid-Scalp Alopecia in a Woman

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An African American woman, aged 48-years, presents with marked alopecia of her mid-scalp that has progressed over several years. Her medical history is positive for adult-onset diabetes and hypertension, and she currently is taking several oral medications. In the past, she used hot combs and braided her hair. She denies itching and burning. Surrounding hairs reveal evidence of breakage, and the vertex scalp is shiny and devoid of follicular openings.

Central centrifugal cicatricial alopecia, formerly referred to ashot-comb alopecia, is a scarring type of hair loss that occurs primarily in African American women and is engendered by traumatic hair practices such as chemical relaxation and thermal straightening.1,2 It is the most...

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Central centrifugal cicatricial alopecia, formerly referred to ashot-comb alopecia, is a scarring type of hair loss that occurs primarily in African American women and is engendered by traumatic hair practices such as chemical relaxation and thermal straightening.1,2 It is the most common form of alopecia in this population.3

Hair loss begins at the vertex or mid-scalp and extends outward in a centrifugal pattern. The loss occurs in a gradual but progressive fashion and may be accompanied by burning or itching. Loss of follicles may result in a shiny appearance.

Diagnosis is based on history of traumatic hair procedures and clinical appearance. A scalp biopsy, best taken from the periphery, is warranted when there is a question about the etiology. Histopathology may reveal hair breakage, lymphocytic inflammatory infiltrate around the base of the hair follicle, and fibrosis.3,4

Early diagnosis is important to prevent continued hair loss, and affected patients must be advised to discontinue traumatic hair treatments. Hair will not regrow in fibrosed areas. Some patients benefit from hair transplantation, although the presence of scarring often decreases the survival rate of the transplanted graft.5 

Stephen SchleicherMD, is an associate professor of medicine at the Commonwealth Medical College in Scranton, Pennsylvania, and an adjunct assistant professor of dermatology at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. He practices dermatology in Hazleton, Pennsylvania.

References:

  1. Shah SK, Alexis AF. Central centrifugal cicatricial alopecia: retrospective chart review. J Cutan Med Surg.2010;14(5):212-222.
  2. Kyei A, Bergfeld WF, Piliang M, Summers P. Medical and environmental risk factors for the development of central centrifugal cicatricial alopecia: a population study. Arch Dermatol. 2011;147(8):909-914.
  3. Uhlenhake EE, Mehregan DM. Prospective histologic examinations in patients who practice traumatic hairstyling. Int J Dermatol. 2013;52(12):1506-1512.
  4. Callender V, Wright D, Davis EC, Sperling LC. Hair breakage as a presenting sign of early or occult central centrifugal cicatricial alopecia: clinicopathologic findings in 9 patients. Arch Dermatol. 2012;148(9):1047-1052.
  5. McMichael AJ. Ethnic hair update: past and present. J Am Acad Dermatol. 2003;48(6 Suppl):S127-S133.