MIAMI A strong association was found between the use of sewn-in or glued-in weaves by black women and development of central centrifugal cicatricial alopecia in a retrospective survey.
Investigators did not, however, find a strong association with genetics or other hair-grooming practices, such as the use of hot combs or Jheri curling, as other anecdotal evidence has suggested.
"We don't really know what causes central centrifugal cicatricial alopecia [CCCA]," Dr. Raechele Cochran Gathers said during a poster session at an international symposium sponsored by L'Oréal Institute for Ethnic Hair and Skin Research. "We tell patients that relaxers have been implicated and to limit the amount of heat in pressing or combing."
"The exact etiology is poorly understood and it is likely multifactorial," Dr. Sejal K. Shah, a research fellow at the Skin of Color Center, St. Luke's-Roosevelt Hospital Center in New York City, said during a separate presentation at the meeting. "Most of what we know about CCCA is based on anecdotal evidence."
CCCA is a chronic, progressive, crown- or vertex-centered alopecia that disproportionately affects black women. Most active disease is in the peripheral zone of hair loss, where both clinical and histologic evidence of inflammation is found. And its impact is considerableCCCA is responsible for more hair loss in African Americans than all other causes of alopecia combined, said Dr. Gathers, a dermatologist at the multicultural dermatology center at Henry Ford Medical Center, Detroit.
"It is a very common and very distressing disease to these patients," session moderator Leonard Sperling said. "It has an emotional and physical toll that I think is underappreciated."
Dr. Sperling is professor and chair of dermatology at Uniformed Services University, Bethesda, Md.
To explore possible etiologies, Dr. Gathers and Dr. Henry W. Lim, chair of dermatology at Henry Ford Medical Center, developed a seven-page, 20-question hair grooming assessment survey. They compared survey responses from 51 women with biopsy-proven CCCA with 50 controls with no history of alopecia. All participants were treated at the medical center between 2000 and 2007.
Almost 50% of women reported onset by age 40, emphasizing a need for early intervention, Dr. Gathers said at the meeting, which was also sponsored by Howard University, Washington. In addition, some patients may be unaware of initial hair loss21% of women in the survey were first alerted by their stylist.
Use of extensions or artificial hair appears to be associated with CCCA, as does a history of damage from cornrows or braids, Dr. Gathers said. Those in the CCCA group who wore cornrows and braids with added hair were more likely to report a history of damage than those who did not use these hair care options (odds ratio, 2.7). In addition, those in the CCCA group who wore sewn-in weaves were 5.6 times more likely to report tender scalp and 8.1 times more likely to report uncomfortable pulling compared with controls.
Duration and initiation of these hair care practices made a difference. For every 10 years with cornrows or braids, respondents were 1.6 times more likely to have CCCA.
"Interestingly, women who reported that they wore their hair natural before the age of 20 had an 86% decrease in likelihood to develop CCCA," Dr. Gathers said.
There also was no significant correlation with the use of relaxers, curly perms, or history of burns or raw spots after use of relaxers. People with CCCA were not more likely to report an affected mother, grandmother, aunt, or cousin. However, 46% of CCCA group had a sister with hair loss. "It is unlikely that CCCA is genetic, despite this association in sisters," Dr. Gathers said. "It can be an environmental insult, such as sisters using similar grooming practices."
People with CCCA have premature desquamation of the root sheath in affected follicles. Perifollicular fibrosis, inflammation, and thinning of the epithelium at the isthmus are among the consequences. Then the follicle is replaced with a scar, which is the end of that follicle, Dr. Sperling said.
A meeting attendee asked why CCCA occurs predominantly in the center of the scalp.
"It's only a hypothesis, but it may be that sometime during adulthood, the [inner sheath] defect begins to be expressed," Dr. Sperling responded. A differential mode of expression of this defect in different parts of the scalp may be much like balding.
"There is a need for larger population-based studies in different geographic locales," Dr. Gathers said.
"There is a lot left to be done: Define pathogenesis, epidemiology, and the public health impact, and improve treatment on a rational, scientific basis. We also need to increase public awareness about this disease," concluded Dr. Sperling.