International Journal of Women s Dermatology | 2021
Camouflaging techniques for patients with central centrifugal cicatricial alopecia
Abstract
https://doi.org/10.1016/j.ijwd.2020.11.003 2352-6475/ 2020 The Authors. Published by Elsevier Inc. on behalf of Women’s Dermatologic Society. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Dear Editor: Central centrifugal cicatricial alopecia (CCCA) is the most common form of scarring alopecia in women of African descent (Herskovitz and Miteva, 2016). A significant gap in the literature concerns the use of camouflaging techniques for scarring alopecias, which is a critical component of management in these patients. Dermatologists should be aware of these techniques and refer patients to salons that are expert in their use. CCCA is type of scarring alopecia defined by a central area of symmetrical hair loss that is progressive and expands centrifugally (LoPresti et al., 1968). CCCA occurs in young to middle-aged women of African descent and progresses through life. It may begin with signs of hair breakage at the scalp vertex but can be asymptomatic initially (Herskovitz and Miteva, 2016; LoPresti et al., 1968). CCCA often has an insidious course, and patients often present at late stages when the scalp is irreversibly scarred (LoPresti et al., 1968). Although the etiology has not been determined with certainty, the use of straightening tools, such as hot combs and curling irons, has been postulated to play a role (Ogunleye et al., 2014). This idea was largely abandoned after a study in African-American women who did not participate in this hairstyling practice (LoPresti et al., 1968). However, most patients report a history of traumatic hairstyling techniques involving the use of excessive heat, oils, chemicals, or traction (Herskovitz and Miteva, 2016). CCCA is best managed using several approaches concurrently (Tanus et al., 2015). Hair styling practices that may contribute to this condition should be eliminated. Antiinflammatory agents, such as topical and intralesional steroids and oral antibiotics, are used to arrest the progression of hair loss and relieve symptoms (Tanus et al., 2015). In later stages, surgical intervention via hair transplantation may be possible in stable, nonprogressive disease, but may not be feasible due to procedure cost or lack of access to dermatologists trained in transplanting scarring alopecia (Okereke et al., 2019). Irrespective of these approaches, almost all women with CCCA are interested in the immediate use of camouflage to disguise the alopecia. Furthermore, in advanced stages that are not amenable to treatment, camouflage is the only option aside from psychological support (Tanus et al., 2015). This study was institutional review board exempt. We performed a search across social media to ascertain the camouflage techniques being used in this specific patient population. On Instagram, the hashtags CCCA, CCCA alopecia, and alopecia were used to locate hair stylists who manage this type of hair loss. The search generated >12,000 hashtags, but it did not distinguish between treating dermatologists, clinics, trichologists, hair stylists, or salons. In a Facebook group of African-American hairstylists with >2000 members, we requested that those who have experience with CCCA clients submit photos of techniques used. Of the 13 stylists who elucidated their techniques, only two were willing to submit photos due to their clients’ sensitivity to hair loss. A comprehensive list of these techniques is detailed in Table 1. These modalities can be helpful, but are not always practical or affordable for the specific patient population affected by CCCA. Of the included techniques, lace wigs were the most widely used and the safest for this patient population. In conclusion, crochet styling, cornrow braids, and frontal, closure, and braided lace wigs are among the current styling techniques widely employed for CCCA and advertised by hairstylists across social media. Health care providers should work with stylists who are both ethnically proficient and artistic to produce an optimal camouflage approach for each patient. In addition, stylists should be made aware that relaxers can exacerbate hair loss and avoid approaches that produce tension on hairs, leading to further damage to healthy follicles. Patients should also be counseled to discontinue harmful styling practices that may potentiate the scarring process. These efforts will certainly help improve the psychological impact of hair loss in these patients. Future studies focusing on the impact of treatment, including camouflage, on the quality of life of patients with CCCA are needed.