What are treatment recommendations for managing CCCA?
Clinical Applications
Dr. Schwarzenberger is the former physician editor of DermWorld. She interviews the author of a recent study each month.
By Kathryn Schwarzenberger, MD, FAAD, August 1, 2024
In this month’s Clinical Applications column, DermWorld Physician Editor Kathryn Schwarzenberger, MD, FAAD, talks with Susan C. Taylor, MD, FAAD, from Penn Medicine about her JAAD paper, ‘Treatment for central centrifugal cicatricial alopecia — Delphi consensus recommendations.’
DermWorld: You and your expert colleagues recently published treatment recommendations for central centrifugal cicatricial alopecia (CCCA). Since most of us are aware how challenging this condition is to treat, I am sure these will be most appreciated! Your recommendations were based on the Delphi process. Can you briefly explain what this process is and how it differs from a randomized, controlled study? Is there a reason you used it to develop these guidelines?
DermWorld: Many of us use topical therapies to treat CCCA. Did they hold up in your consensus process?
Dr. Taylor: Yes. There was strong consensus among the group for the use of high-potency topical corticosteroids as first-line treatment (alone or in combination) used daily for at least four weeks and then tapered to a maintenance dose of 2-5 times weekly.
There was also strong consensus among the group for the use of either topical or oral minoxidil as an adjunct treatment for adults with CCCA.
DermWorld: Did you find consensus regarding the use of systemic agents?
Dr. Taylor: Yes. Experts agreed that prescribing oral doxycycline (or other tetracycline antibiotics) up to 200 mg per day for up to six months is appropriate for treatment of adults with active CCCA. Consensus disagreement was reached on using doxycycline (or other tetracycline antibiotics) for only three months.
Notably, consensus disagreement was reached on the use of systemic corticosteroids for CCCA.
DermWorld: Did the panel recommend any procedures, such as intralesional corticosteroids or PRP?
Dr. Taylor: We recommend intralesional triamcinolone acetonide 5-10 mg/cc every 4-12 weeks for the treatment of active CCCA and as maintenance therapy, with a maximum dose of 20 mg per session to minimize systemic absorption.
Hair transplantation may improve cosmesis for patients with CCCA if there is no active scalp inflammation for at least a year.
Experts agreed that there is limited evidence to support the use of platelet-rich plasma/fibrin matrix for treating CCCA.
DermWorld: What about supplements? Did the group feel there is any role for nutritional supplements in treating CCCA?
Dr. Taylor: Consensus was reached on the importance of screening patients with CCCA for serum nutritional deficits in vitamin D, iron, and ferritin, and correcting any deficits through oral supplementation if necessary.
DermWorld: CCCA has often been attributed to hair treatments, such as hot comb use or wearing hair in high traction styles. How did the group feel about this?
Dr. Taylor: The group agreed that traction-inducing hairstyles (e.g., tight ponytails, hair braiding) may flare CCCA and should be minimized. It is important to note that the discussion regarding hairstyles should be guided by cultural sensitivity, focusing on healthy hair care practices (e.g., increasing time with natural hair between styles) and alternative low-tension styles as opposed to what the patient should avoid. There was no discussion of hot tool use in this study. However, recent literature suggests that there is no association between hot tool use and CCCA.
DermWorld: What further studies would you recommend so we better understand this potentially devastating hair condition? Is there anything the average dermatologist can do to advocate for our patients with this condition?
Dr. Taylor: We urged heightened research efforts to understand the etiology, comorbidities, and treatment efficacy of CCCA, emphasizing the need for randomized placebo-controlled trials for safety and efficacy of therapeutic agents for CCCA. Given the challenge of detecting CCCA in its earliest stages and evidence that supports increased therapeutic efficacy with earlier intervention, clinicians less familiar with scarring alopecia should be attentive to patients’ hair complaints and consider scalp biopsy if CCCA or another scarring alopecia is suspected. Diagnosing clinicians can guide their patients to the Scarring Alopecia Foundation’s online resources for additional support and information.
Susan C. Taylor, MD, FAAD, is a Bernett L. Johnson, Jr., MD professor of dermatology at Penn Medicine, and is president-elect of the AAD. Her paper appeared in JAAD.
Disclaimer: The views and opinions expressed in this article do not necessarily reflect those of DermWorld.
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