Traction alopecia treatment depends on whether scarring has developed. Early traction alopecia is nonscarring and reversible, while chronic cases can become permanently scarring after follicular miniaturization and perifollicular fibrosis develop [1]. CCCA is a scarring alopecia with patches of permanent hair loss on the vertex or crown that spread outward, usually symmetrically [2]. Hair loss also appears on Cleveland Clinic’s list of symptoms associated with menopause [3]. The menopause sources don’t establish that the transition causes either condition.
What is traction alopecia?
Traction alopecia results from continuous pulling on the hair roots, causing hair loss over time [1]. The practices named in the published description include tight braids, cornrows, ponytails, weaves, dreadlocks, extensions, hair twisting and tight scarves [1]. Chemical relaxers and heat styling can compound the risk described in that source [1].
Traction alopecia predominantly affects women of African descent with tightly curled hair [1]. In a survey of 874 African adults in Cape Town, South Africa, the prevalence was 22.6% overall, 31.7% among women and 2.2% among men [4]. Prevalence was highest among people whose usual hairstyle was extensions attached to relaxed hair, at 48% [4].
These figures describe that survey population. They don’t identify the cause of hair loss on one person’s scalp.
What is CCCA?
Central centrifugal cicatricial alopecia, or CCCA, is a scarring alopecia with patches of permanent hair loss on the vertex or crown that spread outward in a centrifugal pattern, usually symmetrically [2]. It is predominantly observed in women of African descent, shows familial predisposition, and has a mean age of onset around 36 years [2].
Mild burning, tenderness or itching can be confined to the area of hair loss [2]. Hair doesn’t regrow from permanently damaged hair follicles [2]. Treatment includes topical and systemic corticosteroids, oral tetracyclines and other systemic anti-inflammatory agents [2]. Responses are typically modest, and the aim is to prevent progression rather than restore permanently lost hair [2].
In the Cape Town survey, the prevalence of CCCA was 1.9% overall and was highest in women over 50 years, at 6.7%, compared with 1.2% among men [4]. In a separate survey of 529 African American women at six workshops, extensive central scalp hair loss was seen in 5.6% of participants [5]. That survey found no obvious association between extensive hair loss and relaxer or hot comb use. It reported a significant association with a history of tinea capitis [5].
How are traction alopecia and CCCA told apart?
The published descriptions give different patterns, symptoms and treatment aims. Diagnosis of CCCA may be confirmed with two 4-mm punch biopsies taken from the active margin of the alopecia [2].
| Feature | Traction alopecia | Central centrifugal cicatricial alopecia |
|---|---|---|
| Pattern | Hair loss associated with continuous pulling on the roots [1] | Patches on the vertex or crown that spread outward, usually symmetrically [2] |
| Symptoms | Hair loss over time from continuous pulling [1] | Mild burning, tenderness or itching can be confined to the area of hair loss [2] |
| Reversibility | Early disease is nonscarring and reversible. Chronic disease can become permanent after scarring develops [1] | Hair doesn’t regrow from permanently damaged follicles [2] |
| How it is diagnosed | The condition is described in relation to continuous pulling and the stage of scarring [1] | Diagnosis may be confirmed with two 4-mm punch biopsies from the active margin of the alopecia [2] |
| What treatment aims to do | Stop high-tension hairstyles and address inflammation. Medical options include corticosteroids, minoxidil and hair transplantation in scarring cases [1] | Prevent progression with topical and systemic corticosteroids, oral tetracyclines and other systemic anti-inflammatory agents [2] |
For the appointment, write down where the loss began, whether it is spreading, whether the scalp burns, itches or feels tender, and which hairstyles have created tension.
Why does timing matter in traction alopecia?
Early traction alopecia is nonscarring and reversible [1]. Chronic traction can become permanent when follicular miniaturization and perifollicular fibrosis develop [1]. Management includes stopping high-tension hairstyles, alternating styles, and avoiding chemical and heat treatments [1]. Medical options include topical or intralesional corticosteroids for inflammation, minoxidil, and hair transplantation in scarring cases [1].
CCCA has a different treatment aim. Its published treatment is intended to prevent progression rather than restore hair from follicles that have been permanently damaged [2]. Responses are typically modest [2].
Could this be related to perimenopause?
Hair loss appears on Cleveland Clinic’s list of symptoms associated with menopause [3]. That list also includes irregular periods, heavier or lighter periods, mood changes, low libido, hot flashes, night sweats, vaginal dryness with discomfort during sex, urinary urgency and trouble sleeping [6].
Perimenopause is the transitional period before menopause, during which estrogen levels start to decrease [6]. It usually starts in the mid-40s, may begin as early as the mid-30s or as late as the mid-50s, and runs about four years on average, with an upper end of eight years [6]. Menopause is reached when there has been no menstrual period for 12 months in a row [6].
The menopause sources don’t establish that the transition causes traction alopecia or CCCA. Traction alopecia is described in relation to continuous pulling on the hair roots [1]. CCCA is described as a scarring alopecia with familial predisposition [2]. Hair loss appearing on a menopause symptom list doesn’t identify the type of hair loss [3].
If hair loss is attributed to menopause, ask which findings support that explanation and whether traction alopecia or CCCA has been considered.
How common are these conditions?
The available figures come from different populations. In the Cape Town survey, traction alopecia was found in 22.6% of African adults overall and CCCA in 1.9% overall [4]. Traction alopecia was found in 31.7% of women, while CCCA was found in 6.7% of women over 50 years [4].
The survey of 529 African American women found extensive central scalp hair loss in 5.6% of participants [5]. It reported no obvious association between that hair loss and relaxer or hot comb use, and reported a significant association with a history of tinea capitis [5].
These figures come from separate surveys and don’t diagnose the cause of an individual person’s hair loss.
What can treatment not do?
Early traction alopecia is described as reversible, while chronic traction can become permanently scarring [1]. For CCCA, the stated aim is to prevent progression, and permanently damaged follicles don’t regrow hair [2].
The published descriptions do not establish that menopause causes either condition [1][2][3].
What to do next
- Write down where the hair loss began, whether it is spreading, and whether the scalp burns, itches or feels tender.
- List hairstyles that create tension, including braids, cornrows, ponytails, weaves, dreadlocks, extensions, twists and tight scarves [1].
- Add chemical relaxers and heat styling to the hair history [1].
- Open the appointment with: “I have hair loss in this pattern, and I want traction alopecia and CCCA considered.”
- Ask whether the loss appears nonscarring or scarring [1].
- Ask whether two 4-mm punch biopsies from the active margin are needed to confirm CCCA [2].
- Ask what the proposed treatment is intended to do: reduce tension, address inflammation, prevent progression or manage scarring.
- If the loss is attributed to menopause, say: “Hair loss is on the menopause symptom list. What supports this diagnosis rather than traction alopecia or CCCA?” [3]
Related on Ruby: perimenopause symptoms and what is perimenopause.
Sources
- StatPearls, Traction alopecia, NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK470434/
- StatPearls, Central centrifugal cicatricial alopecia, NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK559187
- Cleveland Clinic, Menopause. https://my.clevelandclinic.org/health/diseases/21841-menopause
- Khumalo 2007, Hairdressing and the prevalence of scalp disease in African adults, British Journal of Dermatology, PubMed. https://pubmed.ncbi.nlm.nih.gov/17725667/
- Olsen 2011, Central hair loss in African American women, Journal of the American Academy of Dermatology, PubMed. https://pubmed.ncbi.nlm.nih.gov/21075478/
- Cleveland Clinic, Perimenopause. https://my.clevelandclinic.org/health/diseases/21608-perimenopause