A closer look at three challenging alopecias

Hair loss is traumatic for most patients. Certain challenging hair disorders present further concern because there are not always clear answers for their effective treatment. In the case of central centrifugal cicatricial alopecia (CCCA), frontal fibrosing alopecia (FFA), and hair loss due to chemotherapy, more research is needed to move the needle on treatments and potential hair regrowth. That is the concurrence of speakers from Sunday’s “Managing Challenging Alopecias: Preventing Hair Loss in CCCA, FFA, and Chemotherapy” (U071).

Tiffany Mayo, MD

Central centrifugal cicatricial alopecia (CCCA)

Amy J. McMichael, MD, professor and chair in the department of dermatology at Wake Forest University Health Sciences in Winston-Salem, North Carolina, discussed CCCA, an inflammatory alopecia typically appearing in women of color before the age of 50. According to Dr. McMichael, CCCA predates the use of chemical relaxers as there is usually a genetic disposition for the condition.

“We should be telling patients that this is a lifelong disease,” she said. “It must be managed.”

“Hair breakage could be an early sign of CCCA,” she noted. She recommended taking a biopsy to better understand the patient’s inflammation. “Biopsies can tell you where the hair follicle is in the disease.”

Early treatment is best before permanent hair loss develops. Dr. McMichael said treatment typically includes anti-inflammatory medications, and minoxidil may be used to help stimulate hair growth in follicles that are not scarred.

The goal of treatment is to stop or slow symptoms, particularly by relieving the pain, itching and tenderness. “You want to turn off the inflammatory machinery driving the hair loss. You may not be able to regrow hair; that would just be a bonus,” she said.

Dr. McMichael recommends that patients discontinue the use of hooded dryers, unhelpful oils and tight hairstyles. She noted there is a strong association with extensions, sewn-in weaves, cornrow and braided hair. “It is related, but not causal,” she said.

Frontal fibrosing alopecia (FFA)

Elise Olsen, MD, professor of dermatology and medicine at Duke University, explored FFA, a relatively new disease, first presenting in 1994, but one that is growing in frequency.

We do not have a definite etiology. It is primarily found in Caucasian post-menopausal women, but can occur in pre-menopausal women and men. The hair loss typically affects the front hairline scalp, near the temples, and eyebrows, but can affect any hair-bearing areas,” she said.

“I don’t typically do biopsies, Dr. Olsen said. “My approach to FFA is to evaluate the entire scalp for signs of decrease in hair density; 24% will have occipital/global hair loss. I measure recession of frontal and temporal hairline and evaluate for other coexisting hair conditions. You need to be mindful of medication treatments for premenopausal women who may become pregnant.”

Dr. Olsen said some of the newer sunscreen and makeup products may have chemical elements that could be contributing to the condition. As yet, however, there are no formal studies that can confirm this.

There is no standard treatment for FFA. Dermatologists have prescribed steroids, either applied topically or injected into the scalp, or used finasteride or dutasteride. However, the panelists expressed caution in prescribing dutasteride because of the side effects and dangers presented to premenopausal women.

At this time, the treatments are designed to slow the progression of hair loss, as there is no therapy that can reverse the condition, she said.

Chemotherapy-induced alopecia

Tiffany Mayo, MD, assistant professor of dermatology at the University of Alabama at Birmingham, discussed findings in the use of scalp cooling during chemotherapy to reduce hair loss.

“What is the first thought of a patient who is diagnosed with cancer?” Dr. Mayo asked. “How does the world see me? One patient said, ‘I felt like my face has been erased.’”

She said hair loss unveils the patient’s vulnerabilities. What effects does this have on patients and their thoughts of treatment?

“Alopecia has been noted as the most distressing side effect of chemotherapy in up to 58% of women with cancer,” she said. “And 8% of women may decline treatment due to the fear of alopecia.”

Scalp cooling, which was first introduced in the 1970s, was recently cleared by the FDA for use in the United States. Dr. Mayo said scalp cooling is thought to reduce blood flow to the hair follicles via vasoconstriction in the scalp, ultimately reducing chemotherapy uptake and reducing the biochemical activity of the hair follicle.

There are currently two FDA-cleared automatic cooling systems, as well as manual caps in which ice must be added during treatment. Effectiveness with manual caps can vary, according to Dr. Mayo, because of the need to maintain consistent temperatures.

“Proper fit of the cap also affects results, making differences in hair characteristics among different ethnicities relevant,” she said.

Dr. Mayo said that scalp cooling is expensive and is not covered by most insurances. However, she provided three associations that dermatologists could refer patients to. They are:

  • Hair to Stay: National non-profit organization to provide cost assistance for scalp cooling.
  • Hope for Hair: Provides assistance to North Carolina.
  • Cold Capital Fund: Provides assistance to the DC, Maryland, and Virginia.
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