Central Centrifugal Cicatricial Alopecia (CCCA): Causes And Treatment
Last reviewed on 25 July 2026. We review our treatment guides every six months to keep them accurate.
Key points
Central centrifugal cicatricial alopecia (CCCA) is a scarring hair loss that destroys hair follicles and replaces them with scar tissue, so the hair loss it causes is permanent.
It occurs almost exclusively in women of African descent aged around 30 to 40 with tightly curled hair, and is the most common scarring alopecia in this group, with a reported prevalence of 2 to 7 per cent.
It starts as a small patch of thinning at the crown and spreads slowly outwards in a circular pattern, which is where the name comes from.
The cause is not fully known and is thought to be multiple factors together, including genetics: a change in the PADI3 gene is found in about a quarter of patients, according to the British Association of Dermatologists.
There is no cure. Treatment aims to calm the inflammation and stop further loss, so starting early, before the follicles are scarred, matters more here than in most hair loss.
A hair transplant is only an option once the disease has been quiet for at least a year, and it carries a raised risk of keloid scarring, so many people with CCCA are not suitable candidates.
Central centrifugal cicatricial alopecia is one of the more distressing forms of hair loss, because unlike the common pattern balding it can be permanent from the outset, and because it is frequently mistaken for something more easily treated until scarring has already set in. It is also under-discussed, despite being the most common scarring alopecia among Black women.
This guide explains what CCCA is, who it affects and why, what can be done about it, and the honest position on hair transplantation, which is more limited than for ordinary pattern hair loss. Because early treatment is what protects the hair, the single most useful thing this page can do is encourage anyone who suspects it to see a doctor sooner rather than later.
For the current UK clinical position, the British Association of Dermatologists patient leaflet on CCCA is the authoritative source and is kept up to date by dermatologists.
What is CCCA?
CCCA is a form of scarring, or cicatricial, alopecia. In scarring alopecias the inflammation that drives the hair loss destroys the follicle itself and replaces it with fibrous scar tissue. Once a follicle has been scarred it cannot grow a hair again, which is what separates CCCA from pattern hair loss, where the follicle shrinks but survives and can often be coaxed back.
The British Association of Dermatologists describes CCCA as a condition that "destroys the hair follicles and replaces them with scar tissue, causing permanent hair loss". In the past it was known by other names, including hot comb alopecia and follicular degeneration syndrome, which reflect older ideas about its cause.
The pattern is characteristic. It usually begins as a slight patch of thinning on the midline of the crown, the top of the scalp, and expands outwards in all directions, described as a centrifugal pattern, with the most severe loss remaining in the centre. The exposed scalp may look shiny where follicles have been lost, and shorter, finer hairs are often visible within the patch. The progression is usually very slow, over years.
Who gets CCCA, and what does it feel like?
CCCA occurs almost exclusively in women of African descent, typically between the ages of 30 and 40 and with hair that grows in tight curls, according to the British Association of Dermatologists. Men and children of African descent can be affected but far less often. A StatPearls clinical review describes it as the most common cicatricial alopecia among middle-aged women of African descent, with a mean age of onset of 36 and a reported prevalence varying between studies from 2 to 7 per cent.
Often there are no symptoms at all, which is part of why it is caught late. Some people notice burning, tingling, itching, soreness or tenderness of the scalp. Hair breakage can be an early sign before any obvious patch develops. Because the early changes are subtle and painless, CCCA is easy to dismiss as ordinary thinning or as a styling problem, and the window in which treatment protects the most hair is often missed.
If you have noticed thinning that began at the crown, this guide sits alongside our explainer on spotting and slowing a balding crown, though CCCA and ordinary crown thinning are different conditions with very different outlooks, and telling them apart is a job for a clinician.
What causes CCCA?
The honest answer is that the cause is not yet known. The British Association of Dermatologists states plainly that what triggers the inflammation "is not yet known, but it is likely to be due to multiple factors". Those thought to contribute include:
Genetics. CCCA can run in families, and a change in a gene called PADI3, which helps form the hair shaft, is found in about a quarter of patients. This change makes the hair more fragile and prone to breakage.
An increased tendency to scar. Keloid scars and uterine fibroids, both conditions of excess fibrous tissue, are more common in women affected by CCCA.
An autoimmune element, in which the immune system reacts against the person's own hair follicles and causes inflammation.
Associated health conditions. CCCA has been linked with type 2 diabetes, with low vitamin D levels, and with a higher body mass index.
Is CCCA caused by relaxers, weaves or hot combs?
This is the most sensitive question about CCCA and it deserves a careful answer, because for years the condition was blamed squarely on Black hair-care practices, which is where the old name "hot comb alopecia" came from.
The current position is more measured. Hair straightening with hot combs, chemical relaxers, tight hairstyles, braids and weaves have all been suggested as increasing the risk, but as the British Association of Dermatologists notes, not all studies have found this link. CCCA is now understood as a condition with a strong genetic and inflammatory basis, on which hair-care practices may act as one contributing factor rather than the sole cause. Blaming the person's styling alone is both unsupported and unfair.
Two practical points do follow from the evidence, however. Traction alopecia, the hair loss caused by sustained pulling from tight styles, frequently occurs alongside CCCA and is a separate, preventable problem worth addressing in its own right; our guide on traction alopecia covers it. And separately, seborrhoeic dermatitis, ordinary dandruff, is the most common scalp problem seen alongside CCCA and may worsen it, so keeping it controlled is worthwhile; our guide on whether dandruff causes hair loss explains the relationship.
Can CCCA be treated?
There is no cure for CCCA, and hair lost to scarring will not return. What treatment can do is stop the inflammation and preserve the hair that remains, which is why early diagnosis matters so much. The British Association of Dermatologists is direct about this: "Starting treatment in the very early stages of the condition is critical for maximising the likelihood of successful results." Response is slow, and it usually takes at least six months before any effect can be seen.
Treatment has two aims, and usually combines both. The first is to calm the inflammation. The StatPearls review describes anti-inflammatory therapy as the first-line treatment, using topical steroids or steroid injections into the scalp. Where that is not enough, an anti-inflammatory antibiotic from the tetracycline family, such as doxycycline, is commonly used for several months, and more powerful anti-inflammatory or immune-suppressing tablets are reserved for stubborn cases. Topical calcineurin inhibitors and anti-dandruff shampoos also have a place. All of these require a doctor, and the specifics are a matter for your own dermatologist.
The second aim is to encourage the surviving follicles to grow, for which topical minoxidil is used alongside the anti-inflammatory treatment. It is worth being clear about what minoxidil can and cannot do here: it may help follicles that are still alive, but it cannot regenerate ones that scarring has destroyed.
Alongside medical treatment, the British Association of Dermatologists encourages reducing damaging grooming practices, and notes that patients wearing natural hairstyles have been found to have higher chances of the condition improving. That does not mean styling caused it; it means reducing tension and heat gives the treatment the best chance to work.
Can you have a hair transplant with CCCA?
Sometimes, but the bar is high, and for many people with CCCA the honest answer is that surgery is not appropriate. This is an area where it is worth being straightforward rather than encouraging, because getting it wrong has real consequences.
Three conditions govern it. First, the disease must be inactive. A transplant is only an option once the inflammation has been well controlled with treatment for at least a year, because operating on an actively inflamed scalp risks the disease attacking the newly placed grafts just as it attacked the original follicles. Second, there is the scarring itself. People with CCCA have a raised tendency to form keloid scars, and the British Association of Dermatologists advises that transplantation "should be done with caution due to the high risk of keloid scar formation". Third, the scarred scalp is a poorer host for grafts: as the StatPearls review puts it, "a chance that scarring may reduce the survival rate of transplanted grafts exists".
Put together, these mean a transplant for CCCA is a considered decision made with a dermatologist and surgeon after the disease has been stable for a long period, not a routine procedure. It is not offered on the NHS and would be a private undertaking. Anyone told they can proceed without first bringing the underlying condition under control, or without a frank discussion of the keloid and graft-survival risks, is not being served well. A responsible clinic will sometimes advise against surgery, and with CCCA that advice is common and correct.
CCCA is one of several scarring alopecias where the same caution applies. If your diagnosis is uncertain, our guide on frontal fibrosing alopecia, a different scarring alopecia affecting the frontal hairline, may also be relevant, though only a clinician can tell these conditions apart.
Living with CCCA
Because CCCA can cause visible, permanent hair loss, its effect on confidence and wellbeing is significant, and the British Association of Dermatologists notes that studies have found a significant negative impact on quality of life. Support is a legitimate part of managing it, not an afterthought.
Practical options for disguising hair loss include wigs and hairpieces, which can be obtained through the NHS with a consultant's prescription, though prescription charges apply, as well as cosmetic camouflage sprays and fibres. Protecting any bald areas of scalp from the sun with a hat or sun block is also worth doing, since exposed skin can burn.
For information and peer support, Alopecia UK is a well established UK charity covering all forms of hair loss, including scarring alopecias. It is also sensible, as the British Association of Dermatologists advises, to be wary of online products promising quick or instant regrowth, which scarring alopecia cannot deliver.
When should you see a doctor?
Sooner than you might think. Because the hair loss becomes permanent once follicles scar, and because treatment works best before that happens, any persistent thinning at the crown, unexplained hair breakage, or a scalp that itches, burns or feels tender is worth having assessed. In the UK the route is usually your GP, who can refer you to a dermatologist; diagnosis is based on the history and the appearance of the scalp, and a small scalp biopsy is sometimes needed to confirm it. This guide is general information and not a substitute for that assessment.
Frequently asked questions
Does hair grow back after CCCA?
Hair lost to CCCA does not grow back, because the follicles have been replaced by scar tissue and scarring is permanent. This is why early treatment is so important: it cannot recover what has already been lost, but it can protect the follicles that are still alive. Where some regrowth does occur, it comes from follicles that were inflamed but not yet destroyed.
Is CCCA caused by relaxers and weaves?
Not straightforwardly. Hot combs, relaxers and tight styles have been suggested as risk factors, but not all studies support the link, and CCCA is now understood to have a strong genetic and inflammatory basis. Hair-care practices may contribute in some people, but the condition is not simply the result of styling, and blaming it entirely on hair care is neither accurate nor fair.
Can you get a hair transplant for CCCA?
Only in limited circumstances. The disease must have been inactive for at least a year, and even then there is a raised risk of keloid scarring and a chance that the scarred scalp reduces graft survival. Many people with CCCA are not suitable candidates, and a responsible clinic will sometimes advise against surgery. It is a decision made with a dermatologist and surgeon, not a routine procedure, and it is not available on the NHS.
Is CCCA the same as pattern hair loss?
No. In pattern hair loss the follicle shrinks but survives, so the loss can often be slowed or partly reversed with treatment. In CCCA the follicle is destroyed and replaced by scar tissue, so the loss is permanent. They can look similar early on, especially at the crown, which is one reason a proper diagnosis matters.
Is CCCA hereditary?
There is a genetic component. CCCA can run in families, and a change in the PADI3 gene, which affects how the hair shaft is formed, is found in about a quarter of patients according to the British Association of Dermatologists. Genetics is only part of the picture, however, and having the gene change does not mean the condition is inevitable.
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