Genetics, hair care practices linked to CCCA


Amy McMichael, MD

Often thought to be the cause of central centrifugal cicatricial alopecia (CCCA), chemical relaxers are not entirely the culprit. For Amy McMichael, MD, the role of hair care practices in the development of CCCA is particularly complex, especially because a genetic component likely plays a role.

“We see people who have never relaxed their hair who have it,” said Dr. McMichael, professor and chair of dermatology at Wake Forest Baptist Health Medical Center, Winston-Salem, North Carolina. “There is probably a genetic predisposition that is coupled with traction and other hair care practices.”

During the Friday Plenary, Dr. McMichael presented “Uncovering the Importance of Hair Disorders in the Skin of Color Patient.” She shared how hair care practices, such as chemical relaxers, other chemicals, heat, and tight braiding play a role in the development of several hair disorders in this population.

A longtime advocate for treating the underlying causes of hair and scalp disorders and how they affect quality of life, Dr. McMichael said she remembered from a young age how older girls in her North Philadelphia neighborhood would single out girls who did and did not have what they perceived as good hair.

Although there are many socioeconomic and cultural reasons for this, she said she knew as a child that such expectations about her hair could have ramifications about her ability to be “a more able-bodied worker, nicer person, or perhaps someone you shouldn’t like.” When she trained as a dermatology resident in the hair clinic at the University of Michigan, she returned to this concept that touched a nerve as a child.

“The clinic would see many African-American patients and give them recommendations for seborrheic dermatitis and so forth,” Dr. McMichael said. “It would always puzzle me as to why they were telling these women to wash their hair so frequently, when culturally that wasn’t common to do, and it was difficult to do because of manageability of the hair or lack thereof. I saw a niche for myself. I could help patients with their hair disorders, especially in the African-American population.”

The majority of her research has been around women of color, and one area she has examined is how hair care issues cause African-American women to forego exercise. In one study of 100 women queried in her clinic, she found that 45 percent did not exercise because of hair concerns, including sweating, itchy scalp, and hair breakage.

She cautioned that although there are many hair care products for people of color, the scientific chemistry behind them and how well they work has not been proven.

Regarding CCCA, Dr. McMichael pointed to research out of South Africa that identified a genetic component, adding that the prevalence of CCCA among African-American women in the U.S. is 5.7 percent.

“The missing piece is the mechanism,” Dr. McMichael said. “We know that inflammatory white blood cells attack hair follicles and cause damage, which then leads to scarring and changes that appear to be fibrotic under the microscope in the place of where the hair follicles were. However, we really don’t know all the steps in-between and that’s what we need to work out. What we can address is how we treat these patients because we know about the inflammation and the traction component.”

She employs a range of treatment options.

“I usually approach it with an anti-inflammatory, so that’s with steroids topically and inter-lesionally, potentially with oral antibiotics, and, at times, we even do other things one would potentially think of as anti-inflammatory,” said Dr. McMichael, adding that in one study she found seborrheic dermatitis was common in patients with CCCA and even more common in early CCCA patients.

“You don’t have to be in the patient’s shoes to understand how to address hair disorders in skin of color patients. You can be knowledgeable when you approach these patients, and they can actually start to feel comfortable doing the treatments,” she said.

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