To the rescue: Lectureship spotlights CCCA hair loss research

Personal experience counts for a lot and often serves as the motivation for a career choice as an adult. Such was the case for Amy J. McMichael, MD, a professor of dermatology at Wake Forest Baptist Medical Center in Winston-Salem, North Carolina. Dr. McMichael delivered the Everett C. Fox, MD Memorial Award and Lectureship, “Hair Loss: A Journey of Follicular Rescue” during Friday’s Plenary (P151).

Amy J. McMichael, MD.

As a young, African American girl growing up in North Philadelphia, Dr. McMichael said she became aware of the power that hair loss and hair health held for African American girls and women. While in her dermatology residency, she said she was able to appreciate hair and scalp-related complaints as well as the paucity of recommendations and available treatments.

It sparked an interest in scarring hair loss, and more specifically in central centrifugal cicatricial alopecia (CCCA). The condition is common in women of African ancestry. It occurs mainly on the crown of the scalp and radiates outward in a circular pattern. Often, it encompasses over 60% of the scalp, and at times is accompanied by pain and pruritus. Typically, the condition progresses slowly and its cause is unknown.

Causes still cloudy, story still forming

Citing patients with skin of color, Dr. McMichael said “there is precious little research into the causative factors of these entities. From hair care practices to the roles of inflammation and genetics in the causation of disease, the journey to improve this knowledge is building a compelling story.”

Dr. McMichael, who has written about the condition, its diagnosis, clinical characterization, and treatments, has worked closely with colleagues to establish diagnostic criteria for scarring alopecia. Currently, she has put a spotlight on genetic markers as a potential cause, using research she has conducted on the genetic markers of CCCA with colleagues in South Africa and Israel.

“I am working with patients with skin of color to improve the management of these patients,” Dr. McMichael said. “On the journey, I have had mentorship and sponsorship from colleagues, and I will be integrating these individuals and groups to highlight how this model can lead to success.”

The power of collaboration

Dr. McMichael said the collaborative culture at the Department of Dermatology at Wake Forrest, as well as the sponsorship and mentorship she has received, has helped her pursue her passion for dermatology. During her plenary session, she credited the program director and chair of her residency at the University of Michigan, Chuck Ellis, MD, and John Voorhees, MD, respectively, as well as Chris Griffiths, MD, who was instrumental in helping her to “understand the importance of research.”

Dr. McMichael also thanked the Skin of Color Society, the Women’s Dermatologic Society, the National Medical Association, and the AAD for in supporting her CCCA research.

A revolutionary approach

“In the last decade, recent developments have revolutionized the approach to autoimmune-mediated hair loss and exposed a new form of scarring hair loss rarely seen in the past,” she said. “These discoveries have allowed for exploration of novel etiologies of disease and innovative treatment regimens. As exciting as these current advances may be, there are forms of scarring alopecia that remain common and understudied.”

Dr. McMichael told attendees that new ways to study populations with these ubiquitous scarring scalp diseases, training new researchers, and creating treatment plans are giving patients hope for follicular rescue.

“I got interested in hair loss because I saw a niche where patients needed better diagnosis, more recommendations for treatment, and where other dermatologists needed better understanding of the appropriate approach to treatment,” she said.

Updating the therapeutic ladder

The longstanding idea of building a therapeutic ladder for treatment is now being revised to include genetics and mechanistic approaches to treatment, she said. During her plenary session, Dr. McMichael discussed her latest research, which compares biopsies obtained by dermatoscope to a visual exam. This new research suggests that the visual exam may not show progressive disease, while the dermatoscopic exam can reveal early changes and allow a comparison to histologic findings (the gold standard).

According to Dr. McMichael, treating the condition with intralesional corticosteroids, topical steroids, and/or topical minoxidil increased hair growth or stabilized the disease in 46% of patients treated in her cases series.

“We will need much more work to understand how the genetic markers we discovered are activated and how we can potentially block the cascade of events leading to scarring hair loss,” she said. “As far as future work, my hope is that my team and other up-and-coming researchers can figure out more of the story that we and others have started.”