Camouflaging techniques for patients with central centrifugal cicatricial alopecia.

Dear Editor:

Central centrifugal cicatricial alopecia (CCCA) is the most common form of scarring alopecia in women of African descent (Herskovitz and Miteva, 2016). A significant gap in the literature concerns the use of camouflaging techniques for scarring alopecias, which is a critical component of management in these patients. Dermatologists should be aware of these techniques and refer patients to salons that are expert in their use.

CCCA is type of scarring alopecia defined by a central area of symmetrical hair loss that is progressive and expands centrifugally (LoPresti et al., 1968). CCCA occurs in young to middle-aged women of African descent and progresses through life. It may begin with signs of hair breakage at the scalp vertex but can be asymptomatic initially (Herskovitz and Miteva, 2016, LoPresti et al., 1968). CCCA often has an insidious course, and patients often present at late stages when the scalp is irreversibly scarred (LoPresti et al., 1968). Although the etiology has not been determined with certainty, the use of straightening tools, such as hot combs and curling irons, has been postulated to play a role (Ogunleye et al., 2014). This idea was largely abandoned after a study in African-American women who did not participate in this hairstyling practice (LoPresti et al., 1968). However, most patients report a history of traumatic hairstyling techniques involving the use of excessive heat, oils, chemicals, or traction (Herskovitz and Miteva, 2016).

CCCA is best managed using several approaches concurrently (Tanus et al., 2015). Hair styling practices that may contribute to this condition should be eliminated. Antiinflammatory agents, such as topical and intralesional steroids and oral antibiotics, are used to arrest the progression of hair loss and relieve symptoms (Tanus et al., 2015). In later stages, surgical intervention via hair transplantation may be possible in stable, nonprogressive disease, but may not be feasible due to procedure cost or lack of access to dermatologists trained in transplanting scarring alopecia (Okereke et al., 2019). Irrespective of these approaches, almost all women with CCCA are interested in the immediate use of camouflage to disguise the alopecia. Furthermore, in advanced stages that are not amenable to treatment, camouflage is the only option aside from psychological support (Tanus et al., 2015).

This study was institutional review board exempt. We performed a search across social media to ascertain the camouflage techniques being used in this specific patient population. On Instagram, the hashtags CCCA, CCCA alopecia, and alopecia were used to locate hair stylists who manage this type of hair loss. The search generated >12,000 hashtags, but it did not distinguish between treating dermatologists, clinics, trichologists, hair stylists, or salons. In a Facebook group of African-American hairstylists with >2000 members, we requested that those who have experience with CCCA clients submit photos of techniques used. Of the 13 stylists who elucidated their techniques, only two were willing to submit photos due to their clients’ sensitivity to hair loss.

A comprehensive list of these techniques is detailed in Table 1. These modalities can be helpful, but are not always practical or affordable for the specific patient population affected by CCCA. Of the included techniques, lace wigs were the most widely used and the safest for this patient population.

Table 1

Images and descriptions of camouflage techniques for central centrifugal cicatricial alopecia.

Technique	Illustration	Overview
Crochet styling		Individually looped, often synthetic hair crocheted onto a braided or netted base. A net can be used over hair loss site as an alternative base to crochet onto and protect the site from further trauma. It disguises the area of hair loss using textures similar to African curl patterns and textures. This is a form of protective styling that tucks hair away from damaging agents and minimizes constant manipulation. Because the scalp is still exposed, moisturizers and oils can be applied directly while worn.Disadvantage: Cornrow base may produce traction alopecia if done too tightly
Hair braiding		Hair is braided into a selected style that specifically avoids and conceals the hair loss site, which is located under the braided bun. Style can be altered based on hair loss site.The scalp is widely accessible for moisturizing agents to be applied.Disadvantage: This braiding style is notorious for causing traction alopecia; therefore, it is recommended for only short periods of time.
Lace wigs		This technique completely covers the hair loss site while allowing the hairline to appear realistic because the individual’s scalp peeks through. It can be customized to create the sparsity and staggered look of the individual’s natural hair line and measured to specifically fit any size head. These wigs are often virgin hair from a human donor, allowing for manipulation, such as lifting of the hair, coloring, and heat styling. Bonding methods often employed, although optional, include glue, gels, and holding sprays. It often allows for daily moisturizing, which is essential to the health of African-American hair textures. Of the techniques found, this is the most widely used.Disadvantage: This option is most expensive, ranging from hundreds to thousands of dollars depending on the quality of the human hair source and due to its longevity. Bonding techniques should be carefully applied to avoid pulling follicles on the hairline.
Braided lace wigs		Much like the human hair lace wig, a lace cap is ventilated with human hair and then braided using hair fibers that mimic the texture of African-American braided hair, a popular styling practice among this population without the tension and traction this styling practice is notorious for.
Styling to conceal hair loss		Hair loss site is temporarily concealed with the use of semipermanent hair color, relaxer, heat, and haircut.Disadvantage: This technique is least sustainable due to the extent of manipulation required, which may worsen trauma to the follicles. Additionally, chemical processing can further exacerbate hair loss; therefore, this method should be avoided.

In conclusion, crochet styling, cornrow braids, and frontal, closure, and braided lace wigs are among the current styling techniques widely employed for CCCA and advertised by hairstylists across social media. Health care providers should work with stylists who are both ethnically proficient and artistic to produce an optimal camouflage approach for each patient. In addition, stylists should be made aware that relaxers can exacerbate hair loss and avoid approaches that produce tension on hairs, leading to further damage to healthy follicles. Patients should also be counseled to discontinue harmful styling practices that may potentiate the scarring process. These efforts will certainly help improve the psychological impact of hair loss in these patients. Future studies focusing on the impact of treatment, including camouflage, on the quality of life of patients with CCCA are needed.

Funding

None.

Study approval

The author(s) confirm that any aspect of the work covered in this manuscript that has involved human patients has been conducted with the ethical approval of all relevant bodies.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.