Approach to Central Centrifugal Cicatricial Alopecia: Disease Activity Scoring, Anti-Inflammatory and Anti-Fibrotic Treatment

Conclusions

• CCCA appears to be driven by both inflammation and fibrosis, so effective treatment needs to target both processes rather than inflammation alone.
• Disease activity in CCCA can continue even when redness is minimal or absent, making symptom- and trichoscopy-based monitoring more reliable than visual inspection alone.
• The C-CAT scale offers a practical way to quantify CCCA severity and guide treatment escalation, de-escalation, and remission monitoring over time.
• Intralesional steroids and high-potency topical steroids remain core first-line therapies, often paired with doxycycline and other adjuncts based on symptoms and comorbidities.
• Metformin emerged as a particularly promising therapy because it showed anti-fibrotic and anti-inflammatory effects, including reversal of profibrotic gene pathways in CCCA.
• Scalp pain, pruritus, erythema, and injection resistance can each signal specific active disease domains and help tailor individualized therapy.
• Most patients in the speaker’s series improved with standard treatment, and a substantial proportion reached remission when disease activity was tracked systematically.
• Hair regrowth is more likely after sustained control of disease activity, suggesting that prolonged management is needed before therapy can be spaced out or stopped.
• Healthy hair practices are still important adjuncts, but the presentation argues they are supportive measures rather than the primary cause of CCCA.
• CCCA management should be integrated with broader scalp and hair care counseling, including avoiding damaging styles when possible and using a consistent healthy hair routine.