CCCA Doesn’t Always Start With a Bald Spot: Early Warning Signs You May Notice Before Hair Loss

This is the first article in my 7-Day CCCA Awareness Series, and I wanted to start with something I wish more women knew much earlier:

CCCA does not always start with a bald spot.

When many women hear the words Central Centrifugal Cicatricial Alopecia, or CCCA, they picture an obvious smooth bald area in the center of the scalp. But by the time that type of visible hair loss develops, changes may have been happening in the scalp for years.

That is exactly why early CCCA warning signs are so important to talk about.

For me, my journey with CCCA stretched over many years. Looking back, there were signs long before I understood what was actually happening to my crown. My hair would break repeatedly in the same area. I could grow hair, but maintaining the hair on my crown was another story.

At one point I jokingly described the look as my “George Jefferson” stage because the crown would break down so badly.

But it was not funny when I was actually living through it.

I spent approximately 10 years not fully understanding what was happening to my scalp and hair.

And research now shows that long delays in CCCA diagnosis are not unusual.

What Is CCCA?

CCCA stands for Central Centrifugal Cicatricial Alopecia.

It is a type of scarring alopecia that most commonly affects the crown or vertex of the scalp and is seen disproportionately in Black women and women of African descent.

“Central” refers to the central area of the scalp.

“Centrifugal” describes the way the condition can gradually spread outward from the center.

“Cicatricial” means scarring.

“Alopecia” means hair loss.

With scarring alopecia, inflammation can eventually damage and destroy hair follicles. When a follicle has been completely replaced by scar tissue, regrowing hair from that follicle becomes much more difficult or impossible.

That is one of the reasons recognizing CCCA early matters so much.

CCCA Can Begin Before You See a Bald Spot

One of the biggest misconceptions surrounding CCCA is that you have to see a bald area before something is wrong.

You do not.

Early CCCA may show up as changes in the hair itself, including unexplained breakage around the crown.

A published study specifically examined hair breakage as a presenting sign of early or “occult,” meaning hidden, CCCA.

Researchers evaluated patients who had hair breakage on the vertex of the scalp, with or without additional scalp symptoms. Scalp biopsies in several of those patients showed changes consistent with CCCA or changes that suggested early CCCA.

That is important because crown breakage can easily be blamed on dryness, styling, heat, chemical processing, lack of moisture, protective styles or simply having fragile natural hair.

Sometimes it may be one of those things.

But persistent breakage in the same central area should not automatically be dismissed.

Hair Breakage Can Be an Early Warning Sign of CCCA

Hair breakage is one of the signs I want women with textured and natural hair to pay very close attention to.

Ask yourself:

Does the hair in the middle of your scalp seem shorter than the hair surrounding it?

Does your crown repeatedly break even after you trim it and start over?

Does the hair grow but seem unable to retain length in that one particular area?

Does your crown feel different from the rest of your scalp?

Have you noticed thinning at the crown even though you do not have a completely bald spot?

Those changes deserve attention.

The American Academy of Dermatology also identifies hair breakage, particularly breakage in the center of the scalp, as a possible first sign of CCCA.

For Black women especially, this distinction is important because breakage is extremely common and can have many causes. Breakage alone does not mean someone has CCCA.

What matters is recognizing patterns.

If the same area continues to break, thin or behave differently from the rest of your hair, do not automatically assume that your hair simply “doesn’t grow there.”

It may be giving you information.

Other Early CCCA Symptoms

CCCA does not feel the same for every person.

Some people experience scalp symptoms while others can have very few symptoms.

Possible CCCA symptoms described in medical literature include itching, tenderness, pain, burning, altered scalp sensation and hair breakage.

Other changes may include thinning concentrated around the crown, shorter hairs around the vertex, changes in hair density and gradual expansion of the affected area.

Some people may have virtually no discomfort at all.

That is another reason CCCA can progress without someone realizing exactly what is happening.

A person may simply notice that her hairstyles do not look as full anymore.

She may start parting her hair differently.

She may wear wigs.

She may cover the crown.

She may blame aging.

She may blame relaxers.

She may blame braids.

She may blame hormones.

She may blame stress.

She may buy another hair growth product.

Meanwhile, the underlying issue has never actually been identified.

 

Why Are Women Being Diagnosed So Late?

A major 2025 study published in JAAD International and included in the journal’s 2026 collection examined time to diagnosis among people living with different forms of scarring alopecia.

The researchers analyzed information from more than 1,000 participants.

Across all forms of scarring alopecia in the study, the average time between symptom onset and diagnosis was approximately 3.5 years.

For participants with CCCA, the average was approximately 5.67 years.

That does not mean every woman with CCCA waits almost six years for a diagnosis. The study was based on self-reported survey data from participants connected with a patient advocacy organization, so those numbers should not be interpreted as representing every person with CCCA.

However, the results highlight a serious problem: CCCA can go unrecognized for years.

The researchers discussed several possible reasons, including CCCA being mistaken for other scalp conditions, limited awareness of the disease and challenges surrounding the understanding of Afro-textured hair.

That part really stood out to me because so many Black women have been conditioned to believe hair breakage is simply something we have to deal with.

It is not something we should automatically ignore.

CCCA Was Once Called “Hot Comb Alopecia”

Another important part of CCCA history is the connection to hair practices.

CCCA was once commonly called “hot comb alopecia.”

Researchers originally believed hot combing and heated petroleum products were major causes of the condition.

Our understanding has changed.

Current research does not support the idea that hot comb use alone explains CCCA.

CCCA is considered much more complex and likely involves multiple factors.

Research has explored possible genetic influences, inflammation, hair-care practices and other biological factors.

Certain practices that cause repeated pulling, tension, heat or chemical injury can certainly damage hair and may complicate an already vulnerable scalp, but women should not be made to believe that developing CCCA simply means they “did something wrong” to their hair.

There are women who develop CCCA without a history of aggressive chemical processing or hot comb use.

There are also families in which several women experience similar patterns of hair loss, which has led researchers to investigate genetic susceptibility.

Why the Crown Matters

The crown is extremely important when discussing CCCA because the classic pattern frequently begins around the vertex or central scalp.

In early stages, the area may simply appear thinner.

Later, as follicles are lost, the scalp can become smoother or shinier and follicular openings may become less visible.

That later appearance is very different from simply having fine or low-density hair.

This is why I encourage women to learn what their scalp looks like before major hair loss develops.

Take photographs.

Part your hair.

Look at your crown.

Compare it with pictures from six months or a year ago.

Pay attention to changes.

Sometimes we see ourselves every day and do not realize how much something has changed until we compare photographs.

This has been extremely important throughout my own CCCA journey.

CCCA Versus Regular Hair Breakage

Not every broken hair means CCCA.

Natural and textured hair can break for many reasons, including dryness, excessive manipulation, chemical damage, heat damage, tight hairstyles and mechanical damage.

The question is whether there is a pattern.

One random area of breakage after wearing a tight style is very different from the same area repeatedly thinning and breaking over several years.

Persistent crown breakage deserves a closer look.

That is especially true when breakage occurs along with itching, burning, tenderness, pain, scalp sensitivity or progressively decreasing hair density.

Early Detection Matters

The purpose of sharing this information is not to make women panic every time they find a broken hair.

It is to make women aware.

There is a huge difference between fear and awareness.

CCCA is a scarring alopecia, which means waiting until significant follicular destruction has occurred can limit what can be recovered.

Earlier recognition may give someone an opportunity to identify what is happening before extensive scarring develops.

If you are experiencing unexplained crown thinning, recurring breakage or persistent scalp symptoms, document what is happening and consider getting the scalp evaluated by a qualified healthcare professional who understands CCCA, scarring alopecia and textured hair.

Ask questions.

Take your older photographs with you.

Explain when you first noticed the change.

Mention itching, tenderness or burning even if it seems minor.

Your timeline matters.

Hair Health Is Bigger Than Hair Products

Throughout this series, I am also going to talk about something that is extremely important to me: looking at hair health from the inside and the outside.

Hair is part of the body.

Scalp health does not exist in isolation from everything else happening in our bodies.

That means my personal approach includes paying attention to nutrition, lifestyle, inflammation, stress, blood work, nutrient deficiencies and overall wellness in addition to caring for my hair and scalp externally.

That does not mean juice, vitamins, oils or other natural approaches have been proven to cure CCCA.

In fact, a systematic review looking at natural ingredients for alopecia reported that there were no randomized controlled trials demonstrating that natural ingredients treat CCCA.

That distinction matters.

I believe strongly in caring for my entire body, but I also believe women deserve accurate information about what research has and has not proven.

Throughout this 7-Day CCCA Series, we are going to talk about both.

My CCCA Story Is Why I Am Sharing This

I know what it feels like to look at your crown and wonder why the hair will not stay.

I know what it feels like to think you have solved the problem only to experience breakage again.

And I know how different it feels once you finally have language for what you have been experiencing.

Today I have been able to maintain hair on my crown in a way that I could not years ago.

That journey did not happen overnight.

It involved learning my scalp, reducing unnecessary manipulation, protecting my hair, focusing on moisture and length retention, paying attention to my overall health and becoming much more intentional about what I do to my hair.

My goal with this series is to help other women recognize things earlier than I did.

You do not have to wait for a large bald spot before you start paying attention to your crown.

Your scalp may have been communicating with you long before that.

Watch Video 1 of My 7-Day CCCA Series

CCCA Doesn’t Always Start With a Bald Spot

In the first video of this series, I explain some of the signs I experienced before understanding that I was dealing with CCCA and why I believe women need to start paying attention to crown breakage much earlier.

This is only Day 1.

Over the next seven videos, we are going deeper into CCCA, what the name means, early symptoms, my personal journey, scalp health and the things I wish I had understood years ago.

If you know another woman who has been struggling with unexplained breakage or thinning around her crown, please share this information with her.

Sometimes the information that seems obvious to one of us is exactly what another woman has been searching for.

It is time to take your crown back®.

Sydney Nicole Products

Educational Disclaimer

This article is for educational and informational purposes only and is not intended to diagnose, treat, cure or prevent any medical condition. Hair loss and scalp symptoms can have many different causes. Individual treatment decisions should be made with an appropriately qualified healthcare professional.

Research References

Issa T, Klomhaus AM, Kasakevich C, Pickford J, Goh C. Central centrifugal cicatricial alopecia is associated with longer time to diagnosis among scarring alopecias. JAAD International. Published December 2025; journal collection February 2026. DOI: 10.1016/j.jdin.2025.11.021. PMID: 41561206. PMCID: PMC12814682.

Callender VD, Wright DR, Davis EC, Sperling LC. Hair breakage as a presenting sign of early or occult central centrifugal cicatricial alopecia: clinicopathologic findings in 9 patients. Archives of Dermatology. 2012;148(9):1047-1052. DOI: 10.1001/archdermatol.2011.3428. PMID: 22986858.

Herskovitz I, Miteva M. Central centrifugal cicatricial alopecia: challenges and solutions. Clinical, Cosmetic and Investigational Dermatology. 2016;9:175-181. DOI: 10.2147/CCID.S100816. PMID: 27574457. PMCID: PMC4993262.

American Academy of Dermatology. Central centrifugal cicatricial alopecia: Signs and symptoms.

Ogunleye TA, McMichael A, Olsen EA. Central centrifugal cicatricial alopecia: retrospective chart review. Dermatology Online Journal. PMID: 20868618.

Use of Natural Ingredients in the Treatment of Alopecias with an Emphasis on Central Centrifugal Cicatricial Alopecia: A Systematic Review. PMCID: PMC7595365.