Understanding Alopecia: Local Dermatologist Shares What to Watch For, Explains Different Types

By Solomon Crenshaw Jr. | For the Birmingham Times

A diagnosis of alopecia only tells part of the story.

“Alopecia is an umbrella term. It’s very nonspecific. It just means hair loss,” said Dr. Amena Alkeswani of Hoover’s Olive Branch Dermatology. “It could be many, many, many other causes of hair loss that fall under alopecia. People usually use that term sometimes just too broadly. There are so many different types. There are so many different causes. It’s a lot more complicated than just hair falling.”

As an example, Alkeswani cited central centrifugal cicatricial alopecia (CCCA), a scarring type of hair loss that affects 5% of Black women.

“It’s a very unrecognized entity because for something that affects 5% of Black women, most Black women have not heard of it,” she said. “It is a huge issue because everyone just thinks, ‘Oh alopecia. Hair loss.’ For a Black woman, she’s like, ‘Oh, my friend tried Rogaine over the counter.’ Black women would try it and it doesn’t work for them. Truthfully, they’ve never been diagnosed correctly because the treatment for that type of hair loss is very, very different than the other types of hair loss.

“The public needs to understand you can’t just lump hair loss into one category,” the doctor continued. “This is a true medical condition. It’s no different than your hypertension or diabetes. It needs to be addressed by a dermatologist to make the correct diagnosis.”

With CCCA, the hair loss usually begins near the rear top of the head and extends outward, she explained.

Alkeswani said CCCA is very, very common, genetic and unrecognized. Unfortunately, she said, Black women are not coming in when the condition is in its early stages, when they’re in their late 30s or early 40s, when they start just having breakage and itching.

“They think they might have dandruff or something else,” Alkeswani said. “We see it when it scars, when they’ve already lost the hair. It’s much harder to treat when it’s scarred, and sometimes impossible, to get the hair back. But you still can get some results. But it’s very much harder to treat.”

A Breakthrough for Black Women

For years, Black women who did see their doctors about hair loss often didn’t get the answers they needed.

“Black women have been dealing with this for decades and decades and decades,” Alkeswani said. “Doctors in medicine have been blaming it on Black women’s hair practices. It was always because Black women do relaxers. It’s because Black women do this type of hairstyle that is damaging their hair follicles. Instead, this is a genetic condition. It was a Black dermatologist who found the genetic mutation because she refused to just accept, ‘Oh, it’s all because Black women have harsher hair practices.’”

That dermatologist was Dr. Amy McMichael, a professor and chair of the Department of Dermatology at Wake Forest University, specializing in skin of color and hair disorders. She sent DNA to be tested, and researchers found the genetic mutation that causes the condition.

Alkeswani expressed frustration at dermatologists who for 30 years responded to Black women by blaming them. They told them to stop relaxing their hair or stop putting on hair pieces or cut down on braids.

“No, they’re actually dealing with a very serious type of hair loss that is scarring progressively,” the doctor said. “They have not done anything to cause it. They were just born with a genetic mutation.”

More Cases of Hair Loss

Alkeswani said alopecia has become prevalent.

“Especially right now with a lot of people being on weight loss drugs,” she said. “We have been seeing more cases of hair loss, but also COVID has triggered a lot of hair loss cases.”

Alkeswani cited other types of alopecia and their characteristics.

“If you’re gonna talk about androgenic alopecia, it’s more common in men, which is a subtype of alopecia,” the doctor said. “But if you’re gonna talk about CCCA (central centrifugal cicatricial alopecia), which is a type of a scarring alopecia, it’s more common in Black women.”

Demographics, including ethnicity, factor into an alopecia diagnosis. There are also some that are more common in men, and some that are more common in women.

Androgenic alopecia is what most people think about as male pattern baldness.

“Women can have it too, but this one is more common in men,” the doctor said. “They get that receding hairline and thinning at the crown. For women, hair in the middle part gets widened and then they have temporal recessing.”

“This is why you can’t all lump alopecia into one category,” Alkeswani said. “There are several different ones.”

Types of Hair Loss

Androgenetic Alopecia (Pattern Hair Loss)

• Genetic and hormonal cause
• Men: receding hairline, thinning crown
• Women: diffuse thinning, widened part.

Telogen Effluvium

• Sudden shedding triggered by stress, illness, childbirth, surgery, or medications
• Often temporary; resolves when triggers are addressed

Alopecia Areata

• Autoimmune attack on hair follicles
• Round smooth patches of hair loss
• Can sometimes progress to complete scalp or body loss

Central Centrifugal Cicatricial Alopecia (CCCA)

• Common scarring alopecia in women of African descent
• Starts at the crown and spreads outward
• Can cause permanent loss if untreated

Scarring Alopecias (FFA & LPP)

• Frontal Fibrosing Alopecia (FFA): Hairline recessions, often in postmenopausal women
• Lichen Planopilaris (LPP): Inflammatory, patchy scarring loss with itching/burning

Traction Alopecia

• From tight hairstyles, braids, ponytails, extensions
• Early cases reversible; chronic traction can cause scarring loss

Source: Olive Branch Dermatology