Alopecia

Key Takeaways

• Alopecia means hair loss, but it is not one single condition. Hair loss can come from genetics, inflammation, autoimmune disease, hormonal changes, stress, hairstyling practices, or scarring scalp conditions.

• In skin of color, some types of hair loss are more common, more easily missed, or more likely to become permanent. This includes traction alopecia, central centrifugal cicatricial alopecia (CCCA), acne keloidalis nuchae, and dissecting cellulitis of the scalp.

• The most important question is whether the hair loss is scarring or non-scarring. Non-scarring hair loss may regrow. Scarring hair loss can permanently destroy hair follicles if not treated early.

• Hair loss in Black women is not “just from relaxers.” Conditions like CCCA have genetic and inflammatory components, although chemical relaxers, heat, and tight hairstyles may worsen hair loss in some people.

• Pain, itching, burning, tenderness, bumps, crusting, or shiny smooth scalp skin are warning signs. These may suggest inflammation or scarring and should be evaluated early.

• Treatment depends on the type of alopecia. Minoxidil may help several types of hair loss, but conditions like CCCA, alopecia areata, traction alopecia, and acne keloidalis nuchae each require different treatment plans.

What is Alopecia?

Alopecia is the medical term for hair loss. It can affect the scalp, eyebrows, eyelashes, beard area, or body hair. Some types of hair loss are temporary, while others can become permanent.

Hair loss can happen for many reasons, including:

• genetics

• autoimmune disease

• inflammation

• hormonal changes

• stress or illness

• medications

• nutritional deficiencies

• tight hairstyles

• chemical or heat damage

• scalp disorders that cause scarring

For people with skin of color, especially people of African descent, some forms of alopecia deserve special attention because they are more common, more likely to be underdiagnosed, or more likely to become permanent without early treatment.

One of the most important distinctions is whether the hair loss is non-scarring or scarring.

Non-Scarring Alopecia

In non-scarring alopecia, the hair follicle is usually still present. This means regrowth may be possible if the underlying cause is treated. Examples include:

• alopecia areata

• androgenetic alopecia

• telogen effluvium

• early traction alopecia

Scarring Alopecia

In scarring alopecia, inflammation damages and destroys the hair follicle. Once the follicle is replaced by scar tissue, that hair cannot regrow from that area. Examples include:

• central centrifugal cicatricial alopecia (CCCA)

• late-stage traction alopecia

• acne keloidalis nuchae

• dissecting cellulitis of the scalp

• discoid lupus involving the scalp

This is why early diagnosis matters so much. In scarring alopecia, the goal is not just to regrow hair. The first goal is often to stop progression and preserve the hair follicles that remain.

Fast Facts

• What does alopecia mean?

  Hair loss

• Is alopecia one condition?

  No. It is a broad term for many types of hair loss

• Can hair grow back?

  Sometimes. It depends on whether the follicle is still alive

• What is scarring alopecia?

  Hair loss where the follicle is permanently destroyed

• Why does early treatment matter?

  Early treatment can prevent permanent hair loss in scarring conditions

• What areas should I watch closely?

  Crown of scalp, edges/hairline, back of neck, beard area, eyebrows, and sudden round patches

• Can hair practices contribute?

  Yes, especially tight styles, chronic tension, heat, and some chemical practices in susceptible people

Hair loss affects all races, ethnicities, and genders, but certain forms disproportionately affect people with skin of color. Traction alopecia is common among people who wear tight hairstyles. CCCA is most often seen in women of African ancestry. Acne keloidalis nuchae predominantly affects Black men. Alopecia areata also appears to be more common in several populations of color compared with White patients.

Why Hair Loss in Skin of Color Deserves Special Attention

Hair is not just biological. For many communities of color, hair is deeply connected to identity, culture, family, creativity, spirituality, professionalism, and self-expression. That matters because hair loss is not “just cosmetic.” It can affect:

• confidence

• self-image

• social comfort

• work life

• mental health

• cultural expression

• daily routines

It also matters because some hair loss conditions in skin of color are tied to a combination of hair structure, genetics, inflammation, and grooming practices. A good treatment plan should not simply tell patients to “stop doing” culturally important hairstyles. It should explain risk, offer alternatives, and focus on protecting the scalp and hair follicles while respecting the patient’s identity.

What Hair Loss Can Look Like

Hair loss can show up in different ways depending on the type of alopecia.

Common signs include:

• thinning at the crown

• widening of the part

• thinning or recession along the edges

• round or oval bald patches

• sudden shedding

• breakage

• scalp itching, burning, or tenderness

• bumps or pustules on the scalp

• firm bumps on the back of the neck

• shiny or smooth areas where follicle openings are missing

• hair loss involving eyebrows, eyelashes, beard, or body hair

The pattern matters. Hair loss along the edges suggests a different set of causes than hair loss at the crown. Sudden smooth patches suggest something different from slow thinning over years. Bumps on the back of the neck suggest something different from diffuse shedding after stress or illness.

Non-Scarring vs Scarring Hair Loss

This is one of the most important concepts in alopecia.

Non-scarring hair loss

In non-scarring hair loss, the follicle is still present. Hair may be thin, shedding, or temporarily inactive, but the follicle has not been permanently destroyed.

Examples include:

• alopecia areata

• androgenetic alopecia

• telogen effluvium

• early traction alopecia
  
  

Scarring hair loss

In scarring hair loss, inflammation damages the follicle and replaces it with scar tissue. Once this happens, the hair cannot regrow from that follicle.

Signs that may suggest scarring include:

• smooth or shiny scalp skin

• loss of visible follicle openings

• scalp tenderness, burning, or itching
  pustules or crusting

• progressive thinning that does not recover

• firm bumps or keloid-like plaques

• hair loss that keeps expanding despite changing hair practices

Scarring hair loss is one of the biggest reasons not to delay evaluation.

Common Types of Alopecia in Skin of Color

• Traction Alopecia

  Traction alopecia happens when repeated tension pulls on the hair follicle over time. It commonly affects the frontotemporal hairline, often called the edges.

  It may be caused or worsened by:

  • tight braids

  • tight ponytails or buns

  • tight cornrows

  • locs under tension

  • sew-ins or extensions

  • heavy hair ornaments

  • tight head coverings

  • repeated tension on relaxed or chemically treated hair

  What traction alopecia looks like

  Early signs may include:

  • thinning along the edges

  • scalp tenderness after styling

  • bumps or irritation near the hairline

  • itching or stinging

  • broken hairs

  • a “fringe sign,” where a thin row of hair remains along the very front of the hairline while hair behind it thins

  Early traction alopecia can improve if tension is reduced. But if the pulling continues for months to years, it can become scarring and permanent.

• Central Centrifugal Cicatricial Alopecia (CCCA)

  CCCA is one of the most important hair loss conditions to understand in skin of color. It is the most common

  form of primary scarring alopecia in women of African ancestry.

  CCCA usually begins at the crown or vertex of the scalp and gradually spreads outward in a circular pattern.

  What CCCA may look or feel like

  People with CCCA may notice:

  • thinning at the crown

  • hair breakage before obvious thinning

  • scalp tenderness

  • itching

  • burning

  • soreness at the top of the scalp

  • widening or expansion of the thinning area

  • shiny scalp skin in more advanced disease

  CCCA can sometimes be mistaken for female pattern hair loss because both can involve central scalp

  thinning. This is one reason careful scalp examination, trichoscopy, and sometimes biopsy are important.

  Is CCCA caused by relaxers?

  Not by relaxers alone.

  CCCA appears to have a genetic and inflammatory basis. Hair grooming practices such as chemical relaxers, heat styling, and traction may trigger or worsen the condition in people who are already susceptible, but they do not fully explain the disease.

  This distinction matters. Patients should not be blamed for their hair loss. The goal is to identify the condition early, reduce triggers where possible, and treat the inflammation before more follicles are permanently lost.

• Alopecia Areata

  Alopecia areata is an autoimmune condition where the immune system attacks hair follicles. It often causes sudden, smooth, round or oval patches of hair loss.

  It can affect:

  • scalp hair

  • eyebrows

  • eyelashes

  • beard hair

  • body hair

  The patches are usually non-scarring, meaning the follicles are still present. Some people have only a few patches that regrow. Others develop more extensive disease.

• Androgenetic Alopecia

  Androgenetic alopecia is often called male or female pattern hair loss. It is related to genetics and hormone sensitivity at the hair follicle.

  In women, it often appears as:

  • gradual thinning over the central scalp

  • widening of the part

  • preservation of the frontal hairline

  • increased scalp visibility

  In men, it may appear as:

  • recession at the temples

  • thinning at the crown

  • progressive patterned hair loss

  This is one of the most common forms of hair loss overall, but in skin of color it may overlap with other scalp conditions. For example, central thinning in a Black woman could be androgenetic alopecia, CCCA, traction alopecia, or a combination. Accurate diagnosis matters.

• Acne Keloidalis Nuchae

  Acne keloidalis nuchae, often shortened to AKN, is a chronic inflammatory condition that affects the hair follicles at the back of the scalp and neck.

  It is most common in Black men and can lead to scarring hair loss.

  What AKN looks like

  AKN may cause:

  • firm bumps on the back of the neck

  • keloid-like plaques

  • itching

  • tenderness or pain

  • pustules

  • scarring

  • hair loss in the affected area

  It is sometimes mistaken for razor lumps, but it is a different condition and often requires a different treatment approach.

  Close shaving, friction from helmets or collars, and repeated irritation may worsen AKN.

• Dissecting Cellulitis of the Scalp

  Dissecting cellulitis is a chronic inflammatory scalp condition that can cause:

  • painful nodules

  • pustules

  • drainage

  • sinus tracts

  • scarring hair loss

  It predominantly affects Black men and may be associated with other follicular occlusion conditions,

  including hidradenitis suppurativa and acne conglobata.

  This condition deserves dermatology care because it can be painful, chronic, and scarring.

Skin of Color Perspective

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Skin of Color Perspective |

Why diagnosis can be harder

Hair loss in skin of color can be harder to diagnose for several reasons.

First, redness around hair follicles may be subtle or difficult to see on darker skin. This can make early inflammation easier to miss.

Second, several types of hair loss can overlap. CCCA can resemble androgenetic alopecia. Traction alopecia can look patchy and mimic alopecia areata. Acne keloidalis nuchae can be mistaken for razor bumps.

Third, medical training and dermatology images have historically underrepresented scalp and hairdisorders in skin of color. That can contribute to delayed diagnosis or incomplete evaluation.

Why culturally sensitive care matters

Hair practices are often tied to culture, convenience, professionalism, and identity. A helpful treatment plan should not shame the patient or dismiss their hairstyle choices.

Instead, the conversation should focus on harm reduction:

• loosening styles

• alternating hairstyles

• avoiding pain during styling

• reducing tension on the hairline

• using satin wig caps when appropriate

• avoiding combining chemical relaxers with high-tension styles

• minimizing heat and harsh manipulation

• choosing treatment vehicles that work with the patient’s hair texture and routine

Respectful counseling is part of good medical care.

Why Alopecia Matters

Hair loss can deeply affect quality of life.

For some people, hair loss changes how they see themselves. For others, it affects confidence, relationships, work, mental health, or cultural expression. Children and adolescents with visible hair loss may experience teasing or bullying.

Hair loss can also be medically important because some types are associated with other conditions. For example:

• CCCA has been linked with type 2 diabetes and uterine fibroids.

• Alopecia areata may be associated with thyroid disease, vitiligo, atopic dermatitis, and other autoimmune conditions.

• Acne keloidalis nuchae may be associated with metabolic syndrome.

• Dissecting cellulitis can be associated with other follicular occlusion disorders.

Hair loss deserves real medical attention, not dismissal.

How Alopecia Is Diagnosed

1. History

   They may ask about when the hair loss started, whether it came on suddenly or gradually, itching, burning, tenderness, pain, or shedding, family history, hairstyling practices, relaxers, heat, braids, wigs, extensions, or locs, medications, stress, illness, pregnancy, or weight changes, autoimmune disease or thyroid disease, menstrual history or hormonal symptoms

2. Scalp examination

   The pattern of hair loss gives important clues.

3. Trichoscopy

   Trichoscopy is a magnified examination of the scalp and hair. It can help identify signs of inflammation, scarring, miniaturization, broken hairs, or loss of follicle openings.

4. Scalp biopsy

   A biopsy may be needed when the diagnosis is unclear, especially if scarring alopecia is suspected. This is especially important in skin of color, where CCCA may be confused with androgenetic alopecia or other forms of hair loss.

Treatment Depends on the Type of Alopecia

There is no one-size-fits-all treatment for hair loss. The right plan depends on the diagnosis.

• Treatment for traction alopecia

  The most important treatment is reducing tension before permanent scarring occurs.

  Helpful changes include:

  • avoiding styles that cause pain, bumps, stinging, or crusting

  • loosening braids, ponytails, buns, locs, and extensions

  • avoiding tight styles on chemically relaxed hair

  • alternating hairstyles

  • avoiding heavy extensions

  • protecting the hairline

  • using wigs in a way that avoids friction and traction

  If inflammation is present, a dermatologist may use anti-inflammatory treatments such as topical or injected corticosteroids. Minoxidil may also be used in some cases.

• Treatment for CCCA

  The goal of CCCA treatment is to stop inflammation and prevent progression. Regrowth may be limited in areas where follicles have already scarred, but early treatment can preserve remaining hair.

  Treatment may include:

  • topical corticosteroids

  • steroid injections

  • oral anti-inflammatory antibiotics such as doxycycline or minocycline

  • minoxidil to support hair growth

  • treatment of itching or tenderness

  • reduction of heat, tension, and chemical trauma

  • in selected cases, additional medications based on dermatologist evaluation

  Some emerging research is exploring medications such as metformin and JAK inhibitors for scarring alopecia, but these are not routine first-line treatments for every patient.

• Treatment for alopecia areata

  Treatment depends on how much hair loss is present.

  For limited alopecia areata, treatment may include:

  • steroid injections

  • topical corticosteroids

  • topical minoxidil as an add-on

  • observation in mild cases

  For more severe alopecia areata, newer oral JAK inhibitor medications may be considered. These medications can be effective for some patients but require medical monitoring and a careful discussion of risks and benefits.

• Treatment for androgenetic alopecia

  Treatment may include:

  • topical minoxidil

  • oral minoxidil in selected patients

  • spironolactone in some women

  • finasteride or related medications in selected patients

  • platelet-rich plasma

  • microneedling or other adjunctive procedures

  Because androgenetic alopecia can overlap with CCCA or traction alopecia, diagnosis matters before assuming it is “just genetic thinning.”

• Treatment for acne keloidalis nuchae

  Treatment depends on severity and may include:

  • avoiding close shaving on the back of the neck

  • reducing friction from collars, helmets, and hats

  • topical steroids or steroid injections

  • topical retinoids

  • topical or oral antibiotics when inflammation or pustules are present

  • benzoyl peroxide wash

  • laser therapy

  • surgical treatment in more severe cases

  Early treatment is important because AKN can lead to scarring.

Over-the-Counter Options: What You Can Do at Home

Minoxidil

Minoxidil is the main over-the-counter medication used for hair growth. It may help several types of non-scarring hair loss and may be used as part of a broader plan in some scarring alopecias.

Important things to know:

• results often take 3–6 months

• early shedding can happen when starting

• it must be continued to maintain results

• foam may be easier for some people with textured hair than solution

• irritation or dryness can occur

• it does not treat every cause of hair loss by itself

If hair loss is scarring or inflammatory, minoxidil alone is not enough.

Gentle hair care

Gentle hair care can reduce breakage and lower additional stress on the hair.

Helpful practices include:

• detangling from the ends upward

• using a wide-tooth comb

• keeping hair moisturized

• limiting excessive heat

• using heat protectant when heat is used

• sleeping on satin or silk pillowcases or using a satin bonnet/scarf

• avoiding styles that cause pain, bumps, crusting, or scalp tenting

• reducing friction from tight head coverings or wig caps

Supplements

Supplements are often marketed for hair growth, but they are not always helpful.

Biotin

Biotin deficiency can cause hair problems, but most people are not deficient. Taking biotin without a deficiency has limited evidence of benefit and can interfere with some lab tests.

Iron and vitamin D

Low iron or vitamin D may contribute to hair shedding in some people. It is better to test levels before supplementing rather than guessing.

Build a Routine

Weekly or regular routine

1. Cleanse the scalp regularly with a gentle shampoo that fits your hair type.

2. Deep condition as needed.

3. Keep the scalp accessible enough to apply treatments if prescribed.

4. Avoid chronic tight tension on the same areas.

5. Rotate styles when possible.

6. Watch for itching, tenderness, burning, bumps, or soreness.

Styling rule of thumb

A protective style should still protect the scalp.

If a hairstyle causes:

• pain

• stinging

• bumps

• crusting

• headache

• scalp tenting

• visible pulling along the hairline

it is too tight and should be loosened or removed.

Common Mistakes That Can Make Hair Loss Worse

1. Waiting too long to seek care- This is especially risky with scarring alopecia. Once follicles are permanently destroyed, regrowth is not possible in that area.

2. Assuming all hair loss is from styling- Styling can contribute, but it is not the only cause. CCCA, alopecia areata, androgenetic alopecia, thyroid disease, medications, and inflammatory scalp disease can all cause hair loss.

3. Treating all thinning with oils only- Oils may help with lubrication or hair shaft dryness, but they do not treat autoimmune hair loss, scarring inflammation, or genetic miniaturization.

4. Continuing styles that cause pain- Pain is not normal. Tenderness, bumps, and stinging during or after styling are warning signs.

5. Using minoxidil without knowing the diagnosis- Minoxidil can be helpful, but if the hair loss is inflammatory or scarring, the underlying inflammation still needs treatment.

6. Avoiding biopsy when the diagnosis is unclear- A biopsy can be very helpful when scarring alopecia is possible. It can prevent months or years of treating the wrong condition.

When to See a Dermatologist

See a dermatologist if:

• you notice unexplained hair thinning, breakage, or bald patches

• hair loss is occurring at the crown of the scalp

• hair loss is occurring along the edges or hairline

• you have smooth, round patches of sudden hair loss

• you have scalp burning, itching, tenderness, or pain

• your scalp has bumps, pustules, crusting, or drainage

• you have firm bumps or keloid-like plaques on the back of the neck

• your scalp looks shiny or smooth in areas of hair loss

• your hair is not regrowing after changing styling practices

• hair loss affects your eyebrows, eyelashes, beard, or body hair

• over-the-counter minoxidil has not helped after consistent use

• hair loss is affecting your confidence, mood, or daily life

• you have a family history of CCCA or scarring hair loss

For scarring alopecia, early referral is critical. The goal is to stop progression before more follicles are permanently lost.

FAQ

• Is alopecia one disease?

  No. Alopecia simply means hair loss. There are many types, and each has different causes and treatments.

• Can hair grow back after alopecia?

  Sometimes. Hair may regrow if the follicle is still alive. In scarring alopecia, the follicle is permanently destroyed, so regrowth from that area is not possible.

• Is hair loss in Black women only caused by relaxers?

  No. Relaxers and heat can contribute to breakage or worsen certain types of hair loss, but conditions like CCCA have genetic and inflammatory components.

• How do I know if my hairstyle is too tight?

  If it causes pain, stinging, bumps, crusting, headache, or visible pulling at the hairline, it is too tight.

• What is the difference between breakage and hair loss?

  Breakage means the hair shaft is breaking. Hair loss means the hair is shedding from the follicle or the follicle is being damaged. Both can happen at the same time.

• Does minoxidil work for everyone?

  No. Minoxidil can help certain types of hair loss, but it does not treat every cause. If inflammation or scarring is present, additional treatment is needed.

• When is hair loss an emergency?

  Hair loss should be evaluated promptly if it is sudden, rapidly spreading, painful, associated with scalp inflammation, or showing signs of scarring.