Lack of association between Table I.

Demographic characteristics of CCCA and

comorbidities and central nonscarring alopecia patients
centrifugal cicatricial alopecia: A CCCA Nonscarring alopecia
retrospective cohort study of 153 cases (N = 153) controls (N = 153)
patients Age
Range 29-91 18-88
Mean 57.2 56.8
To the Editor: We read with great interest the study SD 11.2 14.2
conducted by Leung et al,1 which sought to identify n (%) n (%)
comorbidities associated with central centrifugal Sex
cicatricial alopecia (CCCA). Previous studies have Female 153 (100) 153 (100)
Ethnicity
found associations between CCCA and medical risk
Non-Hispanic Black 153 (100) 153 (100)
factors such as uterine leiomyoma, diabetes mellitus Insurance status
type 2, and bacterial scalp infections.2,3 Leung et al1 Insured 145 (94.8) 145 (94.8)
determined that hyperlipidemia was an associated Uninsured 8 (5.2) 8 (5.2)
CCCA comorbidity in their study, which compared
CCCA patients with individuals in the Dallas Heart CCCA, Central centrifugal cicatricial alopecia; SD, standard
Study. deviation.
We conducted a retrospective chart review with
similar objectives in New Orleans, Louisiana, from syndrome, Hashimoto’s thyroiditis, or Graves’
January 2011 to December 2021. This study was disease) (P ¼ .195). Percentages of hormonally
exempt from institutional board review. A total of driven diagnoses (uterine leiomyoma, endometrial
153 CCCA patients were seen during the study hyperplasia, or hirsutism) (11.1% of CCCA cases
period, and all were $18 years of age. The control versus 4.6% of NSA patients) and psychiatric disease
group consisted of 153 patients $18 years of age (22.9% of CCCA cases versus 15.0% of NSA patients)
with nonscarring alopecia (NSA) who were matched were higher in CCCA cases compared to NSA
for demographic variables (Table I). Diagnoses for patients; however, this was not statistically
both groups were made by board-certified significant.
dermatologists. CCCA was diagnosed based on While Leung et al1 identified hyperlipidemia as a
clinical features (central pattern of alopecia), significant risk factor for CCCA, we did not detect the
trichoscopy (scarring with absence of both same observation using matched patients with NSA.
prominent miniaturized hair and perifollicular scale), Both studies examined similar demographic and
and/or histopathology (scarring alopecia). Patient geographic characteristics: CCCA patients in
charts were reviewed for demographics and the southern US cities. An important question is the
comorbidities of interest, as listed in Table II, prior temporality of comorbidities in relation to the onset
to onset of CCCA. Descriptive statistics were of CCCA. It is unclear how Leung et al1 captured the
calculated, age was compared using Student t test timing of CCCA comorbidities. We included only
for 2 independent groups, and P values were comorbidities present prior to CCCA diagnosis. A
calculated using a 2-tailed 2-test with Yates’ limitation of both our study and that of Leung et al1 is
continuity correction for comorbidities. All statistical that the extent of screening for comorbidities is
analyses were performed using RStudio v4.2.1 likely different between cases and controls,
(RStudio, PBC). thereby attenuating the accuracy of comparisons.
No comorbidities were found to be significant Additional studies with larger cohorts of CCCA
between CCCA patients and NSA patients. patients are needed to provide a more accurate
Proportions of cardiovascular comorbidities such as understanding of the comorbidities associated with
hypertension, obesity, peripheral artery disease, the disease.
dyslipidemia, diabetes mellitus type 2, and tobacco
use were similar across both the groups (Table II). Alexander J. Jafari, MD, MPH, Christen Brown,
Endocrine disorders (hyperparathyroidism, adrenal MD, Harika Echuri, MD, and Andrea T. Murina,
nodule), hidradenitis suppurativa, and HIV were MD
not associated with CCCA. 22.9% of CCCA patients
and 16.3% of NSA patients had a comorbid From the Department of Dermatology, Tulane
autoimmune disorder (systemic lupus erythemato- University School of Medicine, New Orleans,
sus, sarcoidosis, Crohn’s disease, vitiligo, Sj€
ogren’s Louisiana.

J AM ACAD DERMATOL FEBRUARY 2023 e101

e102 Notes & Comments J AM ACAD DERMATOL
FEBRUARY 2023

Table II. Comorbidities and risk factors investi- Table II. Cont’d
gated in this retrospective chart review among
Nonscarring
CCCA and nonscarring alopecia (NSA) patients CCCA alopecia
(N ¼ 153) (N ¼ 153)
Nonscarring
n (%) n (%) P value
CCCA alopecia
(N = 153) (N = 153) History of fungal scalp .832
n (%) n (%) P value infection
Hypertension .759 Yes 13 (8.5) 11 (7.2)
Yes 129 (84.3) 126 (82.4) No 140 (91.5) 142 (92.8)
No 24 (15.7) 27 (17.6) Family history of 1.00
Obesity (BMI $30) 1.000 alopecia
Yes 44 (28.8) 44 (28.8) Yes 2 (1.3) 2 (1.3)
No 109 (71.2) 109 (71.2) No 151 (98.7) 151 (98.7)
Peripheral artery disease .759
Yes 6 (3.9) 5 (3.3) BMI, Body mass index.
No 147 (96.1) 148 (96.7) *Autoimmune disorders included: systemic lupus erythematosus
(10 CCCA, 4 NSA), discoid lupus erythematosus (1 CCCA, 3 NSA),
Dyslipidemia .819
sarcoidosis (6 CCCA, 2 NSA), Crohn’s disease (2 CCCA, 0 NSA),
Yes 74 (48.4) 71 (46.4) vitiligo (2 CCCA, 2 NSA), Sj€ogren’s syndrome (3 CCCA, 0 NSA),
No 79 (51.6) 82 (53.6) Hashimoto’s thyroiditis (8 CCCA, 8 NSA), Graves’ disease (3 CCCA, 6
Diabetes mellitus type 2 .647 NSA).
Yes 77 (50.3) 72 (47.1) y
Hormonally driven diagnoses included: endometrial hyperplasia
No 76 (49.7) 81 (52.9) (4 CCCA, 0 NSA), uterine leiomyoma (8 CCCA, 6 NSA), hirsutism (5
Tobacco use .909 CCCA, 1 NSA).
z
Yes 73 (47.7) 71 (46.4) Psychiatric disease included: bipolar disorder (3 CCCA, 0 NSA),
No 80 (52.3) 82 (53.6) major depressive disorder (18 CCCA, 17 NSA), generalized anxiety
Hyperparathyroidism 1.000 disorder (9 CCCA, 6 NSA), schizophrenia (4 CCCA, 0 NSA).
Yes 6 (3.9) 6 (3.9)
No 147 (96.1) 147 (96.1) Funding sources: None.
Adrenal nodule 1.000
Yes 4 (2.6) 3 (2.0) IRB approval status: Exempt from IRB review;
No 149 (97.4) 150 (98.0) Tulane-IRB 2021-665.
Hidradenitis suppurativa 1.000
Yes 4 (2.6) 4 (2.6) Patient consent: N/A.
No 149 (97.4) 149 (97.4) Key words: alopecia; CCCA; central centrifugal
HIV 1.000
cicatricial alopecia; comorbidities; hair loss;
Yes 7 (4.6) 8 (5.2)
scarring alopecia; skin of color; risk factors.
No 146 (95.4) 145 (94.8)
Autoimmune disorder* .195 Correspondence to: Alexander J. Jafari, MD, MPH,
Yes 35 (22.9) 25 (16.3) Department of Dermatology, Tulane University
No 118 (77.1) 128 (83.7) School of Medicine, 1430 Tulane Ave, #8036,
Hormonally driven .056
New Orleans, LA 70112
diagnosisy
Yes 17 (11.1) 7 (4.6) E-mail: ajafari@tulane.edu
No 136 (88.9) 146 (95.4)
Previous pregnancy 1.00
Yes 5 (3.3) 5 (3.3)
Conflicts of interest
No 148 (96.7) 148 (96.7)
Drs Jafari, Brown, and Echuri have no conflicts of
Psychiatric diseasez .142
interest. Dr Andrea Murina is a speaker for Abbvie, Amgen,
Yes 34 (22.2) 23 (15.0)
Bristol-Meyers-Squibb, Eli Lilly and Company, Janssen,
No 119 (77.8) 130 (85.0)
and Ortho-Dermatologics. She has served as a consultant
Seborrheic dermatitis .884
for Bristol-Meyers-Squibb, Janssen, Novartis, Ortho-
Yes 30 (19.6) 28 (18.3)
Dermatologics, and UCB.
No 123 (80.4) 125 (81.7)
History of bacterial scalp .651
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