A woman with long braids standing at a bathroom mirror

Traction Alopecia or CCCA: How to Tell the Difference

A woman with long braids standing at a bathroom mirror

the part where you don't know what it is yet

It usually starts as a suspicion you keep to yourself. A part that looks wider in one photo than in another from two winters ago. A patch at the crown you only ever see when somebody else is doing your hair. You tell yourself it's the lighting, or that those braids were too tight and it'll fill back in once you leave them out a while. Years go by in that posture.

Somebody finally counted how many. A secondary analysis of the CAPAIR survey, published in JAAD International in December 2025, looked at 1,034 people with scarring alopecia and measured the gap between the first symptom they noticed and the year a doctor named it. For CCCA that gap came out at 5.67 ± 7.16 years. For frontal fibrosing alopecia and lichen planopilaris it was 2.88 ± 5.04. The measure is blunt — self-reported, year of diagnosis minus year of onset, nothing more — and those standard deviations are enormous, which means some people got an answer quickly and some waited a great deal longer than five and a half years. The authors compared by race as well and found a difference there, but it washed out once they adjusted for everything else; the type of scarring alopecia was the only thing left standing.

They give the reason for the delay themselves, and it's the reason for a page like this one. CCCA is hard to diagnose because it can look like traction alopecia, or like seborrheic dermatitis, and it doesn't always present the way a textbook says it should.

The difference between the two is mostly location. Traction alopecia turns up where the hair gets pulled — your edges, the corners, the strip above your ears. CCCA starts in the middle of the crown and widens out from there. Traction alopecia has an early phase that's reversible; CCCA scars wherever it has already been. You can't settle it from a photo, and plenty of women turn out to have both. That's the version worth carrying into a fifteen-minute appointment.

traction alopecia: the edges, and the hair that stays

The hair that goes first is usually the thin strip in front of your ears and along the temples. StatPearls puts the usual starting ground at the temporal and preauricular regions and above the ears — preauricular meaning right in front of the ear. That's the band a too-tight style pulls hardest on, and it's the band that thins while the rest of your head looks untouched.

What clinicians look for there is counterintuitive, because the thing that points at the diagnosis is the hair that stayed. A row of fine hairs often survives at the very front edge, with the loss sitting just behind it. That's the fringe sign. The 2011 paper that named it reviewed 41 women at a single center and called it both sensitive and specific for traction alopecia when the loss involves the marginal hairline. Forty-one women, no comparison group. Useful to a dermatologist, not decisive on its own. What does and doesn't come back at a hairline is a long answer of its own, and we went through it separately.

CCCA: the crown, widening

CCCA works outward from the middle of the crown, slowly enough that almost nobody catches the start of it. The British Association of Dermatologists describes a slight patch of thinning on the midline that expands outward in every direction, with the worst of the loss staying in the center, and says that progression is usually very slow. The AAD's version is a small round balding patch in the center of the scalp that grows over time, and it calls CCCA the most common type of scarring hair loss in women of African descent.

StatPearls gives the mean age of onset in women as 36. BAD's picture is women of African descent between 30 and 40 whose hair grows in tight curls. That's early enough in life that by the time anybody notices it in a photograph, it has usually been underway for years.

what scarring means, and what it doesn't

“Once they're damaged, theyre damaged and can take yearsss to regrow” is how it gets put on forums, typo and all. The first half is right and the second half isn't. A scarred follicle doesn't come back slowly. It doesn't come back. What is true splits along the two conditions.

Traction alopecia runs in two phases, and StatPearls is clear about the split: early disease is nonscarring and reversible, and chronic cases end in permanent scarring alopecia. Early, the follicle is still there and still capable. The AAD describes the far end without softening it — the hair stops growing, and “Where you once had hair, you'll see shiny, bald skin. When traction alopecia advances to this stage, your hair cannot grow back.”

CCCA is scarring by definition, so the ground it has already taken doesn't come back; BAD says flatly that in the areas where the hair is lost there is no potential for it to regrow. That isn't the same as saying it's too late everywhere, and both sources are explicit that stage matters. StatPearls says early diagnosis and standard treatment may be able to enhance regrowth. BAD makes the same point harder: starting treatment in the very early stages is critical to the odds of anything working. What treatment is aiming at is stopping the loss and holding what's left rather than filling anything back in, and the guide doesn't dress that up — regrowth, it says, is unlikely. There's no cure. Early recognition limits how far it gets, and it works slowly; BAD warns that a response usually takes at least six months before any effect can be seen.

So the urgency was never about what's already gone. It's the border that's worth the appointment.

what each one feels like, and the trap in that

Pull hard enough and your scalp tells you in real time, which is the one real advantage traction has over the other. The AAD's reasons to take a style down are all physical: pain from tightly pulled hair, stinging, crusts, and sections of scalp tented up by the tension. The British Association of Dermatologists puts it more bluntly: pain, tenderness or pimples from a hairstyle shouldn't be tolerated at all, and a style causing them should come out or be loosened straight away. If it hurts, that's information, not something to sit through. “It's not a protective style, which is why it's thinning your edges” is how it gets said in comment sections, and it isn't wrong: BAD notes that extensions, and tugging on the hair to braid it, put excess tension on it and promote inflammation.

CCCA is where that instinct fails, because it frequently doesn't hurt at all. In CCCA, the BAD notes, there are often no symptoms at all. Some people do get burning, tingling, itching, soreness or tenderness, and the AAD says many people with untreated CCCA report a scalp that burns, stings or itches. Both are ordinary. A scalp that feels fine isn't evidence either way.

BAD adds one more thing worth knowing: breakage can be an early sign, turning up before any CCCA patch does. Breakage at the crown reads as a moisture problem, or a protein problem, or the wrong product for your porosity. Sometimes that's all it is, and there's no way to tell from the outside which one you're looking at.

they can both be happening

BAD puts the overlap right inside its CCCA guide: loss and breakage at the front and sides from traction — tight ponytails, braids, that kind of thing — are often seen in women who have CCCA as well, because tight hairstyles and traumatic haircare are associated with both conditions. Elsewhere in the same document it makes the point in passing, that some people have another cause of hair loss running at the same time, traction alopecia among them. Recognizing one pattern and stopping there is how the other one keeps going unnoticed. Loosening your styles is the right call for the edges, and it is not a treatment for the crown.

CCCA also isn't simply traction gone too far. BAD is careful here in a way most writing on this isn't: the cause is not yet known and is likely to come down to several factors at once. Hot combs, relaxers, tight hairstyles, braids and weaves have all been suggested as raising the risk, and not all studies have found that link. There's a genetic thread as well — a PADI3 gene link turns up in about a quarter of patients, and that change makes the hair itself more fragile and more prone to breaking. BAD says hardening gels and sprays should be avoided because they increase the hair's fragility, which rules out a fair amount of what gets sold for edges. It also reports something more encouraging: recent research found that patients wearing natural hairstyles have higher chances of CCCA improving than patients who aren't.

locs, retwisting, and a crown you can't see

There's no number for how tight is too tight. Nobody has run that trial, and any article handing you a figure is inventing it, so the guidance falls back on tension and discomfort in general: BAD tells people who can't give up a traction style to alter it so it puts less tension on the hair, to take it down whenever possible, and to avoid any practice that causes scalp discomfort or irritation. A retwist that stings while it's being done, or that leaves your scalp sore that evening, sits inside that description. So does a fresh set gripping at the front rows. So does the weight of long locs, which pulls at the same edges all day whether or not anyone has touched them this month.

The harder problem with locs is that you can't see the thing you're supposed to be watching. A crown you can't part is a crown you can't photograph the same way twice, and the standard advice to track your part over time quietly assumes a part. Same light, same spot, same phone, every couple of months, shot by someone standing behind you if you can get them — that's about as close as it gets. The scalp between locs also has its own ordinary complaints, mostly dryness and buildup, which is a separate problem entirely: it's the subject of the post on rosemary oil and locs, and the everyday job a water-based leave-in like our Rosemary & Rice Water Spray is for.

what none of this responds to

Anything sold in a bottle. Traction alopecia and CCCA are medical conditions that a doctor diagnoses and manages, and a rosemary and rice water spray is a cosmetic, which means it does not treat either one, does not slow either one, and will not bring back what either one has taken. That holds for ours the same as for everyone else's. The BAD's own advice is to get unbiased medical help and treat anything promising a fast fix online with suspicion.

People usually ask about the rosemary trials around here. Those were run in androgenetic alopecia — pattern hair loss — which is neither of the conditions on this page, so what they measured doesn't carry across to it. If you want what was measured and over how long anyway, we went through the rosemary oil timeline separately.

Keep that warning of BAD's apart from a different one that gets aimed at Black women constantly, which is that anything handed down — oils, rinses, rice water, whatever your grandmother did on a Sunday — doesn't count until a journal has weighed in. Those aren't the same claim. Being skeptical of a product, ours included, is reasonable. A scarring alopecia needing a doctor stays true either way, whether the bottle on your shelf came out of a lab or a kitchen.

what actually settles it, and what to bring

An examination, and sometimes a small piece of your scalp. BAD puts diagnosis on history and clinical features — the pattern of the loss, how the scalp skin and the hair look — and adds that a scalp biopsy, a skin sample taken from the scalp, may be required if that leaves things unclear. StatPearls is specific about the biopsy: two 4-mm punch biopsies, for vertical and horizontal sectioning, taken from the active margin of the alopecia. From the active margin, which is the edge of the thinning rather than the middle, because the edge is where anything still happening is happening. The AAD's account of the same moment is unglamorous, a dermatologist numbing part of your scalp and removing a small bit of skin.

You can make that visit considerably better before you walk in, and the useful parts are things you already have. The photos on your phone are how this usually gets noticed in the first place, so bring them, the older the better. Bring the styling history too, as far back as you can honestly reconstruct it — braids, weaves, locs, relaxers, hot combs, how tight and how often, including whatever was being done to your head before you had any say in it. Say whether anything itches, burns or feels tender, and whether what you're looking at is breakage rather than loss. Mention your mother's crown, and your aunt's. Then ask out loud whether more than one thing could be going on, because that single question does more work than anything else you'll say in the room.

four questions that come up every time

does traction alopecia grow back?

Early on it can. StatPearls describes a biphasic pattern: nonscarring and reversible at the start, permanent scarring alopecia once it's chronic. Late, the AAD doesn't soften it, and says that once traction alopecia has advanced to shiny, bald skin, the hair cannot grow back. Which phase you're in is a question for someone looking at your scalp, not for a website.

can you have traction alopecia and CCCA at the same time?

Yes, and BAD says so inside its CCCA guide: hairline loss from traction is often seen in women affected by CCCA too, because tight hairstyles and traumatic haircare are associated with both conditions. Common enough that it's worth raising at the appointment rather than waiting to be asked.

what does CCCA look like in the beginning?

Small, and slow enough to be missed. BAD describes a slight patch of thinning on the midline of the crown that expands outward in all directions, with progression that's usually very slow. Often there's nothing to feel at all, and breakage can turn up before any patch does.

is CCCA caused by tight hairstyles?

Nobody knows for certain, and BAD says so rather than picking a side. Hot combs, relaxers, tight hairstyles, braids and weaves have all been suggested as raising the risk, and not all studies have found that link. The cause is not yet known, it's likely to be multifactorial, and genetics are part of the picture.

sources

Nothing on this page is a diagnosis, and nothing written down can look at your scalp. If you have been watching the same spot in photographs for a couple of years, that is the wait this page opened with. Book the appointment and take the pictures with you.

Back to blog