Association of Uterine Leiomyomas With Central Centrifugal Cicatricial Alopecia

Central centrifugal cicatricial alopecia (CCCA) is a primary cicatricial alopecia that predominantly affects black women.¹ Although the exact prevalence is unclear, CCCA is the most common form of permanent alopecia in this population.² For most patients with CCCA, the effect of hair loss can be psychologically devastating, affecting social functioning and personal relationships.³ Past studies have attempted to implicate hairstyling habits in the pathogenesis of CCCA, but no clear associations have been established.⁴ Histologically, CCCA can display a lymphocytic perifollicular infiltrate that progresses to end-stage fibrosis out of proportion to the degree of clinical signs of inflammation.¹

People of African descent are at increased risk for fibroproliferative disorders such as sarcoidosis, uterine leiomyomas (ULs), and keloids.⁵ This risk is possibly due to the protective effect that profibrotic alleles have against endemic helminthic infections seen in sub-Saharan Africa.⁵ Commonly referred to as fibroids, ULs are benign proliferations of smooth muscle that are more severe in black women than in women of other races/ethnicities and occur at an earlier age in black women.⁶ Uterine leiomyomas, like CCCA, occur most frequently in black women and present with an abnormal proliferation of fibrous tissue.^2,6 Given the similarities in patient populations and histologic findings, we sought to determine the risk of ULs in women with CCCA.

We analyzed Johns Hopkins Hospital patient medical records from August 1, 2013, to August 1, 2017, using Epic Slicer Dicer software (Epic). The medical records of all black women older than 18 years of age who were seen at Johns Hopkins Hospital during this period were reviewed. Women with UL included those with a medical history of UL, a diagnosis of ULs, or a history of myomectomy. Rates of UL were compared between patients with CCCA and patients without CCCA. Rates of myomectomies and age at evaluation were used as proxies for severity of ULs. P values were calculated using a 2-tailed χ² test with Yates correction, and odds ratios were calculated with 95% CIs. P < .05 was considered significant. Johns Hopkins Hospital waived institutional review board approval because only aggregate-level data counts were used during this study and patient data were deidentified.

A total of 487 104 black women older than 18 years of age were seen at Johns Hopkins Hospital during the 4-year study period. A total of 447 women (0.09%) with a medical history of CCCA were identified, 62 of whom had ULs. Approximately 13.9% of women with CCCA had a history of ULs (62 of 447) compared with 3.3% of women without CCCA (16 212 of 486 657; odds ratio, 4.68; 95% CI, 3.57-6.12; P < .001) (Table 1). No significant differences were found in the rates of myomectomy (Table 1) or the age distribution of women with ULs with or without CCCA (Table 2).

Our findings show that women with CCCA have nearly 5 times increased odds of having ULs compared with race-, age-, and sex-matched controls. This risk may be due to similar underlying mechanisms in the pathogenesis of both conditions. This study is limited by its use of retrospective data from a single center and thus may not be applicable to the general population. In addition, these data may be an underrepresentation of the burden of ULs in patients with CCCA because the patients identified as having CCCA represent only those who sought evaluation for hair loss.

Because ULs are often asymptomatic and may go undiagnosed, this study likely captures only patients with symptomatic ULs. However, patients may experience symptoms such as heavy menstrual cycles, fatigue, and infertility and may be unaware that these are symptoms of ULs.⁶ We suggest that dermatologists screen for symptoms of ULs in patients with CCCA and encourage evaluation if appropriate. Multicenter studies are needed to further evaluate the prevalence of ULs and other fibroproliferative disorders in women with CCCA.

Accepted for Publication: October 18, 2017.

Corresponding Author: Crystal Aguh, MD, Department of Dermatology, Johns Hopkins School of Medicine, Mason F. Lord Building Center Tower, Ste 2500, 5200 Eastern Ave, Baltimore, MD 21224 (cagi1@jhmi.edu).

Published Online: December 27, 2017. doi:10.1001/jamadermatol.2017.5163

Author Contributions: Ms Dina and Dr Aguh had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Okoye, Aguh.

Acquisition, analysis, or interpretation of data: Dina, Aguh.

Drafting of the manuscript: Dina.

Critical revision of the manuscript for important intellectual content: Okoye, Aguh.

Statistical analysis: Dina, Aguh.

Administrative, technical, or material support: Okoye, Aguh.

Study supervision: Aguh.

Conflict of Interest Disclosures: Ms Dina reported being a participant of the Vanderbilt Medical Scholars Program and is partially funded by Clinical and Translational Science Award grant UL1 RR 024975 from the National Institutes of Health. No other disclosures were reported.

Additional Contributions: Diana Gumas, MS, Johns Hopkins Institute for Clinical and Translational Research, assisted in using the Slicer Dicer program. She was not compensated for her contribution.