Dermatology · Medical Literature
Systemic Comorbidities in Central Centrifugal Cicatricial Alopecia: A Systematic Review and Meta-analysis.
Abstract
Central centrifugal cicatricial alopecia (CCCA) is the most common scarring alopecia among women of African descent and has been increasingly associated with systemic comorbidities, particularly cardiometabolic and fibroproliferative conditions. We conducted a PRISMA 2020 compliant systematic review and random-effects meta-analysis, prospectively registered in PROSPERO (CRD420250656067), to quantify pooled prevalence estimates and case-control associations for comorbidities in CCCA. MEDLINE and Embase were searched through 18 June 2025 for observational studies reporting comorbidities in CCCA. Twenty three studies, comprising 9,103 patients with CCCA, were eligible. Hypertension (51.9%, 95% CI 33.8-69.6), dyslipidemia (58.4%, 95% CI 29.0 82.8), obesity (37.1%, 95% CI 10.8-74.2) and uterine leiomyomas (28.0%, 95% CI 8.0-64.0) were frequently reported, with substantial heterogeneity across studies. In case-control analyses, CCCA was significantly associated with dyslipidaemia (OR 4.46, 95% CI 1.09-18.25), uterine leiomyomas (OR 2.25, 95% CI 1.10-4.58) and anxiety disorders (OR 3.27, 95% CI 1.22-8.79), whereas hypertension, obesity and thyroid disease were not consistently associated. Most included studies were retrospective and predominantly U.S.-based, contributing to methodological heterogeneity. These findings suggest that CCCA may be accompanied by a substantial burden of medically recorded systemic comorbidities and support holistic, individualized clinical assessment.
Clinical relevance
What are the pooled prevalence estimates and case-control associations between central centrifugal cicatricial alopecia (CCCA) and systemic comorbidities, particularly cardiometabolic and fibroproliferative conditions, in women of African descent? __SNAPSHOT__ {"studyDesign":"PRISMA 2020-compliant systematic review with random-effects meta-analysis; prospectively registered in PROSPERO (CRD420250656067)","setting":"Multinational; based on MEDLINE and Embase literature search through 18 June 2025; observational studies only","sampleSize":"n=9,103 patients with CCCA across 23 eligible studies; control arm size not reported at aggregate level","population":"Predominantly women of African descent with a diagnosis of CCCA; specific age ranges, diagnostic criteria, and geographic distribution across included studies not reported in the abstract","intervention":"Presence of CCCA (exposure)","comparator":"General or disease-specific control populations in case-control analyses; not applicable for single-arm prevalence analyses","primaryOutcome":"Pooled prevalence estimates of systemic comorbidities in CCCA and odds ratios (ORs) for comorbidity associations from case-control analyses","followUp":"Not reported (cross-sectional or retrospective observational designs implied; follow-up duration not specified in the abstract)","fundingSource":"Not reported"}
Key findings
Across 23 studies (n=9,103 CCCA patients), pooled prevalence estimates demonstrated high rates of cardiometabolic and fibroproliferative comorbidities, all with substantial heterogeneity: hypertension 51.9% (95% CI 33.8–69.6), dyslipidemia 58.4% (95% CI 29.0–82.8), obesity 37.1% (95% CI 10.8–74.2), and uterine leiomyomas 28.0% (95% CI 8.0–64.0). The extremely wide confidence intervals for each estimate reflect high between-study heterogeneity and preclude precise point estimates. In case-control analyses, CCCA was significantly associated with dyslipidemia (OR 4.46, 95% CI 1.09–18.25), uterine leiomyomas (OR 2.25, 95% CI 1.10–4.58), and anxiety disorders (OR 3.27, 95% CI 1.22–8.79). Notably, the lower bounds of CIs for dyslipidemia and anxiety disorders approach unity, indicating considerable imprecision. Hypertension, obesity, and thyroid disease were not consistently associated with CCCA in case-control analyses. P-values, I² statistics, number of studies per case-control analysis, NNT/NNH, and adverse event data were not reported in the abstract. No NNT or NNH is calculable from the available data.
Practice implications
This meta-analysis provides the largest quantitative synthesis to date of systemic comorbidities in CCCA, formally establishing statistically significant associations between CCCA and dyslipidemia, uterine leiomyomas, and anxiety disorders in case-control analyses. These associations, if causal or bidirectional, suggest a systemic fibroproliferative and cardiometabolic diathesis in CCCA beyond the scalp. However, several critical caveats apply. First, all underlying studies are observational; temporality and directionality cannot be established. Second, the very wide confidence intervals for pooled prevalence estimates (e.g., dyslipidemia 29.0–82.8%) indicate substantial heterogeneity likely driven by differences in diagnostic criteria, comparator selection, referral bias, and demographic confounding across included studies. Third, the association with dyslipidemia (OR 4.46, 95% CI 1.09–18.25) carries a lower CI bound near 1, and the limited number of case-control studies available for each comorbidity may have reduced precision and power. Fourth, the finding that hypertension and obesity were not consistently associated in case-control analyses—despite high pooled prevalences—underscores that high prevalence in a single-arm analysis does not confirm disease-specific association, particularly in a population (Black women) with independently elevated baseline cardiometabolic risk. Fifth, male patients and non-African-descent populations are substantially underrepresented or absent, limiting generalizability. Clinical implications: dermatologists evaluating CCCA patients should consider systematic screening for dyslipidemia, uterine leiomyomas, and anxiety disorders as part of a holistic care approach; however, routine screening protocols should not be formally adopted on the basis of this abstract alone. Confirmation from prospective studies with well-matched controls, standardized CCCA diagnostic criteria, and race-stratified cardiometabolic baselines is needed. NOTE: This summary is based on the published abstract only (PMID 42549602); full-text methodology, including individual study quality assessments (ROBINS-I or Newcastle-Ottawa), subgroup analyses, and funnel plot asymmetry data, could not be reviewed and may alter interpretation. __LIMITATIONS__ All included studies are observational (cross-sectional, retrospective cohort, or case-control), precluding causal inference.,Substantial heterogeneity across all pooled prevalence estimates, with confidence intervals spanning the majority of the 0–100% range, severely limiting interpretability of point estimates.,The lower confidence bounds for dyslipidemia (OR 4.46, 95% CI 1.09–18.25) and anxiety disorders (OR 3.27, 95% CI 1.22–8.79) approach unity, indicating possible type I error or small-study effects.,Referral and ascertainment bias likely: academic or tertiary dermatology cohorts enriched for comorbid conditions may systematically overestimate prevalence.,Confounding by baseline population risk: Black women have elevated background rates of hypertension, dyslipidemia, obesity, and uterine leiomyomas independent of CCCA, and it is unclear whether included studies adjusted for these baseline differences.,Heterogeneous CCCA diagnostic criteria across included studies (clinical vs. trichoscopic vs. histopathologic) may introduce misclassification bias.,Anxiety disorder association (OR 3.27) may partly reflect surveillance bias (greater psychiatric contact in specialty dermatology settings) or disease burden rather than shared pathophysiology.,Thyroid disease, hypertension, and obesity were not consistently associated in case-control analyses despite high point prevalences, highlighting the risk of overinterpreting single-arm prevalence data without matched controls.,Generalizability is limited to women of African descent seen in academic or specialty settings; male patients, pediatric populations, and non-African-descent patients are inadequately represented.,Funding source was not reported in the abstract, limiting assessment of potential sponsorship bias.,Full-text review was not possible; methodological quality assessments, subgroup analyses, and publication bias evaluations could not be independently appraised. __BOTTOM_LINE_CATEGORY__ potentially_practice_informing __BOTTOM_LINE__ This systematic review and meta-analysis of 9,103 CCCA patients identifies statistically significant case-control associations between CCCA and dyslipidemia (OR 4.46), uterine leiomyomas (OR 2.25), and anxiety disorders (OR 3.27), supporting a systemic comorbidity profile beyond the scalp. However, all estimates carry wide confidence intervals, substantial heterogeneity, and are derived from observational data in a population with independently elevated baseline cardiometabolic risk, making causal attribution premature. Clinicians caring for CCCA patients—particularly women of African descent—may reasonably consider targeted screening for dyslipidemia, uterine leiomyomas, and anxiety, while awaiting prospective, controlled confirmation before formalizing protocol-level screening recommendations.