Podcast Summary: Derms on Drugs

Episode: The Best Central Centrifugal Scarring Alopecia Discussion You've Ever Heard
Date: November 21, 2025
Host: Matt Zirwas (A), with Dr. Laura Ferris (D), Dr. Tim Patton (C)
Special Guest: Dr. Crystal Agu (B), Johns Hopkins

Episode Overview

This lively and education-packed episode explores the management and understanding of Central Centrifugal Cicatricial Alopecia (CCCA), focusing on the latest research, practical tools for disease assessment, and the clinical realities and emotional aspects of caring for affected patients. With expert guest Dr. Crystal Agu, the hosts break down recent studies, share practical pearls, and debate the intricacies of CCCA management through a mix of clinical science and comedic banter.

Key Discussion Points & Insights

1. The CCCA Clinical Assessment Tool (CCAT)

[02:00–09:37]

• Introduction: Dr. Patton reviews the CCAT, a novel symptom-based scoring tool aimed at guiding treatment and tracking disease activity in CCCA.
  • Components scored: progression, pain, pruritus, erythema, and scalp resistance (evaluated during intralesional injections).
  • Practicality: If no injections performed, scalp resistance score is omitted (max score 8 rather than 10).
• Purpose: Unlike other inflammatory scales, CCAT aims to track improvement toward zero, with "zero" sustained for 12 months as the goal before tapering treatment.
• Clinical Pearls:
  • The "scalp resistance" score is notably subjective but highly specific; residents learn to judge resistance by comparing to non-scarring conditions (bent needle = high score).
  • Quantifying symptoms helps engage and motivate patients:
    “So much of it is trying to turn a visit that is mostly qualitative a little bit quantitative.” – Dr. Agu [09:07]

2. Standard Therapies for CCCA

[09:37–14:17]

• Real-World Application: The panel discusses which standard treatments are used and effective:
  • Most common: intralesional triamcinolone ("tac") and minoxidil (oral/topical)
  • Doxycycline underutilized, but recognized for anti-inflammatory and anti-fibrotic properties—Dr. Agu now uses it more due to its mechanistic fit.
  • Metformin emerging as promising in select cases.
• Critical counseling message:
  “Success is not measured by hair regrowth, but by disease stability and reduced inflammation.” – Dr. Agu [12:22]

3. When to Treat (and When Not to)

[14:17–16:11]

• End-stage CCCA: For patients with extensive, longstanding disease (e.g., 70% scalp, wearing a wig), treatment may offer little benefit and can be needlessly painful.
• Honest Communication:
  “There are very few tough conversations in derm, but this is one of them... I don’t want them to torture themselves to keep things the same.” – Dr. Agu [14:44]

4. Doxycycline: Dosing, Timing, and Efficacy

[16:11–18:24]

• Early use supported by retrospective data.
• Dr. Agu now favors starting with low-dose doxycycline (50mg BID) for its anti-fibrotic effect, lowering further as needed.
• Compliance and side effects are considered (“I could probably go down even lower…a year from now you may catch me and I’m down to 20.” – Dr. Agu [18:24])

5. Antihistamines for Symptom Control

[19:46–20:43]

• High-dose cetirizine (Zyrtec) BID can help very symptomatic (itchy) patients, though compliance is a challenge.

6. Adjunct & Emerging Therapies: Topical and Oral Metformin

[22:01–27:44]

• Topical Metformin: Recent case series show it may promote true hair regrowth, especially when compounded with clobetasol.
  • Mechanism: Targets fibrosis, major element in CCCA pathogenesis.
  • “Of the big three scarring alopecias, CCCA is probably most likely to regrow.” – Dr. Agu [24:35]
• Oral Metformin: Small case series and molecular studies demonstrate reversal of disease pathways, especially effective in insulin-resistant patients.
  • Clinical approach: “Probably everybody could be on topical metformin… I compound it with clobetasol.” [29:51]

7. Insulin Resistance & HOMA-IR in CCCA

[31:05–40:49]

• Importance of Screening: Dermatologists often spot early hyperinsulinemia via skin findings, not picked up by primary care.
• Testing: HOMA-IR (Homeostatic Model Assessment for Insulin Resistance)—order fasting insulin and glucose; if >2, indicates resistance.
  • “In medicine… dermatology is uniquely positioned to identify patients with hyperinsulinemia.” – Dr. Agu [34:29]
• For insulin-resistant CCCA: oral metformin favored.
• For non–insulin-resistant: topical metformin-clobetasol or clobetasol alone.
• Clinical take-home:
  “If you wanted to stick with your topical metformin, that's fine… but I would encourage you to try [HOMA-IR] for all your acanthosis nigricans patients." – Dr. Agu [39:40]

8. Socioeconomic and Genetic Factors in CCCA and FFA

[41:04–45:25]

• Pathogenesis Theory: CCCA may be a fibrotic variant of female pattern hair loss, disproportionately affecting Black women due to vertex-only presentation, with metabolic disturbances (insulin resistance) triggering fibrosis.
• Genetics: PADI3 gene mutations account for some cases, but far from the whole story.
  • “Probably PADI3 is not enough to explain 100% [of cases].” – Dr. Agu [43:41]
• Socioeconomic Correlates: Affluence predicts FFA (frontal fibrosing alopecia) far more than race; CCCA less so.

9. Hair Practices and Patient Counseling

[49:45–50:44]

• Modern Approach: Counseling about hair practices focuses on avoiding secondary trauma (traction, breakage) rather than blaming the patient for CCCA.
  • “You’re already dealing with one form of hair loss. Let’s not add a second.” – Dr. Agu [50:05]

Notable Quotes & Memorable Moments

• On the hope (and reality) for regrowth:
  “When you talk to patients, they say, ‘what’s the chance I’m going to get my hair back?’ I tell them there’s no chance. That’s visit one… We can at least make sure the next five years look better than the last five years.” – Dr. Agu [24:35]

• On inflammation vs. fibrosis:
  “Anti-inflammatories aren’t super helpful because really, the big issue is fibrosis.” – Dr. Agu [26:10]

• On clinical empowerment:
  “With the scale, patients are like ‘Wow, you’re getting better, your itching’s decreased, your scalp pain.’ And then you see the patients who aren’t responding…you can really quantify it and say, gosh, you’ve had this same itch score, you have the same erythema score for three visits. Like, we need to add in something else.” – Dr. Agu [08:26]

• On dermatology's unique perspective:
  “Derm is the only specialty that’s going to see hyperinsulinemia manifest.” – Dr. Agu [37:41]

Practical Pearls & Quick Glance Table

| Therapy | When to Use | Notes | |--------------------------|--------------------------------------------------|----------------------------------------------------------------------| | Intralesional TAC | Most patients | Standard; 96% use in study | | Topical/Oral Minoxidil | Most patients | Topical 56%, Oral 40% | | Topical Clobetasol | Most patients | Often compounded with metformin | | Oral Doxycycline | If ongoing inflammation | Low dose (50mg BID), anti-inflammatory & anti-fibrotic | | Topical Metformin | Most; especially if not insulin resistant | 10% compounded, especially with clobetasol | | Oral Metformin | If HOMA-IR >2 (insulin resistance) | 500mg QD, works best in insulin resistant patients | | High-dose Cetirizine | For recalcitrant itch/pruritus | 10mg BID (off-label); compliance an issue | | Supplements | Not routinely used; minimal supportive evidence | May consider at patient request | | Hydroxychloroquine | Generally NOT used | “I will never use it.” – Dr. Agu [20:59] |

Lab Screening:

• For suspected insulin resistance: order fasting insulin + glucose, calculate HOMA-IR.

Important Timestamps

• 02:00 – Introduction of CCAT scoring system and rationale
• 05:50 – Approach to initial/ongoing CCCA visits with symptom tracking
• 14:17 – Discussion of end-stage disease and when to withhold further treatment
• 16:11 – Doxycycline: rationale for early and low-dose use
• 22:01 – Introduction to topical metformin case studies
• 27:44 – Oral metformin study and application
• 34:29 – HOMA-IR explained for assessing insulin resistance
• 41:04 – Pathogenesis theories (fibrosis, vertex-pattern hair loss)
• 49:45 – Counseling on hair practices: avoid additional (traction) alopecias

Pop Culture Trivia Segment

[51:00–54:16]

• The panel closes with black hair representation in pop culture:
  • “Barber Shop” (2002 Ice Cube film)
  • “Good Hair” (2009 Chris Rock documentary)
  • Salt-N-Pepa’s iconic hairstyle originated from a hair mishap
• Reflections on changes in hair practices since 2009: “Hairstyling practices have changed so dramatically it would be obsolete.” – Dr. Agu [52:48]

Overall Takeaways

• CCCA requires patient-centered, honest, and quantitative management to optimize outcomes and expectation-setting.
• Combinatorial regimens—anchored by symptom-based scores—personalize therapy and tapering schedules.
• Dermatologists should leverage their unique vantage point to screen for and address metabolic syndromes (insulin resistance) early.
• Topical and oral metformin are promising adjuncts, specifically tailored to metabolic profiles.
• Cultural competence and avoiding unnecessary “blame” directed at hair care practices remain crucial in counseling.

This episode exemplifies the fusion of the newest research with practical, compassionate clinical care—plus a dash of the hosts' signature irreverent humor.