Whether chemical relaxers or styling with excessive heat causes CCCA remains to be determined; however, it is clear that these hair grooming practices can injure the hair shaft.16- 18 A population study by Kyei et al19 found that patients with CCCA had a significant increase in the use of traction hairstyles (eg, braids and weaves), which can cause scalp folliculitis, than patients with less severe central hair loss. Thus, the difficulty in attributing hair breakage to early CCCA alone lies in determining the true causative factors because most of the women who develop CCCA also use traumatic hair care practices. On the other hand, not all women who use these traumatic hair care practices develop CCCA. Chemical relaxers, permanents, hair dyes, and heat styling can damage and weaken the hair shaft, whereas certain styling products, such as gels and hair sprays, lead to increased dryness and difficultly manipulating the hair, causing breakage.13,14,20- 22 However, in this study, hair breakage was localized to the exact areas of the scalp normally affected by CCCA, and the presence of CCCA was confirmed by biopsy in most of our cases. Chemical relaxers and permanents, on the other hand, are typically applied to the hair diffusely, and known chemically induced hair breakage is not solely limited to the vertex and often occurs in the anterior or posterior hairline or as several patchy areas on the scalp.23 More clinical studies are needed to determine the mechanism of follicular abnormalities present in CCCA, which lead to hair shaft damage, and whether traumatic hair care practices also contribute to the development of this finding.