What is Scarring Alopecia?

Scarring Alopecia also known as Cicatratial alopecia is an inflammatory hair loss disorders. It results in bald patches on scalp due to permanent destruction of hair follicles. The underlying tissues in and around the hair get destroyed or scarred and replaced by fibrous tissue. Once the hair follicles get destroyed, the hair cannot be regrown. In most cases scarring alopecia starts as a non-scarring type of alopecia that slowly progresses into permanent or irreversible baldness.

Scarring Alopecia: Types, Cause, Treatment & Hair Care

Scarring Alopecia is a type of baldness caused by destruction of hair follicles. The prevalence of scarring alopecia is about 3% to 7% in men and women who are otherwise healthy. People who get bald due to scarring alopecia usually suffer from lot of distress because there is no way to rejuvenate or regrow the hair. Scarring alopecia is not contagious and can affect anyone. This article explains how scarring alopecia occurs, its symptoms, types, and treatment options.

Background of Scarring Alopecia

Scarring Alopecia is a relatively rare hair disorder that results in permanent hair loss leading to baldness. This condition is also known as Cicatratial alopecia; cicatrice meaning the scar. The hair loss with scarring alopecia can occur slowly over a period of few years or it may happen rapidly within a few months. In some cases the hair loss in scarring alopecia may not show typical symptoms and so go unnoticed. The rapid hair loss is usually accompanied by symptoms such as severe itching, pain, burning and shedding of hair in bunches. The inflammation that causes the destruction of hair follicles happens below the skin surface and does not show the scar on the scalp. However, once the follicle gets scarred the scalp may start to show signs of inflammation such as redness, scaling, pigmentation, pustules, or hard ply board like appearance.

Who Gets Scarring Alopecia?

Scarring alopecia can affect any healthy man or woman. It is not contagious and may not always have a genetic link up. Some types are seen more commonly in women than in men. Pseudopelade is a type of scarring alopecia that mainly affects adult women. Generally, Scarring alopecia is not seen in children; however, some specific type can affect adolescent men.

What are the Types of Scarring Alopecia?

Scarring alopecia is classified as primary, secondary and developmental/hereditary alopecia.

Primary scarring alopecia: This is caused as the hair follicle is irreversibly destroyed and replaced by fibrous tissue. In primary scarring alopecia the hair follicle is the main target of destruction from where the disease begins. The hair cannot be regrown because the stem cells in the bulge of hair root are totally destroyed. The hair follicle is mainly affected by inflammatory cells such as lymphocytes, neutrophils, or combination of these. Based on the type of inflammation causing cells primary scarring alopecia is further classified as lymphocytic, neutrophilic or mixed alopecia.

  1. Neutrophilic Cicatratial alopecia: Folliculitis decalvans and dissecting cellulitis of the scalp fall under this category. Both the conditions are seen predominately in adolescent males or young adults.
  2. Lymphocytic alopecia: Lichen planopilaris (lichen planus follicularis), chronic cutaneous lupus erythematosus, frontal fibrosing alopecia, acne keloidalis nuchae, central centrifugal cicatricial alopecia and Brocq pseudopelade are caused by lymphocytes.

Secondary scarring alopecia: This too is a type of irreversible scarring alopecia. However, the hair follicles are secondarily damaged as a result of inflammation or destructive process to the skin that eventually affects the hair follicles. This type of alopecia occurs when the follicle are destroyed due to burns, cancers, trauma or radiation therapy.

Developmental/hereditary alopecia: This is caused by one or more factors such as genetics, hormone imbalances or natural ageing process commonly known as Male / Female pattern baldness.

Symptoms of Scarring Alopecia

Scarring alopecia begins as one or more permanent bald patches of on the scalp. These patches may remain discrete or coalesce to produce bigger bald areas on the scalp slowly progressing to near total alopecia. The bald patches on the skin have smooth and shiny appearance. The skin pores are absent because of a complete loss of follicular openings.

The symptoms of scarring alopecia may vary based on type of alopecia. However some typical symptoms of scarring alopecia include,

  • Itching scalp
  • Burning of scalp
  • Pus of purulent discharge from scalp
  • Pain
  • Patches of rough and scaly skin
  • Formation of blisters
  • crusting

Causes of Scarring Alopecia

The causes of Scarring alopecia are not understood fully yet but inflammation appears to be the main contributing factor. Most types of scarring alopecia are caused by permanent destruction of hair follicles due to inflammation, progressive deposition of collagen, and are frequently associated with loss of sebaceous glands.

Destruction of slow-cycling hair follicle stem cell (HFSC) is thought to be the main cause of scarring alopecia. HFSCs are located in the ‘bulge’ region of hair follicle in outer root sheath. The stem cells produce secondary germ cells or transient amplifying cells that that migrate upwards and downwards to restore and renew the upper follicle. The stem cells are responsible for regrowth of the lower hair follicle during normal telogen–anagen cycling. Since scarring alopecia may also show other symptoms such as erythema, epidermal atrophy, and follicular plugging experts believe that there must be some more biological pathways involved in causing scarring alopecia.

Another theory explains involvement of proliferator-activated receptor (PPAR), a receptor protein in causing scarring alopecia. PPAR gamma plays an important role in maintaining the integrity of hair follicle cells, including stem cells, and sebaceous glands. Abnormal function of PPAR gamma leads to dysfunction of sebaceous gland, and causes the build-up of “toxic” lipids. When the level of lipids increases in the body it triggers inflammation which eventually destroys the hair follicle.

Hair-care habits that include excessive use of hot combs, relaxants and excessive traction can also be responsible for scarring alopecia especially in women.

Experts summarise the cause of scarring alopecia as given below

  • Destruction of hair follicle stem cells
  • Impairment in self-maintenance of HFSCs
  • Alteration in lipid metabolism
  • Inflammation
  • Factors such as injuries, burns, tumours
  • Genetic factors

What Are The Available Treatment Options For Scarring Alopecia?

The goal of treatment for scarring alopecia is to prevent further hair loss and to cover the bald areas using hair systems or hair wigs. Since hair regrowth is not possible, the treatment is mainly intended for reducing the symptoms of inflammation. Hair transplantation can be performed to cover bald patches only if there is sufficient undamaged donor hair elsewhere on the scalp, and the disease is not progressing or is inactive.

Since the primary scarring alopecia can be caused by different inflammatory cells such as neutrophils or lymphocytes, the treatment options vary for specific type.

Treatment For Scarring Alopecia Caused By Lymphocytes

Lymphocytic alopecia such as Lichen planopilaris and frontal fibrosing alopecia are mainly treated using topical, intralesional and oral therapies. Application of topical corticosteroid creams helps to control the itching or burning in lesions on scalp. In some cases an injection of corticosteroid is given in the inflammatory lesion. This helps to stop hair loss at the site of injection. Injections may need to be repeated every 6 to 8 weeks. Prolonged use of steroids injectable as well as topical can cause the shrinking of skin at the site of use.

Oral medications given to treat lymphocytic oral medication include antimalarial drugs, oral corticosteroids, and oral retinoids.

Since some lymphocytic scarring alopecia are known to aggravate on exposure to sunlight use of sunscreen agent with good sun protection factor (SPF) is also recommended.

What are the side effects of treatment for Lymphocytic scarring alopecia?

  • The antimalarial medications may cause side effects such as abdominal pain, anorexia, skin hyperpigmentation, hematologic changes and ophthalmologic damage. Therefore, regular monitoring for the development of retinopathy is needed in patients who are taking antimalarial treatment for 3 to 6 months.
  • Repeated use of steroids may cause steroid-induced dermal atrophy

Treatment modalities for Lymphocytic scarring alopecia can be summarised as follows,

  • Topics steroids applied on the lesion
  • Injectable steroids
  • Oral medications such as antimalarial drugs , corticosteroids, and retinoids
  • Broad-spectrum sunscreen agents

Treatment For Scarring Alopecia Caused By Neutrophils

Since Staphylococcus aureus is the main causative organism people with folliculitis decalvans are advised to use antiseptic shampoo. Topical creams containing benzoyl peroxide or clindamycin are recommended in mild cases. The severe cases often require treatment with oral antibiotics. Other type of neutrophilic scarring alopecia called dissecting cellulitis is usually treated with isotretinoin.

What are the side effects of treatment for neutrophilic scarring alopecia?

  • Prolonged use of some antibiotics such as oral clindamycin may cause diarrhoea

Treatment modalities for Lymphocytic scarring alopecia can be summarised as follows,

  • Topical creams containing benzoyl peroxide or clindamycin
  • Antiseptic shampoos
  • Oral antibiotics for severe lesions
  • Oral retinoid such as isotretinoin

Surgical Treatment For Scarring Alopecia

Surgical treatment for scarring alopecia is recommended in people who show lesions that are stable in size. The surgery can be performed only if the inflammation causing the hair loss is under control for at least one year. The suitable candidates can undergo a treatment called scalp reduction surgery, which can be complemented by hair transplantation, for best effects.

How Are Scarring Or Cicatratial Alopecia Diagnosed?

Ideally one has to do the scalp biopsy to confirm the diagnosis of Scarring alopecia but are usually diagnosed on the basis of careful examination of hair and scalp by an experienced trichologist. The trichologist may need to track the patient history, age at onset of the condition, possibility of other skin or scalp conditions. Some obvious and typical signs such as itching or burning of the scalp with purulent discharge also help in diagnosis of scarring alopecia.

Age of the patient is an important criterion as some types of scarring alopecia occur in specific age groups. For instance, frontal fibrosing alopecia occurs in postmenopausal women. But, most forms of primary cicatricial alopecia develop in early adult life.

Absence of pores within the area of hair loss seen under magnification is also an important parameter in diagnosis of scarring alopecia.

The trichologist may also perform hair pull test to understand the degree of damage to hair follicles. If on pulling; hairs are easily removed, then the test is considered positive. This confirms that the alopecia is active and spreading.

The diagnosis of scarring alopecia is done on the basis of,

  • Scalp examination
  • Age of the patient
  • Previous skin or scalp conditions
  • Some common symptoms such as burning, itching or discharge from scalp
  • Absence of pores in area of hair loss
  • Hair pull test
  • Scalp biopsy

How Should I Care For My Hair?

Hair care is very important once you know you are suffering from scarring alopecia. You can continue the use of your regular hair care products after consultation with trichologist. Here are some hair care tips for people with scarring alopecia

  1. Do not use any hair products including shampoos or other styling products that may have harsh chemicals and irritate the scalp
  2. Protect your hair and scalp with hat or scarf and also wear broad-spectrum sunscreen on a daily basis as some types of scarring alopecia worsen on exposure to UV light.
  3. Use antiseptic shampoos as recommended by your dermatologist to reduce the inflammatory lesions
  4. Continue the course of antibiotics as prescribed to you
  5. Use hair wigs or other hair pieces to camouflage the bald patches


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