Scarring Alopecia: Everything You Need to Know

a woman looking at her scarring scalp in the mirror

All about Scarring Alopecia 

The generality of scarring alopecia is about 3% to 7% in men and women who are usually healthy. People who get bald due to scarring alopecia suffer from a lot of distress because there is no way to regenerate or regrow the black hair. Scarring alopecia can affect anyone and is not contagious.

What is Scarring Alopecia?

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

What are the Types of Scarring Alopecia?

Scarring alopecia is of 3 types primary, secondary and developmental/hereditary alopecia.

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

  1. Neutrophilic Cicatricial alopecia: Folliculitis decalvans and dissecting cellulitis of the scalp fall under this category. Both the conditions are seen predominantly 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 all are caused by lymphocytes.

Secondary scarring alopecia: This is also a type of permanent scarring alopecia. However, the hair follicles are secondarily damaged as a cause of inflammation or a destructive process to the skin that eventually damages the hair follicles. This type of alopecia occurs when the follicles are damaged 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 the natural ageing process also known as male pattern baldness or female pattern baldness.

Symptoms of Scarring Alopecia

Scarring alopecia begins as one or more permanent bald patches on the scalp. These patches may remain discrete or combined to produce bigger bald areas on the scalp slowly developing into near-total alopecia. The bald patches on the skin have a smooth and lustrous appearance. The skin pores are not there because of a complete loss of follicular openings.

The scarring alopecia symptoms vary based on the type of alopecia. However,r some typical symptoms of scarring alopecia are:

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

Causes of Scarring Alopecia

Inflammation appears to be the main contributing factor to Scarring alopecia. Most types of scarring alopecia are caused by permanent damage to hair follicles due to inflammation, and progressive deposition of collagen, and are frequently linked to loss of sebaceous glands.

Causes of scarring alopecia as per the experts:

  • 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 Alopecia Treatment?

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

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

Let us look at some of the alopecia hair loss treatment options available for different alopecia types:

Treatment For Scarring Alopecia Caused By Lymphocytes

Lymphocytic alopecia such as Lichen planopilaris and frontal fibrosing alopecia is certainly treated using topical, oral and intralesional therapies. Applying topical corticosteroid creams helps to prevent the itching or burning in lesions on the scalp. In a few cases, an injection of corticosteroid is given to the inflammatory lesion. This helps to stop hair loss at the place of injection. Injections may need to be applied every 6 to 8 weeks. Long time usage of steroids injectable as well as topical can cause the shrinking of skin at the site of injection.

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

Since some lymphocytic scarring alopecia are known to aggravate when exposed to the sun, the use of sunscreen with a good sun protection factor (SPF) is also recommended.

Treatment For Scarring Alopecia Caused By Neutrophils

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

How Are Scarring Or Cicatracial Alopecia Diagnosed?

Ideally, one has to go through a scalp biopsy to confirm the diagnosis of Scarring alopecia but is usually diagnosed by careful examination of hair and scalp by a well-experienced trichologist. The trichologist may be required to track the patient's history, age at the time of the condition, and the possibility of other skin or scalp conditions. 

A patient's age is an important criterion as some types of scarring alopecia usually occur in specific age groups. Like, frontal fibrosing alopecia usually occurs in women in the postmenopausal phase. But, most forms of primary cicatricial alopecia develop in adults in the early stage of life.

No pores within the area of hair loss seen under magnification are also a vital parameter in the diagnosis of scarring alopecia.

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

The scarring alopecia diagnosis is based on,

  • Scalp examination
  • Age of the patient
  • Previous skin or scalp conditions
  • Burning, itching or discharge from the  scalp
  • No pores in the area of hair loss
  • Hair pull test
  • Scalp biopsy

Take Away

This problem is best addressed with a healthcare provider, and as quickly as you think you see signs of scarring alopecia, you should reach out for help. Apart from this, one can also use hair regrowth oil and hair fall control treatments like minoxidil.