December 14, 2020

Are you concerned about patches of baldness on your scalp and wondering what the problem is? Both men and women across the globe are prone to scarring hair loss. This differs from non-scarring hair loss, which is hair loss that is not accompanied by scarring.

This piece will expound on what scarring hair loss is, its causes, types, and treatment options. Let’s dive in:

What is Scarring Alopecia?

Scarring alopecia, also called Cicatricial Alopecia, is a term used to describe a rare group of hair loss disorders accompanied by scarring. These disorders cause irreversible hair follicle damage and a subsequent replacement with scar tissue. Hair growth becomes impossible, thus resulting in permanent baldness.


How It Forms

Hair follicles are usually found just beneath the skin. There are sebaceous glands and stem cells on the upper part of these follicles responsible for sebum production. When these sebaceous glands and stem cells are destroyed, the cells are no longer regenerated, which results in permanent hair loss.

Causes of Scarring Hair Loss

The causes of scarring alopecia are still unknown. Scarring alopecia is not contagious, and it affects healthy people worldwide. It is common in adults, although people of all ages are susceptible. 

A significant number of people with scarring alopecia have no history of people in their family that had it. However, an exception is Central Centrifugal Cicatricial Alopecia, CCCA mostly affects women with African ancestry and is genetic.

What does scarring hair loss look like?

In some cases, the signs are barely noticeable for an extended period. And, the patches appear small at first and gradually expand, and no other significant symptoms show.

In other cases of scarring hair loss, the patient first notices the appearance of small patches of baldness, which expand rapidly. Since the hair follicles’ destruction happens below the skin surface, the only visible signs are smooth baldness patches. 

These types of hair loss are sometimes associated with pain, burning sensation, and itching. And there may also be little signs of scaling, redness, increased or decreased pigmentation, and inflamed blisters with pus and fluids.

Types of Scarring Alopecia

Some common types of scarring alopecia include:

1. Frontal Fibrosing Alopecia (FFA)

This type of alopecia looks like a straight narrow band of baldness at the front of the head. Typically, FFA occurs around the hairline and temples.

Frontal fibrosing alopecia mostly affects postmenopausal women over 50 years. Some women also lose eyebrow hair when they have FFA.

How FFA looks like: The scalp of the affected person seems discolored, shiny, and red in some areas. The hair follicles in the regions will look closed when observed under a microscope.

The leading causes of FFA remain unknown. However, speculations indicate that it occurs due to hormonal fluctuations after menopause.

2. Central Centrifugal Cicatricial Alopecia (CCCA)

This type of alopecia is the most common form of hair loss disorder. The disorder causes hair follicle destruction due to inflammatory cells that attack hair follicle cells. 

It’s common in both men and women of any race. However, it is more common in African American women. 

To diagnose CCCA, you need to see a dermatologist who will do a scalp biopsy to confirm it's there. CCCA can look like any other type of hair loss such as alopecia areata, genetic hair loss, or diffuse hair loss.

The common signs of CCCA include tingling sensation, burning, or tenderness of the scalp.  

CCCA can start as a small invisible bald patch that appears on the scalp, and the spot expands over time. These scalps appear smooth and shiny. Sometimes, CCCA may seem small and become larger rapidly, leading to hair loss in a short period.

CCCA is quite challenging to diagnose and treat. To treat CCCA, visit a dermatologist who specializes in scalp and hair disorders. Some doctors prescribe medications that can help reduce or stop lymphocytic cells from destroying the person’s hair follicles.

3. Lichen Planopilaris (LPP)

This is different from FFA and CCCA because it’s an inflammatory autoimmune type of skin condition. The immune system of someone with LPP mistakenly attacks hair follicle cells, and it replaces them with scar tissue.

What does LLP look like? The person first notices a small spot of baldness or multiple areas of white hairlessness. Then, the spots can grow in size and become as big as the palm of your hand. 

The scalp in these areas has a rough texture. And may appear purplish, with itchy bumps, which tend to be painful due to inflammation.  

It’s vital to do a biopsy to determine if the hair loss patches are LPP as many hair loss types have similar characteristics. 

To treat LPP, some dermatologists recommend topical treatments like corticosteroid creams, antihistamines to relieve itching, and prednisone shots to reduce bumps and swelling.  

LPP can disappear on its own, and thus the therapy mainly helps relieve the symptoms.

Diagnoses for Scarring Alopecia

To diagnose any scarring hair loss, performing a scalp biopsy is vital. The biopsy findings can help determine the location, amount, and type of inflammation present on your scalp, the degree of activity, and any other changes. Understanding these scalp activities can help you choose the ideal therapy.

The dermatologist must also conduct a clinical evaluation. Signs such as scalp tenderness, itching, burning, or any form of pain indicates an ongoing scalp activity. The doctor may also evaluate signs of scalp inflammation, which include scaling, redness, and pimples.

The dermatologist must also ask the patient if they have used braids, hairpieces, straighteners, and relaxers. The use of some cosmetic products can be the cause of alopecia.

Sometimes a ‘hair pull’ to determine the presence of anagen is done. When examined under a microscope, it helps decide whether it’s growing or just resting hair. Trichoscopy, which is a new non-invasive diagnostic technique, also helps in diagnosis.

Treatment Options for Scarring Hair Loss

Since the hair follicles’ damage is permanent and irreversible, the treatment options are usually very aggressive. The nature of the treatment will also depend on the specific diagnoses.

The alopecia that involves hair follicle lymphocyte inflammation, such as pseudopelade and lichen planopilaris, are typically treated with oral medications, topical creams, and injections in the affected area.

  • Some of the oral medications include doxycycline, hydroxychloroquine, cyclosporine, mycophenolate mofetil, or corticosteroid.
  • Topical treatments used include pimecrolimus, tacrolimus, corticosteroid, Derma-Smoothe or FS scalp oil.
  • Injections of Triamcinolone acetonide and a corticosteroid into the inflamed areas.

For the scarring alopecia types with inflammation of neutrophils or a mixture of cells like folliculitis decalvans, or the tufted folliculitis, the available treatment options are focused on removing the pathogenic microbes which are customarily involved in the inflammatory activities.

Oral antibiotics and topical antibiotics may be used. Pathogenic microbes are usually not present in dissecting cellulitis. Small doses of Isotretinoin is used in the treatment of dissecting cellulitis.

For treating a mixed group of scarring alopecias like folliculitis keloidalis, doctors prescribe Isotretinoin, antimicrobials, and other anti-inflammatory medications.

Patients must exhaustively talk through any treatment option with their dermatologists. They should also fully understand the potential complications and side effects that come with each treatment option.

They should also be ready to do several lab tests as needed before they begin any treatment and will need to be closely monitored throughout the treatment course.

Cicatricial alopecia treatment is usually prolonged until the inflammation symptoms are under control and the progression of hair loss has stopped.  

The treatment should continue until the patient experiences no more pain, itching, tenderness, redness, scaling, or no pustules. Cicatricial alopecia is likely to reoccur after some time, and the patient may have to treat it again.

Surgical treatment is an ideal option for cosmetic benefits in some instances and if the disorder has not been active for over a year or two. Also, patients may consider scalp reduction or hair restoration surgery /hair transplant in those instances.

There are two main hair transplant techniques, including follicular unit extraction and follicular unit transplantation. Hair transplant procedures may cause scarring. And the procedure option you choose determines the type of scar you get. 

You can get plug scars, dot scars, scalp reduction scars, or strip scars. You may consider scar revision surgery, laser skin resurfacing, scalp micro-pigmentation, or silicone products like silicone gel and sheets to treat the hair transplant scars.

Does Scarring Alopecia Stop Completely?

Yes. Scarring hair loss almost always burns out. The bald spots and patches stop expanding, and any itching, inflammation, pain, and burning ceases.

In this final stage of scarring alopecia, the scalp biopsy shows no inflammation around the hair follicles. That means that those bald areas no longer have hair follicles as they have been destroyed completely.

All that remains to show where the hair follicles were are longitudinal scars that are skin deep.

Hair does not regrow after the destruction of the hair follicles. However, treating inflammation surrounding hair follicles may be probable before the hair follicles have been destroyed. Therefore, it’s vital to start treatment as soon as possible to stop the inflammation process.

Applying Minoxidil solution ( usually 2% or 5%) to the scalp’s affected areas twice per day can help stimulate any remaining, small, unscarred follicles.

Key Takeaway

The hair loss progression in scarring alopecia is unpredictable and sometimes can occur slowly or rapidly. Visit a dermatologist as soon as you notice the signs of baldy spots to help treat the scarring before it progresses further. Scarring hair loss can be prevented to a large extent by early intervention.

Haircare is also vital during the process. Patients should use gentle shampoos and hair care products to avoid irritating the scalp. 

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