Scarring or cicatricial alopecia is an umbrella term for a group of hair disorders that cause permanent destruction of hair follicles.
With scarring alopecia, it’s not even possible to predict how severe the hair loss will be. And above that, the exact cause of this condition is not exactly understood.
In this guide, you will learn what scarring/cicatricial hair loss is, its various types, symptoms, and treatments.
What Is Scarring Alopecia?
Scarring alopecia occurs when the hair follicles are destroyed directly by inflammation or indirectly by an internal or external factor. In any case, it’s characterised by the destruction of hair follicles, which are then replaced by scar tissue.
There are no scars visible on the scalp, but the absence of hair follicles is evident by the lack of small pinpoint openings in the skin called follicular ostia.
Usually, hair loss takes place slowly over the years (however, it can also occur rapidly) until it reaches the end-stage burnout.
Once this happens, the inflammation clears up, and the bald spot doesn’t grow in size anymore. Unfortunately, at this stage, treatments for hair loss are likely to be less effective.
While it mainly affects the scalp, keep in mind that cicatricial alopecia can also cause hair loss on the face and body; it isn’t contagious, however. And it’s not that common either, as only 3-7% of people have this type of hair loss — most of them are adults, but it can also affect children and adolescents.
Scarring vs Non-Scarring Alopecia: What’s The Difference?
A major difference between non-scarring and scarring alopecias is the preservation of the hair follicle in the former while its destruction in the latter, according to a 2018 study.
Therefore, in non-scarring hair loss, it is possible for hair regrowth to occur, though it’s not always guaranteed. On the other hand, hair loss in scarring alopecia is permanent as the hair follicle is replaced by scar tissue.
What Causes Scarring Alopecia?
It’s not exactly understood what causes scarring alopecia, but depending on how the hair follicle is destroyed, it has two types:
- Primary cicatricial alopecia
- Secondary cicatricial alopecia
Primary Cicatricial Alopecia
In primary cicatricial alopecia, the “bulge” of the hair follicle is directly targeted through an inflammatory process. It ends up damaging the hair follicle stem cells, without which the hair growth cycle cannot be sustained.
Depending on the types of inflammatory cells that cause primary cicatricial alopecia, it is further divided into lymphocytic, neutrophilic, and mixed infiltrates types.
Both lymphocytes and neutrophils are types of white blood cells that help the body’s immune system. However, both these cells can also be involved in the inflammation of the hair follicles, resulting in primary cicatricial alopecias.
For instance, scarring alopecias that mainly involve lymphocytes include:
- Lichen planopilaris (and its variant frontal fibrosing alopecia)
(A), Frontoparietal, eyebrow alopecia and facial papules in the frontal region (FFA). (B), Areas of multifocal alopecia in parietal region and vertex (LPP). Fechine COC, Valente NYS, Romiti R. Lichen planopilaris and frontal fibrosing alopecia: review and update of diagnostic and therapeutic features. An Bras Dermatol. 2022 May-Jun;97(3):348-357. doi: 10.1016/j.abd.2021.08.008. Epub 2022 Apr 2. PMID: 35379508; PMCID: PMC9133245/CC BY 4.0
Palmer V, Valdebran M. Central Centrifugal Cicatricial Alopecia in the Adolescent Population: An Overview of Available Literature. Life (Basel). 2023 Apr 15;13(4):1022. doi: 10.3390/life13041022. PMID: 37109551; PMCID: PMC10142262/CC BY 4.0
Nair PA, Singhal R, Pariath K. Primary Idiopathic Pseudopelade of Brocq in a Young Child. Int J Trichology. 2017 Jul-Sep;9(3):113-115. doi: 10.4103/ijt.ijt_24_17. PMID: 28932062; PMCID: PMC5596645/CC BY-NC-SA 3.0
- Chronic cutaneous lupus erythematosus
- Graham-Little syndrome
Brar B, Khanna E, Mahajan BB. Graham little piccardi lasseur syndrome: a rare case report with concomitant hypertrophic lichen planus. Int J Trichology. 2013 Oct;5(4):199-200. doi: 10.4103/0974-7753.130403. PMID: 24778531; PMCID: PMC3999651/CC BY-NC-SA 3.0
There are others as well.
Alternatively, when it comes to neutrophilic inflammation, the following cicatricial alopecias are included:
- Folliculitis decalvans
- Dissecting cellulitis of the scalp
It could also be a mixture of inflammatory cells. And when that happens, it could be a case of acne keloidalis, acne necrotic or erosive pustulosis.
Most of the scarring alopecias are primary (lichen planopilaris being the most common), affecting more women than men.
Secondary Cicatricial Alopecia
Secondary cicatricial alopecia is when the hair follicle is destroyed as a result of something else. It’s not the direct target, it’s just collateral damage. This can happen as a result of traumatic injury, burns, radiation, metastatic cancer, or an underlying illness. But even in this case, the hair loss is irreversible.
What Does Scarring Alopecia Look Like?
Scarring alopecia will result in the formation of bald patches on the scalp. While scar tissue replaces hair follicles, in most cases, there’s no visible scarring on the scalp. Instead, the bald patch (or patches) will appear smooth and shiny.
It can also be accompanied by other symptoms, such as:
- Itchiness
- Pain
- Burning sensation
- Redness
- Pustules
- Blisters
- Scaly skin
- Changes in skin pigmentation
These symptoms can vary depending on the type of hair loss you’re experiencing. Even between individuals, the progression of scarring alopecia can be different.
How Do You Know If You Have Scarring Alopecia?
You can look out for the signs and symptoms of scarring alopecia on your own. However, for an accurate diagnosis, a skin biopsy is usually needed.
For this, a small sample of your skin (2-4mm) will be removed for lab testing. Your doctor will give you local anaesthesia before cutting the skin so you don’t feel pain.
Is Scarring Alopecia Permanent?
Scarring alopecia doesn’t preserve the hair follicle or the stem cells in it. Therefore, the hair loss resulting from it is permanent and irreversible.
Keep in mind that hair follicle neogenesis (regeneration) is not something that happens in adults (although wound–induced hair neogenesis has been noted to occur). Therefore, you cannot expect new hair follicles to grow after they’ve been destroyed.
How To Stop Scarring Alopecia?
The treatment for scarring alopecia usually includes anti-inflammatory medications, steroids and antibiotics. The treatment plan will be based on the type of scarring alopecia you have (depending on the inflammatory cells).
For instance, for lymphocytes, some of the following medications have been used:
- Hydroxychloroquine (antimalarial)
- Corticosteroids
- Cyclosporine (immunosuppressant)
- Retinoid
- Methotrexate (antimetabolite)
- Mycophenolate mofetil (immunosuppressants)
On the other hand, for neutrophilic cicatricial alopecia, the following might be used for treatment:
- Antibiotics like clindamycin and doxycycline
- Isotretinoin
- Corticosteroids
- Sulfone like dapsone
To promote hair growth in scarring alopecia, your doctor may also recommend the use of minoxidil and finasteride.
These treatments can control and might even undo some of the damage caused by scarring alopecia.
Here, you should also note that in certain scarring alopecias, even bad hair practices (like tight hairstyles, chemical relaxers, and dyes) are implicated. So, you should consider changing your hair styling routine, and make sure to keep your scalp protected with sunscreen and other hair accessories.
Early treatment may yield satisfactory results. However, if the hair loss has progressed significantly, it might not get much better. In this case, you can consider camouflage with wigs, hair fibres, makeup or even scalp micropigmentation.
Can scarring alopecia be cured?
Unfortunately, there’s no cure for scarring alopecia. However, while it can’t be reversed, there are treatments that can help control it.
It’s important to seek early treatment to save as much of your hair as possible. Otherwise, scarring alopecia can even leave you almost completely bald.
Can You Get A Hair Transplant With Scarring Alopecia?
You may be able to get a hair transplant with scarring alopecia. However, you need to wait until your condition has stabilised for at least 2 years.
Even then, the surgery might not be a complete success since fewer hair grafts might survive. You may also be at increased risk of scarring.
Also, note that a hair transplant is only possible if you have sufficient “donor hair” on your scalp. If that’s not the case, you won’t be able to have this surgery.
Learn More About FUE Hair Transplants
Does PRP Work For Scarring Alopecia?
Platelet-rich plasma (PRP) injections can help reduce inflammation caused by scarring alopecia.
A 2022 review published in Frontiers in Medicine found platelet-rich plasma to be a “promising treatment” for primary cicatricial alopecia patients unable to achieve favorable outcomes with conventional treatment. Therefore, you can consider getting these injections.
Experiencing Hair Loss?
Longevita is a UK and Istanbul-based facilitator of hair transplants and platelet-rich plasma injections, in addition to other non-surgical treatments. We arrange patients affordable prices, and peace of mind from the moment they book with us until they see their final results. If you’re interested in starting your journey with us, feel free to get in touch!
Frequently Asked Questions
No, androgenetic alopecia or pattern baldness is a type of non-scarring alopecia, and it’s the most common one.
Scarring alopecia is not considered hereditary. However, in some of its forms, genetic factors have been implicated.
No, alopecia areata is a type of non-scarring alopecia. However, notably, even though it’s non-scarring, it can still cause permanent hair loss.
Scarring alopecia can spread beyond the original site of occurrence. Different bald patches can even join together to form a bigger one.
Proper treatment may stop the spread of cicatricial alopecia in which case you might not lose all of your hair. However, it’s important that you seek a professional consultation as soon as possible.
To our knowledge, there is no “natural” treatment for scarring alopecias. You must get in touch with a medical professional for a proper treatment plan.
Dr Hassan
Based in London, Dr Hassan is a highly qualified plastic surgeon with over decades of experience. He is well-accomplished and experienced in the art of hair transplantation surgery, and his specialities include non-surgical treatments, such as platelet-rich plasma (PRP) injections for the scalp. Dr Hassan can always be counted on to achieve the best possible outcomes for his patients.
Dr Hassan is an independent, GMC-registered plastic surgeon (GMC: 6107783) with over 20 years of experience in hair restoration and cosmetic surgery. He performs his hair transplant procedures at Kensington Cosmetic Clinic, a CQC-registered (1-14206333213) independent hospital in London.
