Cicatricial alopecia is an inflammatory condition causing destruction of the hair follicle and resulting in localized scarring in addition to symptoms like pain, itching, or burning followed by permanent hair loss.
This type of alopecia more commonly appears on the scalp, however it can affect any part of the body, and can be caused by inflammation, burns, or autoimmune disorders.
Treatment of cicatricial (scarring) alopecia is managed by a dermatologist and typically involves the use of medications to reduce inflammation and prevent hair loss, or surgery, such as a hair transplant.
Common symptoms
The main symptoms of cicatricial alopecia are:
- Inflammation of the hair follicle;
- Itching or burning sensation;
- Localized pain or sensitivity;
- Redness or peeling of the skin;
- Bumps on the scalp that may contain pus;
- Crusts or wounds in the affected area;
- Permanent hair loss.
Symptoms of cicatricial alopecia can be progressive, coming on slowly in the form of bald spots, or occur rapidly, affecting larger areas of the body.
Cicatricial alopecia can occur in people of all genders in any region of the body that has hair, although it more commonly affects the scalp.
Confirming a diagnosis
The diagnosis of cicatricial alopecia is made by a dermatologist based on symptoms, medical history, and a physical exam of the affected area.
Your provider may use a technique called trichoscopy to diagnosis cicatricial alopecia, which involves the use of a dermatoscope to closely examine the scalp and hair strands.
To confirm the diagnosis, a skin biopsy may be done that will be analyzed in the lab in order to identify the type of cicatricial alopecia.
Possible causes
The main causes of cicatricial alopecia include:
- Inflammatory or autoimmune disorders;
- Use of chemical products like chemical straighteners or hair relaxation treatments;
- Trauma to the scalp from the use of hair extensions or braids;
- Burns;
- Skin infections;
- Radiation or tumors.
These conditions can cause inflammation and destruction of the hair follicle, resulting in hair loss.
What is the difference between scarring and non-scarring alopecia?
While all types of alopecia lead to hair loss, the hair loss associated with cicatricial (scarring) alopecia is the result of irreversible destruction to the hair follicle and localized scarring.
The most common types of non-scarring alopecia are telogen effluvium and alopecia areata, in which the hair follicle is preserved. These conditions do not typically involve inflammation.
Main types
The main types of cicatricial alopecia are:
1. Primary cicatricial alopecia
Primary cicatricial alopecia is caused by autoimmune, inflammatory, or infectious conditions that cause destruction of the stem cells in the hair follicle, which are responsible for hair growth.
This type of cicatricial alopecia can be divided into different types based on certain characteristics.
2. Secondary cicatricial alopecia
Secondary cicatricial alopecia can be triggered by other health conditions that cause destruction of the hair follicle.
The main causes of this type of cicatricial alopecia are infections, burns, radiation, and tumors.
3. Frontal fibrosing alopecia
Frontal fibrosing alopecia (FFA) is a type of primary cicatricial alopecia and is a variant of lichen planopilaris. Frontal fibrosing alopecia is a progressive condition that evolves slowly over time, typically affecting the top of the forehead.
FFA can also affect the eyebrows or eyelashes, however, and the cause of the condition is not completely understood.
4. Central centrifugal cicatricial alopecia
Central centrifugal cicatricial alopecia (CCCA) is another type of primary cicatricial alopecia that causes bald spots and permanent hair loss on the crown, or vertex, of the scalp.
This type of cicatricial alopecia is more common in Black women and is the result of genetic, autoimmune, infectious, and/or environmental factors, such as the use of chemical hair products and tight hairstyles causing traction on the scalp.
5. Lichen planopilaris
Lichen planopilaris is a more common type of primary cicatricial alopecia and is a variation of lichen planus. It primarily affects women between 40 and 60 years of age.
This type of cicatricial alopecia does not have a well-defined cause, however it appears to be related to autoimmune factors and activation of T cells that damage the hair follicle.
6. Folliculitis decalvans
Folliculitis decalvans is a type of primary cicatricial alopecia that is associated with an exaggerated immune response to the presence of Staphylococcus aureus bacteria that normally live on the skin.
It can also be triggered by bacterial folliculitis caused by S. aureus bacteria.
Treatment options
Treatment of cicatricial alopecia is managed by a dermatologist and varies according to the cause of the condition as well as the severity of symptoms.
The main treatments for cicatricial alopecia are:
1. Medications
Topical or oral medications may be prescribed by a dermatologist to reduce inflammation and prevent hair loss.
The main types of medications prescribed by cicatricial alopecia include:
- Corticosteroids, such as triamcinolone acetonide;
- Antimalarials, such as hydroxychloroquine;
- Immunosuppressants, such as tacrolimus, methotrexate, cyclosporine, or mycophenolate mofetil;
- Antibiotics, such as tetracyclines;
- Retinoids, such as tretinoin;
- Monoclonal antibodies, such as adalimumab or ustekinumab.
These medications should be prescribed by a healthcare provider based on the type of cicatricial alopecia, with regular follow up recommended to measure the effectiveness of treatment and evaluate for the presence of any side effects.
2. Corticosteroid injections
Corticosteroid injections, such as triamcinolone acetonide, may be prescribed by a dermatologist to be injected directly into lesions on the scalp to reduce inflammation and prevent progression of the disease.
3. Phototherapy
Phototherapy may be indicated to treat certain types of cicatricial alopecia, such as central centrifugal cicatricial alopecia (CCCA) or lichen planopilaris, that do not respond to treatment with medications.
This type of treatment has anti-inflammatory and immunosuppressant effects and involves the application of ultraviolet (UV) light to reduce inflammation and stimulate hair growth.
4. Hair transplantation
A hair transplant is a surgical treatment for cicatricial alopecia that involves removing hair from the same individual and transplanting it into areas of the scalp without hair.
Another surgical treatment that may be indicated is scalp reduction surgery, in which a doctor removes areas of the scalp without hair and connects areas of the scalp that do have hair together to cover the bald spot.
Is it curable?
Cicatricial alopecia is not curable, since the affected hair follicles have been destroyed. Currently, no treatments exist that can regenerate the hair follicles.
However, with treatments recommended by your dermatologist, it is possible to reduce inflammation of the hair follicle and prevent hair loss.