What You Should Know About Scarring Alopecia
Scarring alopecia is a family of hair loss conditions experienced by about 7% of the population. While there are a variety of conditions that fall under this umbrella, the common characteristic of scarring alopecias is the permanent destruction of the hair follicles.
What causes scarring alopecias, how are they treated, and can the hair loss be reversed? Read on to better understand this form of hair loss, including expert insights on diagnosis and treatment—plus, find out what you need to do to ensure you're supporting holistic hair health and wellness.
What Is Scarring Alopecia?
Cicatricial (or scarring) alopecia is a family of inflammatory hair loss conditions that may present or progress in a wide variety of ways. Scarring alopecia conditions share one characteristic in common: permanent damage to hair follicles and the development of scar tissue around them.
“[In cicatricial alopecia], the underlying tissue gets destroyed or scarred and replaced by fibrous tissue, preventing any regrowth of your lost locks,” explained Beth Hawkes, board-certified registered nurse, speaker and author at NurseCode.com.
The scarring that occurs with cicatricial alopecia does not look like a typical scar, since the damage occurs under the surface of the skin. Instead, after the scarring has occurred, the skin surface might look smooth or shiny, with no visible pores.
Certified trichologist Jules Annen, PhD explained that there are different classifications of cicatricial alopecia, depending on the underlying causes: primary and secondary. Both primary cicatricial alopecia and secondary cicatricial alopecia involve inflammatory disorders that damage hair follicles resulting in permanent hair loss, but there are differences in classification.
- Primary cicatricial alopecia (primary scarring alopecia) refers to hair loss as the disease itself. In types of primary cicatricial alopecia, the hair follicle is destroyed. Permanent scar tissue forms around the hair follicle, and hair loss is permanent. Most forms of primary scarring alopecia present during early adult life.
- Secondary cicatricial alopecia (secondary scarring alopecia) refers to scarring hair loss that is due to external physical factors that destroy the hair follicle. According to Dr. Annen, severe infection, burns, trauma, radiation, allergens, harsh chemicals used on the scalp and hair and damaging hair styling practices can all make primary cicatricial alopecia develop.
Whether primary or secondary, cicatricial alopecia does cause scarring and destruction of the hair follicle, meaning that hair cannot regrow.
Which Hair Loss Disorders Are Considered Scarring Alopecia?
There are several different hair disorders that are classified as scarring alopecias. Some can develop slowly over time and may be undetectable until hair loss becomes more noticeable or severe. Others progress rapidly over the course of just a few months and may present with noticeable symptoms, such as burning or itching.
Scarring alopecias are classified according to the inflammatory cells involved—lymphocytic inflammatory cells (lymphocytic alopecia), neutrophilic inflammatory cells (neutrophilic alopecia) or mixed inflammatory cells.
The following are a few of the most common types of scarring alopecia.
Lichen planopilaris (LPP) is an inflammatory condition that affects the skin and its mucous membranes. It causes patchy hair loss and is often accompanied by swelling and discomfort around the areas of hair loss, as well as scaly skin. While the exact causes of lichen planopilaris are not known, it is thought to be an autoimmune condition.
Frontal Fibrosing Alopecia
Frontal fibrosing alopecia (FFA) is a form of lichen planopilaris that typically progresses slowly from the hairline at the forehead. While frontal fibrosing alopecia occurs predominantly at the hairline, it can also affect the eyebrows and eyelashes. FFA is characterized by scalp symptoms including pain, itching and small raised bumps called papules, as well as skin hyperpigmentation.
As with lichen planopilaris, the causes behind frontal fibrosing alopecia are not well understood. VEGAMOUR spoke to Dr. Viktoryia Kazlouskaya, a dermatologist at the University of Pittsburgh, who said that she and her colleagues have seen an increasing number of patients with FFA.
“We even call it an ‘FFA epidemic,’” Kazlouskaya said. “We do not know why it is happening. Some skin care products [such as sunscreens] were investigated, but no associations were found.”
Acne Keloidalis Nuchae
Acne keloidalis nuchae (AKN) is a skin and hair loss condition that usually first develops around the nape of the neck. Patches of inflammation, papules and plaques damage the scalp and lead to hair loss. AKN appears to impact otherwise healthy men and persons of African descent more than others, but anyone can develop it. It may be treatable with topical creams or with phototherapy. By causing damage to the skin, AKN can lead to scarring on the scalp, thereby preventing hair regrowth.
Central Centrifugal Cicatricial Alopecia
Central centrifugal cicatricial alopecia (CCCA), sometimes called follicular degeneration syndrome, is another form of scarring hair loss that is still poorly understood. Cases of CCCA have been observed almost exclusively in Black women aged 30 to 55. With CCCA, hair loss typically starts at the crown of the head and radiates outward over time, eventually developing into scarring and permanent loss of hair. Hair transplantation is a possible treatment option if there is not sufficient hair remaining to cover bald patches already.
Discoid Lupus Erythematosus
Discoid lupus erythematosus (DLE) is a type of chronic cutaneous lupus erythematosus (CCLE), a group of autoimmune diseases that affect the skin. Unlike systemic lupus erythematosus (SLE)—the version commonly known as lupus—CCLE disorders including DLE do not impact the internal organs.
Instead, DLE causes severe lesions, called discoid lesions, on the skin, typically on the face, ears and scalp. When DLE develops on the scalp, it permanently damages the affected hair follicles, causing hair loss.
Folliculitis decalvans (FD) is a rare type of scarring hair loss characterized by chronic inflammation of the scalp. FD is believed to be caused by a staph bacteria commonly found on skin, causing pustules (small pus-filled bumps) to develop on the hair follicles. It usually causes oval-shaped bald patches on the scalp.
Dissecting Cellulitis of the Scalp
Dissecting cellulitis of the scalp (DCS), similar to folliculitis decalvans, causes painful pustules to develop on the scalp. DCS causes patchy, permanent hair loss. Anyone can develop DCS, but it seems to be most common in Black males between 20 and 40 years of age.
What Causes Scarring Alopecia?
Given the wide variety of hair loss conditions that are considered to be forms of scarring alopecia, there are several underlying causes at play. But the common culprit among all forms of scarring alopecia is inflammation.
Inflammatory damage is the cause behind permanent loss of function for hair follicles. Excessive, chronic inflammation leads to scarring, destroying the sebaceous gland on the scalp as well as the hair follicles and their stem cells. With significant hair follicle destruction and sebaceous gland loss, hair follicle stem cells can no longer regrow hair.
Common Symptoms of Scarring Alopecia
Since scarring alopecia cannot be reversed, it's important to recognize potential symptoms so that the condition can be treated to prevent further hair loss. Symptoms can vary widely depending on the associated condition, but there are some common symptoms that occur in several types of scarring alopecia. Symptoms can include:
- Severe itching on the scalp
- Pain at the site of hair loss
- Burning on the scalp
- Shedding or loss of hair in clumps
- Scalp redness
- Inflammation and sensitivity of the scalp
- Pus discharge from the scalp
- Scales or plaques on the skin/scalp
- Blisters on the skin/scalp
- Crusting over of the skin/scalp
How Is Scarring Alopecia Diagnosed?
While distinguishing one type of scarring alopecia from another can be challenging, one thing is clear: Since scarring alopecias—unlike other types of alopecia—are irreversible, early diagnosis and treatment is critical to successfully managing these forms of hair loss.
“Diagnosis should be established by an experienced dermatologist, because the features may be similar among [the different] conditions,” said Dr. Kazlouskaya. “It is essential to diagnose [the] condition early so that scarring be prevented as promptly as possible."
Diagnosing can be tricky because different forms of scarring alopecia may present and develop in similar ways. Adding to the complication, scarring alopecia may also initially look like other non-scarring forms of hair loss, such as alopecia areata or androgenetic alopecia (such as male- or female-pattern hair loss).
Your doctor will typically get a detailed medical history from you, and they will examine your scalp. They may do a hair pull test, use trichoscopy (microscopy of the hair and scalp) or take a small scalp biopsy if needed. Especially if symptoms are mild, a scalp biopsy can help identify active inflammation that is characteristic of scarring alopecia.
How Is Scarring Alopecia Treated?
Unlike non-scarring forms of hair loss, scarring alopecias often result in permanent damage to follicles, causing irreversible hair loss. Addressing and treating scarring alopecia early on is the best way to slow the progression of hair loss, preserve existing hair and prevent further hair loss.
“Scarring alopecia, [as] a type of permanent hair loss, can be challenging to manage,” said Dr. Erum Ilyas, board-certified dermatologist and founder of skincare brand AmberNoon. Treatment depends on the underlying condition, but generally speaking, treatments are aimed at controlling inflammation. According to Dr. Ilyas, inflammation may be treated with:
- Anti-inflammatory medications
- Topical steroids
- Steroid injections
- Oral antibiotics
- Metformin (topical cream)
- Miscellaneous immunosuppressant oral medications or immunomodulator topical creams
Related: Does Metformin Cause Hair Loss?
Management of scarring alopecias often includes one or several of the listed treatment options in an effort to slow the progression of hair loss and bring inflammation under control.
If the loss of hair is already permanent and noticeable, there are also a variety of cosmetic treatment options available, including scalp micropigmentation or surgical treatment options such as scalp reduction surgery and hair transplantation surgery.
Taking a Holistic Approach to Managing Scarring Alopecia
In addition to diagnosing and treating the underlying causes of scarring alopecia, there are other ways to support your body in maintaining a healthy scalp and healthy hair follicles.
A varied diet full of fruits, vegetables, whole grains, proteins and healthy fats has been shown to have benefits not just for general health but for your follicles, too. The role of diet in helping reduce the effects of scarring alopecia is still being explored, but researchers are hopeful that anti-inflammatory foods, like anti-inflammatory medications, may help prevent chronic scalp inflammation.
“New evidence-based recommendations suggest that micronutrients, including specific vitamins and minerals, have shown promising results,” Dr. Kazlouskaya said. “Vitamin D has shown to help regulate the immune response, and it is also crucial in protecting the hair follicles from an autoimmune attack.”
Vitamins, minerals and other micronutrients like biotin (B-7), zinc, iron, magnesium and selenium (among others) are essential to healthy hair growth, so consider a hair-friendly supplement if you think your diet could use a boost.
When it comes to caring for your scalp in the face of scarring alopecia, gentle is the name of the game. Showing your scalp some extra TLC with all-natural, non-irritating shampoos and conditioners, a restorative scalp serum to help ease some of the stress on inflamed hair follicles.
It's also important to stick to a hair care routine and hairstyling that goes easy on your strands. From how often you wash your hair to what you put in it and how you dry it, being intentional about how you treat your hair will help keep your follicles happy.
“In general, avoiding tight hair styles is helpful to prevent progression,” Dr. Kazlouskaya said. Heat styling, chemical treatments and coloring should also be avoided when you're trying to help hair grow.
Stress is often a complicating factor when it comes to hair loss, and in some cases, it’s actually the underlying cause itself. Research has begun to uncover the complex relationship between stress and inflammation—and the impact both can have on hair growth.
As such, active stress management is vital to supporting your hair follicles as well as your holistic health and wellness. The good news is that stress management can include a variety of different tools and might look simpler than you'd think. Whether it's spending time in the sun, practicing yoga, having a good laugh, taking a few deep breaths or even going on a short walk, there are lots of options to de-stress that you can integrate into your daily life.
Scarring Alopecia: The Takeaway
Scarring alopecia refers to multiple types of permanent hair loss that include chronic inflammation of the scalp and hair follicles. While scarring alopecia is permanent, detecting and treating the underlying causes and conditions early can slow the progression of hair loss.
If you’re noticing that you've lost hair or are experiencing increased hair shedding, redness, inflammation, tenderness or burning on your scalp, be sure to speak with your doctor. Having a doctor examine your scalp early on can be crucial to addressing scarring alopecia by identifying it before it progresses and finding ways to manage it to prevent further loss of hair.
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