Cicatricial Alopecia: Understanding Scarring Alopecia

Hair loss is often associated with conditions such as male or female pattern hair loss, where the follicles gradually become smaller but remain present within the scalp. Cicatricial alopecia, also known as scarring alopecia, is different. In cicatricial alopecia, inflammation or injury damages the hair follicle and can ultimately destroy it. Once a follicle has been permanently destroyed and replaced by scar-like tissue, it can no longer produce a new hair. This makes early recognition particularly important. Some forms of cicatricial alopecia can progress slowly and almost unnoticed, while others may cause itching, burning, tenderness, redness or rapidly expanding areas of hair loss. For patients considering hair restoration, there is another important issue: scarring alopecia must be properly evaluated before hair transplantation is considered. Transplanting hair into a scalp affected by active inflammatory disease can place the transplanted follicles at risk and may potentially aggravate the underlying condition.

What is Cicatricial Alopecia?

Cicatricial alopecia is not one single disease. It is a group of disorders that result in permanent destruction of hair follicles. Normally, the hair follicle is capable of repeatedly producing new hairs through successive hair-growth cycles. In cicatricial alopecia, inflammation or physical damage can destroy critical structures within the follicle. The damaged follicle is eventually replaced by fibrous tissue. The result is permanent hair loss in the affected area. One of the clues doctors look for when examining the scalp is the loss of normal follicular openings the tiny openings in the skin from which individual hairs emerge. However, identifying the underlying cause requires considerably more than simply looking at an area of hair loss.

Primary and Secondary Cicatricial Alopecia

Cicatricial alopecia is generally divided into two broad categories.

Primary Cicatricial Alopecia

In primary cicatricial alopecia, the inflammatory disease specifically targets structures within the hair follicle. Several different conditions fall into this category, including:

Lichen planopilaris (LPP)
Frontal fibrosing alopecia (FFA)
Central centrifugal cicatricial alopecia (CCCA)
Discoid lupus erythematosus (DLE)
Folliculitis decalvans
Dissecting cellulitis of the scalp

Although these conditions can all result in permanent hair loss, their patterns, symptoms, progression and treatment can be quite different.

Secondary Cicatricial Alopecia

Secondary cicatricial alopecia occurs when hair follicles are destroyed as a consequence of another type of damage rather than a disease primarily directed at the follicle. Possible causes include significant burns, trauma, surgery, radiation, severe infections and certain other injuries or inflammatory processes affecting the scalp. Determining whether scarring hair loss is primary or secondary can have important implications when assessing treatment and the possibility of surgical hair restoration.

What does Scarring Alopecia look and feel like?

There is no single appearance that identifies every form of cicatricial alopecia. Some patients have surprisingly few symptoms. That is one reason a professional evaluation can be important. The absence of pain, redness or itching does not necessarily mean that a scarring process is inactive. Depending upon the underlying condition, a patient may notice:

Smooth or shiny areas of hair loss
Recession of the frontal hairline
Patchy areas of permanent hair loss
Hair loss beginning near the crown and gradually expanding outward
Redness surrounding individual follicles
Scaling or crusting
Small pustules
Itching
Burning
Tenderness or discomfort

These are several Types of Scarring Alopecia’s

Lichen Planopilaris

Lichen planopilaris is an inflammatory condition in which the immune system attacks structures associated with the hair follicle. It may cause irregular patches of hair loss accompanied by redness and scaling around remaining hairs. Some patients experience itching, burning or scalp tenderness, while others have relatively few symptoms. Because continued inflammation can progressively destroy follicles, identifying and controlling active disease is an important priority.

Frontal Fibrosing Alopecia

Frontal fibrosing alopecia is considered a clinical variant of lichen planopilaris and most characteristically causes progressive recession along the frontal and temporal hairline. Loss of the eyebrows is also common and, in some individuals, may occur before obvious scalp hair loss develops. Although FFA was initially recognized primarily in postmenopausal women, it can occur in other populations as well. Its resemblance to a naturally receding hairline makes careful diagnosis particularly important before surgical hairline restoration is contemplated.

Central Centrifugal Cicatricial Alopecia

CCCA typically begins around the central or crown region of the scalp and gradually spreads outward. It occurs most commonly in women of African ancestry, although it can occur in other individuals. Patients may experience itching, tenderness or burning, but symptoms vary considerably. Early recognition can be particularly valuable because the condition may continue to progress while the initial changes appear relatively subtle.

Discoid Lupus Erythematosus

Discoid lupus can affect the scalp and produce inflammatory lesions that eventually result in permanent scarring and hair loss. Affected areas may show redness, scaling, pigmentary changes and follicular destruction. Because discoid lupus is an inflammatory autoimmune disorder, appropriate medical evaluation and management are important before cosmetic restoration of the affected area is considered.

Why diagnosis is necessary for effective treatment

Different forms of hair loss can resemble one another, particularly during their early stages. For example, frontal fibrosing alopecia may initially look like a receding hairline. CCCA can sometimes be mistaken for other forms of crown thinning. A patient may even have more than one type of hair loss at the same time. This is why simply identifying that hair is missing is not enough. The clinician needs to determine Why is the hair disappearing, and is the process still active? A thorough evaluation may include a detailed medical and hair-loss history, examination of the scalp, assessment of the pattern of loss and magnified examination of the follicles and surrounding skin. In some cases, a scalp biopsy may be recommended. A small sample of scalp tissue can be examined microscopically to help identify the type and location of inflammation; the degree of follicular damage and other characteristics that can help distinguish one cicatricial alopecia from another.

Can hair be restored if I have scarring alopecia?

We have successfully stabilized many patients with scarring alopecia using non surgical methods. If inflammation is identified before a follicle has been permanently destroyed, treatment of the underlying disease may help preserve remaining hair. However, once the follicle itself has been destroyed and replaced by fibrous tissue, it cannot spontaneously regenerate. For this reason, initial treatment of active cicatricial alopecia generally focuses on stopping or slowing further follicular destruction and preserving the hair that remains. Cosmetic restoration of areas where follicles have already been lost is a consideration only after the disease is stabilized.

Can you have a transplant if you have scarring alopecia?

Potentially you could have a transplant, but this requires considerably more caution than transplantation for conventional androgenetic hair loss. A hair transplant does not treat the disease responsible for primary cicatricial alopecia. If transplanted follicles are placed into an area where an inflammatory process remains active, those new follicles may also be damaged. In some circumstances, surgery itself may stimulate renewed inflammatory activity. For this reason, hair transplantation is generally not considered until the disease has become inactive and stable for a considerable amount of time. Before surgery is considered, the underlying condition should be accurately diagnosed and appropriately managed, with evidence that the disease has remained clinically inactive for a meaningful period. The appropriate period of stability varies according to the condition and the individual patient. Even when disease appears stable, patients should understand that transplantation into previously scarred tissue can be less predictable than transplantation into a healthy scalp. Healthy scalp tissue has a rich vascular network capable of supporting transplanted follicles. Scarred tissue may have an altered or reduced blood supply, and the thickness, flexibility and quality of the tissue can vary considerably.

As a result, graft survival and achievable density may be less predictable. The objective is not simply to place as many grafts as possible. It is to determine whether the recipient tissue can safely and successfully support transplanted follicles. For patients with cicatricial alopecia, the first goal is not transplantation. It is protecting and revving follicles that are still alive. Hair transplantation can move healthy follicles from one location to another, but it cannot replace an unlimited number of follicles, and it cannot stop an active inflammatory disease. For some patients, transplantation may ultimately offer a meaningful cosmetic improvement. For others, surgery may not be advisable. An ethical in-depth hair-restoration assessment will be able to make that distinction and give you all your options for restoring your hair and stabilizing the scarring alopecia.

Conclusion

At De Haar Hair Restoration, careful patient selection and appropriate diagnosis are fundamental parts of planning hair restoration. When scarring alopecia is suspected, the priority is establishing the nature and stability of the condition before determining which are your best options for restoration. and whether surgical restoration should be considered. Hair transplantation can be a valuable option for appropriately selected patients with stable cicatricial alopecia but sometimes the most important decision a hair-restoration specialist can make is knowing when and when not to transplant.

If you are experiencing unexplained patches of hair loss, progressive recession, scalp inflammation or have previously been diagnosed with a form of scarring alopecia, a comprehensive hair-loss assessment can help determine the appropriate next step.

Cicatricial Alopecia: Understanding Scarring Alopecia