- Best ResultsVariable
- Treatment RecoveryNA
- Procedure TimeVariable
- Skin SpecialistDermatologist
- Duration of ResultsVariable
- Back to Work1-2 days
In rare cases, hair loss or alopecia is due to inflammation of the hair follicles, resulting in destruction. This is termed scarring alopecia. Dermatologists diagnose & manage all forms of hair loss including lupus, lichen planopilaris, Folliculitis deCalvans & other causes of inflammation. In many cases scarring alopecia can be associated with androgenetic alopecia. The aim of treatment for all forms of hair loss is to slow down hair fall at the earliest stages.
FactsFacts on Scarring Alopecia
- Scarring alopecia permanently destroys hair follicles
- Destruction of follicles is mediated via inflammation
- Common causes include lichen planopilaris, lupus & inflammatory folliculitis
- Early & effective medical management can halt or markedly slow down hair fall
- Your dermatologist will discuss various treatment options
- Hair restoration surgery can be consider in some cases
- Most specialists would not consider surgery until 2 years post quiessence
What is scarring alopecia?
The term scarring alopecia refers to a group of dermatological conditions that destroy hair follicles. The outcome is permanent hair loss. Although more commonly seen in women, scarring alopecia can occur in both sexes.
This destructive process may be asymptomatic, namely hair loss is gradual with no symptoms.In other cases, the hair loss is rapidly progressive and associated with itching, burning and pain/discomfort. Examples include lichen planus, lupus & folliculitis.
Because the inflammation that destroys the follicle is below the skin surface, there is usually no visible “scar” on the scalp. Instead, end stage scarring alopecia is characterised by smooth, shiny areas devoid of hair follicles. In early stage scarring alopecia clinical features such as scale, redness (inflammation), & pustules / pimples may be present.
What are the common types of scarring alopecia?
There are over 80 causes of scarring alopecia. Your dermatologist will be super familiar with most of them. A classification of all cases is beyond the scope of this landing page. The most common causes include-
- Lichen planus/ frontal fibrosing alopecia
- Folliculitis deCalvans
- Traction alopecia
- Central centrifugal alopecia
- Tumid lupus, tumors, post radiotherapy
Who is affected by scarring hair loss?
Cicatricial alopecia occurs in both men and women. Although it can affect anyone of any age, it is not usually seen in children (unless due to marked inflammatory tinea). Cicatricial alopecias are not contagious and, in general, they are not associated with other illnesses. The majority of patients with cicatricial alopecia have no family history of a similar condition.
A common form of scarring alopecia affects postmenpausal women; namely frontal fibrosing alopecia. It presents as progressive hair loss of the eyebrows, temporal & frontal hair lines. Some cases are itchy, others describe a burning sensation, whilst some are asymptomatic.
Who to see for a diagnosis?
Your dermatologist can examine your pattern of hair loss & guide you accordingly. Some cases are easily diagnosed due to the pattern of hair loss. An example is frontal fibrosing alopecia or FFA (eyebrows, frontal & temporal hair loss). In other cases special biopsies are required. Be guided by your physician.
Disclaimer: I do not treat hair loss with medical management. For a diagnosis & management plan, please see my colleagues at Clinic Cutis.
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What treatments are available?
There are many treatments available to slow down hair loss. The most important concept to grasp is that time is of the essence. Inflammation causes permanent damage to the hair follicle, meaning it will not grow back. Your dermatologist will urge you to consider timely & effective management to slow down your hair loss with drugs. These are some methods we use to slow down the process
Lichen Planopilaris / Frontal Fibrosing Alopecia: Topical & intralesional steroids, short course of oral prednisone, methotrexate & hydroxychloroquine. Low level lasers have been reported.
Discoid Lupus: Topical cs lotions, injections, hydroxychloroquine, oral prednisone. In severe & progressive cases, azathioprine or methotrexate.
Acne Keloidalis Nuchae: most cases can be treated with intralesional steroid injections & topical lotions. Dermatologists frequently use Accutane. Severe cases can be treated with CO2 laser & or surgical excision & radiotherapy.
Folliculitis DeCalvans: most cases can be treated with oral antibiotics (often dual therapy or rotational), staphylococcus eradication. Topical or intralesional cs to scalp. Accutane in some cases.
Disclaimer: I am a procedural dermatologist. I do not get involved in medical management of hair loss. Please consult your dermatologist for a diagnosis & management plan.
What is the prognosis of scarring alopecia?
Although hair will not regrow once the follicle is compromised, dermatologists can often treat the inflammation before too many follicles have been destroyed. It is paramount to begin treatment in a timely fashion to control the inflammatory process. Often, there is sufficient hair in the surrounding areas to cover the affected scalp. If you are concerned that you may have symptoms of a scarring alopecia or other forms of hair loss, it is important to see a hair loss dermatologist as soon as possible.
Hair restoration surgery is not first line therapy, be guided by your dermatologist as to follow up intervals & medical management.
Can male & female pattern hair loss occur with other forms of hair fall?
Yes. This is a common occurrence & can be challenging to diagnose in some cases. Scarring alopecia may occur with androgenic alopecia & even telogen effluvium. Your dermatologist can tell the difference with biopsies, hair microscopy (of the hair roots) & high magnification of your scalp.
If your physician suspects dual pathology (especially if there is an element of patterned hair loss), they may initiate treatments such as oral minoxidil, spironolactone, cyproterone acetate & or finasteride.
What DIY treatments are available?
There is a time and place for DIY treatments, however for scarring alopecia, DIY treatments are not a crash hot idea. Follicular description is permanent, hence time is of the essence. Consider DIY home remedies as adjunctive therapy to anti-inflammatories prescribed by dermatologists.
Low level laser devices (helmets) can be considered. Red or orange light in the 600 to 1050 nm spectrum has been shown to slow down hair fall. LEDs can stimulate surviving germ cells.
Vitamins such as iron, zinc (modulation of inflammation), B12, Biotin & minerals can offer hair growth support for regeneration of follicles. See the section on natural hair loss treatments for more ideas.
Does alopecia areata scar?
No, alopecia areata (AA) is a non-scarring form of hair loss (even though inflammation is the primary cause. AA is best managed with medical therapy by a dermatologist.
Is hair restoration surgery an option for scarring hair loss?
Yes, but most dermatologists would not consider hair transplants for at least 24 months after inflammation has subsided. Hair restoration surgery in cases of scarring alopecia adds several layers of complexity to the procedure-
- Inflammation may develop in the recipient & donor sites. Hence close medical follow up is required.
- Donor hair follicles are depleted due to scarring. This means less hair to transfer.
- The recipient site has scar tissue. This can compromise blood supply & nutrients to the implanted follicles.
- The donor follicles may have fibrosis (scars), hence compromising the grafts.
In some cases I perform a test spot of limited follicular transfer (around 50 to 150 follicles). This area is carefully observed for 12 months before further consideration of follicular transplantation. As a guide, between 60% to 80% of hair follicles survive transfer if inflammation is quiescent.
Davin’s Viewpoint on Scarring Alopecia
Management is medical. Early & effective therapy will prevent permanent hair loss. With this group of hair loss conditions, inflammation knocks out the germ & stem cells in hair follicles. Inflammation may be acute or in many cases insidious.
There are times when patients want to have a go at treating hair loss with fluffy stuff like herbs, vitamins, diet, meditation, acupuncture, fairy dust & other natural remedies. Probably not a good idea with this group of hair loss disorders. Once the follicle is destroyed, it is gone. Forever. We are probably two to three decades away from true stem cell follicular cloning, so replacement of destroyed follicles can only be achieved with repurposing hair from other areas. Transplant specialists will not consider surgery for at least 2 years after activity has subsided.
In summary, be guided by your dermatologist as to the best course of action. In some cases there may be dual pathology, namely inflammation & gender specific patterned hair loss.
Disclaimer: I am a procedural dermatologist, please see a medical dermatologist for management of this group of conditions.
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