Scarring Alopecia: Symptoms, Types, Causes and Treatment

Scarring alopecia—also known as cicatricial alopecia—is a group of hair loss disorders that can have a life-changing impact on those affected. Unlike more common forms of hair loss, scarring alopecia is marked by permanent destruction of hair follicles and their replacement with scar tissue, leading to irreversible bald patches. Understanding the symptoms, different types, causes, and available treatments for scarring alopecia is crucial for early intervention and preserving both scalp health and self-esteem. This article delves into the key aspects of scarring alopecia with evidence-based insights.

Symptoms of Scarring Alopecia

Recognizing the symptoms of scarring alopecia is the first step toward diagnosis and treatment. Unlike non-scarring forms, this type of alopecia leaves lasting changes to the scalp. Let’s explore what sets it apart.

Symptom	Description	Prevalence/Pattern	Source(s)
Hair Loss	Permanent patches of hair loss	Circumscribed or widespread	2 6 8
Scalp Changes	Scarring, atrophy, sclerosis	Affected areas only	2 6 8 4
Inflammation	Redness, scaling, pustules	Early/active disease phase	3 6 8
Sensations	Itching, burning, tenderness	Variable, often early on	1 6 8

Table 1: Key Symptoms

Visible and Physical Changes

Scarring alopecia often begins insidiously, with patients noticing one or more bald patches that do not regrow hair. These areas may be smooth, shiny, or even depressed due to the loss of underlying structures. Over time, the scalp in these spots may appear sclerosed (hardened) or atrophic (thinned) 6 8.

In some cases, yellow crusting, hyperpigmentation around the lesion edges, or plaques may be observed, especially with underlying conditions like cutaneous sarcoidosis or discoid lupus erythematosus 1 6. The borders of affected areas can be ragged or well-defined, varying by subtype 3.

Sensory Symptoms

While not always present, symptoms such as itching, burning, tenderness, and even pain can occur, particularly in the early, inflammatory stages. These sensations may subside as the disease progresses and the follicles are irreversibly damaged 1 6 8.

Inflammatory Signs

Early in the disease, redness (erythema), scaling, and pustules may be noted. These indicate active inflammation, which, if identified promptly, presents a window for intervention before permanent scarring sets in 6 8.

Patterns of Hair Loss

Patterns can vary:

• Unifocal, ragged borders: Seen in central centrifugal cicatricial alopecia (CCCA) and discoid lupus erythematosus (DLE).
• Multifocal, interconnected: More common in lichen planopilaris (LPP) and folliculitis decalvans (FD).
• Multifocal, separated: Typical in dissecting cellulitis (DC) 3.

Types of Scarring Alopecia

Scarring alopecia isn’t a single disease but a family of disorders, each with distinct characteristics and implications. Understanding the main types aids in diagnosis and tailored treatment.

Type	Inflammatory Cell Type	Key Features	Source(s)
Lichen Planopilaris (LPP)	Lymphocytic	Multifocal, interconnected plaques, perifollicular erythema	3 8 6
Discoid Lupus Erythematosus (DLE)	Lymphocytic	Well-defined, atrophic patches, scaling, follicular plugging	3 4 6 8
Central Centrifugal Cicatricial Alopecia (CCCA)	Lymphocytic	Expanding central patches, more common in women of color	3 9
Folliculitis Decalvans (FD)	Neutrophilic	Pustules, tufted hair, crusting	3 8 6
Dissecting Cellulitis (DC)	Neutrophilic	Nodules, abscesses, sinus tracts	3 8 6
Acne Keloidalis Nuchae (AKN)	Mixed	Papules, keloidal plaques, neck involvement	3 8
Pseudopelade of Brocq (PPB)	Lymphocytic	Small, smooth patches, "footprints in the snow"	3 8
Sarcoidosis	Granulomatous	Scarring, plaques, possible systemic signs	1 6

Table 2: Main Types of Scarring Alopecia

Lymphocytic Types

Lichen Planopilaris (LPP)

This is one of the most common forms, characterized by patches of hair loss with perifollicular erythema (redness around hair follicles) and scaling. It often presents in middle-aged women and may be associated with itching or burning 3 6 8.

Discoid Lupus Erythematosus (DLE)

DLE causes well-defined, round patches of scarring alopecia, often with scaling, follicular plugging, and pigment changes. This form can be associated with systemic lupus but may also occur in isolation 3 4 6 8.

Central Centrifugal Cicatricial Alopecia (CCCA)

CCCA typically affects women of African descent, starting at the vertex (crown) and expanding outward. It may be linked to hair care practices as well as genetic factors 3 9.

Pseudopelade of Brocq (PPB)

PPB is considered a diagnosis of exclusion, presenting as small, smooth, irregular patches that slowly coalesce. The cause remains unclear, but it is thought to be a "burnt-out" stage of other forms 3 8.

Neutrophilic Types

Folliculitis Decalvans (FD)

FD is marked by pustules, crusting, and groups of hairs emerging together ("tufted" folliculitis). It often affects younger males and can progress rapidly if untreated 3 8 6.

Dissecting Cellulitis (DC)

This severe type presents with deep nodules, abscesses, and interconnected sinus tracts, most commonly in young to middle-aged men. It can be painful and lead to extensive scarring 3 8 6.

Mixed/Other Types

Acne Keloidalis Nuchae (AKN)

AKN presents as firm papules and keloidal plaques, usually at the nape of the neck. It is more prevalent in men of African descent 3 8.

Cutaneous Sarcoidosis

Though rare, sarcoidosis can cause scarring alopecia as a manifestation of systemic disease, often accompanied by non-caseating granulomas on biopsy and other systemic findings such as uveitis 1 6.

Causes of Scarring Alopecia

Understanding what leads to the destruction of hair follicles and irreversible hair loss is key for both prevention and treatment.

Cause	Mechanism	Examples/Subtypes	Source(s)
Autoimmune	Immune attack on follicles	LPP, DLE, FFA, PPB	6 7 8 11
Infectious	Bacterial/fungal invasion	FD, DC	6 8
Physical/Chemical	Trauma, burns, radiation	Traumatic alopecia, pressure alopecia	5 6 14
Genetic/Hormonal	Inherited predisposition	CCCA, AKN	3 9
Granulomatous Disease	Granuloma formation	Sarcoidosis, tuberculosis	1 6

Table 3: Main Causes of Scarring Alopecia

Autoimmune and Inflammatory Causes

Most primary scarring alopecias result from an immune-mediated attack on hair follicles—especially their stem cells located in the follicular bulge—leading to permanent destruction. The immune infiltrate may be predominantly lymphocytic (as in LPP, DLE, FFA) or neutrophilic (as in FD, DC) 7 8 6.

The specific triggers for this immune response are often unknown, but genetic susceptibility and environmental factors likely play a role. For example, recent research suggests that disruption of the immune-privileged niche of hair follicle stem cells is central to disease development 7 11.

Infectious Causes

In some cases, chronic bacterial or fungal infection leads to follicular destruction, most notably in folliculitis decalvans and dissecting cellulitis. Here, neutrophilic inflammation predominates, and timely antimicrobial therapy is essential to halt progression 6 8.

Physical and Chemical Trauma

Secondary scarring alopecias result from direct injury to the scalp, including burns, radiation, surgical scars, or even pressure-induced ischemia (as in pressure alopecia following surgery or immobility). Scarring from cosmetic procedures is also increasingly reported 5 6 14.

Genetic and Hormonal Factors

Certain forms, such as CCCA and AKN, are more common in specific ethnic groups and may be linked to both genetic predisposition and particular hair care practices (e.g., tight hairstyles, chemical relaxers) 3 9.

Granulomatous Disease

Systemic diseases like sarcoidosis can involve the scalp, forming granulomas that destroy follicles and lead to scarring alopecia. Other granulomatous diseases, such as tuberculosis, may have similar effects but are less common 1 6.

Treatment of Scarring Alopecia

Effective management of scarring alopecia hinges on early diagnosis and targeted therapy to halt inflammation before irreversible scarring occurs. Let’s review the main treatments.

Treatment	Purpose	Suitability/Notes	Source(s)
Anti-inflammatories	Halt inflammation	Topical/oral steroids, calcineurin inhibitors	2 6 11 13
Immunosuppressives	Modulate immune response	Hydroxychloroquine, retinoids, cyclosporine	11 13
Antibiotics	Control infection	Neutrophilic/folliculitis types	6 8
Physical Approaches	Support drug delivery, healing	Lasers, microneedling, iontophoresis	13 12 14
Hair Transplantation	Cosmetic restoration	Stable, inactive disease only	10 12 14

Table 4: Treatment Modalities

Anti-inflammatory and Immunosuppressive Therapies

Topical and Intralesional Corticosteroids

Corticosteroids are the mainstay for most lymphocytic types (LPP, DLE, FFA, PPB). They reduce inflammation and can slow or stop disease progression if started early 2 6 13.

Calcineurin Inhibitors and Other Immunosuppressants

Topical calcineurin inhibitors (like tacrolimus) and systemic agents such as hydroxychloroquine, mycophenolate mofetil, or oral retinoids may be used in refractory cases, especially for LPP and FFA 11 13.

Hydroxychloroquine and Retinoids

These are often employed for lupus-related and other inflammatory scarring alopecias. Newer agents, including Janus kinase inhibitors and biologics, are under investigation 11.

Antibiotics and Antimicrobial Therapies

For neutrophilic forms (FD, DC), oral or topical antibiotics are crucial. They reduce bacterial load and inflammation. In some cases, long-term suppressive therapy is required to maintain remission 6 8.

Physical and Device-based Treatments

Emerging technologies—like microneedling, lasers, and iontophoresis—are being studied to improve drug delivery or stimulate healing. Fractional lasers and platelet-rich plasma may help remodel scars and improve outcomes in selected cases 13 12 14.

Hair Transplantation

Hair transplantation can be an option for patients whose disease is inactive (“burnt-out”) and stable for at least 1-2 years. Follicular unit extraction (FUE) or follicular unit transplantation (FUT) is used to restore hair to scarred areas, with good-to-excellent cosmetic results reported in many cases 10 12 14. However, success depends on careful patient selection, and recurrence is possible if the disease reactivates.

Supportive Care

• Wigs and hairpieces: For extensive or active disease.
• Scalp camouflage: Cosmetic products can improve appearance and confidence.
• Psychological support: Addressing the emotional impact of permanent hair loss is essential 2 12.

Conclusion

Scarring alopecia is a complex group of disorders with potentially devastating consequences for affected individuals. Early recognition and intervention are vital to preserving hair and scalp health. Here’s a summary of key points:

• Symptoms: Include permanent hair loss with scarring, scalp atrophy, and variable inflammation or sensory changes.
• Types: Encompass a range of disorders, including lymphocytic (LPP, DLE, CCCA), neutrophilic (FD, DC), mixed (AKN), and granulomatous (sarcoidosis) forms.
• Causes: Most are autoimmune/inflammatory, but infections, trauma, genetic factors, and systemic diseases can also play roles.
• Treatment: Early anti-inflammatory therapy is crucial; antibiotics for infectious types, physical therapies, and hair transplantation for stable cases offer hope for cosmetic restoration.

Take-home messages:

• Scarring alopecia requires urgent, accurate diagnosis.
• Treatment is most effective early in the disease course.
• Multidisciplinary, patient-centered care—including emotional support—is key to optimal outcomes.

If you suspect scarring alopecia, consult a dermatologist promptly to maximize your chances of halting progression and restoring confidence.