Overview

Hair loss is normal and extremely common. We can lose between 50 and 100 hairs a day. However, extreme hair loss can be a sign of a medical condition.

Scarring alopecia, also known as cicatricial alopecia, is a type of hair loss caused by irreversible damage to your hair follicles. It is often a result of infections, chemicals, burns or autoimmune disorders. As the hair follicles are destroyed, hair cannot regrow.¹

This article will explore the symptoms and causes of scarring alopecia. It will also detail how scarring alopecia is diagnosed and the treatment options that are available to you.

Signs and symptoms

Hair loss is the main symptom of scarring alopecia which can affect any part of the body but mainly affects the scalp. This may start slowly and happen gradually over years or it may start suddenly and progress quickly. It often causes focal hair loss which means you lose hair in patches.¹

Some people also experience other skin problems, such as:

• Bleeding
• Burning
• Itching or tenderness
• Crusting
• Blistering
• Redness or other discoloration
• Pustules

Types of scarring alopecia

There are two types of scarring alopecia:¹

• Primary cicatricial alopecia - hair follicles are directly targeted and destroyed by  an inflammatory or autoimmune disorder
• Secondary cicatricial alopecia - the destruction of hair follicles is usually due to an injury or damage to your skin such as burns, metastatic cancer, trauma or radiation

There are many different types of primary cicatricial alopecia, some include:

• Central centrifugal cicatricial alopecia (CCCA) - is the most common type of hair loss in people of African descent and usually occurs around the age of 30. It usually begins as a bald patch at the crown of your head and then spreads outward. It may be caused by chemical hair products such as hot combs and relaxants or too much tension on hair follicles from braids, weaves or extensions. However, research suggests that CCCA may be genetically inherited.¹
• Chronic cutaneous lupus erythematosus (CCLE) - is caused by lupus erythematosus, an autoimmune disease. It is more common in women or adults assigned female at birth (AFAB). Along with hair loss, people may also suffer from skin rashes, discolouration and sensitivity to the sun. ²
• Folliculitis decalvans - may be caused by a bacterial infection such as Staphylococcus aureus (Staph A). Inflammation and bacteria in hair follicles cause pustules to form and hair follicles to eventually die which prevents new hair growth.^1,2
• Lichen planopilaris - is the most common type of primary cicatricial alopecia that mostly affects women or people AFAB, who are over 50. It is a type of lichen planus which is a condition that causes skin inflammation. Common symptoms include skin scaling, itching, burning discolouration, ulcers and papules (inflamed bumps).^1,2

Causes of scarring alopecia

Most cases of scarring alopecia are caused by inflammation around the middle of your hair follicle, known as the bulge. This area contains stem cells and oil glands which are both needed for new hair growth. Inflammation causes irreversible damage by destroying this part of the follicle and replacing it with scar tissue (fibrous tissue). This means that the openings in your skin where hair follicles are found, known as follicular ostia, are closed in people with scarring alopecia so hair cannot regenerate. This leaves the hair smooth and bare without hair or the usual pore markings.¹

This is different to other types of alopecia such as (non-scarring) alopecia areata and androgenetic alopecia where hair follicle bulbs are not destroyed so the follicles can regenerate and hair regrowth is possible with the right treatment.¹

Diagnosis

There are a few different ways to diagnose  scarring alopecia, such as:

• Physical exam - your healthcare provider will check the location and pattern of your hair loss. They will also check the affected skin to see if the hair follicle openings are present and if there are any visible signs of inflammation. They will also take note of your symptoms and when you first noticed hair loss.
• Medical history - your healthcare provider will then review your medical history and evaluate your age, sex, hair care practices and overall health. They will also take note of any medical conditions you have, such as anaemia, lupus or thyroid disease. You may also have to do blood tests to check for diseases that cause hair loss.¹
• Skin biopsy - your healthcare provider will perform a skin biopsy to confirm a diagnosis of scarring alopecia. A small skin sample is taken from your scalp or another area affected by hair loss and examined under a microscope. This is useful in checking for inflammatory immune cells as well as the type of inflammation present, location and amount of inflammation.^1,2

At times, a biopsy may show scar tissue but no inflammatory cells which means the condition has progressed to end-stage scarring alopecia (ESSA). This means the condition is past the point of active inflammation, so treatment is not as effective.

Management and treatment

There is no cure for scarring alopecia but treatment is useful in managing symptoms and slowing or stopping more hair loss. As well as this, cosmetic treatments are useful in improving the appearance of bald patches.¹

Treatment of scarring alopecia depends on the type of cicatricial alopecia you have. Treatment aims to reduce or eliminate the inflammatory cells that are attacking and destroying the hair follicle. It is important to treat cicatricial alopecia as soon as possible to control the inflammatory process and the progression of hair loss.¹

Medication

Anti-inflammatory medication is the most common treatment for scarring alopecia and is effective at fighting inflammatory cells that destroy hair follicles. This can be in the form of a pill or you may receive a corticosteroid injection. You may also be prescribed an anti-inflammatory medication in the form of a cream or oil that you can apply to your skin.

You may be prescribed antibiotics if you have scarring alopecia that is caused by a bacterial infection. Medication for scarring alopecia is usually taken for 6 to 12 months until symptoms have improved. However, scarring alopecia may reactivate and you may start losing more hair so treatment may have to be repeated.¹

Platelet-rich plasma therapy

Platelet-rich plasma therapy uses platelets from your blood to reduce inflammation and improve tissue function. It is usually used to treat non-scarring alopecia by regrowing hair but can also be used to treat certain types of scarring alopecia, such as lichen planopilaris.

Surgical treatment 

Surgical treatment may be an option for individuals after the condition has been inactive for at least one year. This includes hair transplant surgery and scalp reduction. Hair transplant surgery involves transferring hair from one part of the scalp to an area with little or no hair.¹

Hair care products

Hair care products and shampoos are considered safe as long as they are not irritating the scalp. A healthcare provider may recommend specific products and shampoos to decrease scalp symptoms and inflammation. Wigs, hats, scarves and hair pieces are safe and can be used freely.¹

Prognosis and outlook

The outlook for scarring alopecia depends on the progression of your condition and how soon you get treatment. While some people only experience a small amount of hair loss, others have widespread hair loss. As well as this, hair loss may return after treatment so some people may need to be on medication for a long time.¹

FAQs - Frequently asked questions

Can my hair regrow if I have scarring alopecia?

Scarring alopecia can cause irreversible damage to your hair follicles which makes it difficult for your hair to regrow. However, treating the condition as early as possible may be effective at stopping inflammation before it destroys the hair follicle.¹

Can cancer treatment cause scarring alopecia?

Although chemotherapy causes hair loss, it does not cause scarring alopecia. Chemotherapy causes cells in your hair follicle to die so your hair falls out but it does not destroy the hair follicle so hair can grow back. However, radiation therapy can cause skin burns that permanently damage hair follicles which can lead to secondary scarring alopecia.

How common is scarring alopecia?

Scarring alopecia affects about 7% of the population. It is less common than non-scarring alopecia which affects around 50% to 75% of adults over 50.¹

Summary

In summary, hair loss caused by scarring alopecia can be a difficult and unpleasant condition to manage. As well as hair loss, some people may experience skin problems such as bleeding, blistering, scaling, redness and pustules. To diagnose scarring alopecia, a healthcare provider will perform a physical exam, check your medical history and take a skin biopsy. It is important to treat the condition as soon as possible to prevent more hair loss. Treatment includes anti-inflammatory medication, antibiotics, platelet-rich plasma therapy and surgical treatment. Although this condition does not cause serious health problems, it can trigger feelings of embarrassment and shame. You can talk to a healthcare provider to receive the right treatments and support services to help you feel better.