Scarring Alopecia: What It Is, Types, and How to Treat It - Medical Aesthetics & Skin Care Clinic in Singapore

Scarring alopecia refers to a group of conditions that cause permanent destruction of hair follicles. The follicles are replaced by fibrous tissue, resulting in irreversible hair loss.

Unlike common forms of hair loss where follicles are miniaturised but still present, scarring alopecia involves true follicular destruction. Once scarring has occurred, regrowth is no longer possible.

The underlying mechanism is typically an inflammatory process targeting the follicle.

Types of Scarring Alopecia

Primary scarring alopecia occurs when inflammation directly targets the hair follicle. These are broadly classified based on the dominant inflammatory cell type.

Lymphocytic Types

Lichen Planopilaris (LPP)

Lichen planopilaris is one of the more commonly encountered forms.

Features include:

Progressive hair loss
Perifollicular erythema
Perifollicular hyperkeratosis
Itching, burning, or scalp tenderness

Diagnosis requires a scalp biopsy demonstrating a lymphocytic inflammatory pattern consistent with LPP.

Important concepts:

There is no cure for LPP.
The disease course is unpredictable.
Treatment aims to halt progression.
Regrowth in scarred areas is unlikely.

Frontal Fibrosing Alopecia (FFA)

FFA is considered a subtype of LPP.

It typically presents as:

A band-like recession of the frontal hairline
Sparing of isolated hairs within the receded area (“lonely hair” sign)
Loss of eyebrows in some cases

There is a statistically significant association between FFA and sunscreen use, although causality has not been established.

Discoid Lupus Erythematosus (DLE)

DLE is a cutaneous form of systemic lupus erythematosus.

It presents with:

Well-demarcated inflammatory plaques
Scaling and erythema
Progression to atrophic scarring

Central Centrifugal Cicatricial Alopecia (CCCA)

CCCA primarily affects women of African descent.

It typically begins at the crown and spreads centrifugally toward the parietal areas.

Symptoms may include:

Itching
Tenderness
Prickling sensations

Over time, hypopigmentation, hyperpigmentation, and extensive scarring may develop.

Less Common Lymphocytic Types

Graham-Little-Piccardi-Lasseur syndrome
Keratosis follicularis spinulosa decalvans

Neutrophilic Types

These forms are often pustular or infection-driven.

Examples include:

Folliculitis decalvans
Dissecting cellulitis of the scalp

Mixed Types

These show both lymphocytic and neutrophilic features.

Examples include:

Acne keloidalis nuchae
Acne necrotica
Erosive pustular dermatitis of the scalp

Secondary Scarring Alopecia

Secondary forms occur when follicles are destroyed by external factors rather than primary inflammatory disease.

Causes include:

Burns
Radiation
Severe infections
Trauma

Diagnosis of Scarring Alopecia

Clinical History

A detailed history is essential. Symptoms such as pain, burning, or rapid progression may suggest active inflammation.

Scarring alopecia often presents with:

Irreversible hair loss
Scalp itching, burning, tenderness, or pain
Visible signs of inflammation

Common clinical signs include:

Erythema
Scale
Pustules
Atrophic plaques

Patterns vary depending on the specific subtype.

Trichoscopy

Trichoscopy is crucial in evaluation.

Common findings include:

Loss of follicular ostia
Perifollicular erythema
Perifollicular hyperkeratosis

These findings strongly suggest scarring alopecia.

Scalp Biopsy

A scalp biopsy is required to confirm the diagnosis and determine the inflammatory subtype.

Accurate diagnosis is essential because treatment varies significantly depending on the condition.

Scarring Alopecia Treatment

The primary goal of treatment is to halt disease progression and preserve remaining hair.

Early intervention is critical because established scarring is irreversible.

Treatment depends entirely on the underlying diagnosis.

Lichen Planopilaris

First-line:

High-potency topical corticosteroids
Intralesional corticosteroids

Second-line:

Oral prednisolone
Hydroxychloroquine

Frontal Fibrosing Alopecia

Management may include:

Topical tacrolimus
Clobetasol
Minoxidil twice daily
Intralesional corticosteroids
5-alpha reductase inhibitors (finasteride or dutasteride)
Hydroxychloroquine
Doxycycline
Methotrexate in resistant cases

Acne Keloidalis Nuchae

Oral doxycycline
Topical corticosteroids
Topical retinoids

Dissecting Cellulitis

Treatment focuses on controlling active infection:

Culture-guided systemic antibiotics
Anti-inflammatory therapy

Treatment varies significantly between subtypes. Establishing the correct diagnosis is the most important step.

Hair Transplant in Scarring Alopecia – A Controversial Discussion

Hair transplantation in scarring alopecia remains a complex and controversial topic.

In my view, transplantation should only be considered when the underlying inflammatory process is fully quiescent.

Active disease significantly increases the risk of:

Poor graft survival
Disease reactivation

Ideal candidates should demonstrate:

No clinical signs of active inflammation
No clinical signs of active inflammation
Biopsy-confirmed absence of ongoing inflammation

A cautious approach involves performing a small trial transplant to assess graft survival before planning a larger procedure. Patient selection and disease stability are critical to achieving acceptable outcomes.