Scarring Alopecia: Causes, Stages & Treatment Options

Scarring alopecia is a type of permanent, irreversible hair loss that destroys hair follicles and replaces them with scar tissue. It occurs in 7% of hair loss patients, so while it’s not the most common cause of hair loss, it still affects hundreds of thousands of people worldwide [1-3].

Scarring or cicatricial alopecia is often referred to as a single entity. But it actually refers to a group of hair loss conditions that cause scarring on the scalp. These include:

• Central centrifugal cicatricial alopecia (CCCA)
• Frontal fibrosing alopecia (FFA)
• Lichen planopilaris
• Dissecting cellulitis.

In this article, you’ll discover what causes scarring alopecia in each of these conditions, how to diagnose your symptoms, and how to treat scarring alopecia.

What is scarring alopecia?

There are 2 overarching types of scarring alopecia: primary and secondary. Primary alopecia happens when hair follicles are destroyed as a result of a follicular disorder, like those listed above. Secondary alopecia happens when follicular scarring is caused by an external factor, such as trauma, burns, or radiation.

While both types create scar tissue in and around the follicles, they should usually be treated differently. This article focuses on the causes of and treatments for primary scarring alopecia.

What’s the difference between scarring and non-scarring alopecia?

Almost all hair loss conditions fall into one of two categories: scarring and non-scarring alopecia.

Scarring alopecia damages the hair bulge, leading to permanent hair loss. Stem cells within the hair bulge are central to the hair growth cycle, so when these are destroyed, the follicle can no longer survive [4-5].

Inflammation at the hair bulge in permanent scarring alopecia versus inflammation at the hair bulb in non-scarring hair loss conditions [2].

In contrast, reversible non-scarring hair loss conditions like alopecia areata and telogen effluvium are characterised by damage to the hair bulb. Damage to the hair bulb forces follicles to miniaturise, preventing hair growth temporarily. But the follicle survives, and may produce hair again when the hair growth cycle restarts [2].

Scarring alopecia: causes, symptoms, and treatments

Because scarring alopecia consists of a group of conditions, there’s no single underlying cause. And in some cases, the cause remains unknown.

Here are the causes and symptoms of the most common cicatricial alopecias, and standard treatments for each condition.

Central centrifugal cicatricial alopecia (CCCA)

Causes

CCCA has been linked with damaging hair styling techniques like tight ponytails, hair extensions, and heat styling. Heat is a known cause of hair loss and breakage, but it can also lead to irreversible alopecia if you develop CCCA [6].

Recent studies have shown that certain genetic changes may also lead to CCCA development [7]. As a result, this condition is particularly common in women of African ancestry, and may be hereditary [8].

Symptoms

Symptoms of central centrifugal cicatricial alopecia include burning, itching, soreness, scaly skin, and pimples on the scalp.

You may also see hair loss in the centre of the scalp, which can look similar to hair loss caused by telogen effluvium or female pattern hair loss. The key difference is the scarring — but this isn’t usually visible above the skin, so you’ll need a specialist to diagnose this.

Treatments

The most effective treatments for stopping progression of CCCA are:

• Minimising the use of damaging styling practices, such as tight braids, ponytails, and dreadlocks
• Topical, oral, or injectable steroids — to reduce inflammation and promote healing
• Anti-inflammatory medication — to ease swelling and soreness
• Anti-dandruff shampoo — to ease itching and flakiness
• Hair transplants have been shown to be effective for people with CCCA [15].

Frontal fibrosing alopecia (FFA)

Causes

Many causes have been linked with FFA, including autoimmunity (in which white blood cells attack the hair follicles, causing them to stop producing hair), hormones, and triggers like lotions, stress, and environmental toxins [9]. Often, these factors only trigger FFA if you’re genetically susceptible to this type of scarring hair loss.

Symptoms

The most common symptom of FFA is a receding hairline. This is also common in those with male pattern baldness, so there’s some overlap between these symptoms in men (although pattern baldness is a type of non-scarring alopecia). If you can see a distinct line between your forehead and scalp when you raise both eyebrows, you may have FFA.

Patients with receding hairlines due to frontal fibrosing alopecia.

Eyebrow hair loss is common in those with FFA, and approximately half of all FFA patients experience itchiness on the scalp. A quarter find the sensation painful [9].

Treatments

There are few widely successful treatments for FFA. The most prescribed treatments include:

• Topical, oral, or injectable steroids — to reduce inflammation and promote healing
• Antimalarial drugs — to treat inflammation
• Immunosuppressant drugs — to minimise the body’s immune response
• Anti-androgens — to promote hair growth in those who also have androgenetic alopecia.

Lichen planopilaris

Causes

Lichen planopilaris is one of the most common scarring alopecias [10]. A variant of lichen planus, lichen planopilaris is an autoimmune condition that affects the scalp, causing hair loss.

Certain triggers that have been known to cause a lichen planopilaris outbreak include:

• Viruses, including HIV, HPV, and hepatitis C
• Drugs and medication, including antimalarials and beta-blockers
• Contact sensitisers, which cause the body to have an allergic reaction.

Symptoms

Unlike other types of scarring hair loss, there’s no distinct pattern to the hair loss caused by lichen planopilaris. Bald patches are usually scattered around the head, with redness and scaly skin around the edges of each patch. Itchiness, burning, and pain are also common symptoms [10].

Two patients with typical symptoms of lichen planopilaris.

Lichen planopilaris typically affects younger women, though it can affect people of all ages. It’s much less common in men [10].

Treatments

The most effective treatments for treating lichen planopilaris are:

• Topical, oral, or injectable steroids — to reduce inflammation and promote healing
• Antimalarial drugs — to treat inflammation
• Immunosuppressant drugs — to minimise the body’s immune response
• Antibiotics — to prevent or treat infection.

Dissecting cellulitis

Causes

Dissecting cellulitis is a rare condition [11]. Unlike CCCA and FFA, it’s not usually hereditary — and is more likely to impact men of African or Caribbean descent than women.

Unfortunately, the conclusive cause of dissecting cellulitis isn’t yet known. Some studies have linked it with joint conditions like arthritis and sternoclavicular hyperostosis, as well as Crohn’s disease [11].

Symptoms

Dissecting cellulitis is characterised by blocked hair follicles. This often presents as abscesses or cysts which drain pus. Dissecting cellulitis can be very painful. It may cause more hair loss on one side of the head than the other.

A patient with cysts on the head caused by dissecting cellulitis.

Treatments

There is no cure for dissecting cellulitis, but it can be managed with:

• Topical or injectable steroids — to reduce inflammation
• Antibacterial medications — to stop progression of dissecting cellulitis
• Retinoids — a vitamin A derivative that can prevent follicle blockages, although these are unsuitable for some patients (including pregnant women — learn more about pregnancy and hair loss)
• Oral zinc sulphate tablets — to reduce inflammation (find out more about vitamins for hair growth)
• Surgery — to drain or cut out large abscesses on the scalp
• Antibiotics — to eliminate infection.

Other types of scarring alopecia

There are many other types of scarring alopecia, though these are rare and impact a smaller proportion of people. The best way to determine the cause of your hair loss is to see a professional trichologist.

Symptoms of scarring alopecia vs non-scarring alopecia

While symptoms vary depending on the condition, there are some common symptoms you can look for to establish if your hair loss is scarring or non-scarring. These include:

• Small patches of hair loss that expand over time — apart from pattern baldness, most types of non-scarring alopecia may improve, while scarring alopecia usually gets progressively worse
• Pain, burning, and itchiness — scarring alopecia tends to cause more discomfort than non-scarring alopecia
• Ragged or uneven bald patches — alopecia areata usually develops as small circles or ovals; scarring alopecia patches tend to be more uneven
• Scaly skin and cysts — unlike non-scarring hair loss, scarring alopecia is associated with visible symptoms like flaky skin, blisters, and abscesses.

The placement of these symptoms can also help define the type of scarring alopecia [12]. Frontal balding may suggest FFA, while symptoms across the scalp are more likely to be CCCA or lichen planopilaris.

Despite the name, you’re unlikely to see scar tissue on your scalp. Most of the hair follicle destruction happens beneath your scalp, so it’s not usually visible without a scalp biopsy.

Treatments for scarring alopecia

Because the causes of each type of scarring alopecia are different, they should be treated in a different way. But there is some overlap between treatments for scarring alopecia. The most common treatments include:

• Steroids — corticosteroids reduce the body’s inflammatory response, reducing redness and pain
• Antibiotics — drugs like tetracycline can fight infection, which is especially important if you have open sores or abscesses
• Immunosuppressant drugs — medication like cyclosporine minimises the body’s immune response, preventing white blood cells from attacking the follicles
• JAK inhibitors — JAK inhibitors have shown promise for treating lichen planopilaris; the FDA also recently approved the JAK inhibitor Olumiant for treating alopecia areata [13]. Ritlecitinib, a Pfizer alopecia JAK inhibitor, is also in the pipeline for FDA and EMA approval.

Other non-medical treatments may help prevent the progression of scarring alopecia. If you have CCCA, avoiding tight hairstyles can minimise the effects of the condition.

Can you get a hair transplant if you have scarring alopecia?

The jury is still out on the effectiveness of hair transplants for patients with scarring alopecia. While it’s possible to get a hair transplant into scar tissue, there are other factors to consider — including safety, hair transplant scarring, and hair transplant success rates for these conditions.

In one systematic review of hair transplants in scarring alopecia patients, researchers found a 76% positive outcome rate — meaning more than three-quarters of patients had good results following a hair transplant [14]. It’s shown particular success for patients who have central centrifugal cicatricial alopecia [15].

Results are mixed for patients with lichen planopilaris and frontal fibrosing alopecia. Most cases of hair transplant in patients with FFA have failed, although at least one was successful [14, 16].

Regardless of the type of scarring alopecia, surgical treatment can only be considered when the condition has been stabilised [12]. Sometimes, this is never achieved — which means hair transplants are out of reach for some patients with scarring alopecia.

But for others, FUT and FUE hair transplants may be a viable option for restoring permanent hair loss. Discuss your treatment plan with your hair loss consultant to find out if you’re eligible for a hair transplant.

How do I know which type of scarring alopecia I have?

Some types of scarring alopecia have very unique symptoms (such as dissecting cellulitis). Others are much less clear — and they can happen at the same time as other hair loss conditions, making it difficult to know why you’re losing hair.

The only way to really know what’s causing your hair loss is to see a trichologist. They’ll examine your hair and scalp to determine the underlying cause of hair loss. Armed with this knowledge, they can prescribe the right treatment to slow your scarring alopecia.

Book a free consultation at the Wimpole Clinic to diagnose your hair loss, and find the right treatment path to restore your hair.

Sources:

1. Cicatricial alopecia: clinico-pathological findings and treatment
2. Primary cicatricial alopecia: diagnosis and treatment
3. International Society of Hair Restoration Surgery: 2022 Practice Census Results
4. Hair follicle bulge: A fascinating reservoir of epithelial stem cells
5. The Pathogenesis of Primary Cicatricial Alopecias
6. Central centrifugal cicatricial alopecia: challenges and solutions
7. Variant PADI3 in Central Centrifugal Cicatricial Alopecia
8. Central Centrifugal Cicatricial Alopecia
9. Frontal Fibrosing Alopecia: A Review
10. Lichen Planopilaris
11. Dissecting Cellulitis of the Scalp: A Review and Case Studies of Surgical Reconstruction
12. Role of Hair Transplantation in Scarring Alopecia—To Do or Not to Do
13. Tofacitinib for the treatment of lichen planopilaris: A case series
14. A Systematic Review of the Outcome of Hair Transplantation in Primary Scarring Alopecia
15. Hair transplantation in the surgical treatment of central centrifugal cicatricial alopecia
16. Hair transplantation for the treatment of lichen planopilaris and frontal fibrosing alopecia: A report of two cases