Scarring Alopecia, also known as Cicatricial alopecia, is a condition that causes permanent hair loss, resulting in bald patches on the scalp. It occurs when inflammation damages the hair follicles, leading to scarring and preventing hair regrowth. This condition can be distressing as it affects both men and women, causing emotional distress due to the irreversible nature of the hair loss.

Background of Scarring Alopecia

Scarring Alopecia is not common and leads to permanent hair loss, eventually resulting in baldness. Also referred to as Cicatricial alopecia, this condition can develop gradually over several years or rapidly within a few months. Rapid hair loss may be accompanied by symptoms such as severe itching, pain, burning sensations, and shedding of hair in clusters. Although the inflammation causing follicle destruction occurs beneath the skin’s surface initially, visible signs such as redness, scaling, pigmentation changes, pustules, or a hardened appearance may develop once the follicles become scarred.

Who Is Affected by Scarring Alopecia?

Scarring alopecia can affect individuals of any gender or age group and is not contagious. While some types may have a genetic predisposition, others are more commonly observed in women than in men. For example, Pseudopelade primarily affects adult women. Generally, scarring alopecia is rare in children, although certain specific types may affect adolescent males.

Types of Scarring Alopecia

Scarring alopecia is categorized into primary, secondary, and developmental/hereditary alopecia:

• • Primary Scarring Alopecia: This type results from the irreversible destruction of hair follicles, leading to their replacement with fibrous tissue. Inflammatory cells primarily target the hair follicles, causing their destruction. Depending on the type of inflammation, primary scarring alopecia is further classified as lymphocytic, neutrophilic, or mixed alopecia.
  • Secondary Scarring Alopecia: Hair follicle damage occurs as a secondary effect of inflammation or skin-destructive processes. This type of alopecia occurs when follicles are damaged due to burns, trauma, cancer, or radiation therapy.
  • Developmental/Hereditary Alopecia: This type is influenced by factors such as genetics, hormonal imbalances, or natural aging, commonly known as Male/Female pattern baldness.

Symptoms of Scarring Alopecia

Scarring alopecia typically presents as one or more permanent bald patches on the scalp, which may gradually enlarge and coalesce, leading to extensive hair loss. These bald areas often appear smooth and shiny, lacking skin pores due to the complete loss of follicular openings. Symptoms may vary depending on the type of alopecia but commonly include itching, scalp burning, discharge, pain, rough or scaly skin patches, blistering, and crusting.

The exact causes of Scarring alopecia remain partially understood, but inflammation appears to play a significant role. Most instances of scarring alopecia stem from the permanent destruction of hair follicles due to inflammation, leading to the progressive deposition of collagen and often the loss of sebaceous glands.

One primary cause of scarring alopecia is believed to be the destruction of slow-cycling hair follicle stem cells (HFSC). These stem cells, located in the ‘bulge’ region of the hair follicle’s outer root sheath, are crucial for regenerating and renewing the follicle. However, scarring alopecia may involve additional biological pathways, as it can present with symptoms such as erythema, epidermal atrophy, and follicular plugging.

Another theory implicates the involvement of proliferator-activated receptor (PPAR), a receptor protein, in causing scarring alopecia. PPAR gamma plays a vital role in maintaining the integrity of hair follicle cells, including stem cells, and sebaceous glands. Dysfunction of PPAR gamma can lead to sebaceous gland dysfunction and the accumulation of “toxic” lipids, triggering inflammation that ultimately destroys the hair follicle.

Certain hair-care practices, such as excessive use of hot combs, relaxants, or traction, particularly in women, can also contribute to scarring alopecia.

In summary, the causes of scarring alopecia can include:

• • Destruction of hair follicle stem cells
  • Impairment in the self-maintenance of HFSCs
  • Alteration in lipid metabolism
  • Inflammation
  • Factors like injuries, burns, or tumors
  • Genetic factors

The primary goal of treating scarring alopecia is to halt further hair loss and potentially cover bald areas using hair systems or wigs, as regrowth of hair is not possible. Treatment focuses on reducing inflammation and managing symptoms. In cases where there is undamaged donor hair elsewhere on the scalp and the disease is not progressing, hair transplantation may be an option to cover bald patches.

Treatment approaches for scarring alopecia vary depending on the specific type and the inflammatory cells involved. For instances caused by lymphocytes, like Lichen planopilaris and frontal fibrosing alopecia, several therapies are available:

Topical Treatments: Applying corticosteroid creams to affected areas can help control itching or burning sensations. In some cases, corticosteroids are injected directly into the inflammatory lesion to halt hair loss. However, prolonged use of steroids—whether topical or injectable—can lead to skin shrinking at the application site.

Oral Medications: Antimalarial drugs, oral corticosteroids, and oral retinoids may be prescribed to manage lymphocytic scarring alopecia. However, antimalarial medications can have side effects such as abdominal pain, skin hyperpigmentation, and ophthalmologic damage. Regular monitoring is essential, particularly for retinopathy, in patients undergoing antimalarial treatment for an extended period.

Sun Protection: Since certain forms of lymphocytic scarring alopecia can worsen with sun exposure, using sunscreen with a high sun protection factor (SPF) is advisable.

In summary, treatment options for lymphocytic scarring alopecia may include:

• • Topical corticosteroids
  • Injectable corticosteroids
  • Oral medications like antimalarial drugs, corticosteroids, and retinoids
  • Broad-spectrum sunscreen agents

Treatment for scarring alopecia caused by neutrophils varies depending on the specific condition. For instance, folliculitis decalvans, often associated with Staphylococcus aureus, may require different approaches:

Antiseptic Shampoos: Individuals with folliculitis decalvans are often advised to use antiseptic shampoos to address the underlying bacterial infection.

Topical Treatments: Mild cases may be managed with topical creams containing benzoyl peroxide or clindamycin to reduce inflammation and control symptoms.

Oral Antibiotics: Severe cases may necessitate treatment with oral antibiotics to combat the bacterial infection more effectively.

Dissecting Cellulitis: Another type of neutrophilic scarring alopecia, dissecting cellulitis, is typically treated with isotretinoin, an oral retinoid medication.

Potential side effects of treatment for neutrophilic scarring alopecia, such as prolonged use of oral clindamycin, may include gastrointestinal symptoms like diarrhea.

In summary, treatment options for neutrophilic scarring alopecia may include:

• • Topical creams containing benzoyl peroxide or clindamycin
  • Antiseptic shampoos
  • Oral antibiotics for severe lesions
  • Oral retinoids such as isotretinoin

Surgical Treatment for Scarring Alopecia:

In cases where lesions are stable in size and inflammation is under control for at least one year, surgical treatment may be considered. Scalp reduction surgery, complemented by hair transplantation, can be an option for suitable candidates to achieve optimal results.

Diagnosing scarring or cicatricial alopecia typically involves a thorough examination of the hair and scalp by an experienced trichologist. While scalp biopsy remains the definitive method for confirmation, diagnosis often relies on various clinical observations and patient history.

Key aspects considered during diagnosis include the patient’s age at the onset of symptoms, any previous scalp conditions, and the presence of common symptoms such as itching, burning, or discharge from the scalp. Specific signs, like the absence of pores within the affected area, are also significant indicators.

Furthermore, age plays a crucial role, as certain types of scarring alopecia tend to occur in distinct age groups. For instance, frontal fibrosing alopecia is more prevalent among postmenopausal women, whereas primary cicatricial alopecia typically manifests in early adulthood.

Additionally, a hair pull test may be performed to assess the degree of follicle damage. A positive result, where hairs are easily removed, indicates active and spreading alopecia.

In summary, diagnosis of scarring alopecia involves:

• • Scalp examination
  • Patient’s age and medical history
  • Assessment of previous scalp conditions
  • Observation of symptoms such as itching or burning
  • Evaluation of pore absence within affected areas
  • Hair pull test
  • Scalp biopsy (if necessary)

Hair Care Tips for Scarring Alopecia:

Proper hair care is crucial for individuals with scarring alopecia to manage symptoms effectively:

• • Avoid hair products containing harsh chemicals that may irritate the scalp.
  • Protect the hair and scalp from UV exposure with hats, scarves, or sunscreen, as some types of scarring alopecia worsen with sunlight exposure.
  • Use antiseptic shampoos as prescribed by a dermatologist to reduce inflammatory lesions.
  • Adhere to antibiotic treatments as prescribed.
  • Consider using hair wigs or other hairpieces to conceal bald patches.