Scarring Hair Loss Disorders

Cicatricial Alopecia
Hair loss disorders that are associated with scarring are referred to as “cicatricial” alopecias. Cicatricial is simply the medical term for scarring; unlike pattern hair loss, these less common forms of balding cause scarring in the affected areas. Regions of the scalp affected by cicatricial alopecia will therefore have an unusual smooth and shiny appearance from loss of the normally present follicular openings or pores. There are two general categories, primary cicatricial alopecia and secondary cicatricial alopecia.

Primary cicatricial alopecia, is the result of a destructive inflammatory process. In secondary cicatricial alopecia, the hair loss and scarring are the result of some form of external injury to the scalp and hair follicles.

Primary Cicatricial Alopecia (PCA)
In primary cicatricial alopecia( PCA), lymphocytes or neutrophils that normally have a protective role, attack hair follicles. In individuals with PCA, the inflammatory cells that attack the affected hair follicles cause inflammation, injury and scarring of the surrounding scalp. Subsequent hair loss is therefore permanent since the hair follicle is destroyed and replaced with scar tissue. Patients will frequently have signs of inflammation in the involved areas when the disease is active.

PCA is classified by the type of inflammatory cells predominantly involved, being either Lymphocytic PCA or Neutrophilic PCA.

Lymphocytic PCAs
The Lymphocytic PCAs include lichen planopilaris (LPP), frontal fibrosing alopecia (FFA), central centrifugal alopecia (CCS), and pseudopelade of Brocq (PB).

Lymphocytes such as T cells and B cells are the main cells found in Lymphatic fluid and play a key role in our immune response. Lymphocytic PCAs are generally treated with drugs such as corticosteroids, applied as a topical or via injection into the affected scalp, in addition to several other medications.

Neutrophilic PCAs
Neutrophils are the main cell type found in pus. They are also the most abundant type of white cell and are responsible for acute (immediate) inflammation, as in a bacterial infection. Neutrophils can be rapidly recruited, within minutes, to a site of injury; the presence of neutrophils is hence a hallmark of acute inflammation or infection.

Neutrophilic PCAs include Decalvans folliculitis, dissecting cellulitis of the scalp (also called perifolliculitis capitis abscedens et suffodiens) and tufted folliculitis (note: tufted folliculitis may represent a very advanced stage of scarring and follicular injury resulting from the aforementioned forms of scarring alopecia)

Mixed PCAs
In mixed PCAs such as folliculitis keloidalis, sometimes called acne keloidalis nuchae (AKN), both Lymphocytes and Neutrophils may play a role in this poorly understood process.

In individuals with Neutrophilic PCAs or a mixed cell PCAs, the treatment typically includes antibiotics or isotretinoin. Other experimental agents have also been used.

Occasionally, if a scarring alopecia has reached the “burnt-out” stage amd there has been no active inflammation or hair loss for several years, bald areas can be either surgically removed, if small, or transplanted with hair follicles transferred from unaffected areas, in select patients.

Please consult with your physician before considering any of the drugs or treatments discussed on this website