Cicatricial (Scarring) Alopecia: Diagnosis & Treatment Guide

Cicatricial alopecia, commonly known as scarring hair loss, can often be seen as a permanent, irreversible disorder. The causes of cicatricial alopecia are relatively unknown; what’s known is that it triggers an autoaggressive immune response. 

This disorder could be caused by genetics, or external factors like infections, trauma, burns, or radiation could also cause it. Early detection is the key to getting ahead of this condition.

Here’s some of the key information on Cicatricial alopecia: 

Symptoms – You will not only see hair loss but will also experience scalp redness, pustules, itching, and burning. 

Types – It’s divided into primary (genetic) and secondary (external factors). For example. While the external factors may vary, Cicatricial alopecia caused by primary or internal factors can be in 3 main types: 

• Lichen Planopilaris (LPP) 
• Central Centrifugal Cicatricial Alopecia (CCCA) 
• Discoid Lupus Erythematosus (DLE)

Diagnosis: You will need to undergo a scalp biopsy to determine the exact type of inflammation and the course of treatment.

Treatment: While lost hair rarely regrows in this condition, treatment can help stop further hair loss. Steroids, antibiotics, and immunosuppressants can treat this condition through injections or topical solutions.

Cicatricial alopecia is a rare group of disorders in which inflammation destroys hair follicles, replacing them with scar tissue. In fact, the word cicatricial itself means to form a scar.  

Read further to find a complete guide on Cicatricial Alopecia and how you can get ahead of it. 

What is cicatricial alopecia? 

There are 2 main types of hair loss disorders, or alopecias: scarring and non-scarring. Among non-scarring hair loss disorders, androgenetic alopecia is the medical name of male or female pattern baldness. Alopecia Areata, the second type of alopecia, is commonly associated with thyroid disease, diabetes and stress. However, these two patterns of baldness are relatively easier to reverse. 

Cicatricial Alopecia, on the other hand, ensures that the hair follicles it affects are irreversibly destroyed and replaced by scar tissue. These types of scarring hair loss disorders cannot be reversed naturally; however, they can be medically treated and controlled to limit damage.  

Let’s understand the types of scarring hair loss before defining how to diagnose and treat it. 

Types of cicatricial alopecia 

In broad terms, there are 2 main types of hair-scarring alopecia. Primary cicatricial alopecia occurs when the hair follicle is the target of the inflammation. Secondary cicatricial alopecia is where the hair follicles are permanently destroyed due to external factors. 

Let’s break this down into further details.

Primary cicatricial alopecia

1. Lymphocytic 

This occurs when your own immune cells, mainly lymphocytes, attack your hair follicles. It means your body mistakes your hair for its enemy. This condition can be chronic and autoimmune in nature. While cicatricial alopecia is rare, this is the most common type of Cicatricial Alopecia.

The common examples include: 

2. Neurophilic 

This occurs when your infection-fighting cells, neutrophils, cause the inflammation. The cause is usually an infection or a bacterial contaminant. These conditions tend to be more acute and aggressive. 

The common examples of these conditions include 

Secondary cicatricial alopecia

This condition occurs when the hair is not the direct target but is permanently damaged by external factors. These external factors often include:

• Burns or injuries 
• Severe infections 
• Radiation 
• Physical trauma

These secondary factors can also trigger primary conditions in your body, which, in turn, can lead to cicatricial alopecia.

With so many risks and identification patterns. How can you identify scarring hair loss? 

Symptoms of cicatricial alopecia

The symptoms of scarring hair loss can vary depending on its subtype. However, there is a clear link from early inflammation to eventual permanent damage.  

If you’re able to identify this condition in its early stages, chances are you will be able to treat and control your hair loss. So, with that in mind, let's look at a breakdown of what the journey of scarring hair loss looks like.

Early symptoms 

In the initial stages, symptoms will be related to scalp inflammation. 

• Itching and burning sensation
• Tender scalp with increased sensitivity 
• Redness around the hair follicles 
• Flaking around the hair roots 
• More hair falls in isolated areas around the scalp

While cicatricial alopecia is still in this stage, it can be controlled, even if it’s not reversed. 

Advanced symptoms 

As the condition progresses to this stage, the damage is usually permanent and likely to leave scars. 

• Clearly defined patches of hair loss. 
• Increasingly scarred skin on your scalp 
• Lesser visible posts or follicles 
• Skin pigmentation on the scalp, either lighter or darker 
• Pustules that might also leak
• Crusting from the discharge 
• Softer, more swollen scalp. 

While the patterns will vary by alopecia subtype, knowing where to look can help with early identification. Here are some of the common areas where these changes are likely to appear first. 

Key areas affected 

Here are some common areas of the scalp where cicatricial alopecia often has an early impact. 

• Crown – This is common, especially for central centrifugal cicatricial alopecia (CCCA), and it will most likely spread outwards from here. 
• Hairline and temple – A receding hairline, hair loss in the eyebrows, and signs of inflammation can indicate scarring hair loss. 
• Patchy areas across the scalp – For Lichen Planopilaris (LPP) and lupus-related alopecia, hair fall often starts in small patches before spreading across the scalp. 

Now that we’ve understood how to identify cicatricial alopecia, let’s look at how to diagnose its subtypes and how to treat them.

How is cicatricial alopecia diagnosed? 

Diagnosis of scarring hair loss requires a combination of clinical evaluation and specialised tests. This is mainly because in the early stages, this disease can resemble other common types of alopecia. 

The treatments rely on accurate identification of the subtypes based on scarring and other features.

Clinical exams

A detailed scalp and medical evaluation is the first step. In this stage, the doctor will assess 

• The pattern and location of hair loss are commonly in the crown, hairline, or in patches.
• Presence of any inflammation, redness or swelling. 
• Decrease or destruction of follicular openings 

They might also require your medical history and ask about your hair care practices to better understand your ailment. This will help them identify if your alopecia is scarring or non-scarring. 

Trichoscopy 

Also known as scalp dermoscopy, this is a non-invasive imaging technique that is used to examine the scalp and identify: 

• Blocked follicular openings 
• Active inflammation or redness near your follicles. 
• Abnormal hair shafts 
• Signs of irritation or swelling around the blood vessels on your scalp  

Triposcopy is another effective tool for identifying cicatricial alopecia early and zeroing in on the right areas for biopsy. 

Scalp biopsy 

This is the most effective way to diagnose cicatricial alopecia. In this process, a tiny sample of scalp tissue is examined under a microscope. It helps identify 

• Types of inflammatory cells: lymphocytic, neutrophilic or mixed. 
• Extent of the damage to the follicles 
• Specific subtypes of the disease - LPP, DLE, folliculitis decalvans, etc. 

Now that we know how to identify cicatricial alopecia, let’s look at the treatment options available for this condition. 

Treatment options for cicatricial alopecia

Once your hair follicles are replaced by scar tissue, there’s little to no chance of hair regrowth. So, how can you treat cicatricial alopecia? Well, in most cases, the goal is not to regrow hair but to manage the symptoms and stop the condition from worsening. This includes controlling inflammation and preventing further hair loss.

Tried & tested medical treatments 

Traditional treatments usually include corticosteroids, a class of steroids used to treat inflammation. This can be delivered as an injection, a topical or oral solution. This treatment can help slow down the damage to your hair follicles. 

Targeted treatments

This method usually focuses on adjusting treatment based on the subtype of cicatricial alopecia and the associated scarring. In general, lymphocytic scarring alopecias are treated with anti-inflammatory therapies that can also help curb your immune responses. 

On the other hand, neutrophilic scarring alopecias are treated with antimicrobial and antibacterial therapies. This shift in medication matters because while the symptoms might overlap, the causes of the condition differ. 

Surgical options

Surgical options are only considered when the disease has been inactive and stable for a long period, usually a year or more. The main surgical options offered usually include hair transplants, scalp reduction or tissue expansion. 

However, the effectiveness of these treatments usually depends on the quality and volume of your donor's hair, good disease stability and adequate blood supply to your scarred areas.

Suppose you want to ensure that your hair remains relatively healthy after the surgical procedures. You might want to check out our Ultimate Hair Supplements Combo, which brings together the best of Ayurveda and modern dermatology to support your hair without side effects. 

Emerging treatments

While these solutions seem either painful or rather bleak for hair regrowth, the picture is not all gloomy. Studies suggest future treatment options could support hair growth even after scarring blocks hair follicles. Latest studies also suggest using developments in stem cell therapies and bioengineered human hair follicles. 

However, all of these treatments are still in the testing stage, with a focus on the main subtype of cicatricial alopecia, Lichen Planopilaris (LPP). 

Frequently Asked Questions

1. Is cicatricial alopecia permanent?

Yes, it causes permanent hair loss due to follicle destruction, but early treatment can stop progression.

2. What is the main cause of cicatricial alopecia?

It is usually caused by inflammation or immune system damage to hair follicles.

3. Can hair grow back after scarring alopecia?

As of today, hair regrowth is not possible once follicles are destroyed, but treatment can preserve existing hair.

4, How do I know if my hair loss is scarring?

Signs include pain, itching, redness, and smooth, shiny bald patches without visible pores.

5. Is cicatricial alopecia common in India?

It is less common than pattern hair loss but often underdiagnosed.

6. Can stress cause cicatricial alopecia?

Stress alone doesn’t directly cause it, but may worsen inflammatory conditions.

References:

1. https://dermatrials.medicine.iu.edu/blogs/understanding-scarring-alopecia
2. https://pubmed.ncbi.nlm.nih.gov/40654557/
3. https://emedicine.medscape.com/article/1073559-overview
4. https://pmc.ncbi.nlm.nih.gov/articles/PMC3855115/

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