Cicatricial alopecia, also called scarring alopecia, is a group of rare disorders that destroy hair follicles, the part of the skin from which the hair grows. The follicles are replaced with scar tissue, causing permanent hair loss.

Normal hair follicle and surrounding structures in the skin.

Cicatricial alopecia has two forms:

• In the primary form, immune cells inflame and destroy the hair follicle. There are two types of immune cells that can do this: lymphocytes or neutrophils. These immune cells could either work alone or with each other.
• In the secondary form, the hair follicle is not the direct target. Instead, it is destroyed by another cause, such as a severe burn, infection, radiation, or a tumor.

This content focuses on the primary form.

Forms of Cicatricial Alopecias

Those involving mostly lymphocytes:

• Lichen planopilaris (LPP).
• Frontal fibrosing alopecia.
• Central centrifugal alopecia.
• Pseudopelade of Brocq.

Those involving mostly neutrophils:

• Folliculitis decalvans.
• Tufted folliculitis.

Those involving both (called mixed inflammatory infiltrate):

• Dissecting cellulitis.
• Folliculitis keloidalis.

Cicatricial alopecia is not contagious. It occurs worldwide in otherwise healthy men and women. It affects all ages, but is not common in children. Having the disease does not typically mean someone else in your family will have it.

One exception is central centrifugal alopecia. It most commonly affects women of African ancestry and may occur in more than one family member.

There is not much known about what causes cicatricial alopecia. What researchers do know is that redness, heat, pain, or swelling occurs at the upper part of the hair follicle. This is where stem cells and oil glands are located. Stem cells are cells that can develop into many different kinds of cells. If the stem cells and oil glands are destroyed, the hair follicle cannot regrow. This means hair is permanently lost.

Hair loss can happen quickly. In this case, you would feel severe itching, pain, and burning. In other cases, hair loss is gradual, and there are no other symptoms.

To diagnose cicatricial alopecia, your doctor may take a sample from the area of the scalp where you’ve lost hair follicles. The sample provides information about which type of cell is involved, where and how much inflammation there is, and whether the oil gland is still there. It can also show other changes in the scalp.

Other things your doctor will do:

• Look at your scalp for signs of redness, scaling, and infection; and to see how much hair you’ve lost and where.
• Ask you if there are areas on your scalp where you feel itching, burning, or tenderness.
• See if hairs easily pull out to find areas of active disease.
• Look at the base of the hair to see if hairs pulled out are resting or growing.
• Take samples of any fluid-filled bumps to find out what is causing the inflammation.

Medication. Because hair does not grow back if you have cicatricial alopecia, it is important to begin treatment before too much hair is lost. Treatment depends upon the type of immune cell that is destroying the hair follicle. Medicines could be taken by mouth, applied to the top of the skin, or injected into affected areas.

Although hair cannot grow back after a follicle has been destroyed, it may be possible to stimulate follicles in the affected area before permanent damage occurs. A medicine used to treat high blood pressure may stimulate follicles to promote hair growth.

Treatment usually lasts a long time. It continues until the symptoms and signs are controlled, and hair loss slows or stops. Unfortunately, hair loss may continue silently even after the symptoms and signs have been removed. After cicatricial alopecia stabilizes, it may start up again after a period of years, and treatment may need to be restarted.

Surgery. After the disease has been inactive for 1 or 2 years, surgical hair restoration or scalp reduction may be useful for restoring hair to bald areas. In hair restoration surgery, also known as hair transplantation or follicular micrografting, follicles from the back of the head are surgically removed and transplanted into bare areas of the scalp. In scalp reduction, a bald area of the scalp is removed, and the part of the scalp next to it is pulled together to cover the gap. It is important to understand that cicatricial alopecia may recur even after these surgeries.

Dermatologists diagnose and treat cicatricial alopecia. Dermatologists are doctors trained to diagnose and treat diseases of the skin, hair, and nails.