Hair Loss

Scarring (Cicatricial) Hair Loss

Scarring (Cicatricial) Hair Loss

Scarring hair loss is typically caused by inflammation that results in destruction of the hair follicle leading to irreversible hair loss. The main goal of the treatment is to reduce inflammation and itching, burning, tenderness and hair loss caused by inflammation, before the follicles are completely destroyed.

Lichen Planopilaris (LPP):

It is a type of Primary Cicatricial Alopecia that usually occurs in the middle of the scalp, the sides of the scalp or lower back of the scalp with one or more oval shiny hair loss, the shedding is in the form of a patch.

The symptoms are itching and sensitivity at the lesion area. Examination reveals initial perifollicular erythema (redness around the follicle) and / or hyperkeratosis. In the late stage, burning and tenderness and redness on the scalp can be observed. Skin biopsy can be done to confirm the diagnosis. During the biopsy, loss of sebaceous glands, a lymphocytic leak in follicles can be observed. Skin, mucous and nail lesions often accompany. There is no FDA approved therapy for this condition. Treatment options include topical corticosteroids, intra-dermal steroid injections into the lesion area, and doxycycline (anti-inflammatory). Hydroxychloroquine, methotrexate, mycophenolate mofetil and oral 5-alpha reductase inhibitors can be found. There are some evidences that the diabetes drug pioglitazone may also help the treatment.

Frontal Fibrosing Alopecia:

It is characterized by band-like cicatricial alopecia of the frontotemporal zone of the scalp. In some cases, the eyebrows, eye lashes and/or other parts of the body may be involved, as well. Usually itching and burning may be seen at the lesion area.

A slight redness and keratosis can be seen on the hairline. The scalp pathology report is very similar to those seen with LPP, and a lymphocytic leak is observed around the hair follicles. Again there is no FDA approved therapy for this condition, however, topical and intralesional corticosteroids, doxycycline, hydroxychloroquine, methotrexate, mycophenolate mofetil and oral 5-alpha reductase inhibitors are used in primary care. The diabetes drug pioglitazone is being tested also.

Central Centrifugal Cicatricial Alopecia (CCCA):

This type of hair loss can be seen almost exclusively and most commonly at African origin patients. Hair loss, itching, burning and tenderness are seen at the top of the scalp, in a round shape, extends outward in a centrifugal manner. There are some evidences that it may be inherited. Although there is an association with hot combs and narcotics which are applied to the hair, there is no evidence and satisfactory observation.

Hair loss typically begins at the vertex or mid-scalp and extends outward in a centrifugal manner. Patients may also complain of itching, burning or tenderness in the affected areas. There are evidences that this condition can happen in families, it is less likely due to grooming techniques such as relaxers or hot combs. Fibrosis, loss of sebaceous glands and lymphocytic leakage are observed in the pathology, and a developmental disorder of the inner root sheath can be observed. Intralesional steroid injection, topical steroids and oral doxacillin can be used in the treatment.

Hair Root Inflammation (Folliculitis Decalvans):

This condition can be seen in young men and it has been reported rarely in women.

It is seen in the form of sensitive crusted wounds on the scalp and there are pustules surrounding the hair follicles. Bacteria (Staphylococcus or Streptococcus) or fungi usually cause secondary infection in lesions. Bacterial and fungal culture is recommended in addition to scalp biopsy for diagnosis. Unlike other scarred lesions, biopsy is characterized by a neutrophilic infiltrate. Treatment ideally includes any cleansing where infection is present, topical or intralesional corticosteroids, as well as anti-neutrophilic drugs such as dapsone. The rifampin combination and clindamycin have also been used successfully. In addition, antibiotics or anti-mycotic drugs can be added according to the culture result.

Discoid Lupus Erythematosus (DLE):

Cutaneous lupus erythematosus (CLE) can be divided into three main subtypes: photosensitive acute, subacute and chronic. Acute cutaneous lupus erythematosus (ACLE), most commonly seen as symmetrical erythema facing the malar cheeks and bridge of the nose with nasolabial folds (butterfly rash) nasally.

This condition, also known as chronic cutaneous lupus, is an autoimmune process with scarring, limited to the skin and hair. It most commonly affects patients of African origin, but can also be seen in Caucasians. Classically it presents as many red scaly plaques on sun-exposed areas such as the scalp, ears, and face. Over time, these plaques will heal with leaving scars and pigment changes. Follicular occlusion can occur with hair loss, and scalp pathology shows a very viable lymphocytic infiltrate affecting both skin and hair structures.

Flare-ups are common with increased exposure to sunlight, especially in the spring and summer times. Serious systemic disease is rare, but when it occurs, patients can develop life-changing sequelae. Malignant degeneration is not uncommon in DLE lesions, but it can occur. Therefore, biopsy must be applied immediately to the progressive lesions which develop in chronic DLE lesions.

Only 5-10% of patients continue to develop systemic lupus. Those affected are also at an increased risk of developing certain skin cancers, namely squamous cell carcinoma, in chronic scars. Treatment aims to reduce inflammation and then scarring. Patients must be informed about sun protection techniques and correct use of sunscreens, wide-brimmed hats and protective clothing, and the serious harm of smoking. In addition to sun protection, the mainstay therapy includes topical or intralesional steroids and hydroxychloroquine. Antimalarial therapy appears to reduce the progression to systemic lupus erythematosus (SLE) and reduce the risk of thrombovascular disease. Alternative treatments include thalidomide, oral or topical retinoids, and immunosuppressive agents. Thalidomide is used regularly in patients with antimalarial resistance. Additionally, lenalidomide may benefit some patients.

Folliculitis Keloidalis:

It is a condition characterized by follicular-based papules and pustules that form hypertrophic or keloid-like scars. This condition is mostly seen in young men of African and Asian origin. It starts from the nape with small itchy bumps that resemble keloid scars. Scars can expand and join together and cover large areas behind the scalp. The lesions are caused by folliculitis, broken hairs, clustered hairs and ingrown hairs can be detected within and around the plaques.

The trauma from a haircut can be the cause of this condition. Patients should be aware that the condition can go worse by short haircuts and close shaves. In addition, shirts with tight collars, athletic headgear, and spontaneous manipulation should be avoided as they may result in mechanical cutting of the hair.

Starting the treatment as soon as possible after the first appearance of the lesions can reduce the long-term cosmetic deformities. Gentle foaming benzoyl peroxide washers or topical antimicrobial cleansers / shampoos such as chlorhexidine can help prevent secondary infection. Tar shampoos can provide an effective alternative. In addition, mild keratolytic substances containing alpha-hydroxy acids or topical retinoids can help soften coarse hair. In the early period, mild papular disease may respond to potent or super topical steroids, with or without the use of topical retinoids. This final combination appears to be slightly more effective than super spot topical steroids alone.

If there is pus or serous drainage, a culture should be taken. Using a topical antibiotic (such as clindamycin) twice a day may be advantageous to treat any bacterial superinfection. If active folliculitis is present, oral antibiotics such as doxycycline or minocycline should be used for several weeks to control the inflammation. If active folliculitis persists or progresses despite adequate treatment, culture tissue and antibiotics are determined accordingly.

Intralesional steroid injection can be helpful to reduce the size and density of papules and nodules. Doses range from 5 mg / mL to 40 mg / mL for rough and larger lesions. Lesions can be debulked by shaving or curettage prior to injection with triamcinolone.

Recently, Okoye and her colleagues have demonstrated that targeted ultraviolet B (290-320nm) phototherapy three times a week for 8 weeks can improve the clinical appearance of fibrotic papules. In rare cases where patients have large, inflamed lesions, short-term oral corticosteroids may be considered. The primary option is surgical excision.


Although this is the less understood condition, it occurs as a result of chemical or mechanical trauma in areas of skin damaged by the sun. Patients with a history of skin cancer surgery, radiation or chemotherapy with 5-fluorouracil or imiquimod have been reported in the literature. Scalp pathology shows a mixed inflammatory infiltrate, often with secondary bacterial colonization. This condition usually improves with high potency topical steroids such as clobetasol and clearance of any infection.


It is a rare disease. It is mostly seen in black men. This condition begins with wavy, drooping patches on the scalp and can develop into conjoining sinus ducts containing sterile pus. Scalp pathology shows a neutrophilic infiltrate and bacterial or fungal cultures are usually negative. The prognosis for recovery is poor, the disease is not life threatening, but it is a chronic and recurrent disease.

Complications can include;

– Squamous cell carcinoma: Development is a possibility in chronic, recurrent lesions.

– Permanent alopecia: It is seen in chronically inflamed and injured areas.

– Marginal keratitis: A possible clinical relation has been observed

This is usually treated with oral antibiotics such as doxycycline or sulfamethoxazole / trimethoprim. The disease can be very difficult to treat, but newer biological drugs such as adalimumab can help the treatment.

Erosive Pustular Dermatosis:

Although this is the less understood condition, it occurs as a result of chemical or mechanical trauma in areas of skin damaged by the sun. Erosive pustular dermatosis of the scalp (EPDS), is a chronic skin disease that typically affects the elderly and characterized by keratotic, erosive, and purulent plaques that heal with scar alopecia. Although erosive pustulosis is usually asymptomatic, patients may occasionally complain of pain, itching, or burning in the area. Yellow-brown keratotic crusts, superficial erosions, non-sterile follicular and skin atrophy can be observed.

Patients with a history of skin cancer surgery (Mohs), radiation or chemotherapy with 5-fluorouracil or imiquimod have been reported in the literature. Scalp pathology shows a mixed inflammatory infiltrate, often with secondary bacterial colonization. This condition usually treated with using highly effective topical steroids such as clobetasol and clearance of any infection.

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