Scarring Alopecias

What is scarring hair loss?

Scarring hair loss, also called cicatricial alopecia, describes a group of conditions in which inflammation damages and destroys the hair follicles. The follicles are replaced by scar tissue, so the hair loss is permanent. Early diagnosis is particularly important, because hair that has already been lost cannot regrow, but further loss can often be slowed or stopped.

Types of scarring hair loss

Lichen planopilaris is an inflammatory condition related to lichen planus. It causes patches of hair loss with redness, scaling and sometimes tenderness around the remaining hair follicles, most often on the crown and top of the scalp. Women are affected two to five times as often as men, and most people affected are in their 40s or 50s.

Frontal fibrosing alopecia is a type of lichen planopilaris that causes a band-like recession of the frontal hairline and often loss of the eyebrows. It most often affects white women after the menopause, but it can affect younger women, men and people of all ethnic backgrounds. Small skin-coloured bumps on the face may be seen.

Discoid lupus erythematosus can cause scarring patches of hair loss with redness, scaling and changes in skin colour, and may also affect the face and ears.

Central centrifugal cicatricial alopecia, previously known as hot comb alopecia, starts at the crown and spreads outwards. It is seen almost only in women of African heritage with tightly curled hair, and it generally begins in their 30s.

Folliculitis decalvans and dissecting cellulitis of the scalp cause inflamed, pustular or boggy areas with progressive hair loss.

Traction alopecia, caused by long-term tension on the hair from tight hairstyles, braids, weaves or extensions, can also become permanent if the tension continues for many years.

Who gets it?

Who is affected depends on the type. Lichen planopilaris and frontal fibrosing alopecia mainly affect women, particularly after the menopause. Central centrifugal cicatricial alopecia mainly affects women of African descent. Traction alopecia affects people who wear tight hairstyles over long periods.

What causes it?

The cause varies with the type. Many are thought to involve the immune system attacking the hair follicle. Hormonal factors are thought to play a part in frontal fibrosing alopecia, and in central centrifugal cicatricial alopecia, genetic factors (including changes in a gene called PADI3 in some people), heat styling, chemical relaxers, tight hairstyles and type 2 diabetes may all contribute. Hair care practices are also the cause of traction alopecia.

Is it hereditary or contagious?

Most types of scarring hair loss are not inherited, although genetic factors play a part in some, such as central centrifugal cicatricial alopecia. Scarring hair loss is not contagious.

What does it look and feel like?

Signs that hair loss may be scarring include smooth, shiny patches where follicle openings can no longer be seen; redness, scale or darker discolouration around remaining hairs; and itch, burning, tingling or tenderness of the scalp. Some types are very symptomatic, while others progress quietly with few symptoms apart from gradual thinning or a receding hairline.

How is it diagnosed?

Diagnosis involves a careful history and examination of the scalp with a dermatoscope. A scalp biopsy taken under local anaesthetic is often recommended to confirm the type of scarring alopecia and to guide management. Blood tests may also be suggested.

What is the outlook?

Scarring hair loss is usually long-lasting, although some types, including lichen planopilaris, eventually become inactive in most people. The aim is to calm the inflammation and stop further follicles from being destroyed. Seeking assessment as early as possible gives the best chance of preserving hair.

More information

British Association of Dermatologists patient leaflet on lichen planopilaris: https://www.bad.org.uk/pils/lichen-planopilaris

British Association of Dermatologists patient leaflet on frontal fibrosing alopecia: https://www.bad.org.uk/pils/frontal-fibrosing-alopecia

British Association of Dermatologists patient leaflet on central centrifugal cicatricial alopecia: https://www.bad.org.uk/pils/central-centrifugal-cicatricial-alopecia

This page gives general information only and is not a substitute for a consultation. Everyone's skin is different, and what is right for you will depend on your own circumstances. If you are worried about a skin problem, please book an appointment with Dr Mounsey or speak to your GP. If you have a mole or skin lesion that is changing, bleeding or growing quickly, please seek medical advice promptly.