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Scarring Alopecia

Key Takeaways

Scarring Alopecia is an uncommon form of permanent hair loss categorized by scarring and permanent destruction of the hair follicle.

Scarring Alopecia is often categorized into two categories, Primary and Secondary.

Primary Scarring Alopecia is recognized as scarring alopecia in which the inflammation is directly targeting the hair follicle.

Secondary scarring alopecia can be caused by traumatic stress such as burns, accidents, surgeries or infections.

Scarring Alopecia is a complicated disease that requires expert diagnosis and a highly specific treatment.

Suspecting patients should consult an expert dermatologist for an accurate diagnosis and treatment.

Some patients are left with a cosmetically concerning permanent hair loss which in some cases can be addressed by a hair transplant surgery.

an uncommon form of permanent hair loss categorized by scarring and destruction of the hair.

Scarring Alopecia (Cicatricial Alopecia)

 

While the male and female pattern hair loss and other causes of hair loss (Alopecia Areata) are known as non-scarring, scarring Alopecia is an uncommon form of permanent hair loss categorized by scarring and permanent destruction of the hair follicle which can be caused by a number of infectious, autoimmune or inflammatory conditions.

Scarring Alopecia is often categorized into two categories, Primary and Secondary.

Primary Scarring Alopecia is recognized as scarring alopecia in which the inflammation is directly targeting the hair follicle whereas in secondary scarring alopecia, the inflammation is caused by other sources and the hair follicle is impacted by it. Secondary scarring alopecia can be caused by traumatic stress such as burns, accidents, surgeries or infections such as pemphigus vulgaris or acne-prone keloids. The cause of the secondary Scarring Alopecia inflammation should be investigated and diagnosed by an expert dermatologist considering the patient’s medical and personal history in order to start the right treatment regimen. Primary scarring alopecia is not a rare finding, up to 7% of hair loss patients visiting specialist clinics are diagnosed with it.

an uncommon form of permanent hair loss categorized by scarring and destruction of the hair.

We will focus on Primary Scarring Alopecia (Cicatricial Alopecia) due to its clinical significance. While the exact cause of Cicatricial Alopecia in many cases is unknown and debatable, Scarring Alopecia is often categorized based on the primary inflammatory cells involved in each case. We will focus on the six most common types of primary cicatricial alopecia which are: Lichen Planopilaris, Pseudopelade of Brocq, Central Centrifugal Cicatricial Alopecia, Discoid Lupus Erythematosus, Folliculitis Decalvans, and Acne Keloidalis.

Lichen Planopilaris

 

While the cause of lichen planopilaris is still unknown, it can be subcategorized in to three conditions: lichen planopilaris, frontal fibrosing alopecia, and Graham-Little syndrome.

Lichen planopilaris often affects adult women in their 30s to 60s with a multi focal or diffuse shedding pattern often on the center of scalp. The scalp is often the only affected site where the affected follicles can be pulled easily, leaving a thinner scalp region. Although this disease usually progresses slowly, It can however lead to an extensive rapid loss as well.

Frontal fibrosing alopecia mostly affects post-menopausal women. However a few cases in premenopausal women and some cases in men have been reported in medical literature as well. This condition is distinguished by the recession of frontal and temporal hairline where the healthy skin is replaced by a shiny scarred skin. The extent of this recession can range from a few to several centimeters while patchy or complete eyebrow loss is also frequently observed. In some cases other scalp sites can be affected as well.

Graham-Little syndrome is a rare condition distinguished by its unique symptoms of patchy scarring hair loss in the scalp, non scarring hair loss in the armpits and pubic region and papules and scaling on the trunk of the body.

form of scarring hair loss affecting women causing diffuse shedding.

Pseudopelade of Brocq

 

This disorder occurs in middle-aged adults and unlike lichen planopilaris, pseudopelade of Brocq patients rarely have symptoms of inflammation. It often leads to patches of hair loss (sometimes the entire central scalp is affected) with supple white skin.

 

Central Centrifugal Cicatricial Alopecia (CCCA)

 

This disorder is mainly observed in women of african descent and is also called Hot-comb Alopecia, Follicular Degeneration Syndrome, and Pseudopelade. It is believed that certain hair care practices might be the cause of this disorder, however recent studies has proven that is not the case. Much like pseudopelade of Brocq, this condition has minimal symptoms as well while some patients might experience irritation on the affected areas. CCCA often impacts the center of the scalp and progress outward over years leaving a shiny soft scalp.

Discoid Lupus Erythematosus

This condition is mainly observed in adult women and is also called Chronic Cutaneous Lupus Erythematosus. Discoid lupus usually affects other sites in the body as well with only 11% – 20% of the cases being limited to the scalp alone. This condition often represents as patchy hair loss accompanied with burning or stinging sensation which often progresses. In advanced stages, the skin will change shape and often develop hypo and hyperpigmentation as well. There is a 5% – 10% risk of systemic Lupus Erythematosus more commonly in patients with widespread cutaneous form of the disease. Unlike other forms of primary scarring alopecia, discoid lupus erythematosus is potentially reversible given prompt treatment.

 

Folliculitis Decalvans

Folliculitis Decalvans is the inflammation of the scalp hair follicles caused by Staphylococcus aureus bacterial infection. This condition often occurs in young to middle-aged adults without experiencing Staphylococcus aureus infection elsewhere in the body. Symptoms of infection includes painful pimples, hair loss, pustules, crusting and oozing. As disease progresses, scarring alopecia becomes apparent with large areas of bare scalp.  

 

Acne Keloidalis

Acne Keloidalis often affects post pubertal men of african descent resembling a scar or keloid. This condition presents as scattered brown to red pimples or pustules with or without crusting, while larger keloids like plaques might develop as well.

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Treatments   

Scarring Alopecia is a complicated disease that requires expert diagnosis and a highly specific treatment. Suspecting patients should consult an expert dermatologist for an accurate diagnosis and treatment which can involve a range of options from corticosteroids to antibiotics to other medications.

After the proper diagnosis and treatment is applied, some patients are left with cosmetically concerning permanent hair loss areas. In some cases, this hair loss can be addressed by a hair transplant surgery. Dr. Nagai has years of experience properly diagnosing the suitable candidates and performing successful transplant surgeries to address this cosmetic issue.

REFERENCES
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