Scarring Alopecia: Causes, Diagnosis & Treatment

What Is Scarring Alopecia (Cicatricial Alopecia)?

Scarring alopecia, also called cicatricial alopecia, is a group of hair loss conditions where the hair follicle is destroyed and replaced with scar tissue. Unlike common pattern baldness, where follicles shrink but stay alive, scarring alopecia kills the follicle permanently. Once that happens, the hair cannot grow back on its own. The condition can affect anyone, and it often starts as small patches of hair loss that slowly expand. Because the damage is irreversible, early diagnosis matters a great deal. The sooner a doctor identifies the type and starts treatment, the better the chance of saving the remaining hair.

Causes and Types of Scarring Alopecia

Doctors divide scarring alopecia into two broad groups: primary and secondary. In primary scarring alopecia, the inflammation targets the hair follicle itself. In secondary scarring alopecia, something else damages the follicle from the outside, such as an infection, injury, or another skin disease. The exact cause of many primary types is not fully understood, but the immune system is thought to play a central role in most of them.

• Lichen planopilaris — an autoimmune condition that causes inflammation around the upper part of the follicle, often with redness and scaling.
• Frontal fibrosing alopecia — a variant of lichen planopilaris that mainly affects the hairline and eyebrows, most often in women.
• Discoid lupus erythematosus — a form of lupus that can cause scarring hair loss on the scalp, usually with redness and scaling.
• Folliculitis decalvans — a chronic bacterial infection that leads to pus-filled bumps, crusting, and scarring patches.
• Central centrifugal cicatricial alopecia — a common type in women of African descent, often linked to certain hair care practices.
• Dissecting cellulitis — a painful condition with lumps and pus on the scalp, more common in men of African descent.
• Secondary causes — burns, trauma, radiation, severe infections, or long-term traction from tight hairstyles.

Symptoms and Warning Signs

Scarring alopecia does not always look dramatic at first. Many people notice a small bald patch, some itching, or a bit of redness and assume it will pass. The problem is that the inflammation can quietly destroy follicles for months before the hair loss becomes obvious. Knowing the warning signs helps you act early.

• Patches of hair loss that slowly get bigger
• Itching, burning, or tenderness in the affected area
• Redness, scaling, or flaking around the bald patches
• Pus-filled bumps or crusting on the scalp
• Loss of eyebrows or eyelashes
• Smooth, shiny skin where hair used to be
• A widening part line or thinning at the crown
• Hair that pulls out easily around the edges of a bald patch

How Is Scarring Alopecia Diagnosed?

Diagnosis usually starts with a detailed history and a close look at your scalp. A dermatologist will ask when the hair loss started, whether it itches or hurts, what hair products and styles you use, and whether you have other health conditions. From there, several tests can help pin down the exact type.

• Scalp examination with a dermatoscope to check for loss of follicular openings and signs of inflammation
• Pull test to see how easily hairs come out around the edges of a patch
• Scalp biopsy — a small sample of skin taken to look at the follicles under a microscope
• Blood tests to rule out thyroid problems, lupus, or other autoimmune conditions
• Fungal culture or swab if an infection is suspected
• Photographs to track changes over time

Treatment Options for Scarring Alopecia

Treatment for scarring alopecia aims to stop the inflammation, slow or halt the hair loss, and preserve the hair you still have. There is no cure that brings back hair from scarred follicles, so the focus is on controlling the condition. The right approach depends on the type and how active it is. Some treatments are topical, some are injected, and some are taken by mouth.

• Topical corticosteroids — creams or lotions applied to the scalp to reduce inflammation
• Intralesional corticosteroid injections — shots directly into the affected areas
• Oral medications — such as hydroxychloroquine, doxycycline, or immunosuppressants for more stubborn cases
• Antibiotics — for types like folliculitis decalvans
• Minoxidil — sometimes used to support remaining hair, though it does not reverse scarring
• PRP (platelet-rich plasma) — may help in some cases by promoting healing, but evidence is limited
• Laser therapy — low-level laser may reduce inflammation in certain types
• Hair care changes — avoiding tight styles, harsh chemicals, and heat

Is a Hair Transplant Suitable for Scarring Alopecia?

A hair transplant can sometimes help people with scarring alopecia, but it is not a straightforward fix. The key rule is that the condition must be inactive and stable for at least a year before surgery is considered. If inflammation is still present, a transplant can trigger more scarring and the new grafts may not survive. Even in stable cases, the scar tissue may have poor blood supply, which can limit graft survival. A surgeon will usually test a small area first to see how the scalp responds. If you are exploring surgical options, it helps to understand how procedures like FUE work and what they involve.

Related Hair Loss Conditions

Scarring alopecia is just one of many reasons people lose hair. Some conditions look similar but have very different causes and treatments. If you are not sure which one you have, comparing the basics can help you ask better questions at your appointment. Androgenetic alopecia is the most common form and is driven by genetics and hormones. Telogen effluvium is a temporary shedding condition often triggered by stress, illness, or medication. Alopecia areata is an autoimmune condition that causes smooth, round patches. Traction alopecia comes from years of tight hairstyles and can become permanent if not caught early. Diffuse thinning spreads across the whole scalp rather than forming distinct patches.

Frequently Asked Questions