|Scarring alopecia (Cicatricial alopecia )
alopecia, also known as cicatricial alopecia,
refers to a collection of hair loss disorders
that may be diagnosed in up to 3% of hair loss
patients. It occurs worldwide in otherwise healthy
men and women of all ages.
Each specific diagnosis within this category
is fairly rare, but some examples include dissecting
cellulitis, eosinophilic pustular folliculitis,
follicular degeneration syndrome (previously
called "hot comb" alopecia), folliculitis
decalvans, lichen planopilaris, and pseudopelade
of Brocq, to name a few. Scarring alopecia may
also be part of a much larger condition such
as chronic lupus erythematosus, where many organs
of the body can be affected.
While there are many forms of scarring alopecia,
the common theme is a potentially permanent
and irreversible destruction of hair follicles
and their replacement with scar tissue.
Most forms of scarring alopecia first occur
as small patches of hair loss that may expand
with time. In some cases the hair loss is gradual,
without noticeable symptoms, and may go unnoticed
for a long time. In other instances, the hair
loss is associated with severe itching, burning,
and pain, and is rapidly progressive.
The scarring alopecia patches usually look a
little different from alopecia areata in that
the edges of the bald patches look more "ragged."
The destruction of the hair follicle occurs
below the skin surface so there may not be much
to actually see on the scalp skin surface other
than patchy hair loss. Affected areas may be
smooth and clean, or may have redness, scaling,
increased or decreased pigmentation, or may
have raised blisters with fluids or pus coming
from the affected area.
These visual indicators may help with diagnosis,
but it is difficult to diagnose a scarring alopecia
just from the pattern of the hair loss and the
nature of the scalp skin. Often when scarring
alopecia is suspected, one or more skin biopsies
are done to confirm the diagnosis and help identify
the particular form of scarring alopecia. A
small biopsy of 2 to 4 mm in diameter is taken
and examined under a microscope. A pathologist
or dermatologist will look for destruction of
the hair follicles, scar tissue deep in the
skin, and the presence and location of inflammation
in relation to the hair follicles.
Often, the early stages of a scarring alopecia
will have inflammatory cells around the hair
follicles, which, many researchers believe,
induces the destruction of the hair follicles
and development of scar tissue. However, there
is some argument about this among dermatologists,
as sometimes a biopsy from a scarring alopecia-affected
individual shows very little inflammation.
Scarring alopecia almost always burns out. The
bald patches stop expanding and any inflammation,
itching, burning, or pain goes away. In this
end stage, another skin biopsy usually shows
no inflammation around hair follicles. Bald
areas usually have no more hair follicles. Sometimes,
though, hair follicles, at least those at the
periphery of a bald patch, are not completely
destroyed and they can regrow, but often all
that is left are just a few longitudinal scars
deep in the skin to show where the hair follicles
Scarring alopecia can involve a lot of damage
and permanent hair loss. For this reason treatment
of scarring alopecia should be quite aggressive.
The nature of treatment varies depending on
the particular diagnosis. Scarring alopecias
that involve mostly lymphocyte inflammation
of hair follicles, such as lichen planopilaris
and pseudopelade, are generally treated with
corticosteroids in topical creams and by injection
into the affected skin. In addition, antimalarial
and isotretinoin drugs may be used.
For scarring alopecias with inflammation of
mostly neutrophils or a mixture of cells, the
typical treatment involves antibiotics and isotretinoin.
More experimentally, drugs like methotrexate,
tacrolimus, cyclosporin, and even thalidomide
have been used to treat some forms.
Once a scarring alopecia has reached the burnt-out
stage and there has been no more hair loss for
a few years, bald areas can be either surgically
removed if they are not too big or the bald
patches can be transplanted with hair follicles
taken from unaffected areas