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Scarring alopecia is a challenging form of hair loss that can permanently damage hair follicles, making early diagnosis and treatment especially important. Dr. Zain Husain, Heather Murray, and Courtney Carroll explore several types of scarring alopecia, including lichen planopilaris (LPP), frontal fibrosing alopecia (FFA), central centrifugal cicatricial alopecia (CCCA), folliculitis decalvans, and dissecting cellulitis of the scalp.
The team discusses common warning signs, such as itching, redness, scaling, pustules, tenderness, and changes in the hairline. They also explain how dermatologists evaluate these conditions through medical history, scalp examinations, trichoscopy, and sometimes biopsies. Treatment often focuses on reducing inflammation and preserving remaining hair, with options including topical and injected steroids, oral medications, and antibiotics.
Because damaged follicles are difficult to restore, the conversation emphasizes realistic expectations, ongoing monitoring, and the importance of finding the correct diagnosis before considering a hair transplant. The team also discusses cosmetic options such as scalp micropigmentation and hair systems, along with the emotional challenges of living with hair loss.
00:00 What is scarring alopecia?
00:00 What is scarring alopecia?
01:00 Primary vs. secondary scarring alopecia
02:30 Lichen planopilaris and its warning signs
03:30 Frontal fibrosing alopecia
05:30 Central centrifugal cicatricial alopecia
07:00 Diagnosing CCCA and exploring treatment options
08:30 Folliculitis decalvans and scalp inflammation
09:30 Dissecting cellulitis of the scalp
11:00 How dermatologists diagnose scarring alopecia
13:30 When a scalp biopsy may be needed
14:30 Treatments to reduce inflammation
16:30 Can hair grow back after scarring alopecia?
17:30 Hair transplants and scarring alopecia
19:00 Scalp micropigmentation and hair systems
20:00 Monitoring treatment progress
21:00 Managing expectations and the emotional impact of hair loss
Creators and Guests
Host
Host
What is Skinside Out?
Welcome to Skinside Out, where science meets beauty, the ultimate dermatology podcast! Dive deep into the fascinating world of skin health with expert insights, evidence-based discussions, and myth-busting truths. Each episode explores the medical, cosmetic, and surgical aspects of dermatology, while keeping you informed about trending skincare topics. Whether you’re a skincare enthusiast, medical professional, or just curious about how to achieve your best skin, Skinside Out is your go-to resource for staying informed and inspired.
75 Skinside Out - Deeper Dive: Scarring Alopecia
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[00:00:00]
Dr. Zain Husain, MD: Welcome to Skin Side Out. I'm your host, Dr. Zane, with Heather and Courtney. So today we're continuing our discussion on alopecias, but this time scarring alopecias. Sometimes we refer th- to this as cicatricial alopecia. So Heather, what is scarring alopecia?
Heather Murray, PA-C: scarring alopecia is pretty much where the hair follicles are not, um, open anymore and they're not, um, allowing that hair growth to be as successful in growing within that hair follicle.
Dr. Zain Husain, MD: Yeah, and there's actually like scar tissue- Yeah ... that's kind of, um, just basically obliterating that- Mm-hmm ... hair follicle and that opening.
Heather Murray, PA-C: Yeah. Yeah. And sometimes the scarring is more noticeable than others, but a lot of times it's really hard to see.
Dr. Zain Husain, MD: Yeah. And I find that this type of hair loss is really challenging to treat.
Yeah. So we'll definitely get into that once we kind of go through the different types of, you know, scarring alopecia. So I like dividing scarring alopecias into primary [00:01:00] and secondary scarring alopecia. So how would we characterize a primary cicatricial alopecia?
Courtney Carroll, LE: in the primary, usually the hair follicle is the primary target of the inflammatory process.
So, um, you know...
Dr. Zain Husain, MD: It's immune, it's more like immune mediated, right?
Courtney Carroll, LE: Yeah, I was gonna say. Yeah. Yeah. It's more of like an, almost like a self-attack, like a immune
Dr. Zain Husain, MD: response. Like a inflammatory-
Courtney Carroll, LE: Yeah ...
Dr. Zain Husain, MD: um, and destructive process. So we have like cells such as lymphocytes really kind of doing damage on the hair follicles and also the surrounding tissue leading to that fibrosis or scarring.
And, you know, we're gonna go through different examples of these types of, um, you know, scarring alopecias and, you know, we'll go into depth about LPP, frontal fibrosing alopecia, we're gonna be talking about all these different types of primary, uh, cicatricial alopecia shortly. Um, so we definitely see these immune cells, lymphocytes, neutrophils, or even mixed, um, immune cells, um, really [00:02:00] causing the damage. Now, secondary cicatricial alopecias, how do we characterize those?
Heather Murray, PA-C: So, um, secondary is pretty much where something is damaging the hair follicle.
So this can be, um, from a severe infection, trauma, burns, radiation, um, certain infiltrative or neoplastic diseases or conditions, and then severe inflammatory skin conditions too.
Dr. Zain Husain, MD: Yep. So let's start off with the primary cicatricial alopecias, so starting with lichen planopilaris, commonly referred to as LPP.
What is LPP? Courtney?
Courtney Carroll, LE: You're gonna ask the only one that didn't go to medical school.
Dr. Zain Husain, MD: Oh, that's right.
Heather Murray, PA-C: Yeah. I went to medical school.
Dr. Zain Husain, MD: All right. Then Heather, you
Courtney Carroll, LE: take
Heather Murray, PA-C: it. LPP is this type of cicatricial alopecia that we see, um, that is more lymphocytic, and so we get this, like, patchy type [00:03:00] of hair loss. Um, a lot of times, and very classically, we'll have perifollicular scaling, so a little bit of, like, um, scale, crust, or flake right around the hair follicle.
That's super common. Also, perifollicular erythema, which is redness around the hair follicles. Um, this type of hair loss is usually very itchy for people- Mm-hmm ... and I think, um, that's a big sign that something more may be going on. I think a lot of times people Notice that they have hair loss, and they think, "Oh, it's androgenic alopecia."
And I think a lot of people are quick to assume that. Um, but there are a lot of other things that could be playing a role, and, um, treatments vary a little bit with that, too.
Dr. Zain Husain, MD: Yep. And the next type of alopecia we'll talk about is frontal fibrosing alopecia, so FFA, and it's thought of as a subtype of LPP.
So frontal fibrosing alopecia has a very [00:04:00] distinct clinical presentation. So what are we seeing with these types of patients?
Courtney Carroll, LE: Um, usually that, um, temporal scalp, so right here by the temples, that, like, frontal line is gonna be affected, like, more, um, the eyebrows sometimes can be affected, like, whether that's thinning or just loss of hair in that area.
Um, and then usually it'll have kind of more of that, like, smooth, like, kind of band around the alopecia. It's
Dr. Zain Husain, MD: very shiny.
Courtney Carroll, LE: Yeah.
Dr. Zain Husain, MD: The skin is thin. Yeah. It's atrophic, and you see, like, very prominent blood vessels. Yes. Like, I always see that. Um, and you know, it's, it's got this classic look and typically affects females.
Mm-hmm. And, you know, it's progressive. And I don't know if I've really seen too many patients with significant itch with FFA. No. It's usually LPP I see it more. This is more kind of like a silent kind of progression. It keeps going on and on- Yeah ... until they come in into our office and, you know, like, "Hey, where's my hair?"
Heather Murray, PA-C: [00:05:00] Yeah.
Dr. Zain Husain, MD: And, you know, it is something that I've seen more and more as time has gone on, and I really don't know what's causing this increase. Um, but I do see an uptick in cases- Mm-hmm ... of FFA.
Heather Murray, PA-C: And it can become stable with treatments, but there's always the risk that it could just flare again.
Dr. Zain Husain, MD: Yeah. And with both LPP and FFA, um, it can have an unpredictable course.
Sometimes, you know, it progresses rapidly, then it just stops and burns out. Mm-hmm. And then sometimes it relapses again. So it's really unpredictable. So with patients, you just have to be, you know, very mindful of, you know, discussing that, hey, even though we get it under control, it may not stay under control, and we always have to be on the watch.
Yeah. All right, so next let's go to CCCA, central centrifugal cicatricial alopecia. That's a mouthful Say that five times fast. Um, so Courtney, what do we see with [00:06:00] this?
Courtney Carroll, LE: Um, I would say it's most commonly found in our African American patients. Um, specifically females I feel like get really affected by this.
Um, usually it's gonna begin around kind of like the vertex of the scalp and then kind of gradually like go outwards. So, um, like I said, it... I would say we tend to see it more so in like our African American population.
Dr. Zain Husain, MD: Yeah, and typically there's a history of using, um, harsh treatments.
Courtney Carroll, LE: Mm-hmm, chemicals,
Dr. Zain Husain, MD: heat.
Chemicals, heat. Like- Mm-hmm Relaxers ... they used to call this hot comb alopecia. Mm-hmm. Mm-hmm. And the problem is with repetitive uses of these very damaging treatments leads to essentially scarring. Mm-hmm. Mm-hmm. And it really does kind of cause the hair just to s- be destroyed.
Courtney Carroll, LE: It's like trauma over time.
Heather Murray, PA-C: Yeah. Yeah. I think this one is, um, sometimes a little bit harder to diagnose. I think sometimes in the beginning it can look like female pattern hair loss, so, uh, the female version of androgenetic [00:07:00] alopecia. Um, oftentimes because with androgenetic alopecia, which is non-scarring, um, it often starts in t- You kind of notice a wider scalp.
Mm-hmm. Mm-hmm. And CCCA often affects- The part in the top. Um, so sometimes diagnosis can be delayed. I think if you are not noticing improvement with the treatments that you're on, definitely don't feel like you, um, like there's no treatments for you because there are other options. You know, if you're not getting better, maybe it's worth considering a biopsy.
Maybe it's worth considering something like a steroid injection to see if that helps, if there's a CCCA component. And it's not always textbook as far, as far as the look or the presentation of the hair loss. Sometimes it's patchy. Sometimes it affects one area more than the other. It's not always very classic.
Dr. Zain Husain, MD: Yeah.
Courtney Carroll, LE: Is that the hair loss that sometimes you'll prescribe like dutasteride for?
Dr. Zain Husain, MD: You can. And the thing with this [00:08:00] type of hair loss, there's often concomitant androgenic alopecia and this going on, one's a scarring, one's a non-scarring alopecia. So we kind of throw whatever we can at it in hopes that, you know, we'll get some hair growth.
Mm-hmm. So oftentimes the same medications that we're using for androgenic alopecia, we're using it predominantly to get whatever we can that's the androgenetic component- Mm-hmm ... under control and maybe get some regrowth. But oftentimes with the cicatricial portion of it, it's, it's hard.
Heather Murray, PA-C: Mm-hmm.
Dr. Zain Husain, MD: You typically don't see that hair regrow.
Heather Murray, PA-C: Sometimes you can have a very inflamed scalp, and you can have like pustules, and that typically responds well to oral antibiotics. Mm-hmm. Um, but yeah, treatment is tough.
Dr. Zain Husain, MD: Yeah. So talking about pustules, um, let's get on to folliculitis decalvans. What is that?
Heather Murray, PA-C: So folliculitis decalvans is, um, inflammation that is around the hair follicle, and it's often more of a, a neutrophilic component that is contributing to this.
So we do see a lot [00:09:00] of that inflammatory reaction, so like pustules, crusts- Mm-hmm ... um, redness around the hair follicles, tenderness. Um, tufting is a big thing with folliculitis decalvans, so that is where the hairs, um... You have multiple hairs that emerge through one follicular opening. Um, that's a pretty classic presentation with it.
Dr. Zain Husain, MD: Yeah. Think about like having like inflammatory acne in your scalp.
Heather Murray, PA-C: Yeah.
Dr. Zain Husain, MD: It's kind of like that.
Heather Murray, PA-C: Yeah.
Dr. Zain Husain, MD: So very painful, um, tender, and, you know, can sometimes get some drainage coming out of that. Mm-hmm. And then a more, I guess, extreme presentation of that, um, you see dissecting cellulitis of the scalp.
Mm-hmm. So sounds awful, and it does present fairly, um, aggressively. Mm-hmm. So how does that look? Um, Courtney, what is it?
Courtney Carroll, LE: Um, normally you're gonna have really painful nodules, more like abscess kind of like lesions. Um, it's really [00:10:00] uncomfortable for patients. I've really only seen it a handful of times, and it's, every time it just looks like it hurts.
Um,
Heather Murray, PA-C: usually- You can definitely see the scarring-
Courtney Carroll, LE: Mm-hmm ... looking at this.
Dr. Zain Husain, MD: Yeah. And it's just, this can be disfiguring for the scalp. Mm-hmm. It's sometimes boggy- Mm-hmm ... tender. Um, I often sometimes find, um, palpable lymph nodes that are enlarged.
Courtney Carroll, LE: Yeah. Yeah.
Dr. Zain Husain, MD: So, um, there's a lot of inflammation going on. And many times for the severe, um, types of alopecia, for folliculitis decalvans and dissecting cellulitis of the scalp, I often use Accutane as a treatment option.
Mm. Yeah. Um, obviously after using, you know, antibiotics and other mechanisms to cool down the inflammation, I mean, that tends to be a better long-term option for patients to get it under control.
Heather Murray, PA-C: Yeah. I think it's so satisfying to be able to see that type of scarring alopecia, um, pretty much calm down and their, their hair is much more successful at, at growing.
Dr. Zain Husain, MD: , So [00:11:00] we've talked about all these different types of scarring alopecias, so the clinical exam is really important.
So when we are working up these patients, Heather, how do we approach that?
Heather Murray, PA-C: Um, I think history is a big component of that, getting details on, um, you know, when did it start? Were there any significant, um, events that happened prior? Um, the, with the exam, it's looking at patterns, looking at, um, the follicles themselves, looking for scaling or, um, crusting, pustules, and stuff like that, and that kind of helps, um, hone in on different diagnoses.
If we're worried about something like FFA, then we're taking a look at the eyebrows and, um, maybe other parts of the body too that have hair as well, and looking at that skin on the forehead, like Dr. Hussain mentioned, that it can be very thin and very [00:12:00] vascular. So, um, lots of different components that can, um, contribute to the diagnosis.
Dr. Zain Husain, MD: Yeah, and like patients with lichen planopilaris, for instance, can have lichen planus on other parts of their body. Yeah. So always doing a thorough physical exam, seeing if there's any of these itchy papules, um, on the, say, the extensors, or looking inside their mouth- Mm-hmm ... and seeing if there are, um, any like Wickham striae or anything that shows lichen planus of the mouth.
So it's really important to kind of tie these different clues together so that we can get an appropriate diagnosis. And then in terms of folliculitis decalvans and dissecting cellulitis, oftentimes a history of severe acne, um, is typically found because they're all in that same follicular, um, you know, abnormality, this tetrad of conditions like severe acne, like acne conglobata.
Um, there's, you know, pilonidal cysts- Mm-hmm ... and hidradenitis suppurativa. [00:13:00] These are all in the same spectrum of disease, so oftentimes you can see different types of inflammatory, you know, skin conditions going on at the same time.
Heather Murray, PA-C: Yeah, and I think trichoscopy is helpful. I don't think it's, um Necessary in some instances, especially- What is
Dr. Zain Husain, MD: trichoscopy?
Heather Murray, PA-C: Trichoscopy is like dermoscopy for the scalp, meaning we are using, um, magnification to look really closely at the hair follicles and see the skin around it. So I think it's, um, it's really helpful, especially, like, in terms of scarring alopecia for, like, a subtle LPP, for example. But I think a lot of times folliculitis decalvans or dissecting cellulitis of the scalp is often something that we can clinically diagnose without trichoscopy.
Dr. Zain Husain, MD: Yep. And I find that scalp biopsies are more important for cicatricial alopecia, especially active phases- Yeah ... or if they're subtle presentations, especially for, um, you know, lichen planopilaris and frontal [00:14:00] fibrosing alopecia. There are distinct clinical, um, and histological signs that we see, um, and the biopsy can really help us clinch that diagnosis and make sure that we're treating the patient appropriately and giving them the appropriate treatment.
All right. So let's talk about different treatment options that we have. So I kind of group them into two classes, right? So we've got those, you know, inflammatory primary alopecias like FFA, um, LPP, and then more like the infectious inflammatory, um, conditions like folliculitis decalvans and dissecting cellulitis.
So what do we typically treat our more primary, um, alopecias that have more of that, you know, inflammatory component?
Heather Murray, PA-C: I think calming down the inflammation is the biggest thing. Uh, topical steroids and intralesional steroids are huge for cicatricial alopecia. [00:15:00] Um, s- I think that is kind of like the primary goal is to calm down that inflammation, um, prevent any further follicular destruction, um, because once it is destroyed, it's really hard to get that hair back.
And I think setting realistic expectations is a big part of that too. Um, but also we wanna try to preserve the hair that you have too, um, to prevent those from being destroyed. And so, um, just kind of taking time to talk to the patients about realistic expectations, um, as well, I think makes the biggest, a big difference.
Dr. Zain Husain, MD: What about systemic medications?
Heather Murray, PA-C: Um, systemic medications are really great. Hydroxychloroquine is one that works really well. We talked about doxy-- or, um, antibiotics like doxycycline, for example. Um, there are lots of others, um, depending on the severity, like, um, less commonly, but like cyclosporine, for [00:16:00] example.
Um, I think depending on the involvement, I do think a lot of times with cicatricial alopecias, oral and systemic options are necessary.
Dr. Zain Husain, MD: Yeah. And hopefully there'll be more treatments down the road as we continue to advance in this particular type of, um, you know, hair loss. Um, so a common question I get from these patients, um, "So I have scarring alopecia.
Can I get my hair back?" What do you tell your patients?
Heather Murray, PA-C: , so I think a lot of times... I don't know what your experience has been, but I do feel like a lot of patients with, um, scarring alopecia understand that, um, trajectory. Um, it's unfortunate, but there, it's very difficult to get the hair growth to come back.
Dr. Zain Husain, MD: Yeah. And then what I really focus on is trying to get maybe the surrounding hair to grow [00:17:00] more efficiently- Yeah ... or denser to kind of help them, you know, get more coverage or density. So, many of the treatments that we use for, like, our androgenic alopecia patients, I often use for these patients, too, to kind of help facilitate growth- Yeah
in any way we can. Mm-hmm. So at least give them some hope, maybe see some growth, feel a little bit better, um, about their condition. And like you had mentioned, we also want to stop that inflammation in its tracks because if it continues and progresses, you know, it just gets harder and harder to treat.
Heather Murray, PA-C: Yeah.
Dr. Zain Husain, MD: Yeah. Now, other patients have asked me, "Can I do a hair transplant? So I've got all this scar tissue, why don't I just get plugs or, you know, a hair transplant and, you know, call it a day?" Why does that not work? '
Courtney Carroll, LE: Cause the follicles are essentially not gonna take the, the hair. I mean, those follicles are basically inactive, so it's, the retention is really not gonna, um, [00:18:00] happen like you would with healthy follicles.
Dr. Zain Husain, MD: Yeah. However, um, so that's in scarred areas. In areas that are still clinically active, so like, like in planopilaris, for instance, there is a possibility of doing hair transplant once the disease state is quiet and under control, with the v- uh, inflammation has been reduced for, you know, a significant period of time and it's under, you know, good control.
You can potentially contemplate doing hair transplantation, but you always have to have that, you know, thought in the back of your mind that this disease state can become active again, and it will destroy those grafts.
So it's really important when you know, seeking treatment for hair transplantation, doing a good physical exam and history is essential. I actually had a patient maybe a week or two ago, she has elements of FFA, [00:19:00] um, and she went to Bosley for a consult for hair transplantation. They're like, "Yeah, let's go.
Come on, let's schedule it."
Courtney Carroll, LE: Mm.
Dr. Zain Husain, MD: And she didn't. She just didn't feel comfortable, but I'm glad she didn't, because they weren't even treating the FFA. They didn't even know that she had FFA. Mm-hmm. And, you know, essentially they just wanna do the hair transplant and make a ton of money and, you know, she'd probably lose those grafts anyway.
Courtney Carroll, LE: Mm-hmm.
Dr. Zain Husain, MD: So it is really important.
Courtney Carroll, LE: There are, like, a lot of, um, things nowadays, like the camouflage, um, you know-
Dr. Zain Husain, MD: Scalp micropigmentation ...
Courtney Carroll, LE: scalp micropigmentation is another one, where you're basically using, yeah, ink to kind of just fill in the gaps. So it's more of, like, a visual or a cosmetic fix rather than an actual, like, medicinal fix where we're growing back the hair, but it does help to camouflage the, um, you know, the, the decrease in density.
Dr. Zain Husain, MD: Yeah. Yeah. And let's not discount, like, hair systems. Yeah. I mean, I think that that could be a really nice way of getting a good aesthetic result. You feel more confident and, you know, it's just understanding the, you know, the reality of the disease, and if you feel better about yourself wearing [00:20:00] this hairpiece, I don't think that that's a bad idea either.
Courtney Carroll, LE: Yeah. Mm-hmm.
Dr. Zain Husain, MD: Some of them look really good and really natural.
Heather Murray, PA-C: Mm-hmm.
Dr. Zain Husain, MD: All right. So what are things that we can monitor with these patients as we're treating them?
Heather Murray, PA-C: Um, I think photos are huge because, um, they're probably looking and feeling their hair every day, and so comparing on whether it's a monthly or, um, quarterly basis, I do think comparing before and after photos can really help the patient, um, get a sense on what is working and what may not be working.
Um, but also just monitoring, like, the hair density, um, looking for any changes to inflammation and scarring, um, redness, scaling, those pustules, seeing if that inflammation is truly headed in the right direction.
Dr. Zain Husain, MD: Yeah, absolutely.
Heather Murray, PA-C: And then also symptoms, so how itchy they are, if they're having burning or pain.
Dr. Zain Husain, MD: Yeah. [00:21:00] So these are very complex patients, very difficult to treat, and I think that setting up realistic expectation is really crucial early on. And although we have a lot of tools that we can use, it's not always successful, and I do really want my patients to know that you may not get your hair back, and, you know, maybe coping with that, and that's a hard swell- uh, pill to swallow.
And it's very emotional, and I know that especially, especially for female patients, I think it's very tied into their identity and how they present themselves to the world, and, you know, supporting them, and there are support groups for, you know, alopecias. And I think that, you know, getting plugged in with that group can also be very helpful.
Courtney Carroll, LE: Yeah, I was gonna say, I think there's a little bit more of, like, an emotional component with these patients, for sure. Kind of more [00:22:00] reassurance, more, um, just time spent to, to hopefully help them realize that they're not alone and that, you know, there's nothing that they can be doing more. It's just an unfortunate response that's happening.
Dr. Zain Husain, MD: So that wraps up our episode on scarring alopecias. Please comment, like, and subscribe, but until next time, Skin Side out. [00:23:00]