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Group of disorders that destroy hair follicles and replace them with scar tissue, resulting in permanent hair loss; early diagnosis is critical for treatment.
Scarring alopecia, also referred to as cicatricial alopecia, encompasses a group of rare but serious hair loss disorders characterised by the irreversible destruction of hair follicles. In these conditions, the hair follicle is replaced by fibrous scar tissue, resulting in permanent hair loss in the affected areas. Unlike non-scarring forms of hair loss, the damage caused by scarring alopecia cannot be reversed once follicle destruction has occurred.
Scarring alopecia affects people of all ages and ethnic backgrounds, though certain subtypes show a predilection for specific populations. The conditions within this category are broadly divided into primary and secondary forms. In primary scarring alopecia, the hair follicle itself is the direct target of inflammatory destruction. In secondary scarring alopecia, follicle damage occurs as a consequence of an external process, such as infection, trauma, or tumour infiltration.
Because hair follicle loss is permanent, early recognition and prompt treatment are essential to halting disease progression and preserving remaining hair. Patients who notice patches of hair loss accompanied by scalp symptoms are encouraged to seek dermatological assessment without delay.
The causes of scarring alopecia vary according to the specific subtype. Primary scarring alopecias are driven by inflammatory processes that target and destroy the stem cells located in the hair follicle bulge region. Once these stem cells are eliminated, follicular regeneration is no longer possible. The major primary subtypes include the following.
Secondary scarring alopecia may result from physical trauma, burns, radiation therapy, fungal infections such as tinea capitis with kerion formation, bacterial infections, neoplastic infiltration, or chronic skin conditions such as morphoea and scleroderma. Genetic predisposition, immune dysregulation, and environmental triggers are all considered contributing risk factors depending on the underlying subtype.
The clinical presentation of scarring alopecia varies between subtypes, but several features are commonly observed across the group. Affected areas typically show smooth, shiny patches of skin where follicular openings are absent, a hallmark sign of follicular destruction. The borders of the hair loss patches may appear slightly inflamed, with redness, scaling, or perifollicular discolouration.
Symptoms reported by patients may include the following.
It is important to note that scarring alopecia may be relatively asymptomatic in some patients during early stages, which can delay presentation. Any unexplained or progressive patch of hair loss warrants evaluation, even in the absence of significant symptoms.
Accurate diagnosis of scarring alopecia requires a thorough clinical assessment combined with histopathological examination. The diagnostic process typically includes the following steps.
Early biopsy is strongly encouraged, as the histopathological changes of end-stage scarring alopecia may be non-specific, making subtype identification difficult once significant fibrosis has occurred. Timely and accurate diagnosis directly influences treatment selection and outcomes.
There is currently no treatment capable of reversing established scarring or regrowing hair from destroyed follicles. The primary goal of therapy is to suppress active inflammation, halt disease progression, and preserve the remaining hair follicles. Treatment is guided by the specific subtype and the degree of inflammatory activity observed clinically and histologically.
Topical and intralesional therapies
High-potency topical corticosteroids are commonly prescribed as first-line therapy to reduce perifollicular inflammation. Intralesional corticosteroid injections, typically triamcinolone acetonide, are administered directly into active areas of the scalp to achieve more targeted anti-inflammatory effects. Topical calcineurin inhibitors, such as tacrolimus or pimecrolimus, may be used as steroid-sparing alternatives, particularly for facial or sensitive areas.
Systemic therapies
Systemic treatment is indicated for moderate to severe or rapidly progressing disease. Options include the following.
Surgical options
Once disease activity has been confirmed to be inactive for a sustained period, typically one to two years, hair transplantation may be considered to address areas of stable scarring. Transplantation is not appropriate in the setting of active inflammation, as transplanted follicles may themselves be destroyed. Not all patients are suitable candidates, and outcomes vary by subtype.
Regular follow-up appointments are an important component of management, as disease activity can fluctuate and treatment regimens may require adjustment over time. Prescription management of topical, intralesional, and systemic therapies is available at the Centre for Medical and Surgical Dermatology.
Prompt evaluation by a dermatologist is recommended if any of the following are observed.
Because the follicle destruction in scarring alopecia is irreversible, the window for effective intervention is limited to the period of active inflammation. Early referral to a dermatologist experienced in hair disorders significantly improves the likelihood of preserving existing hair. At the Centre for Medical and Surgical Dermatology, Dr. Maksym Breslavets provides assessment and management of scarring alopecia using current evidence-based approaches tailored to each patient's condition and subtype. A referral from a family physician is typically required to access dermatology services.
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