If you’ve been seeing patches of hair loss with signs of inflammation on your scalp, you may be experiencing scarring alopecia.
If you’ve been seeing patches of hair loss with signs of inflammation on your scalp, you may be experiencing scarring alopecia (sometimes called central centrifugal cicatricial alopecia or CCCA).
Of the various types of hair loss (also known as alopecias), 73 percent are non-scarring alopecia, and the other 27 percent are scarring alopecia. But it can be difficult to know what type of hair loss you’re dealing with.
What is scarring alopecia? We’ll talk about the symptoms, causes, risk factors, treatment options, and ways to prevent scarring alopecia.
The different types of scarring alopecias are classified as primary or secondary.
Primary cicatricial alopecia. Also known as primary scarring alopecia, this type of scarring alopecia is characterized by inflammation seen specifically at the hair follicle.
Secondary cicatricial alopecia. This typically happens as a side effect when there’s underlying damage to the scalp (from a burn or radiation, for example).
The most common forms of scarring alopecia include frontal fibrosing alopecia and lichen planopilaris.
In primary cicatricial alopecia, you might see a few classifications. Examples include:
Lichen planopilaris. As the most common cause of cicatricial alopecia, this condition makes up about 10 percent of cases. It often looks like itchy patches and blisters, and affected areas beyond the scalp are also possible.
Chronic cutaneous lupus erythematosus. Also known as discoid lupus erythematosus, this is seen as both single patch or multiple spots, along with depigmentation (loss of skin pigment) and follicular plugging (clogged hair follicles).
Central centrifugal cicatricial alopecia. Burning, scaling, and itching on the skin surface are common side effects of this scalp condition. It may look similar to signs of male or female pattern baldness.
Frontal fibrosing alopecia. As the name suggests, this condition usually presents itself in the frontal hairline, but it can also show up in the eyebrows. It most often affects postmenopausal women.
Brocq pseudopelade. This condition is often seen as small or irregular bald patches, typically with no other symptoms.
Collectively, these fall under the umbrella of lymphocytic scarring alopecia — cicatricial alopecia that destroys hair follicle oil glands and stem cells, leading to hair loss.
Forms of neutrophilic (inflammation-related) cicatricial alopecia include:
Dissecting cellulitis of the scalp. Seen with multiple nodules on the scalp, often with discharge, this hair disorder is most common among Black adolescents and adult males.
Folliculitis decalvans. Often seen as one single patch of hair loss that grows bigger over time, folliculitis decalvans can result in pustules and honey-colored crusting. It’s thought to occur from a bacteria called Staphylococcus aureus (Staph).
It’s worth noting that if you’re of African descent, certain conditions (like central centrifugal cicatricial alopecia, acne keloidalis nuchae, and dissecting cellulitis of the scalp) may be more common. Research shows that CCCA disproportionately affects Black women.
Depending on the form of scarring alopecia you have, it may present itself in different forms. That said, most scarring alopecias share a few common features.
Scarring alopecia and cicatricial alopecia symptoms can include:
Loss of sebaceous glands (those that secrete sebum to prevent hair follicles from drying out)
Hair thinning
Naked hair shafts (free-floating strands without supporting structure)
Follicular or diffuse (all-over) dermal scarring
Premature desquamation (flaking) of the inner root sheath
Scarring alopecia symptoms usually result in bald patches, sometimes with rough or textured areas surrounding the hair loss.
Instead of a smooth balding head, you may notice follicular ostia (damage to the hair bulb). And previously smooth hair follicles might revert to scar-like fibrous tissue.
While these are the general symptoms of scarring alopecia, symptoms vary from person to person.
Scarring alopecia or cicatricial alopecia is hair loss characterized by scarring (as the name suggests), along with signs of inflammation. It’s actually an umbrella term for several diseases that result in scarring that causes permanent hair loss.
The biological causes of scarring alopecia are very similar regardless of type.
Though researchers are still trying to pin down its exact causes, these are known factors:
Inflammation. Inflammation is the driving biological mechanism behind scarring alopecia. Inflammation isn’t all bad — it’s one of the body’s natural defense mechanisms to fight infection and begin the healing process. However, with scarring alopecia, inflammatory cells attack the hair follicle.
Hair follicle damage. Hair follicle damage in scarring alopecia can be caused by damage from an infection or when the immune system mistakenly attacks the follicle.
Fibrosis. Fibrosis is the formation of excess fibrous connective tissue. Once the follicle is destroyed, it’s replaced by fibrous scar tissue, which prevents new hair from growing.
Some people are more likely to get scarring alopecia than others due to various factors — these are called risk factors.
Risk factors for scarring alopecia include:
Trauma. Trauma to the scalp could be from burns (including sunburn), radiation, or mechanical traction due to tight hairstyles.
Genetics. Some research suggests that certain types of scarring alopecia, including CCCA, are hereditary.
Chemicals. Exposure to harsh chemicals, including relaxers, perms, and bleach, could make you more susceptible to scarring alopecia.
PPAR gamma. PPAR (peroxisome proliferator–activated receptor) gamma is a protein in the body that’s stored in tissue and controls how certain genes work. Research shows a potential link between a PPAR deficiency and scarring alopecia.
Autoimmune disorders. As mentioned, autoimmune diseases like lupus and lichen planopilaris are linked to scarring alopecia.
Other risk factors for cicatricial alopecia include:
Mucocutaneous lesions (including canker sores)
Vitamin D deficiency
Age (middle age, between 30 and 50
Infection
Previous pregnancies
Type 2 diabetes
Uterine leiomyomas (fibroids)
Hyperlipidemia (high cholesterol)
Scarring alopecia was once thought to be related to haircare practices, like using hot combs, relaxers, or hairstyles that cause excessive tension. But it’s now understood that scarring hair loss can happen for other reasons (or without a known cause).
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Some versions of scarring alopecia may not have telltale signs. You’ll need a diagnosis from your dermatologist or another healthcare provider, which will also help rule out other types of hair loss.
Cicatricial alopecia is fairly rare compared to other forms of hair loss, like male pattern baldness (also called androgenetic alopecia) and female pattern hair loss. As such, some other forms of hair loss may initially resemble scarring alopecia.
For instance, two other types of hair loss that can also cause sudden, irritated patches of baldness are traction alopecia (from tight hairstyles) and alopecia areata (stress-related thinning).
Diagnosing scarring alopecia usually consists of a clinical exam and a scalp biopsy. During the exam, the dermatologist or healthcare provider will ask you questions about your medical history, hair health, and styling habits.
Next, they’ll typically do a scalp biopsy. This is where a small tissue sample is taken from the scalp and sent to a lab to be checked for inflammatory immune cells. The lab assessment will help isolate the type of cicatricial alopecia you’re dealing with.
The psychological impact of hair loss shouldn’t be overlooked, so it might also be a good idea to speak with a mental health counselor. After all, hair loss doesn’t just affect your hairline — it can affect your mental health too.
With numerous potential underlying causes that can create inflammation and damage, treating scarring alopecia is nuanced and sometimes requires trial and error.
A healthcare professional may prescribe one or several treatments to halt the progress of the disease.
Common scarring alopecia treatments include:
Anti-inflammatory medications. These treatments can stop inflammation and mitigate the damage. A pharmacist can help you avoid drug interactions if you’re taking multiple medications.
Topical steroids and steroid injections. Topical steroids are sometimes used to treat conditions like lichen planus and CCCA, which can be commonly seen in Black women. Steroid injections in the scalp can also help treat scarring alopecia
Immunosuppressants. These medications can mitigate damage caused by an autoimmune cause.
Oral steroids. For primary cicatricial alopecia conditions — like lichen planopilaris and frontal fibrosing alopecia or chronic cutaneous lupus erythematosus — oral steroids have shown improvements in hair regrowth for issues like cellulitis of the scalp. These medications are sometimes used in combination with topical corticosteroid lotions and hydroxychloroquine.
Antiseptic shampoo. Conditions like folliculitis decalvans are typically treated with antiseptic shampoo, potentially combined with an antibiotic.
It’s hard to to entirely prevent scarring alopecia, but there are steps you can take that may help:
See a healthcare professional as soon as you notice hair loss, as early intervention is key.
Protect your head from UV rays with sunscreen or a hat.
Use the lowest heat setting on hot tools, including blow dryers and flat irons.
Avoid chemical processing like perms or chemical straightening.
If you think you might have scarring alopecia or another type of alopecia or are interested in discussing hair loss treatment options, consult a dermatology specialist or another healthcare provider to figure out the best course of action.
Hims offers treatments for various types of alopecia, including androgenetic alopecia (aka male pattern baldness, which is genetic) and telogen effluvium (stress-related hair loss).
Explore research-backed men’s hair loss treatments today.
This article is for informational purposes only and does not constitute medical advice. The information contained herein is not a substitute for and should never be relied upon for professional medical advice. Always talk to your doctor about the risks and benefits of any treatment. Learn more about our editorial standards here.
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