Scarring Alopecia

Scarring alopecia also known as “cicatricial alopecia” is a group of hair loss disorders diagnosed in as low as 3%1 of alopecia people in otherwise healthy men and women of all ages around the globe.

As a group of disorders, scarring alopecia has various forms but commonly it includes permanent and irreversible destruction of hair follicles that are replaced with scar tissues. Initially, it appears as a small hairless patch that grows with time. In some cases, symptoms remain unnoticed for longer duration due to gradual hair loss. While in others, rapid hair loss associated with severe itching, burning, and pain sensation.

The pattern/patches of hair loss are quite different than alopecia areata and androgenic alopecia. The patch of scarring alopecia is smooth and clean, or may have redness, scaling, increased or decreased pigmentation, or may have raised blisters with fluids or pus with uneven, rough, and torn edges. 

Pathophysiology:
The pathophysiology for most of the forms of scarring alopecia is unknown. Although, the end mechanism behind all types of scarring alopecia is inflammation and destruction of the root of the hair follicle where the stem cells and sebaceous gland (oil gland) are located. It diminishes the possibility of hair regeneration leading to permanent hair loss. 

However, it is postulated that the autosomal dominant pattern of inheritance along with hairstyling and gender are major contributing factors. The sebaceous gland damage is more common in scarring alopecia, which is responsible for scarring. It can be used as a clue to differentiate from non-scarring alopecia. However, scarring also results from epidermal growth factor receptor inhibitors and chemotherapy-induced scarring.

Types of scarring alopecia:
The scarring alopecia is classified as primary, and secondary.
Primary scarring alopecia/primary cicatricial alopecia: In primary scarring alopecia the hair follicle destruction is the main target of the underlying disease or where the disease begins. The hair follicle destruction is due to inflammatory cells such as lymphocytes, neutrophils, or both. Hence, they are further divided based on the type of inflammatory cells as lymphocytic, neutrophilic or mixed alopecia.

1. Neutrophilic cicatricial alopecia: The diseases like folliculitis decalvans and dissecting cellulitis of the scalp which produce neutrophilic inflammation of hair follicles are fall in this category. 

2. Lymphocytic cicatricial alopecia: In this class following disease fall which causes lymphocytic inflammation of the hair follicles: lichen planopilaris (lichen planus follicularis), chronic cutaneous lupus erythematosus, frontal fibrosing alopecia, acne keloidalis nuchae, central centrifugal cicatricial alopecia, and brocq pseudopelade. 

Secondary scarring alopecia/secondary cicatricial alopecia: In this, the hair follicles are damaged secondary to inflammation or destructive of the skin due to burns, cancers, trauma, and radiation therapy.

Signs and symptoms:
The bald patches are smooth, shiny, without skin pores. One or more patches grow and collate to form near-total alopecia. Based on the type of scarring alopecia the symptoms may vary. However, the common and typical symptoms in all types of scarring alopecia are given below:

• Itching

• Burning

• Pain

• Patches of rough and scaly skin

• Blisters on the patch sometimes pus-filled with discharge

• crusting

Diagnosis:
A careful history, examination, and observation of signs and symptoms along with a biopsy will help decide the type of scarring alopecia and its treatment. 

Treatment:
The treatment strategies are different for different types of scarring alopecia. For cicatricial alopecia, the treatment goal is to decrease or eliminate the lymphocytic inflammatory cells by using anti-inflammatory medications. 

The treatment goal for the neutrophilic cicatricial alopecia is use of microbicidal drugs to eliminate microbes that involved in the inflammatory process. 

For mixed cicatricial alopecias combinations of microbicidal and anti-inflammatory drugs are used.

Generally, scarring alopecia required prolonged treatment until the signs and symptoms of scalp inflammation get subsidized and disease progression has been controlled. However, treatment cannot be stopped the disease progression completely, and silent hair fall remains. In some cases, relapse may also occur.

Surgical treatment is used for cosmetic purposes after progression comes under control. The surgical treatment involves hair restoration surgery or scalp reduction.

The early diagnosis and treatment are helpful as the hair fall is permanent because of follicle destruction. 

Additionally, minoxidil solution or foam (2% or 5%) 5 twice a day may be helpful to stimulate any small, remaining, unscarred follicles. Also, hairpieces, wigs, hats, and scarves can be used safely.