Scarring Alopecia

Overview

What is scarring alopecia?

Scarring alopecia, also called cicatricial alopecia, is a type of hair loss caused by the destruction of your hair follicles (shafts on the surface of your skin that hair grows through). It’s usually the result of infections, chemicals, burns or autoimmune disorders. Hair loss due to scarring alopecia can be permanent because your hair can’t grow back without healthy hair follicles.

What are the effects of scarring alopecia?

Scarring alopecia can affect any part of your body that has hair, but commonly affects the scalp. Visible hair loss due to scarring alopecia can also have emotional and psychological effects.

What does scarring alopecia look like?

Scarring alopecia usually appears as a bald patch where there’s typically hair. There might be one bald area or several. The skin where hair used to be tends to look smooth and shiny. Scarring alopecia can look different on different people. Some people also have redness, flaky skin or blisters.

What’s the difference between scarring and nonscarring alopecia?

Scarring alopecia is permanent hair loss due to hair follicle destruction. In nonscarring alopecia, hair may fall out or get thinner, but your hair follicle isn’t destroyed. So nonscarring alopecia may be temporary, and your hair can sometimes grow back. Androgenetic alopecia, also called male or female pattern baldness, is the most common type of nonscarring alopecia.

Are there different types of scarring alopecia?

Cicatricial alopecia can be one of two types:

  • Primary scarring alopecia is due to an inflammatory or autoimmune disorder that directly targets and destroys your hair follicles.
  • Secondary scarring alopecia is a side effect of injury or damage to your skin. Hair loss might result from burns, infections, radiation or tumors.

There are many types of primary scarring alopecia. Some include:

  • Central centrifugal cicatricial alopecia (CCCA): CCCA is the most common type of hair loss in Black women or people assigned female at birth (AFAB). It usually occurs around age 30. CCCA often starts as a bald patch on the crown of your scalp and then spreads outward. It may be related to chemical hair products, such as relaxers, or hot hair tools, such as combs. CCCA can also result from too much tension on hair follicles from braids, weaves or extensions. But some research suggests that CCCA might be hereditary.
  • Chronic cutaneous lupus erythematosus (CCLE): CCLE describes skin problems caused by lupus erythematosus, an autoimmune disease. In addition to hair loss, some people with CCLE also have skin rashes, discoloration and sensitivity to the sun. CCLE is more common in women or adults AFAB.
  • Folliculitis decalvans: Folliculitis decalvans may be the result of a bacterial infection. Some people with Staphylococcus aureus (Staph A), a staphylococcus infection, have ongoing inflammation that can affect their hair follicles.
  • Lichen planopilaris: This is the most common primary scarring alopecia and mostly affects people over 50 who are AFAB. It’s a type of lichen planus that can cause skin scaling, burning, itching, ulcers, discoloration and papules (inflamed bumps).

Is scarring alopecia contagious?

Scarring alopecia isn’t contagious, so you can’t get it from person-to-person contact.

Who might be affected by scarring alopecia?

Anyone can get scarring alopecia. It tends to affect adults more than children. People of a certain sex or race may be more likely to develop certain types of scarring alopecia. For example, central centrifugal cicatricial alopecia (CCCA) is the most common type of hair loss in Black people AFAB.

How common is scarring alopecia?

Scarring alopecia accounts for about 7% of people who see healthcare providers about hair loss. So it’s much less common than nonscarring alopecia, which affects between 50% and 75% of adults over 50.

Symptoms and Causes

What causes scarring alopecia?

In most types of scarring alopecia, there’s inflammation around the middle (bulge) of your hair follicle. This part of your follicle contains stem cells and oil glands, which are both needed for new hair growth. Inflammation destroys this part of the follicle and causes scar tissue to grow (fibrosis), so hair can’t regenerate.

The follicular ostia (openings in your skin where hair follicles reside) are usually closed in people with scarring alopecia.

In nonscarring alopecia, there’s usually damage to the base (bulb) of your hair follicle, not the bulge. That’s why hair can often regrow if you have nonscarring alopecia.

Can cancer treatment cause scarring alopecia?

You may know that chemotherapy can cause hair loss. But chemotherapy doesn’t lead to scarring alopecia. Chemotherapy drugs can cause cells in your hair follicle to die, so your hair falls out. But the follicle itself isn’t destroyed, so hair can usually grow back after chemotherapy.

Radiation therapy, on the other hand, can lead to secondary scarring alopecia. Some people get skin burns from radiation therapy that permanently destroy hair follicles.

What are the symptoms of scarring alopecia?

Hair loss is the main symptom of cicatricial alopecia. It usually causes focal hair loss, meaning you lose hair in patches. Hair loss might start slowly and happen gradually over many years. Or it can start suddenly and progress quickly.

Scarring alopecia tends to affect the scalp, but it can happen anywhere you have hair.

In addition to hair loss, some people experience skin problems, such as:

  • Bleeding.
  • Blistering.
  • Burning.
  • Crusting or scaling.
  • Itching, tingling or tenderness.
  • Pustules.
  • Redness or other discoloration.

Diagnosis and Tests

How is scarring alopecia diagnosed?

Your healthcare provider uses a few techniques to diagnose hair loss, including:

  • Physical exam: Your provider looks at the location and pattern of your hair loss. They also check your skin where you’ve lost hair. This is to see if you still have hair follicle openings and visible signs of inflammation. Make sure to report when you first noticed hair loss and any symptoms such as tingling, burning or itching.
  • Medical history: Your provider does a careful review of your medical history. They evaluate your age, sex, hair care practices and overall health. Tell your provider about any medical conditions you have, such as lupus, anemia or thyroid disease. They might do blood tests to check for diseases that could cause hair loss.
  • Skin biopsy: A skin biopsy can confirm a diagnosis of scarring alopecia. Your provider takes a small skin sample from your scalp or another area affected by hair loss. A pathologist (healthcare provider specializing in examining tissue samples) looks at the sample under a microscope. They check for inflammatory immune cells, which tell your provider what type of cicatricial alopecia you have.

Are there different stages of scarring alopecia?

Sometimes a biopsy shows scar tissue but no inflammatory cells. Providers might refer to this as end-stage scarring alopecia (ESSA). ESSA means the condition is past the point of active inflammation, so treatment might be less effective.

What type of healthcare provider diagnoses scarring alopecia?

A dermatologist (healthcare provider specializing in skin disorders) can diagnose scarring alopecia. But it can be a difficult condition to diagnose, so it’s important to see a dermatologist with a lot of experience in hair loss.

Management and Treatment

Is there a cure for scarring alopecia?

There isn’t a cure for scarring alopecia. Treatment aims to manage symptoms and slow or stop more hair loss. Some cosmetic treatments can improve the appearance of bald patches.

How is scarring alopecia treated?

Treatment depends on the type of cicatricial alopecia you have. Anti-inflammatory medication is the most common treatment for most forms of scarring alopecia. Anti-inflammatory medication fights the inflammatory cells causing hair follicle destruction. You might take a pill, such as hydroxychloroquine, or receive a corticosteroid injection, such as triamcinolone acetonide. Some anti-inflammatory medications come as creams or oils you apply to your skin.

Scarring alopecia caused by bacterial infections requires antibiotics, such as doxycycline or minocycline.

Most people take medication for six to 12 months until symptoms improve and hair loss slows or stops. You may need to start taking medication again if you start losing more hair.

Can I get a hair transplant for scarring alopecia?

A hair transplant is surgery to move hair from one part of your scalp to an area with little or no hair. It’s usually not a good treatment for people with scarring alopecia. The scar tissue under the skin’s surface can prevent transferred hair from growing. But you may be a candidate for hair restoration if you haven’t lost new hair for a few years. Ask your healthcare provider if a hair transplant might be right for you.

Can I get platelet-rich plasma therapy for scarring alopecia?

Platelet-rich plasma (PRP) uses cells from your own blood to reduce inflammation and help tissues heal. It can also help regrow your hair and treat hair loss caused by nonscarring alopecia. PRP therapy for scarring alopecia is less common, but some studies have shown positive results for certain types, such as lichen planopilaris.

Will my hair regrow if I have scarring alopecia?

Scarring alopecia can cause permanent hair loss, so your hair will be difficult to regrow after the follicle is destroyed. But if you catch the condition very early, medication may be able to stop inflammation before it completely destroys the hair follicle.

Prevention

How can I prevent scarring alopecia?  

It’s challenging to prevent scarring alopecia. Early treatment may help stop more hair loss.

Outlook / Prognosis

What’s the outlook for someone with scarring alopecia?

The outlook for scarring alopecia can vary depending on how soon you get treatment. Some people only experience small patches of hair loss. Others have widespread hair loss. Hair loss may return after treatment, so some people need to be on medication for a long time.

Living With

What questions should I ask my healthcare provider about scarring alopecia?  

If you have scarring alopecia, there are a few questions you may want to ask your healthcare provider: 

  • Are there any natural or home remedies that can help scarring alopecia? 
  • Are there any side effects from being on medication for a long time? 
  • Are there community resources or support groups that can help me? 
  • Can changes to my diet or lifestyle help prevent further hair loss? 
  • Is there a chance I might go completely bald? 

A note from Cleveland Clinic

Hair loss caused by scarring alopecia (cicatricial alopecia) can be a difficult condition to manage. You may face physical symptoms such as skin irritation as well as emotional and psychological challenges. And while the condition doesn’t lead to serious health complications, it can cause you to have feelings of shame or embarrassment. Talk to your healthcare provider about the different ways that scarring alopecia is affecting your life. They can connect you to the treatments and support services you need to feel better.

Medically Reviewed

Last reviewed by a Cleveland Clinic medical professional on 01/06/2023.

Learn more about our editorial process.

References

  • American Skin Association. Alopecia. (https://www.americanskin.org/resource/alopecia.php) Accessed 1/6/2023. 
  • Scarring Alopecia Foundation. Scarring Alopecia. (https://scarringalopecia.org/about-scarring-alopecia/) Accessed 1/6/2023. 
  • Skin of Color Society. Central Centrifugal Cicatricial Alopecia (CCCA). (https://skinofcolorsociety.org/patient-dermatology-education/central-centrifugal-cicatricial-alopecia-ccca/) Accessed 1/6/2023. 
  • Filbrandt R, Rufaut N, Jones L, Sinclair R. Primary cicatricial alopecia: diagnosis and treatment. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3855115/) CMAJ. 2013 Dec 10;185(18):1579-85. Accessed 1/6/2023. 
  • Alves R, Grimalt R. Platelet-Rich Plasma and its Use for Cicatricial and Non-Cicatricial Alopecias: A Narrative Review. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7367994/) Dermatol Ther (Heidelb). 2020 Aug;10(4):623-633. Accessed 1/6/2023. 
  • Vidal CI. Overview of Alopecia: A Dermatopathologist’s Perspective. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6170065/) Mo Med. 2015 Jul-Aug;112(4):308-12. Accessed 1/6/2023.

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