Cicatricial Alopecia: Cause, Symptoms and Treatment
Cicatricial alopecia (or scarring alopecia) is a very rare type of hair loss in which the body's immune system attacks the hair follicles of the scalp.
Cause
Although the cause of this condition is not fully known, it always
appears to involve inflammation of the uppermost section of the hair
follicle where the stem cells and sebaceous gland are situated. And, if
these two structures are destroyed, the hair follicle will not be able
to regenerate and permanent hair loss will result.
It affects about 3% of the population and can develop at any age.
However, it mostly occurs in men and women who are otherwise healthy.
Scarring alopecia does not appear to have any genetic connection;
whilst some reports of it running in families do exist, most cases do
not involve any family history.
And it can't develop from any other form of hair loss either.
However, there are several different types of scarring alopecia, each
classified according to the type of white blood cells involved
(lymphocytes or neutrophils).
Types of cicatricial alopecia involving lymphocytes:
- Central centrifugal alopecia - this type most often affects black women.
- Frontal fibrosing alopecia - this type most often affects post-menopausal women.
- Lichen planopilaris pseudopelade
Types of cicatricial alopecia involving neutrophils:
- Dissecting cellulitis
- Folliculitis decalvans
- Tufted folliculitis
Cicatricial alopecia can also be mixed (i.e., it involves both
lymphocytes and neutrophils) this type is known as folliculitis
keloidalis.
This type of alopecia is also classified as either primary or secondary.
A primary scarring alopecia will directly target the hair follicles,
but a secondary scarring alopecia will first target an unrelated process
or injury (e.g., a serious infection, burns, radiation exposure, etc)
but also attack the follicles nearby.
Despite all of these different types, the mechanism taking place is
always the same - this disorder will destroy hair follicles which then
causes scar tissue to form and permanent hair loss to develop.
Symptoms
Scarring alopecia can develop slowly without any symptoms at all and
the hair loss that does develop may go unnoticed for quite some time.
Instead, it might develop rapidly with symptoms that can include: a red
itchy scalp, burning sensation, blisters (with fluid or pus secretions)
and pain. If this is the case, then patches of hair loss will also
develop very quickly and, as such, may be confused with another
autoimmune disorder - alopecia areata.
However, in scarring alopecia the patches of hair loss normally have a
more ragged appearance at the edges than in alopecia areata.
In most types of scarring alopecia, hair loss first develops quite gradually in small patches which then slowly get bigger.
The autoimmune and inflammatory response that destroys hair follicles
all occurs beneath the surface of the skin. This means that no scarring
will actually appear on the scalp surface in most cases.
Treatment
Treatment will vary according to the type of scarring alopecia that
applies. Diagnosis can be difficult so a scalp biopsy will first be
needed to identify which type it is.
For cicatricial alopecia involving lymphocytes, treatment uses anti-inflammatory medication.
Oral medicines include:
Corticosteroids
Doxycycline
Hydroxychloroquine
Mofetil
Mycophenolate
Topical medicines include:
Corticosteroids
Topical pimecrolimus
Topical tacrolimus
For cicatricial alopecia involving neutrophils, treatment aims to
eliminate microbes involved in the inflammatory process by using oral
antibiotics. Topical antibiotics may also be applied.
Note: Occasionally, following successful treatment, scarring alopecia can reappear and so treatment might need to be restarted.
Minoxidil (Rogaine) can also be used to help try and restore hair growth
in those follicles that were not destroyed by the autoimmune reaction.
Also, if the condition is not widespread, existing hair may be
sufficient to cover over the affected area of the scalp.
If the condition has been inactive for at least 1 to 2 years, hair
transplantation or scalp reduction surgery might be possible in severe
cases.
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