Cicatricial Alopecia – the destruction of follicles


In scarring alopecia, the associated hair follicles and sebaceous glands are destroyed, atrophied and replaced by scar tissue, making the hair loss irreversible.

If hair loss occurs gradually and without symptoms it could go unnoticed for quite some time, in other cases, however, it can be rapid and progressive, associated with itching, burning or discomfort.

Because the inflammation that destroys the follicle is located under the skin, there is usually no visible “scar” on the scalp. Instead, a shiny, smooth, hairless area is visible in the affected areas, showing little or no sign of inflammation. Less frequently, the latter may be marked in patients with redness, scaling, pustules, and increased or decreased pigmentation.

Cause and Type

There are several types of scarring alopecia:

  • Primary cicatricial alopecia: this type of alopecia is produced by alterations in the development of the hair follicle or by hereditary alterations
  • Primary acquired cicatricial alopecia: there are some dermatoses of autoimmune origin or unknown cause that can lead to cicatricial alopecia
  • Secondary cicatricial alopecia: this type of alopecia occurs when the hair follicle is destroyed secondarily in the course of an infection, tumor process or to physical processes such as radiation therapy or burns

Note: The tinea (dermatophytosis) of the scalp can also lead to scarring alopecia.

Researchers do not yet fully understand thecause of the various types of scarring alopecia. However, each form of scarring alopecia includes directed inflammation of the upper part of the hair follicle, where the stem cells and sebaceous glands are located. If these are destroyed, there is no possibility of regeneration of the hair follicle and hair loss results permanent.


Who can have it?

Scarring alopecia occurs in both men and women. While it affects everyone without age restrictions, it does not usually occur in children. A specific type of scarring alopecia, called central centrifugal alopecia, most commonly affects women of African descent and may occur in more than one family member.

Most cases of scarring alopecia are not contagious and are generally not associated with other diseases. It occurs in healthy men and women, with no hereditary factor.



In clinical exploration, it can be observed that the patient has areas of alopecia in which the skin shows alterations in the form of dermal and epidermal atrophy, with absence of hair follicles. The skin has a parchment-like appearance and is difficult to pinch.

Symptoms such as itching, burning, tenderness, or pain may raise suspicion that this disorder is ongoing. Inflammation of the scalp is manifested by redness, scaling and pustules. In cases where the symptoms are inconclusive, a scalp biopsy should be performed to confirm the inflammatory status.

A distinguishing feature of scarring alopecia is the absence of hair follicle openings through which capillary fibers emerge from the skin. When performing abiopsy, it is important to select an area that is still affected by inflammation, as it is then difficult to distinguish the different types of scarring alopecia in the advanced stage of the disease.


The traction test

The hair traction test is useful to support the diagnosis and to direct where to biopsy. In a pull test, the doctor will take a lump of hair from an area where the disease is in an active phase.

The results are based on observation of the number of hairs pulled with each pull and whether or not there are intact follicles. In a positive pull test, 5 or more hairs are usually produced, indicative of active inflammation that damages and loosens the follicles of the surrounding tissue.

The type of inflammation visible in the biopsy of the scalp, along with the of hair loss, helps the physician determine the specific type of scarring alopecia and its degree of activity. This way, the doctor can choose the most appropriate therapy.


Other incidence factors

Other factors that help the doctor make a diagnosis and indicate appropriate treatment:

  • Date of onset and rate of progression
  • Specific symptoms – itching, pain, burning sensation
  • Any previous treatment
  • Any hair growth – this would lead to an unlikely diagnosis of scarring alopecia
  • Medical history – any infection, disease, or trauma
  • Drugs – including exogenous androgens
  • Hair treatments
  • Family history – scarring alopecia rarely occurs in family members, with the exception of central centrifugal alopecia

In addition, if pustules are present, the physician will opt for cultures analysis to identify which microbes, if any, may be contributing to the inflammation.

However, as discussed, there are often few symptoms or signs present and only scalp biopsy shows active inflammation.

Finally, the extent and pattern of hair loss should be photographed so that comparisons can be made in the future.


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