Scarring alopecia is a group of conditions in which inflammation damages hair follicles and replaces them with scar tissue. Hair lost to scarring generally does not grow back, so early diagnosis matters. Warning signs such as scalp pain, burning, redness, scaling or smooth, shiny patches are reasons to see a dermatologist in person rather than waiting.
What scarring alopecia is
Most common types of hair loss, such as pattern hair loss and temporary shedding, are non-scarring. The follicles are still present even when hair becomes finer or sheds more than usual. In scarring alopecia, also called cicatricial alopecia, the follicle itself is destroyed. Once that happens, the follicle cannot produce hair again.
Dermatologists usually describe two broad groups:
- Primary scarring alopecia. The hair follicle is the main target of inflammation. The immune system or another process attacks the follicle directly.
- Secondary scarring alopecia. The follicle is damaged by something else that affects the scalp, such as a burn, radiation, a severe infection, injury or certain tumors.
Scarring alopecia is uncommon compared with pattern hair loss, but it is important to recognize because the goal of treatment is to stop or slow the damage while there is still hair to protect.
Common types of primary scarring alopecia
Lichen planopilaris
Lichen planopilaris is an inflammatory condition that often affects the top of the scalp. People may notice itching, burning or tenderness, along with redness and scaling around individual hairs. Hair loss can spread slowly over time.
Frontal fibrosing alopecia
Frontal fibrosing alopecia is considered a form of lichen planopilaris. It typically causes a band-like recession of the hairline along the forehead and sometimes the temples. Eyebrow loss is common and can appear before changes in the hairline. It is seen most often in women after menopause, though it can affect others.
Central centrifugal cicatricial alopecia
Central centrifugal cicatricial alopecia, often shortened to CCCA, starts at the crown or center of the scalp and spreads outward. It is most commonly diagnosed in women of African descent. Some people have tenderness, itching or tingling, while others have few symptoms at first.
Discoid lupus
Discoid lupus is a form of cutaneous lupus that can cause red, scaly patches on the scalp, face and ears. On the scalp, these patches can lead to permanent hair loss. It may occur on its own or alongside systemic lupus.
Folliculitis decalvans and dissecting cellulitis
These conditions involve pus-filled bumps, crusting and inflammation around follicles. Folliculitis decalvans often appears as tufts of several hairs coming from one opening. Dissecting cellulitis can cause painful, connected nodules on the scalp.
Warning signs to take seriously
Many people do not realize a hair change could be scarring until the condition is advanced. These signs suggest a dermatologist should take a look:
- Itching, burning, stinging, tenderness or pain on the scalp
- Redness, scaling or crusting around individual hairs
- Pus-filled bumps, sores or nodules
- Smooth, shiny patches where follicle openings are no longer visible
- Several hairs growing from one opening, like a small tuft
- A band of hairline moving back along the forehead or temples
- Eyebrow loss, especially with hairline changes
- Hair loss that starts at the crown and spreads outward in a circular pattern
- Patches that slowly enlarge over time
These symptoms do not always mean scarring alopecia. Several other scalp conditions can cause itching, redness or scaling. Our guide to common scalp issues and how they are treated covers some of them. The point is that symptoms like these need an exam rather than a guess.
How it differs from other types of hair loss
Some conditions can look similar early on:
- Alopecia areata causes round, smooth patches, but follicle openings are usually still visible and the follicles are not destroyed. It is still a reason for in-person care. Read more in our article on alopecia areata and why it needs in-person care.
- Traction alopecia comes from repeated pulling on the hair. It is non-scarring at first, but long-term tension can lead to permanent follicle loss. Our article on traction alopecia and tight hairstyles explains the early signs.
- Pattern hair loss causes gradual thinning in a typical pattern, usually without pain, redness or scaling. It is possible to have pattern hair loss and a scarring condition at the same time, which is one more reason a careful exam matters.
How scarring alopecia is diagnosed
A dermatologist will ask about symptoms, how the hair loss started, hair care practices, medications and other health conditions. The exam often includes:
- A close look at the scalp with a handheld magnifying device called a dermatoscope, which can show whether follicle openings are present and whether there is inflammation around them.
- A scalp biopsy. A small sample of skin is taken and examined under a microscope. This is often the most reliable way to confirm scarring alopecia and identify the type.
- Blood tests or cultures in some cases, for example to check for lupus or a bacterial infection.
An in-person exam and biopsy cannot be done through photos alone. That is the main reason these conditions need a dermatologist who can see and examine the scalp directly.
What treatment aims to do
Treatment for scarring alopecia focuses on calming inflammation and slowing or stopping the condition from spreading. The right approach depends on the type, how active it is and the person's overall health. A dermatologist may consider prescription medications applied to the scalp, injected into the scalp or taken by mouth, and some of these require regular monitoring. A licensed provider decides whether treatment is appropriate and which option fits.
Because scarring conditions can be active for a long time, follow-up visits are usually part of care. A dermatologist will check whether symptoms are settling and whether the affected area is still changing. Treatment is aimed at protecting the hair that remains, and outcomes vary from person to person.
When to see someone in person
Book an appointment with a board-certified dermatologist if you notice any of the following:
- Scalp pain, burning, tenderness or persistent itching with hair loss
- Redness, scaling, crusting, pus-filled bumps or sores on the scalp
- Smooth or shiny patches where hair used to be
- A hairline moving back in a band, or eyebrow loss
- Hair loss that spreads from the crown outward
- Sudden or patchy hair loss
- Hair loss with joint pain, rashes elsewhere, fevers or fatigue
- Hair loss in a child
If it is hard to get an appointment quickly, tell the scheduling team about pain, spreading patches or other symptoms, since this can help them prioritize the visit. Taking clear, dated photos of the area can also help a dermatologist see how it has changed.
Where online care fits
Prescribed Essence focuses on prescription treatment for common pattern hair loss. Sudden or patchy loss, scalp pain and signs of scarring are outside what an online consultation is designed for, and they should be evaluated in person. If a licensed provider reviewing an online consultation sees signs that suggest a scarring condition, they will recommend in-person care.
For hair changes without the warning signs above, a licensed provider can review your history and photos and decide whether treatment is appropriate. If treatment is prescribed, a licensed pharmacy prepares a personalized compounded formula. Compounded medications are not FDA-approved. If that sounds right for you, you can start your online consultation.
Prescription required. A licensed provider decides whether treatment is appropriate. Compounded medications are prepared by a licensed pharmacy for an individual patient and are not FDA-approved. Individual results vary. Prescribed Essence currently serves patients in California, Colorado, Florida and New York.
