What is it? Although the cause of hair loss varies patient to patient, I see many patients in my practice who have been suffering from hair loss, sometimes severe, for many years before ever talking to a hair loss physician. Because of this, I wanted to highlight a group of disorders that I frequently diagnose - cicatricial alopecias - which are a very misunderstood family of complications that can masquerade as androgenic alopecia.
If it is suspected, a thorough workup is necessary, but how is it suspected? It is my hope through a series of blog posts on this confused diagnosis that I will bring support and helpful information to those who have also been silently suffering from hair loss.
What is cicatricial (scarring) alopecia and why is it misunderstood?
According to the Cicatricial Alopecia Research Foundation, the term “cicatricial alopecia” refers to a diverse group of rare disorders that destroys the hair follicle, replaces it with scar tissue, which causes permanent hair loss.
CARF suggests there are several reasons why this alopecia can be very confusing:
- Development is highly inconsistent and unpredictable. For example, hair loss may be slowly progressive over many years, without symptoms, and go unnoticed for long periods of time. OR the hair loss may be rapidly destructive within months and associated with severe itching, pain, and burning.
- It is referred to as "scarring" alopecia, but yet there is usually no “scar” seen on the scalp. The inflammation that destroys the follicle is below the skin surface,
- Visible symptoms are not always present. Affected areas of the scalp may show little signs of inflammation, OR have redness, scaling, increased or decreased pigmentation, pustules, or draining sinuses.
- Prevention is not always possible. Cicatricial alopecia occurs in otherwise healthy men and women of all ages, is not contagious, not hereditary, and is seen worldwide.
Are there different kinds of cicatricial alopecia?
Yes, cicatricial alopecias are classified as primary or secondary. This blog series will focus on primary cicatricial alopecias, where the hair follicle itself is the target of the destructive inflammatory process.
In secondary cicatricial alopecias, damage of the hair follicle is linked to either a process not aimed at the hair follicle (different than the primary cicatricial alopecias) or an external injury, such as severe infections, burns, radiation, or tumors.
How do you know if the hair follicle is the target, if symptoms are not always present?
- Primary cicatricial alopecia is categorized currently by the type of inflammatory cells seen on a scalp biopsy, states the Cicatricial Alopecia Research Foundation. These inflammatory cells may be primarily lymphocytes, neutrophils, or sometimes the inflammation has mixed cells.
- Cicatricial alopecias that involve predominantly lymphocytic inflammation include lichen planopilaris (LPP), frontal fibrosing alopecia (FFA), central centrifugal cicatricial alopecia (CCCA), pseudopelade (Brocq), chronic cutaneous lupus erythematosus, and keratosis follicularis spinulosa decalvans.
- Cicatricial alopecias that involve predominantly neutrophilic inflammation include folliculitis decalvans and tufted folliculitis. Sometimes the inflammation shifts from a predominantly neurotrophilic process to a lymphocytic process, or visa versa.
- Cicatricial alopecias with a mixed inflammatory infiltrate include dissecting cellulitis and folliculitis keloidalis, both of which are secondary to follicular rupture.
So, with development so inconsistent and unpredictable, what causes primary cicatricial alopecia, and who is affected?
This topic is discussed in the next blog post in my series on cicatricial alopecias.
Dr. Arthur Gray offers a full range of diagnostic options as well as surgical and medical treatments for hair loss. If you are suffering from hair loss and looking for answers, contact Dr. Gray today to schedule a one-on-one consultation.