Scarring alopecia: types and treatments

Alopecia, or hair loss, comes in many different forms. In some cases, hair that’s lost will grow back. In scarring alopecia, this usually isn’t the case. But there are ways to manage scarring alopecia by catching and treating it as early as possible. Read on to learn more.

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Scarring alopecia (aka cicatricial alopecia) occurs when the hair follicles are destroyed, making it impossible for the hair to grow back (Cardoso, 2021). About 5% of people with hair loss have a scarring type of alopecia (Bolduc, 2016).

Some types of scarring alopecia cause patchy hair loss around the scalp. Others affect the entire hairline. The hair loss can happen quickly or gradually over a number of years. Often, it will “burn out,” leaving patches of balding sections (Cummins, 2021). 

You may not notice the signs of scarring alopecia right away. In other cases, it’s obvious. There are a variety of symptoms to watch out for, including (Cummins, 2021):

• Patchy hair loss

• Shiny bald spots

• A widening, shiny hair part

• Thinning hair

• Receding hairline along the front and sides

• Itching, burning, scalp pain

• Pustules, sores, or plaques on the scalp

• Scalp dryness

Hair loss in scarring alopecia is caused by inflammation or injury that destroys the hair follicle, including the follicle’s stem cells, by a process called fibrosis. Fibrosis creates scar tissue and permanently damages the follicles. Scarring alopecia usually also destroys the sebaceous glands, which provide oil to the scalp. Ultimately, the hair isn’t able to regrow (Cummins, 2021; Al–Zaid, 2011).

Some of the factors that may increase the risk of scarring alopecia include (Al Aboud, 2021; Cummins, 2021): 

• Genetics

• Infections like ringworm (tinea capitis)

• Environmental irritants

• Scalp injuries

• Haircare products like hair relaxers

• Cancers that infiltrate the scalp  

There are a few general ways the hair follicle gets damaged, depending on the type of scarring alopecia you have (Cummins, 2021): 

• Primary scarring alopecia: The follicle is the target of the inflammation. 

• Secondary scarring alopecia: The hair follicle is destroyed by an injury or by inflammation that affects a larger area. Various health conditions, infections, or injuries, such as radiation or burns, can cause secondary scarring hair loss. 

Diagnosing alopecia usually involves a medical history, physical exam, and a range of tests. 

A thorough medical history helps find a diagnosis and narrow down possible causes. It may include questions about (Al Aboud, 2021; Singh, 2021-a):

• Hair loss (amounts and frequency)

• Dietary habits (to identify any nutrient deficiencies)

• Any potential triggers

• Past or current medical conditions (especially skin or autoimmune conditions)

• Family history (prevalence of hair disorders)

• Hair care practices 

After taking a history, a healthcare provider may perform different tests, including (Cummins, 2021; Singh, 2021-a): 

• Trichoscopy: This test offers a close-up look at the follicle.

• Hair pull test: This shows if growing phase (anagen) or resting phase (telogen) hairs are falling out.

• Scalp biopsy: This involves collecting a tissue sample from the scalp to be examined under a microscope. 

• Skin culture: This tests for infectious microbes, like bacteria or fungi.

• Blood test: This can check for other causes of hair loss, like nutritional deficiencies and thyroid disorders

Hair that has fallen out due to scarring alopecia can’t grow back, but there are ways to treat the underlying cause of scarring. If it’s identified and treated early, this may slow down or stop hair loss. It’s a good idea to consult a healthcare provider specializing in dermatology.

Treatments for scarring alopecia may include (Cardoso, 2021): 

• Steroids (A combination of corticosteroid injections to the scalp and strong topical steroids is a common starting treatment.)

• Topical anti-inflammatories (like corticosteroids, tacrolimus, or isotretinoin) 

• Oral or topical antibiotics if an infection caused the hair loss

• Oral medications that regulate the immune system, like hydroxychloroquine or cyclosporine, may be effective in cases caused by an overactive immune system (autoimmune conditions).

• Topical Rogaine (minoxidil) 

Your healthcare provider will advise you on how long to continue treatment. You’ll generally continue until your symptoms have decreased and hair loss has stopped. The hair loss may stop but then start again at a later time, at which point you may need to resume treatment (Cardoso, 2021).

In scarring alopecia, hair will not regrow once the follicle is destroyed. The goal of scarring alopecia treatment is to stop the inflammation to prevent further hair loss. Another approach is to boost any follicles that have survived in the affected area. 

Topical minoxidil on the scalp can spur growth in undamaged follicles when used along with treatment for the underlying condition. Other interventions include various hair restoration approaches and avoiding harsh hair care practices  (Cardoso, 2021).

Hair transplantation

Hair transplantation and other hair restoration approaches like tissue expansion may be an option for those with permanent hair loss. Various procedures can help cover bald areas in people whose hair loss has stabilized. 

In some cases, your healthcare provider may recommend that you wait a while (sometimes two years or more) to make sure the hair loss has stopped before doing a transplantation procedure (Singh, 2021-b). 

Avoiding harsh hair care practices

Hair products and practices like tightly pulled hairstyles have been linked to hair loss and scarring alopecia. The following general practices can help prevent further hair loss (Singh, 2021-a):

• Avoid harsh hair treatments. Spot test hair dyes before using them on your whole scalp, and use gentle shampoos. 

• Avoid hairstyles that pull the hair roots tightly.

• Protect the scalp with hats or sunscreen since UV (ultraviolet) light from the sun can worsen some types of alopecia.

It’s best to contact your healthcare provider if you notice any hair loss that seems unusual. They may refer you to a dermatologist who can discuss treatment options and rule out more common causes of hair loss. 

Many types of hair loss, such as androgenetic alopecia (pattern hair loss) or alopecia areata, are reversible with treatment, or the hair may grow back on its own. Scarring alopecia will not grow back, but the earlier you stop the inflammation, the more hair you can save. There are a variety of treatments and cosmetic options to help with this type of hair loss, so speak to your healthcare provider early when you notice hair loss.

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Current version

May 24, 2022

Written by

Kristin DeJohn

Fact checked by

Gina Allegretti, MD

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About the medical reviewer

Gina Allegretti, MD