If you have noticed bald patches on your scalp that feel different from the gradual thinning that friends or family members describe — patches that may itch, burn, or look smooth and shiny where hair used to be — you may be dealing with something more complex than common pattern hair loss. Cicatricial alopecia, also called scarring alopecia, is a serious group of hair loss disorders in which inflammation destroys the hair follicle and replaces it with scar tissue.
While the diagnosis can feel alarming, understanding what is happening beneath the scalp is the first step toward stopping the progression and protecting the hair you still have. If you are still trying to identify what kind of hair loss you may be experiencing, our overview of the common causes of hair loss is a useful starting point.
This guide explains what cicatricial alopecia is, what it looks like, what causes it, how it differs from non-scarring forms of hair loss, and what treatment options exist today — including when, if ever, surgical hair restoration becomes a reasonable consideration.
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Understanding Cicatricial (Scarring) Alopecia
Cicatricial alopecia is an umbrella term for a group of inflammatory hair loss conditions in which the hair follicle is permanently destroyed and replaced by fibrous scar tissue. Once the follicle is gone, hair cannot regrow from that site. According to dermatology research, primary cicatricial alopecia accounts for roughly 3 to 7 percent of patients seen in specialty hair clinics — a relatively small share of total hair loss cases, but a particularly important one because of how aggressive and irreversible the damage can be when it is not addressed early.
The term cicatricial comes from the Latin word for scar. In every form of this disease, the body’s immune system targets the follicular stem cells and sebaceous glands in the upper portion of the follicle, where the structures responsible for new hair growth reside. When those structures are destroyed, the follicle cannot recover. This is what separates scarring alopecia from far more common conditions like male and female pattern hair loss, in which the follicle shrinks but remains alive and capable of producing hair under the right conditions.
What Is the Cause of Cicatricial Alopecia?
The short answer is that cicatricial alopecia is caused by chronic inflammation that targets and destroys the upper portion of the hair follicle. The longer answer is that the precise trigger of that inflammation is not always known and likely varies from one form of scarring alopecia to another.
Is Cicatricial Alopecia an Autoimmune Disorder?
In many cases, yes… at least in part. Several of the most common forms of scarring alopecia, including lichen planopilaris and frontal fibrosing alopecia, are believed to involve autoimmune mechanisms in which the body’s own immune cells mistakenly identify follicular stem cells as foreign and attack them. Cleveland Clinic notes that lichen planopilaris is considered a likely autoimmune lymphocytic disorder of the hair follicle, and similar pathways appear to be at work in related conditions.
That said, “autoimmune” is not the complete picture for every patient. Some forms — including central centrifugal cicatricial alopecia (CCCA) and certain bacterial folliculitis-related scarring alopecias — appear to involve a mix of genetic susceptibility, hair-care practices, and inflammatory triggers rather than classic autoimmunity alone.
What Triggers Scarring Alopecia?
Triggers vary widely depending on the subtype. Recognized contributors include genetic predisposition, environmental exposures, certain hair-care behaviors (including heat styling and chemical relaxers in the case of CCCA), bacterial or fungal infections, hormonal changes, and broader immune dysregulation. Researchers have identified inherited gene variants, including changes in the PADI3 gene, that may make some individuals far more vulnerable to follicular scarring than others. In short, scarring alopecia is rarely the result of a single cause; it is usually the meeting point of inherited risk and a triggering insult.
What Does Cicatricial Alopecia Look Like?
Visually, cicatricial alopecia can be subtle in the early stages and dramatic later on. Patients often describe small, round, or irregularly shaped patches of hair loss that look different from the rest of the scalp. The skin within these patches may appear smooth, shiny, and slightly pale because the follicular openings — the tiny dots from which hairs emerge — are no longer present.
Other common visual and physical signs include scalp redness, scaling, crusting, or a violet hue around the affected area. Some patients experience itching, burning, tingling, or tenderness, while others have no symptoms at all and only notice the condition when a stylist or family member points out a thinning spot. In Black patients, CCCA typically begins at the crown of the scalp and expands outward in a roughly circular pattern, often with broken hair at the periphery and a smooth, shiny center.
A hallmark sign on close examination is the loss of follicular openings. A dermatologist using magnification will look for the absence of those dots, along with so-called “tufted” hairs — small clusters of multiple hairs growing through a single opening — which can indicate fibrotic damage in conditions such as folliculitis decalvans.
How Can You Tell the Difference Between Scarring and Non-Scarring Alopecia?
The simplest way to think about it: non-scarring alopecia preserves the follicle; scarring alopecia destroys it. In conditions like alopecia areata, telogen effluvium, and female pattern hair loss, the follicle remains intact and can produce hair again under the right circumstances. In cicatricial alopecia, the follicle is replaced by scar tissue, and that ground is no longer fertile.
Clinically, the differences a specialist looks for include:
- The presence or absence of follicular openings on the scalp surface
- Symptoms such as burning, itching, or pain (more common in scarring forms)
- Inflammation, scaling, redness, or color change at the edges of the affected area
- Findings on dermoscopy and, when needed, a small scalp biopsy that allows a pathologist to confirm whether the follicle has been replaced by fibrous tissue
Because the two categories require very different treatment strategies — and because permanent loss is at stake — getting an accurate diagnosis early is one of the most important steps a patient can take.
Common Types of Cicatricial Alopecia
Scarring alopecia is not a single disease but a family of related disorders. They are typically grouped by the type of inflammatory cell that dominates the biopsy.
The lymphocytic group includes lichen planopilaris, frontal fibrosing alopecia, central centrifugal cicatricial alopecia, and discoid lupus erythematosus of the scalp. The neutrophilic group includes folliculitis decalvans and dissecting cellulitis of the scalp, both of which often involve recurrent painful pustules and crusting. A mixed group includes acne keloidalis nuchae and folliculitis (acne) necrotica. While the underlying mechanisms differ, all of these conditions share the end result of replacing follicles with scar tissue.
It is worth noting that frontal fibrosing alopecia has been increasing in incidence since the early 2000s and is now one of the most frequently diagnosed forms of cicatricial alopecia in postmenopausal women — a reminder that these conditions are not as rare as they were once considered.
How Is It Diagnosed?
Because the symptoms of scarring alopecia overlap with so many other scalp conditions, a thorough evaluation by a hair-loss specialist or dermatologist is essential. The workup typically includes a detailed medical and family history, a careful scalp examination using a dermatoscope (a handheld magnifier), and in many cases a small scalp biopsy taken under local anesthesia.
The biopsy is the gold standard because it allows a pathologist to confirm whether follicles have been replaced by fibrosis and to identify the specific subtype. Early diagnosis matters enormously. Once a follicle is destroyed, no current treatment can bring it back. The window for preserving existing hair is widest when the disease is caught early.
How Is Cicatricial Alopecia Treated?
Treatment has two goals: stop the inflammation that is destroying follicles and preserve as much existing hair as possible. The specific protocol depends on the subtype, the severity of disease, and how active inflammation appears at the time of evaluation.
For lymphocytic forms (such as lichen planopilaris, frontal fibrosing alopecia, and CCCA), treatment commonly involves topical and intralesional corticosteroids to reduce inflammation, oral medications such as hydroxychloroquine, doxycycline (used for its anti-inflammatory effect rather than as a traditional antibiotic), and in selected cases mycophenolate mofetil or low-dose oral minoxidil.
For neutrophilic forms (such as folliculitis decalvans), longer courses of antibiotics — sometimes used in combination — are often required to control bacterial overgrowth and the immune response to it.
Adjunctive treatments may include gentle, evidence-based hair-care modifications, anti-androgen therapies in cases such as frontal fibrosing alopecia, and emerging options such as platelet-rich plasma in select stable cases. The American Academy of Dermatology emphasizes that scarring alopecia treatment must be tailored to the underlying cause and aimed at halting progression, because the disease behaves very differently from non-scarring forms.
Is Cicatricial Alopecia Reversible? Can Hair Grow Back After Scarring Alopecia?
This is the most painful question for patients to ask, and we will not soft-pedal the answer. Once a follicle has been destroyed and replaced by scar tissue, hair will not regrow from that site. That part of the disease is, in a strict sense, not reversible.
However, that is not the whole story. Many patients have a mix of active areas, where inflammation is still attacking surviving follicles, and burned-out areas, where the disease has already done its damage. Aggressive, well-targeted treatment can often calm the active areas, allowing follicles that were inflamed but not yet destroyed to recover and resume normal growth.
In other words, while the scarred zones cannot be undone, further loss can frequently be stopped, and partial regrowth is sometimes possible in areas where follicles have not yet been lost. This is why early evaluation and consistent follow-up matter so much.
When a Hair Transplant May Be an Option
Hair transplantation is not a first-line treatment for active cicatricial alopecia, and any reputable specialist will tell you so. Transplanting follicles into actively inflamed tissue typically results in graft loss because the same immune process that destroyed the original follicles tends to target the new ones.
That said, after the underlying disease has been clinically quiet for an extended period(often one to two years or more without active symptoms), surgical hair restoration may be a reasonable option for selected patients.
Modern techniques such as follicular unit extraction allow careful relocation of healthy donor follicles into stable, scarred areas to restore appearance and density. The decision is highly individualized; a thorough evaluation is required to confirm a quiet disease state, adequate donor availability, and realistic expectations about long-term graft survival.
When to See a Specialist
If you are noticing patches of hair loss that look different from gradual thinning — especially if they are accompanied by itching, burning, redness, scaling, or smooth, shiny skin where hair used to be — do not wait. Scarring alopecia is a time-sensitive condition, and the earlier it is identified and treated, the more hair can be preserved. Even when the cause turns out to be something simpler, an evaluation provides clarity, and clarity is one of the most reassuring things of all.
Compassionate, Expert Hair Loss Care in the Lehigh Valley
At Hair Restoration of Lehigh Valley in Easton, PA, Dr. Nish Patel and our team understand that hair loss is rarely just about hair. It is about confidence, identity, and quality of life. We take cicatricial alopecia seriously and evaluate every patient carefully — including microscopic scalp analysis, medical history, and individualized planning — to determine the right path forward, whether that involves medical management, non-surgical therapies, or, when appropriate, surgical hair restoration.
If you are concerned about unusual patches of hair loss, or you simply want a clear answer about what is happening on your scalp, we invite you to book a confidential consultation with our team. There is no medical referral needed and no obligation — only a thoughtful, expert assessment and a plan that puts your hair, and your peace of mind, first.
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