If you’ve noticed unusual hair loss, creeping hairline changes, or patches where the skin looks different, you may be wondering whether something more serious is going on. Many people assume all hair loss behaves the same way, but scarring alopecia is very different from the more familiar non-scarring types like male or female pattern hair thinning.
Scarring alopecia, also known as cicatricial alopecia, is a group of conditions where inflammation destroys the hair follicles permanently. Once those follicles are gone, they cannot grow back. That’s why recognising early warning signs is absolutely crucial. The earlier you understand what’s happening, the better your chances of protecting the follicles that remain.
In this guide, I want to walk you through what scarring alopecia really is, how to identify the early symptoms, how dermatologists confirm the diagnosis, and which treatments help halt its progression. If you’ve been worried about unusual changes on your scalp, this article will give you the clarity you need to take action confidently.
Understanding Scarring Alopecia: What Makes It Different?
To understand the urgency around scarring alopecia, you first need to know what sets it apart from other forms of hair loss. With most non-scarring conditions, such as male pattern baldness or telogen effluvium, the hair follicles remain alive. This means there is always potential for regrowth.
But with scarring alopecia, the story is very different. Inflammation often subtle at the beginning gradually destroys the hair follicle. As it disappears, it gets replaced with fibrous scar tissue. That’s where the term “scarring” comes from. Once a follicle becomes scarred, it will never produce hair again. This is why early diagnosis matters so much. You are essentially racing against time to protect the follicles that have not yet been damaged. Even when visible hair loss seems small, the underlying inflammation may already be active.
Scarring alopecia can affect anyone, but certain types are more common in women, especially around menopause. It can also appear in people who have no family history of hair loss at all, which makes it even more confusing for those experiencing it.
Types of Scarring Alopecia You Should Know About
Scarring alopecia is not one single disease. It includes a group of conditions that behave differently but all share one key feature they destroy the follicle.
The most common types include:
Lichen Planopilaris (LPP)
LPP is one of the most frequent causes of scarring alopecia. It usually appears as patchy hair loss with scalp redness, burning sensations, and scaling around the hair follicles. It can affect the entire scalp.
Frontal Fibrosing Alopecia (FFA)
FFA is a subtype of LPP and has become increasingly common. It mainly affects women and causes the front hairline and eyebrows to gradually recede. The skin may appear pale, smooth, or shiny where follicles have been lost.
Central Centrifugal Cicatricial Alopecia (CCCA)
More common in women of African descent, CCCA usually begins at the crown and expands outward. Early symptoms can be subtle, such as increased tenderness or brittleness.
Discoid Lupus Erythematosus (DLE)
A type of cutaneous lupus that affects the scalp. It often appears as red or purple plaques and can cause patchy scarring with pigment changes.
Folliculitis Decalvans
This presents with pustules and crusting caused by chronic bacterial inflammation. Over time, follicles are permanently lost.
Traction Alopecia (advanced stage)
Long-term pulling forces from hairstyles can eventually destroy follicles and lead to scarring.
Each type may have unique signs, but the underlying mechanism inflammation leading to follicle destruction is the same. Understanding these differences helps you recognise when your hair loss doesn’t fit the typical pattern.
Why Early Detection Is So Important
When you’re dealing with scarring alopecia, timing is everything. Unlike reversible hair loss, scarring alopecia involves an active inflammatory process. Every week or month that passes without proper treatment puts more follicles at risk.
Here’s why early detection matters:
1. Follicles can be saved but only if caught in time
Inflamed follicles can often be calmed with the right medication. But once the follicle has turned into scar tissue, nothing can reverse it.
2. Symptoms at the start are often subtle
Many people ignore the early signs because they can be easy to dismiss mild itching, slight thinning, or small patches. By the time clear bald patches appear, significant damage may have already occurred.
3. Treatments work best during the active phase
Medications are designed to control inflammation. When the disease becomes inactive or “burns out,” the focus shifts from regrowth to cosmetic support.
4. It can mimic other hair loss conditions
Because it doesn’t always show dramatic symptoms early, scarring alopecia can get misdiagnosed as stress-related shedding or age-related thinning.
The goal with early detection is simple: preserve as many healthy follicles as possible. Even a small delay can make a large difference in long-term hair density.
Early Warning Signs You Should Never Ignore
One of the challenges with scarring alopecia is that the symptoms don’t always appear dramatic at the beginning. But if you know what to look for, you can spot the warning signs much earlier.
Let’s break down the most important early symptoms, so you can compare them to what you’re experiencing.
1. Persistent Itching or Burning
A healthy scalp doesn’t normally itch or burn. Occasional irritation is normal, but persistent discomfort is a red flag. In scarring alopecia, inflammation deep within the follicles can create sensations like:
- Burning
- Tingling
- Tightness
- Stinging
- Sensitivity when combing or washing
These sensations often precede visible hair loss.
2. Redness or Red Dots Around the Follicles
Redness around hair follicles known as perifollicular erythema is one of the most significant indicators of active inflammation. You may notice:
- Small red halos around the hairs
- Red patches where thinning is occurring
- Increased colour when the scalp is examined under bright light
Dermatologists often use a dermatoscope to identify this subtle redness.
3. Scaling, Flaking, or Roughness Around the Hair Follicles
Not all flaking is dandruff. In scarring alopecia, the scaling is usually concentrated around individual follicles rather than spread across the scalp.
You may notice:
- Fine white scales
- Tube-like keratin sheaths around the hairs
- Rough, dry areas that don’t improve with dandruff treatments
This pattern often points towards LPP or FFA.
4. Sudden Thinning or Patchy Hair Loss
If you’re losing hair in discrete patches rather than in a diffused pattern, take it seriously. Patchy thinning is especially common in:
- LPP
- CCCA
- DLE
- Folliculitis decalvans
These patches can expand gradually, and early patches may seem small or insignificant.
5. Receding Hairline or Changes in Hairline Shape
FFA is particularly known for causing the hairline to move backward. People often describe:
- A band-like area of thinning
- Loss of sideburns
- Eyebrow thinning or loss
- Skin that appears shiny or pale where hair used to be
These hairline changes usually happen slowly but consistently.
6. Tenderness When Touching or Styling Your Hair
Pain is an important signal of inflammation. If styling your hair, brushing, or touching your scalp causes discomfort, that could be a sign that the follicles are under stress.
7. Pustules, Crusting, or Oozing Areas
This tends to occur in folliculitis decalvans, where bacterial inflammation plays a role. You may notice:
- Yellow crusts
- Spots that resemble acne
- Areas that feel warm or swollen
If you see these changes, seek help right away because this type can progress quickly.
8. Smooth, Shiny Skin in Areas of Hair Loss
Once follicles are destroyed, the skin often looks:
- Smooth
- Polished
- Slightly lighter or darker than surrounding skin
By this stage, the follicles in that area are already gone. This is why noticing earlier symptoms is so essential.
How Dermatologists Diagnose Scarring Alopecia
If you recognise any of the early signs, getting a proper diagnosis is the next critical step. Diagnosing scarring alopecia involves expertise and specialised tools, because early stages can look very similar to other hair loss conditions.
Here’s how dermatologists confirm the diagnosis:
1. Detailed Examination of Your Scalp
Your dermatologist will study:
- Areas of redness
- Follicular scaling
- Hair distribution
- Changes in pigment
- Skin texture
- Early scarring indicators
This exam often gives the first clues.
2. Dermatoscopy (Trichoscopy)
This is one of the most valuable diagnostic tools. A dermatoscope magnifies the scalp, allowing your doctor to see details invisible to the naked eye.
With trichoscopy, a dermatologist can detect:
- Perifollicular scaling
- Follicular openings (or lack of them)
- Redness
- Broken hairs
- Vellus hair loss
- Early scarring signs
This tool helps differentiate scarring alopecia from pattern hair loss.
3. Scalp Biopsy: The Gold Standard
In most cases, a biopsy is needed for an accurate diagnosis. This involves removing a tiny piece of scalp tissue under local anaesthetic. The sample is examined under a microscope.
A biopsy can confirm:
- The exact type of scarring alopecia
- The level of inflammation
- Whether follicles are being destroyed
- How advanced the process is
This information helps guide treatment.
4. Blood Tests
While scarring alopecia itself is not caused by nutritional deficiencies, tests may be used to check for associated conditions or rule out other causes.
These may include tests for:
- Autoimmune markers
- Thyroid function
- Iron levels
5. Photographic Monitoring
High-resolution photos help track changes over time. This allows you and your dermatologist to see whether treatment is working or whether inflammation is still active.
Treatment Options to Halt the Progression of Scarring Alopecia
Once inflammation is confirmed, the primary goal is to stop the disease from continuing to destroy follicles. While hair cannot regrow in scarred areas, stopping progression protects remaining hair and preserves appearance.
Treatment depends on the specific type of scarring alopecia, but typically includes a combination of the following:
1. Anti-Inflammatory Medications
Inflammation is the driver behind follicle destruction. That’s why treatment focuses on calming this reaction as quickly as possible.
Common options include:
Topical corticosteroids
Applied directly to inflamed areas to reduce redness and irritation.
Intralesional steroid injections
Effective for targeted patches. These are often used for LPP and FFA.
Oral anti-inflammatory medications
Drugs such as hydroxychloroquine, doxycycline, or mycophenolate mofetil may be used for more widespread or aggressive disease.
These medications help slow or stop the inflammatory response.
2. Topical Calcineurin Inhibitors
Medications like tacrolimus or pimecrolimus can help calm immune-driven inflammation without the side effects associated with long-term steroid use.
3. Antibiotics for Folliculitis Decalvans
If the cause involves bacterial overgrowth, antibiotics both topical and oral may be essential.
Treatment may include:
- Rifampicin
- Clindamycin
- Tetracyclines
The goal is to control infection and inflammation together.
4. Hormonal Therapies for FFA
Because FFA appears linked to hormonal changes, some patients benefit from:
- Anti-androgen medications
- 5-alpha reductase inhibitors
- HRT discussions (where appropriate)
These help stabilise hair loss in some cases.
5. Minoxidil
While minoxidil cannot revive scarred follicles, it helps strengthen the remaining healthy ones. This can improve density and slow visible loss.
6. Hair Transplantation (Selective Cases)
Hair transplants are generally not performed during active inflammation. However, once the disease has been stable for at least a year, highly selected patients may consider transplantation to improve cosmetic appearance.
A surgeon will only proceed if they are confident the condition is inactive.
7. Lifestyle and Scalp Care Adjustments
Gentle hair care becomes more important than ever:
- Avoid tight hairstyles
- Reduce heat styling
- Avoid chemical relaxers or harsh treatments
- Protect the scalp from sun
- Use gentle, fragrance-free products
These steps help protect inflamed follicles from further stress.
Understanding the Long-Term Outlook
One of the hardest parts of scarring alopecia is that it doesn’t behave predictably. Some people experience slow progression over many years, while others have rapid changes within months.
The long-term goal is always the same: stop the inflammation and preserve as many follicles as possible. Most types of scarring alopecia eventually become inactive. Once the disease “burns out,” inflammation slows or stops. At that point, your dermatologist will shift focus to maintenance and cosmetic options.
Even if progression slows, regular monitoring is essential because flare-ups can occur long after the initial diagnosis.
How to Tell if Your Condition is Stabilising
You may notice:
- Reduced burning or itching
- Less redness
- Fewer hairs shedding
- A stable hairline
- No expansion of patches
Your dermatologist may confirm stability through trichoscopy or follow-up biopsies.
Stability does not reverse damage, but it protects the hair you still have.
Frequently Asked Questions:
1. What exactly is scarring alopecia, and how is it different from pattern hair loss?
Scarring alopecia, or cicatricial alopecia, is a group of inflammatory conditions where the immune system gradually destroys hair follicles, replacing them with scar tissue. Unlike pattern baldness or telogen effluvium, where the follicles stay alive and can regrow hair, scarring alopecia leads to permanent follicle loss. Early on, the signs can be subtle perhaps redness, mild itching or discomfort but without treatment, the inflammation causes irreversible damage.
2. How do I know if my hair loss is due to scarring alopecia or something more common like stress-related shedding?
If your hair loss comes with symptoms like burning, tingling, redness around hair follicles or scaly skin, it may be more than typical shedding. Scarring alopecia tends to produce patches rather than uniform thinning, and the skin in those areas can feel different tighter, shinier or more delicate. A dermatologist will examine your scalp under a dermatoscope (trichoscopy) and may recommend a biopsy if they suspect scarring alopecia. That’s how they differentiate it from non-scarring conditions.
3. Can scarring alopecia affect just a small area, or does it usually spread?
Scarring alopecia can present in both ways. In some people, the disease begins in small, isolated patches, while in others, it progresses in a more continuous or expanding pattern. For example, lichen planopilaris often causes patchy loss across the scalp, whereas frontal fibrosing alopecia usually affects the front hairline and eyebrows. The key thing is that once a follicle is lost, it doesn’t come back which is why even small areas of early inflammation matter.
4. Do I need a scalp biopsy to diagnose scarring alopecia?
Almost always, yes. A scalp biopsy is considered the diagnostic gold standard because it shows exactly what’s happening under the skin how many viable follicles remain, how active the inflammation is, and whether scar tissue has already formed. The dermatologist takes a tiny sample under local anesthesia, and a specialist examines it under a microscope. This helps them identify the specific subtype of scarring alopecia, which is critical for guiding treatment.
5. Is treatment effective once scarring alopecia is diagnosed?
Treatment can be very effective at stopping disease progression, though it can’t reverse scarring once follicles are destroyed. The goal is to calm inflammation before too many follicles are lost. Dermatologists often use anti-inflammatory medications, topical or injected steroids, and sometimes systemic drugs like hydroxychloroquine. With prompt treatment, many people keep much of their remaining hair and prevent further visible loss.
6. What medications are commonly used for scarring alopecia, and do they have side effects?
Treatments often include anti-inflammatory therapies such as corticosteroids, which can be topical, injected or oral, and immunomodulatory drugs like hydroxychloroquine or mycophenolate in more severe cases. Antibiotics may be used for inflammatory types associated with bacteria, such as folliculitis decalvans. While these treatments can have side effects for instance, stomach upset, changes in vision or risk of infection your dermatologist will tailor the plan carefully, monitor for side effects, and adjust dosage to balance safety and efficacy. The benefit of preserving hair follicles is usually judged to far outweigh the risks.
7. Once inflammation is under control, can hair regrow in scarring alopecia?
Hair regrowth in scarring alopecia is limited because once a hair follicle is replaced by scar tissue, it’s gone for good. However, if treatment begins early enough while follicles are still inflamed but not fully destroyed some regrowth may occur, and existing healthy follicles can continue to produce hair. Over time, once the disease stabilises, treatment shifts more toward maintenance and protecting the remaining follicles, rather than aggressive regrowth.
8. Are there different treatments depending on which type of scarring alopecia I have?
Definitely. Treatment depends on the underlying subtype because each one has a different pattern of inflammation. Lichen planopilaris and frontal fibrosing alopecia often respond to anti-inflammatory therapies and steroids. In cases like folliculitis decalvans, where bacteria are involved, antibiotics are central. For discoid lupus erythematosus, treatment may involve both immune suppression and careful sun protection. Your dermatologist will choose a therapy based on biopsy results and your clinical features.
9. What lifestyle changes can support treatment and prevent further damage?
Gentle scalp care is crucial: avoid tight hairstyles, reduce heat styling, and steer clear of harsh chemical treatments. Sun protection matters, too, because UV exposure can exacerbate inflammation. Choose mild, fragrance-free shampoos and avoid frequent vigorous scrubbing. Reducing stress and maintaining a healthy skincare routine helps your scalp stay calm, and this supports the effectiveness of your treatment by reducing additional irritation to vulnerable follicles.
10. What is the long-term outlook if I’m diagnosed with scarring alopecia?
Scarring alopecia is usually a long-term condition, but it does not always progress forever. Many people reach a “burned out” or stable phase where inflammation slows or nearly stops, and hair loss ceases. At that point, treatment shifts from active suppression to maintenance. Ongoing monitoring with your dermatologist using clinical exams, trichoscopy or occasional biopsies helps catch any flare-ups early so they can be treated before more follicles are lost. With early diagnosis and consistent care, many individuals preserve a significant portion of their hair and maintain a healthy scalp.
Final Thought: Early Action Against Scarring Alopecia
Scarring alopecia may start quietly, but its impact can be profound early signs like burning, redness or slight patches of hair loss may feel minor, but they can signal a deeper and irreversible process. With the right diagnosis and prompt treatment, you can calm inflammation and protect the follicles that are still intact. While hair regrowth in scarred areas is not possible, stopping further damage gives you the best chance of preserving your remaining hair.
If you’re looking for alopecia treatment in London, you can contact us at London Dermatology Centre to arrange a consultation. Our specialists can assess your scalp, identify potential scarring alopecia, and craft a personalised plan to prevent further hair loss and safeguard your scalp health.
References:
1. Carmona‑Rodríguez, M., Moro‑Bolado, F., Romero‑Aguilera, G. et al. (2023) ‘Frontal Fibrosing Alopecia: An Observational Single‑Center Study of 306 Cases’, Life, 13(6), 1344. Available at: https://www.mdpi.com/2075-1729/13/6/1344
2. Haider, A. & McLellan, B. (2018) ‘Cicatricial Alopecia’, Journal of the American Academy of Dermatology, [Epub ahead of print]. Available at: https://pubmed.ncbi.nlm.nih.gov/29645394/
3. Rakowska, A., Olszewska, M., Slowinska, M., Rudnicka, L. (2023) ‘Trichoscopic Features of Lichen Planopilaris versus Frontal Fibrosing Alopecia: A Systematic Review’, Dermatology, [Epub ahead of print]. Available at: https://pubmed.ncbi.nlm.nih.gov/40117622/
4. Rudnicka, L. & Gronowski, J. (2011) ‘Cicatricial (scarring) alopecia: an overview of pathogenesis, classification, diagnosis, and treatment’, International Journal of Trichology, [Review]. Available at: https://pubmed.ncbi.nlm.nih.gov/22494477/
5. Cummins, D. M., Chaudhry, I. H. & Harries, M. (2021) ‘Scarring Alopecias: Pathology and an Update on Digital Developments’, Biomedicines, 9(12), 1755. Available at: https://www.mdpi.com/2227-9059/9/12/1755