Skin of Color pp 105-122 | Cite as

Cicatricial Alopecias

  • Yolanda M. Lenzy
  • Amy J. McMichael


This chapter provides a practical approach to the diagnosis and management of the most common types of primary cicatricial alopecias. In primary scarring alopecias, the target of the inflammation is the hair follicle. In secondary scarring alopecias, the hair follicle is an innocent bystander in the disease process and is destroyed in a nonspecific manner. Examples of secondary scarring alopecias include deep burns, radiation dermatitis, cutaneous malignancies, cutaneous sarcoidosis, morphea, necrobiosis lipoidica, and certain chronic infections such as cutaneous tuberculosis. Secondary forms of scarring hair loss are quite common and must be considered in the differential diagnosis of late-stage primary scarring hair loss when inflammatory clues are no longer available to help with diagnosis. The diagnostic hallmark of all forms of cicatricial alopecia (primary and secondary) is visible loss of follicular ostia. In this chapter, we will focus on helpful clinical clues that help distinguish the various primary scarring alopecias and allow distinction from potentially similar non-scarring alopecias. Treatments will be discussed based on the inflammatory level of typical pathologic examination of each entity.


Hair Follicle Mycophenolate Mofetil Hair Loss Lichen Planus Bullous Pemphigoid 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Sperling L, et al. Alopecias. In: Bolognia J, Jorizzo JL, Rapini RP, editors. Dermatology. St. Louis, MO: Elsevier; 2008. p. 996.Google Scholar
  2. 2.
    Finner AM, Otberg N, Shapiro J. Secondary cicatricial and other permanent alopecias. Dermatol Ther. 2008;21(4):279–94.PubMedCrossRefGoogle Scholar
  3. 3.
    Olsen EA, Bergfeld WF, Cotsarelis G, et al. Summary of North American hair research society (NAHRS)-sponsored Workshop on Cicatricial Alopecia, Duke University Medical Center, February 10 and 11, 2001. J Am Acad Dermatol. 2003;48(1):103–10.PubMedCrossRefGoogle Scholar
  4. 4.
    Sperling LC. Scarring alopecia and the dermatopathologist. J Cutan Pathol. 2001;28(7): 333–42.PubMedCrossRefGoogle Scholar
  5. 5.
    Sperling LC, Skelton 3rd HG, Smith KJ, Sau P, Friedman K. Follicular degeneration syndrome in men. Arch Dermatol. 1994;130(6):763–9.PubMedCrossRefGoogle Scholar
  6. 6.
    Sperling LC, Sau P. The follicular degeneration syndrome in black patients. “Hot comb alopecia” revisited and revised. Arch Dermatol. 1992;128(1):68–74.PubMedCrossRefGoogle Scholar
  7. 7.
    LoPresti P, Papa CM, Kligman AM. Hot comb alopecia. Arch Dermatol. 1968;98(3):234–8.PubMedCrossRefGoogle Scholar
  8. 8.
    McMichael AJ. Ethnic hair update: past and present. J Am Acad Dermatol. 2003;48(6 Suppl):S127–33.PubMedCrossRefGoogle Scholar
  9. 9.
    Nnoruka EN. Hair loss: is there a relationship with hair care practices in Nigeria? Int J Dermatol. 2005;44 Suppl 1:13–7.PubMedCrossRefGoogle Scholar
  10. 10.
    McMichael AJ. Hair and scalp disorders in ethnic populations. Dermatol Clin. 2003;21(4): 629–44.PubMedCrossRefGoogle Scholar
  11. 11.
    Bulengo-Ransby SM, Bergfeld WF. Chemical and traumatic alopecia from thioglycolate in a black woman: a case report with unusual clinical and histologic findings. Cutis. 1992;49(2): 99–103.PubMedGoogle Scholar
  12. 12.
    Gathers RC, Jankowski M, Eide M, Lim HW. Hair grooming practices and central centrifugal cicatricial alopecia. J Am Acad Dermatol. 2009;60(4):574–8.PubMedCrossRefGoogle Scholar
  13. 13.
    Martin ES, Elewski BE. Tinea capitis in adult women masquerading as bacterial pyoderma. J Am Acad Dermatol. 2003;49(2 Suppl Case Reports):S177–9.PubMedCrossRefGoogle Scholar
  14. 14.
    Sperling LC, Solomon AR, Whiting DA. A new look at scarring alopecia. Arch Dermatol. 2000;136(2):235–42.PubMedCrossRefGoogle Scholar
  15. 15.
    Ackerman AB, Walton NW, Jones RE, Charissi C. “Hot comb alopecia”/ “Follicular degeneration syndrome” in African American women is traction alopecia. Dermatopath: Practical Conceptual. 2000;6:6–21.Google Scholar
  16. 16.
    Olsen EA. Female pattern hair loss and its relationship to permanent/cicatricial alopecia: a new perspective. j investig dermatol Symp proc. 2005;10(3):217–21.PubMedCrossRefGoogle Scholar
  17. 17.
    Scott DA. Disorders of the hair and scalp in blacks. Dermatol Clin. 1988;6(3):387–95.PubMedGoogle Scholar
  18. 18.
    Price VH. The medical treatment of cicatricial alopecia. Semin Cutan Med Surg. 2006;25(1):56–9.PubMedCrossRefGoogle Scholar
  19. 19.
    Taylor S. Practical tips for managing hair disorders in African-American females. Pract Dermatol. 2006;3(7):25–7.Google Scholar
  20. 20.
    Callender VD, McMichael AJ, Cohen GF. Medical and surgical therapies for alopecias in black women. Dermatol Ther. 2004;17(2):164–76.PubMedCrossRefGoogle Scholar
  21. 21.
    Brown MD, Johnson T, Swanson NA. Extensive keloids following hair transplantation. J Dermatol Surg Oncol. 1990;16(9):867–9.PubMedGoogle Scholar
  22. 22.
    Chieregato C, Zini A, Barba A, Magnanini M, Rosina P. Lichen planopilaris: report of 30 cases and review of the literature. Int J Dermatol. 2003;42(5):342–5.PubMedCrossRefGoogle Scholar
  23. 23.
    Mehregan DA, Van Hale HM, Muller SA. Lichen planopilaris: clinical and pathologic study of forty-five patients. J Am Acad Dermatol. 1992;27(6 Pt 1):935–42.PubMedCrossRefGoogle Scholar
  24. 24.
    Mirmirani P. Cicatricial Alopecia. In: healthcare I, editor. Hair and scalp diseases: medical, surgical and cosmetic treatments. New York: Informa Healthcare; 2008. p. 137–48.Google Scholar
  25. 25.
    Kossard S, Lee MS, Wilkinson B. Postmenopausal frontal fibrosing alopecia: a frontal variant of lichen planopilaris. J Am Acad Dermatol. 1997;36(1):59–66.PubMedCrossRefGoogle Scholar
  26. 26.
    Zinkernagel MS, Trueb RM. Fibrosing alopecia in a pattern distribution: patterned lichen planopilaris or androgenetic alopecia with a lichenoid tissue reaction pattern? Arch Dermatol. 2000;136(2):205–11.PubMedCrossRefGoogle Scholar
  27. 27.
    Bianchi L, Paro Vidolin A, Piemonte P, Carboni I, Chimenti S. Graham Little-Piccardi-Lassueur syndrome: effective treatment with cyclosporin A. Clin Exp Dermatol. 2001;26(6).Google Scholar
  28. 28.
    Amato L, Mei S, Massi D, Gallerani I, Fabbri P. Cicatricial alopecia; a dermatopathologic and immunopathologic study of 33 patients (pseudopelade of Brocq is not a specific clinico-pathologic entity). Int J Dermatol. 2002;41(1):8–15.PubMedCrossRefGoogle Scholar
  29. 29.
    Silvers DN, Katz BE, Young AW. Pseudopelade of Brocq is lichen planopilaris: report of four cases that support this nosology. Cutis. 1993;51(2):99–105.PubMedGoogle Scholar
  30. 30.
    Ronchese F. Pseudopelade. Arch dermat. 1960;82:336–43.CrossRefGoogle Scholar
  31. 31.
    Karnik P, Tekeste Z, McCormick TS, et al. Hair follicle stem cell-specific PPARgamma deletion causes scarring alopecia. J Invest Dermatol. 2009;129(5):1243–57.PubMedCrossRefGoogle Scholar
  32. 32.
    Harries MJ, Paus R. Scarring alopecia and the PPAR-gamma connection. J Invest Dermatol. 2009;129(5):1066–70.PubMedCrossRefGoogle Scholar
  33. 33.
    Otberg N, Wu WY, McElwee KJ, Shapiro J. Diagnosis and management of primary cicatricial alopecia: part I. Skinmed. 2008;7(1):19–26.PubMedCrossRefGoogle Scholar
  34. 34.
    Cevasco NC, Bergfeld WF, Remzi BK, de Knott HR. A case-series of 29 patients with lichen planopilaris: the Cleveland clinic foundation experience on evaluation, diagnosis, and treatment. J Am Acad Dermatol. 2007;57(1):47–53.PubMedCrossRefGoogle Scholar
  35. 35.
    George YA RS, Gottlieb J, et al. Betamethasone valerate 0.12 % in foam vehicle scalp dermatitis in African Americans. Cosmet Dermatol. 2002;15:23–7.Google Scholar
  36. 36.
    Callen JP K-SC, Wolverton SE. Methotrexate. In: Comprehensive dermatologic drug therapy. Seconth ed. Philadelphia: Saunders; 2007.Google Scholar
  37. 37.
    Turan H, Baskan EB, Tunali S, Yazici S, Saricaoglu H. Methotrexate for the treatment of ­generalized lichen planus. J Am Acad Dermatol. 2009;60(1):164–6.PubMedCrossRefGoogle Scholar
  38. 38.
    Nylander Lundqvist E, Wahlin YB, Hofer PA. Methotrexate supplemented with steroid ointments for the treatment of severe erosive lichen ruber. Acta Derm Venereol. 2002;82(1):63–4.PubMedCrossRefGoogle Scholar
  39. 39.
    Mirmirani P, Willey A, Price VH. Short course of oral cyclosporine in lichen planopilaris. J Am Acad Dermatol. 2003;49(4):667–71.PubMedCrossRefGoogle Scholar
  40. 40.
    Bohm M, Beissert S, Schwarz T, Metze D, Luger T. Bullous pemphigoid treated with mycophenolate mofetil. Lancet. 1997;349(9051):541.PubMedCrossRefGoogle Scholar
  41. 41.
    Enk AH, Knop J. Treatment of pemphigus vulgaris with mycophenolate mofetil. Lancet. 1997;350(9076):494.PubMedCrossRefGoogle Scholar
  42. 42.
    Frieling U, Bonsmann G, Schwarz T, Luger TA, Beissert S. Treatment of severe lichen planus with mycophenolate mofetil. J Am Acad Dermatol. 2003;49(6):1063–6.PubMedCrossRefGoogle Scholar
  43. 43.
    Tosti A, Piraccini BM, Iorizzo M, Misciali C. Frontal fibrosing alopecia in postmenopausal women. J Am Acad Dermatol. 2005;52(1):55–60.PubMedCrossRefGoogle Scholar
  44. 44.
    George SJ, Hsu S. Lichen planopilaris treated with thalidomide. J Am Acad Dermatol. 2001;45(6):965–6.PubMedCrossRefGoogle Scholar
  45. 45.
    Callen JP. Chronic cutaneous lupus erythematosus. Clinical, laboratory, therapeutic, and prognostic examination of 62 patients. Arch Dermatol. 1982;118(6):412–6.PubMedCrossRefGoogle Scholar
  46. 46.
    McCarty DJ, Manzi S, Medsger Jr TA, Ramsey-Goldman R, LaPorte RE, Kwoh CK. Incidence of systemic lupus erythematosus. Race and gender differences. Arthritis Rheum. 1995;38(9):1260–70.PubMedCrossRefGoogle Scholar
  47. 47.
    Tebbe B, Mansmann U, Wollina U, et al. Markers in cutaneous lupus erythematosus indicating systemic involvement. A multicenter study on 296 patients. Acta Derm Venereol. 1997;77(4): 305–8.PubMedGoogle Scholar
  48. 48.
    Werth VP, White WL, Sanchez MR, Franks AG. Incidence of alopecia areata in lupus erythematosus. Arch Dermatol. 1992;128(3):368–71.PubMedCrossRefGoogle Scholar
  49. 49.
    Headington JT. Cicatricial alopecia. Dermatol Clin. 1996;14(4):773–82.PubMedCrossRefGoogle Scholar
  50. 50.
    Koca R, Altinyazar HC, Ozen OI, Tekin NS. Dissecting cellulitis in a white male: response to isotretinoin. Int J Dermatol. 2002;41(8):509–13.PubMedCrossRefGoogle Scholar
  51. 51.
    Sukhatme SV, Lenzy YM, Gottlieb AB. Refractory dissecting cellulitis of the scalp treated with adalimumab. J Drugs Dermatol. 2008;7(10):981–3.PubMedGoogle Scholar
  52. 52.
    Scerri L, Williams HC, Allen BR. Dissecting cellulitis of the scalp: response to isotretinoin. Br J Dermatol. 1996;134(6):1105–8.PubMedCrossRefGoogle Scholar
  53. 53.
    Williams CN, Cohen M, Ronan SG, Lewandowski CA. Dissecting cellulitis of the scalp. Plast Reconstr Surg. 1986;77(3):378–82.PubMedCrossRefGoogle Scholar
  54. 54.
    Brandt HR, Malheiros AP, Teixeira MG, Machado MC. Perifolliculitis capitis abscedens et suffodiens successfully controlled with infliximab. Br J Dermatol. 2008;159(2):506–7.PubMedCrossRefGoogle Scholar
  55. 55.
    Bolz S, Jappe U, Hartschuh W. Successful treatment of perifolliculitis capitis abscedens et suffodiens with combined isotretinoin and dapsone. J Dtsch Dermatol Ges. 2008;6(1):44–7.PubMedGoogle Scholar
  56. 56.
    Georgala S, Korfitis C, Ioannidou D, Alestas T, Kylafis G, Georgala C. Dissecting cellulitis of the scalp treated with rifampicin and isotretinoin: case reports. Cutis. 2008;82(3):195–8.PubMedGoogle Scholar
  57. 57.
    Glass LF, Berman B, Laub D. Treatment of perifolliculitis capitis abscedens et suffodiens with the carbon dioxide laser. J Dermatol Surg Oncol. 1989;15(6):673–6.PubMedGoogle Scholar
  58. 58.
    Boyd AS, Binhlam JQ. Use of an 800-nm pulsed-diode laser in the treatment of recalcitrant dissecting cellulitis of the scalp. Arch Dermatol. 2002;138(10):1291–3.PubMedCrossRefGoogle Scholar
  59. 59.
    Chui CT, Berger TG, Price VH, Zachary CB. Recalcitrant scarring follicular disorders treated by laser-assisted hair removal: a preliminary report. Dermatol Surg. 1999;25(1):34–7.PubMedCrossRefGoogle Scholar
  60. 60.
    Krasner BD, Hamzavi FH, Murakawa GJ, Hamzavi IH. Dissecting cellulitis treated with the long-pulsed Nd:YAG laser. Dermatol Surg. 2006;32(8):1039–44.PubMedCrossRefGoogle Scholar
  61. 61.
    Wu WY, Otberg N, McElwee KJ, Shapiro J. Diagnosis and management of primary cicatricial alopecia: part II. Skinmed. 2008;7(2):78–83.PubMedCrossRefGoogle Scholar
  62. 62.
    Powell JJ, Dawber RP, Gatter K. Folliculitis decalvans including tufted folliculitis: clinical, histological and therapeutic findings. Br J Dermatol. 1999;140(2):328–33.PubMedCrossRefGoogle Scholar
  63. 63.
    Powell J, Dawber RP. Folliculitis decalvans and tufted folliculitis are specific infective ­diseases that may lead to scarring, but are not a subset of central centrifugal scarring alopecia. Arch Dermatol. 2001;137(3):373–4.PubMedGoogle Scholar
  64. 64.
    Abeck D, Korting HC, Braun-Falco O. Folliculitis decalvans. Long-lasting response to ­combined therapy with fusidic acid and zinc. Acta Derm Venereol. 1992;72(2):143–5.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  1. 1.Department of DermatologyBoston University School of MedicineBostonUSA
  2. 2.Department of Dermatology, Medical Center BoulevardWake Forest University School of MedicineWinston-SalemUSA

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