Cicatricial alopecia is caused by the destruction of hair follicles and their replacement by scar tissue, leading to permanent loss of the hairs. In some cases of cicatricial alopecia, the loss of the hair happens over time without any symptoms and remains unnoticed. In other cases, cicatricial alopecia is associated with itching, burning and pain, whereas it is rapidly progressive. The inflammation that destroys the follicles is located below the surface of the skin and the scar is not visible. Affected skin usually has redness, scaling, and increased or decreased pigmentation. It occurs in both men and women of all ages, who are otherwise healthy.
Cicatricial Alopecia – Classification
Cicatricial alopecia can be divided into primary and secondary. In the former case, the cause is endogenous, usually an inflammation that targets and destroys the hair follicle. In secondary cicatricial alopecia, the cause is exogenous, e.g. trauma, inflammation, injury, burn, traction or neoplasia. The most common form of primary cicatricial alopecia are lichen planus (follicular lichen) and discoid lupus.
Another classification of cicatricial alopecia is based on the causes, making distinction between the following types:
- Due to development disorders and hereditary diseases (cutis aplasia, moles, prokeratosis, ichtyosis, Darier’s disease)
- From natural causes (injuries, burns, radiodermatitis)
- Due to microbial inflammations (dermatophytosis, bacterial infections, leprosy, syphilis, folliculitis, acne, viral infections, shingles)
- Due to neoplasia (basal-cell carcinoma, squamous-cell carcinoma, metastatic carcinoma)
- Due to skin diseases of unknown aetiology (lichen planus, lupus erythematodes, localised scleroderma, sarcoidosis, follicular mucinosis)
The most common cause of cicatricial alopecia is lichen planus and is called follicular lichen or pseudopelade of Brocq. Lichen planus is a disease that affects the skin, hair, nails and mucous membranes. When it affects the hair follicles, it causes cicatricial alopecia. The cause of the disease is unknown.
The clinical picture of cicatricial alopecia by lichen planus is characterised by bald patches. The nude follicles exhibit edema and erythema around them and are hyperkeratotic. The few remaining hairs resemble doll hair because of the hyperkeratosis and their grow pattern. The primary localisation of this form of cicatricial alopecia is the forehead (frontal fibrosis alopecia) and the androgen-dependent area of the scalp, e.g. the crown of the head.
Cicatricial alopecia due to lichen planus is diagnosed by biopsy, in which the typical histological inflammation picture of lichen planus can be observed.
The choice of treatment due to follicular lichen is hydroxychloroquine (plaquenil), which has very good results in the stabilisation of the damages. Other medications used for this form of cicatricial alopecia are topical and systemic steroids, calcineurin inhibitors, finasteride, and, in advanced cases, azathioprine.
Discoid lupus erythematosus (DLE) is the second most common form of cicatricial alopecia. The cause is autoimmune. The clinical picture of this type consists of circular red inflamed patches that unite to form white atrophic scars. Biopsy and direct and indirect immunofluorescence confirm the diagnosis of cicatricial alopecia due to discoid lupus. It is treated with hydroxychloroquine, topical and systemic steroids, minoxidil and immunosuppressive drugs.
Hair transplantation can be used to treat some forms of cicatricial alopecia. At Advanced Hair Clinics, the hair transplantation teams under the supervision of the plastic surgeon Dr. Anastasios Vekris perform hair transplantation with the FUE method to cicatricial alopecias that are due to injuries or burns. A particular category of traumatic cicatricial alopecia which is often treated with hair transplantation, are traumatic scars after hair transplantation with the FUT or strip method. In these cases, hair follicles are taken from the donor area on the scalp or other areas, such as the face or chest, and placed over the scar, with the objective to cover the scar in a natural looking way.
In small and stable patches of cicatricial alopecia due to lichen planus or discoid lupus erythematosus, transplantation can be successful and has in fact been applied in our clinic in several cases with very good results. In this case, the first step is to set a secure diagnose of the cicatricial alopecia, i.e. to ascertain that it is due to follicular lichen and to exclude the possibility of alopecia areata. Next, the history of the damage is analysed and a conservative treatment is administered. In the case of old lesions of relatively small size, which have remained quite stable or have a very slow development, a test session with FUE hair transplant is suggested, during which a few dozens of follicles are implanted in a specific part of the affected area, and pictures are taken. During the months after the hair transplant session, the patient is re-examined in order to assess the growth of the new hairs and to establish if there has been any reactivation or expansion of the lichen planus patch. If the hair growth is satisfactory and there is no picture of expansion of the follicular lichen, a normal hair transplantation session with FUE method can be performed in order to cover as much of the affected area as possible.