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Cicatricial alopecia, also known as scarring alopecia, refers to a group of rare disorders that result in permanent hair loss due to the destruction of hair follicles and their replacement with scar tissue.
This form of alopecia can affect both men and women of all ages, even those who are otherwise in good health. The course of the condition can vary significantly: in some individuals, hair loss occurs slowly and without noticeable symptoms, while in others, it may develop rapidly and be accompanied by discomfort such as itching, burning, or pain.
The key feature of scarring alopecia is the presence of inflammation beneath the skin surface, which irreversibly damages the hair follicles. Although the scarring is internal and not always visible, the affected areas of the scalp may show signs such as redness, scaling, discoloration (either darkening or lightening of the skin), and changes in texture.
Due to the permanent nature of the hair loss and the underlying inflammatory process, early diagnosis and intervention by a dermatologist are critical in managing symptoms and preventing further damage.
Conservative treatment options for cicatricial alopecia focus on controlling inflammation and preventing further follicular damage. In cases of follicular lichen, hydroxychloroquine is the primary treatment of choice, as it has shown significant effectiveness in stabilizing the condition.
Additional therapies may include topical and systemic corticosteroids to reduce inflammation, calcineurin inhibitors for immunomodulation, and, in more advanced or resistant cases, the immunosuppressive agent azathioprine. Similarly, discoid lupus erythematosus (DLE), another form of scarring alopecia, is commonly managed with hydroxychloroquine in combination with topical and systemic steroids. Minoxidil may be used to stimulate hair growth in non-scarred areas, while more severe cases may require immunosuppressive drugs to control the autoimmune response and limit further follicular destruction.
Hair transplantation can be an effective treatment option for certain forms of cicatricial (scarring) alopecia, particularly when the condition is stable and localized. At Advanced Hair Clinics, under the supervision of plastic surgeon Dr. Anastasios Vekris, the FUE (Follicular Unit Extraction) technique is used to restore hair in cases of cicatricial alopecia caused by trauma, injuries, or burns. A common indication for this procedure is the presence of linear scars resulting from previous hair transplants performed with the FUT (Strip) method. In these cases, hair follicles are harvested from donor areas on the scalp or other parts of the body, such as the beard or chest, and carefully implanted into the scarred region to achieve a natural-looking result and improve the aesthetic appearance.
Hair transplantation is also possible in small, well-defined, and stable patches of cicatricial alopecia caused by conditions such as lichen planopilaris or discoid lupus erythematosus. At our clinic, several such cases have been successfully treated with excellent cosmetic outcomes. The key to success lies in accurate diagnosis and thorough preoperative evaluation. It is essential to confirm that the hair loss is due to a scarring condition such as follicular lichen, while ruling out non-scarring types like alopecia areata. Once the diagnosis is established, the patient’s medical history is reviewed, and appropriate conservative treatment is initiated to ensure the disease is inactive before proceeding with the transplant.
In cases of older, relatively small lesions that have remained stable or show only very slow progression, a cautious approach is recommended before proceeding with full hair restoration. A test session using the FUE (Follicular Unit Extraction) method is often advised, during which a small number of hair follicles—typically a few dozen—are transplanted into a targeted section of the affected area. Photographic documentation is taken at the time of the procedure to allow for accurate monitoring.
In the following months, the patient is regularly re-evaluated to assess both the growth and survival of the transplanted hairs, as well as to monitor for any signs of disease reactivation or expansion of the lichen planus lesion. If the results are favorable—meaning satisfactory hair growth and no evidence of active inflammation or spread—a full FUE hair transplantation can be planned to cover as much of the scarred or alopecic area as possible with confidence in its long-term success.
The diagnosis of scarring alopecia is established through a clinical examination combined with a phototrichogram, which allows detailed analysis of hair density, follicular activity, and scalp condition. Based on the findings, scarring alopecia is typically categorized into two main types, depending on the pattern and characteristics of the hair loss and the underlying inflammatory activity observed during the assessment.
Primary scarring alopecia is caused by internal (endogenous) factors, most commonly an inflammatory process that directly targets and destroys the hair follicle. This leads to irreversible damage and replacement of the follicle with scar tissue. The most frequent types of primary cicatricial alopecia include lichen planopilaris (follicular lichen) and discoid lupus erythematosus, both of which involve autoimmune mechanisms that trigger chronic inflammation in the scalp.
Secondary scarring alopecia results from external (exogenous) factors that damage the hair follicles and surrounding tissue. Unlike primary forms, the follicle is not the initial target of inflammation but becomes destroyed as a consequence of injury or disease. Common causes include trauma, burns, infections, traction (from tight hairstyles), radiation, surgical procedures, or neoplastic conditions. The resulting scarring prevents hair regrowth, making early intervention crucial to minimize permanent hair loss.
Scarring alopecia can result from a wide range of underlying conditions, which are generally grouped based on their origin:
