Scarring Alopecia: What do all the colors mean?

Red and White in Scarring Alopecia: It often matters

Scarring alopecias are a group of hair conditions whereby scar tissue forms in the scalp and this scar tissue ultimately destroys hair follicle stem cells. There are dozens and dozens of different scarring alopecias but there are several that we see most commonly: lichen planopilaris, frontal fibrosinf aloepcia, folliculitis decalvans, central centrifugal cicatricial alopecia, pseudopelade, discoid lupus, dissecting cellulitis and acne keloidalis.

Many of the scarring alopecias are associated with some type of inflammation present in the skin. This inflammation causes the skin around the hair follicles to take on various shades of red. Redness in the scalp in a patient with scarring alopecia should always be given attention because there is a chance it means the patient’s disease is active. (It does not always as sometimes scalps become red with chronic steroid use). This has been labelled “step 1” in the photo. Over time if the hair follicle is destroyed the inflammation disappears from the area as the immune system has nothing further to attack. What is left is a white scarred area that no longer has the original redness (step 2). Of course, if the disease is successfully treated inflammation may also be reduced from the area as well and redness will also disappear. In other words, it is sometimes possible to block step 1 from progressing to step 2 with appropriate treatment. All in all, it is important to understand the significance of various color changes on the scalp in the setting of scarring alopecia.