Cicatricial (Scarring) Alopecia and the "Trichologic Emergency"

The word cicatricial is derived from the Latin term ‘cicatrix’ meaning scar.  Cicatricial alopecias are a group of hair loss conditions that lead to permanent scarring in the scalp.  The cause of most of these conditions is not known. There are many different types of cicatricial alopecias that I see commonly in my practice, including lichen planopilaris, frontal fibrosing alopecia, central centrifugal cicatricial alopecia, discoid lupus, pseudopelade, folliculitis decalvans and dissecting cellulitis. There are dozens of other types of scarring alopecias as well.  Regardless of the type of scarring alopecia, all are characterized by one common entity – a disease process that leads to irreversible destruction of the hair follicle.  For patients, this means that these diseases lead to permanent hair loss – the patient will never regrow hair in areas where hair has been lost.

It was renowned dermatologist Dr. Jerry Shapiro who coined the term “trichologic emergency.”  This is an important term because it reminds us that we need to act quickly in diagnosing and treating patients with cicatricial alopecia.    Once a patient loses hair, it will not grow back.

The photo on the right shows the scalp of a patient with a scarring alopecia known as pseudopelade. The dotted border shows an area of permanent scarring. I know this patient has a scarring alopecia because the follicular openings (i.e. holes in the scalp where the hairs come out) are missing. This area appears very smooth, similar to a ice skating rink. There were once hairs underneath this area. However, these hairs have now been permanently loss and will not regrow in this area. A biopsy was done later and also confirmed the diagnosis of scarring alopecia.

But the diagnosis is only the first step in helping patients with scarring alopecia. The next step is to stop the process.  This border of hair follicle destruction will continue to move outward unless the patient is started on treatment. The small arrows show the direction of the scarring process. In fact, some of the healthy hairs at the outer border of the process are already starting to be affected by the disease.  You can see one hair follicle with the yellow arrow is starting to look very irregular with many twists and turns.  Within a few months this hair follicle will likely be permanently destroyed and fall out of the scalp. Treatment is needed to help slow or halt the process of hair follicle destruction.