Scarring Alopecia

Diagnostic Pearls

Scarring alopecias are not common. However, they are under diagnosed. Here, I’ll review four key points about scarring alopecia that can dramatically increase one’s skills in diagnosing scarring alopecia. These points all pertain to where on the scalp the hair loss starts. The simple diagram shows a bird’s eye view of the top of the scalp.

Lichen planopilaris (LPP) and pseudopelade (PPB) can start anywhere on the scalp but typically start in the mid scalp and crown. Any patient with multiple symptoms such as itching, burning and tenderness in these areas needs to be evaluated for scarring alopecia. Of course there are other reasons for these symptoms too but scarring alopecias are at the top of the list.

Central Centrifugal Cicatricial Alopecia (CCCA) is very much underdiagnosed and predominantly affects women with afro textured hair. The key point is that any black woman age 30-60 with central hair loss needs evaluation for CCCA.

Folliculitis decalvans (FD) can affect many areas of the scalp but not uncommonly affects the crown. This location is common in men. Any male with hair loss accompanied by burning and tenderness in the crown needs evaluation for scarring alopecia.

Patients with Frontal Fibrosing Alopecia (FFA) lose hair in the frontal hairline but also lose eyebrows, eyelashes and body hair. Symptoms are usually absent. While the frontal hairline and eyebrows are often affected early in the disease district patches of hair loss often develop in front of the ears. Men and women with symmetrical (both sides) hair loss in the sideburns should be evaluated for FFA.