National Scarring Alopecia Awareness Month (Day 18, Myth 3): Do We See Visible Scar Tissue on the Scalp in All Scarring Alopecias ?

It’s a Myth that Scarring Alopecias are Always Easily Identified by the Presence of Visible Scar Tissue on the Scalp

The early stages of scarring alopecia show no visible scarring! It’s only in the later stages of scarring alopecia that one sees patches of scarring. The goal of treating scarring alopecia is to identify the condition at the earliest possible stage in order to help prevent progression to these sorts  of permanent patches of hair loss.

If we don’t see scars, what do we see?

Well, the earliest days and weeks and months of lichen planopilaris and folliculitis decalvans and even discoid lupus closely mimic “dandruff” or seborrheic dermatitis or folliculitis. There is often symptoms of itching or burning together with redness and scale and “bumps.” In folliculitis decalvans, specifically, some of these bumps are true pustules but again closely resemble a bacterial folliculitis.  A misdiagnosis of folliculitis or seborrheic dermatitis or even psoriasis is fairly common in these stages.

One needs to be thinking scarring alopecia to be able to diagnose scarring alopecia.

In the case of early central centrifugal cicatricial alopecia (CCCA) there is also no visible scarring. A bit of pins and needles, tingling and perhaps itching is present but often not much in the way of redness. An important concern of affected patients is the degree of hair breakage they experience. A diagnosis of seborrheic dermatitis or traction or hair shaft damage from heat or chemicals is often given as the reason for the hair concerns in those with early CCCA.

One needs to be thinking scarring alopecia to be able to diagnose scarring alopecia.

Let’s dive a bit further again into some of the early stages of scarring alopecia and what to expect

The Early Stages of Folliculitis Decalvans

“Folliculitis” - especially with bumps on the crown of the scalp together with reported symptoms by the patient of bleeding, burning or itching must make one think about a diagnosis of folliculitis decalvans. Closer inspection with trichoscopy can often show classic features in this stage as well - long before scarring is seen. A biopsy should be strongly considered. It will be months and months (and maybe years in some cases) before scarring is seen so the time is now to diagnose it properly through a biopsy and treat it to reduce the chances of progression to any sort of visible scarring.

The Early Stages of Central Centrifugal Cicatricial Alopecia (CCCA)

“Hair breakage’ in the central scalp area in women with afro textured hair - with or without symptoms -  is the clue that CCCA might be the diagnosis. Hair breakage can be one of the earliest signs of CCCA! A biopsy should be considered with localized hair breakage in the mid scalp in women 30-50 especially if symptoms like tingling, pins and needles are present. It will be months and months (and maybe years in some cases) before scarring is seen so the time is now to diagnose it properly through a biopsy and treat it to reduce the chances of progression to any sort of visible scarring.

The Early Stages of Lichen Planopilaris (LPP) and Discoid Lupus (DLE)

Bumps in the scalp with redness, itching and burning and increased shedding is the clue that lichen planopilaris or discoid lupus might be the diagnosis. Closer inspection with trichoscopy can often show classic features in this stage as well - long before scarring is seen. A biopsy should be considered. It will be months and months (and maybe years in some cases) before scarring is seen so the time is now to diagnose it properly through a biopsy and treat it to reduce the chances of progression to any sort of visible scarring.

Conclusion

One does not look at the scalp in these early stages of scarring alopecia and notice any sort of scarring. There is no scarring that is “visible” although there may be scarring under the scalp captured by a biopsy. . There are however, important symptoms and signs for the clinician to identify such as redness, shedding, scalp itching, scalp burning, tenderness flaking,  bumps.and hair breakage. It is the intensity and localization of symptoms and signs  that is the clue to the clinician that something might be wrong and that a 4 mm scalp punch biopsy should be done.