Scarring alopecia represents a form of permanent hair loss where inflammation damages and ultimately destroys hair follicles, replacing them with scar tissue. This article details what scarring alopecia looks like, how it differs from other types of hair loss, and the specific appearances of some common variants.
Hallmark Visual Indicators
Scarring alopecia presents as smooth, shiny bald patches on the scalp. These patches may be irregular in shape. A defining sign is the absence of follicular openings, which are the small pores from which hair emerges.
The affected scalp may also show signs of inflammation, such as redness, scaling, or crusting. Color changes can occur, including hyperpigmentation (darkening) or hypopigmentation (lightening) of the skin in the scarred regions. Small bumps or pustules may be observed. As the condition progresses, the skin in the bald areas can become thinned or atrophic, and may also feel tight or fibrous due to the underlying scar tissue.
Differentiating from Other Hair Loss
Distinguishing scarring alopecia from non-scarring forms of hair loss, like androgenetic alopecia or telogen effluvium, is important. In non-scarring alopecia, hair follicles remain intact, allowing for potential hair regrowth. In scarring alopecia, however, follicles are irreversibly destroyed and replaced by scar tissue.
The texture and appearance of the scalp also vary. Scarring alopecia often results in a smooth, shiny, and sometimes atrophic scalp surface due to fibrosis. In contrast, the scalp in non-scarring hair loss usually maintains a more typical appearance, often without textural changes or visible scarring. While inflammation can be present in both, the inflammation in scarring alopecia directly targets and destroys the hair follicle’s stem cells.
Specific Types and Their Appearances
Different types of scarring alopecia exhibit unique visual patterns. Lichen planopilaris (LPP) often presents with patchy hair loss, characterized by redness and fine scaling around the hair follicles. The affected areas may feel rough, and hairs at the edges of these patches can be easily pulled out. As LPP advances, the scarred patches become smooth and white.
Frontal fibrosing alopecia (FFA), considered a variant of LPP, causes a progressive, band-like recession of the frontal hairline. The skin in the affected area of the forehead may appear pale, shiny, or subtly scarred, and often lacks visible hair follicle openings. Eyebrow thinning or complete loss is a common accompanying feature, sometimes preceding scalp involvement.
Discoid lupus erythematosus (DLE) manifests as red, scaly plaques that can lead to scarring and changes in skin pigmentation. These lesions may leave behind both lighter (hypopigmented) and darker (hyperpigmented) spots once they heal. The plaques can be coin-shaped and may have adherent scales.
Folliculitis decalvans is characterized by pustules, crusting, and a distinctive pattern called “tufted hairs,” where multiple hair shafts emerge from a single follicle opening. This condition typically starts on the crown or back of the scalp and can spread, leading to irregular, atrophic white patches of scarring. The affected areas may show signs of active inflammation with redness around the follicles.
Accompanying Symptoms
Beyond visible changes, individuals with scarring alopecia experience sensory symptoms. Symptoms include itching, burning, pain, or tenderness on the scalp. These can often precede hair loss or scalp changes, intensifying as the condition progresses. Discomfort varies from mild irritation to significant pain, indicating active inflammation within hair follicles.