Cicatricial (scarring) alopecia (hair loss) is the term used for a group of disorders that cause permanent hair loss. During the active, evolving stage of hair loss, patches of alopecia commonly appear red and inflamed at the base of the hair shaft. Sometimes crops of pustules are noted. Some types of cicatricial alopecia destroy the hairs deep within the scalp, without inflammation visible on the skin surface. While some types of cicatricial alopecia result in rapid hair loss, slow progression of hair loss is more common.
A skin biopsy is generally required to establish the diagnosis, and to guide treatment. The biopsy punch is an instrument that removes a plug of skin about the size and shape of a pencil eraser. The biopsy is performed after an injection of local anesthetic to numb the skin. After the skin biopsy is removed, the biopsy site is closed with stitches or filled with a plug of special material that stops the bleeding. Sometimes a single biopsy specimen can establish the diagnosis, but usually more than one specimen is required. Your doctor will try to limit the number of biopsy specimens, but it is generally best to have more than one performed early on in your evaluation, so that an accurate diagnosis can be established and appropriate treatment started.
Some types of hair loss are best diagnosed under the microscope based on slices of the specimen cut vertically from the skin surface down to the deep fat (vertical sections). Other types of hair loss are best diagnosed by horizontal sections cut sideways through the specimen (horizontal sections). Each of these types of examination requires a separate biopsy specimen. Biopsies are best done of active, inflamed sites on the scalp which still have remaining hair. A biopsy of an older scarred area may be helpful to predict the likelihood of regrowth of hair, and to help establish the diagnosis by evaluating the pattern of scar formation. If certain types of cicatricial alopecia are suspected, your doctor may send a biopsy specimen for additional special tests including direct immunofluorescence, and special stains for bacteria, fungi and elastic tissue. In some infectious disorders that can cause cicatricial alopecia, a biopsy must be sent for tissue culture.
At the 2001 AHRS Workshop on Cicatricial Alopecia held at Duke University Medical Center, a useful classification system for cicatricial alopecia was developed, emphasizing the microscopic (histological) findings on a representative biopsy of an area of active loss. This classification divides cicatricial alopecia into hair loss caused by inflammatory cells called lymphocytes versus hair loss caused by inflammatory cells called neutrophils. The new classification will help identify patients who may be appropriate candidates for studies of new treatments since it is likely that medications will not work on both lymphocytic and neutrophilic predominant cases of cicatricial alopecia. Even with the new histological classification, some cases of hair loss remain unclassifiable.
Treatment for cicatricial alopecia remains poor. Once the hair is destroyed, the hair loss becomes permanent. It is primarily the hair at the periphery of the hair loss and/or the islands of remaining hair that are at risk of being destroyed that is the main focus of treatment. The main goals of treatment for cicatricial alopecia are to prevent further hair loss and to eradicate or at least lessen the redness, scale and itching associated with the process. There are no current FDA approved treatments for cicatricial alopecia although the AHRS has been working to initiate interest in this area among industry sponsors. All treatment now for cicatricial alopecia is strictly based on the experience of the prescribing physician or anecdotal reports as there has never been any multicenter clinical trial in this area.