If you get a sore or scar on your scalp does it always cause permanent hair loss?

Question:  I’ve noticed more hair fall out than usual recently, so, upon looking at my scalp and feeling around more closely, I’ve found several different areas with  around my scalp where there is no hair. Some areas of hair loss feel smooth with no hair in them and some are sensitive and painful, as if a sore is there or has healed. HELP!

Answer:  Clinically, we call that cicatricial alopecia which is the medical term for hair loss due to scarring.

Since scars, sores or inflammation  occur due to many different causes, you should head directly to your dermatologist so you can have your scalp examined and a diagnosis made. The sooner you figure out the the source, the sooner you can begin treatment to cure any lesions (sores) so they don’t scar and cause permanent hair loss. Once  hair loss occurs, hair does not usually grow back because the scar tissue has killed the hair follicle.

How we diagnose cicatrical alopecia, or scarring alopecia

It’s a process that starts with many questions. We will ask you about any recent illnesses, injuries, allergies, your lifestyle, medications and your haircare regimen. We will closely examine your scalp using a magnifying glass and a special light to determine if the lesions have bacterial or fungal causes. We will feel your entire scalp and any lesions feeling for inflammation, sores or scales to determine the exact nature of the lesions and how they appear at different stages and locations. We will also document any hair loss that has occurred and take pictures for future reference. Often, we will take a biopsy of the sore or scarred area to determine the exact cause (if bacterial or fungal) and also to examine the health of the hair follicles to ascertain the severity of the condition. (We use a 4mm punch biopsy to provide an adequate specimen from an active lesion. Sometimes we will also take another sample from an unscarred area.)

Any type of scalp reaction or injury resulting in a lesion that causes a scar can cause death to the hair follicles and permanent hair loss and we call that scarring alopecia. Lesions that cause scars and hair loss can be caused by any of the following conditions and diseases:

UNKNOWN ORIGIN & AUTOIMMUNE

• Discoid lupus erythematosus (DLE):  A chronic skin condition characterized by inflamed sores that begin as  a red, inflamed patch with a scaly and/or crusty look and feel. The patches leave noticeably discolored, raised scars. Hair follicles are damaged first by the sores and then the resulting scar tissue causes permanent hair loss.
• Lichen planopilaris: Also called follicular lichen planus, this a rare inflammatory condition results in patchy progressive permanent hair loss. Initially you may notice some small or spiny red bumps around involved follicles which may or may not be itchy. This eventually forms larger reddish lesions (resembling a lichen pattern) and scar tissue which damages hair follicles and causes hair to fall out and not grow back. Additionally, Frontal Fibrosing Alopecia appears to be a variant of lichen planopilaris. This occurs in mostly older women and appears in a band-like pattern in the frontal and temporal areas of the scalp. Often, a patient’s eyebrows are also affected.
• Sarcoidosis: This disease, also with unknown origin,  causes collections of mixed inflammatory cells (granulomas) which form lesions resulting in scarring at many different parts of the body, including the scalp.

FUNGAL

• Seborrheic dermatitis:  We believe this condition is an inflammatory reaction related to an over-abundance of a normal  yeast species  found on the scalp called M. globosa. It produces toxic substances that irritate the scalp causing a scaly rash.
• Ringworm (tinea capitis): On the scalp, this common fungal infection characterized by itchy red rings can result in scaling and hair loss  in children, and can progress to folliculitis, too (see below).

BACTERIAL

• Folliculitis decalvans: Simple folliculitis is any bacterial infection of the hair follicles. But when hair loss is caused by  redness, swelling and pustules surrounding hair follicles that appears to be spreading, it is called folliculitis decalvans. Another type of scarring alopecia, hairs shed as follicles are completely destroyed by the inflammation. A resulting scar is left behind where hair will no longer grow.  Simple folliculitis (one sore) can stem  from a bug bite or a scratch and flare-up or spread if infected with the bacteria Staphylococcus Aureus but recently we have found Methicillin Resistant Staphylococcus Aureus (MRSA) in some lesions and boils, so we always want to take a culture in any open lesions on the scalp, especially those that are spreading. In addition, a variant of folliculitis decalvans occurs in African Americans who present with ingrown hairs of the beard (pseudofolliculitis), acne keloidalis (a destructive folliculitis of the back of the scalp) and scarring alopecia.

TRAUMA

• Central Centrifugal Cicatricial Alopecia (CCCA): Usually seen in African American women, this type of scarring alopecia usually develops on the crown and spreads peripherally to form a large oval of hair loss on the scalp. Originally, this type of hair loss was thought to be caused by hair straightening with a hot comb or due to the hot petrolatum used with the iron; however, was also found to take place in patients without the use of hot combs or straightening methods.

How we aggressively treat lesions that cause scars…

Once we know what may be causing the lesions, we can treat them to minimize spreading, scarring and any resulting hair loss, using any of the following treatments or combinations of treatments:  

• Oral and intra-lesional steroids
• Topical corticosteroids
• Oral retinoids (isotretinoin)
• Antimalarials (hydroxychloroquine)
• Antibiotics (tetracycline, doxycycline, minocycline)
• Antifungals (itraconazole)
• pioglitazone
• Immunosuppressants (cyclosporine, mycophenolate mofetil)
• DHT blockers (dutasteride internally and minxoidil topically to -induce hair growth if follicles are alive.)

I have found that most patients experience hair loss very gradually (and cannot see the back and top of their head) and the prolonged course of the disease may cause a lack of necessary action. You need to know that the progressive destruction of hairs will result in ever-expanding areas of permanent hair loss.  So, no matter what, go see a dermatologist as soon as you feel any sores, pimples, pustules, pain, itchiness, scaliness or inflammation on your scalp, whether or not they have already caused hair loss, because they need to be treated ASAP and aggressively as possible.

-Jodi