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- Presentation
Overview of Scarring Alopecias: Diagnosis, Pathogenesis, and Treatment
Description
The talk reviews scarring alopecias and emphasizes that patients should not be blamed for their hair loss, since most forms have underlying genetic or inflammatory causes rather than something they did, except traction alopecia. The speaker covers several cicatricial alopecias, highlighting newer evidence that many are genetically driven and that understanding pathogenesis may lead to more targeted therapies. Acne keloidalis nuchae is described as a male-predominant, fibrotic inflammatory condition of the occipital scalp, common in Black men but seen across populations; recent research identified fibrotic cell populations and SPP1 signaling, with intralesional corticosteroids, antibiotics, isotretinoin, and retinoids as treatments. Central centrifugal cicatricial alopecia is discussed as common in women of African descent but also seen in men, with trichoscopy helping distinguish scarring from non-scarring alopecia; genetic findings such as PADI-3, S100A3, and trichohyalin variants, plus inflammatory, fibrotic, and metabolic associations, support use of topical/intralesional steroids, minoxidil, antibiotics, hydroxychloroquine, metformin, and emerging JAK inhibitors. Lichen planopilaris and frontal fibrosing alopecia are presented as closely related interferon-gamma–driven diseases that can mimic CCCA, with distinctive trichoscopic patterns, overlap with androgenetic alopecia, and management centered on steroids, hydroxychloroquine, tetracyclines, 5-alpha-reductase inhibitors, and JAK inhibitors. Dissecting cellulitis is framed as a scalp counterpart of hidradenitis suppurativa, requiring more than topical clindamycin and often responding to oral antibiotics, isotretinoin, or biologics. Discoid lupus is also noted as a scarring alopecia that can resemble CCCA and may warrant rheumatologic evaluation. Across conditions, the goals are to reduce symptoms, stop progression, preserve remaining hair, and use trichoscopy and accurate diagnosis to guide therapy, with optimism that improved mechanistic understanding will yield better future treatments.
View moreConclusions
- Scarring alopecias are driven by underlying genetic, inflammatory, fibrotic, and sometimes metabolic mechanisms rather than patient fault, so accurate diagnosis and counseling are essential.
- Acne keloidalis nuchae appears to involve profibrotic SPP1-positive macrophage and POSTN-positive fibroblast signaling, and intralesional corticosteroids may help by reducing this fibrotic pathway.
- Central centrifugal cicatricial alopecia is increasingly linked to PADI3 and related hair-shaft protein mutations, with inflammation, fibrosis, and type 2 diabetes associations suggesting that antifibrotic approaches such as metformin may be useful.
- Consensus-based CCCA treatment relies on multimodal therapy, especially potent topical steroids, minoxidil, intralesional steroids, tetracyclines, and hydroxychloroquine, while JAK inhibitors and other newer agents are promising future options.
- Lichen planopilaris is an interferon-gamma-driven scarring alopecia that can overlap clinically and histologically with frontal fibrosing alopecia, but trichoscopy and distribution patterns can help distinguish them.
- In African American women, LPP often presents with vertex and frontal involvement, frequent concurrent androgenetic alopecia, and an arrowhead pattern that can be mistaken for CCCA, emphasizing the need for trichoscopic assessment.
- Frontal fibrosing alopecia in Black patients may show less scale but more pruritus, earlier onset, robust inflammation, and associated lichen planus pigmentosus, so hyperpigmentation should prompt scalp evaluation rather than being dismissed as melasma.
- FFA and LPP share many features but also differ in genetic and clinical associations, and FFA management often relies on topical calcineurin inhibitors, intralesional steroids, and 5-alpha-reductase inhibitors such as dutasteride.
- Dissecting cellulitis of the scalp is a follicular occlusion disorder best managed like hidradenitis suppurativa, with oral antibiotics, isotretinoin, and biologics being more appropriate than topical clindamycin alone.
- Cutaneous lupus can mimic other scarring alopecias, so scalp findings should trigger broader systemic assessment and possible rheumatology referral, with hydroxychloroquine and topical or intralesional steroids remaining core therapies.
- Across cicatricial alopecias, the main goals are to reduce symptoms, stop progression, and preserve or maximize any remaining hair rather than assuming treatment is futile.
- Treating scarring alopecia matters because untreated disease can progress substantially over time, while proper management can stabilize disease and sometimes produce meaningful hair improvement.
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