A Patient Guide to Understanding Treatments for Scarring Alopecia

Article Summary by Tejashri Venkatesh | MD Candidate 2025 | Chicago Medical School at Rosalind Franklin University

Scarring alopecia, also known as primary cicatricial alopecia, can result in permanent hair loss from destruction of hair follicles. Hence, early intervention is key to halting disease progression and improving hair density. The purpose of this patient guide, adopted from an article published in 20231, is to improve understanding of the treatment options available for scarring alopecia. It details current evidence-based treatments for different types and varied severities of scarring alopecia.

Treatments for scarring alopecia
Lymphocytic alopecia Neutrophilic alopecia
e.g. lichen planopilaris (LPP), frontal fibrosing alopecia (FFA), central centrifugal cicatricial alopecia (CCCA) e.g. folliculitis decalvans, dissecting cellulitis
(Treatments aim to reduce inflammation) (Treatments aim to reduce inflammation and bacterial load)
General:

·       Avoid allergens in cosmetic and personal care products e.g. re-evaluate use of chemical sunscreens and/or sunscreens containing titanium dioxide with your dermatologist

 Folliculitis decalvans:

·       Steroid: Topical/scalp injection

·       Antibacterial/antibiotic: Benzoyl peroxide wash, oral doxycycline, minocycline, cephalexin, rifampin, clindamycin
First-line:

·       Topical steroid: Clobetasol, betamethasone, fluocinonide

·       Steroid scalp injection: Triamcinolone

·       Topical calcineurin inhibitor: Tacrolimus, pimecrolimus
Second-line:

·       Immunomodulator: Hydroxychloroquine

·       Anti-inflammatory: Doxycycline, low-dose naltrexone, oral antihistamines, oral gabapentin

·       Phototherapy: Narrowband UV-B and excimer laser

 Dissecting cellulitis:

·       Oral steroid: Prednisone

·       Isotretinoin: Accutane
Severe disease:

·       Immunosuppressive: Mycophenolate mofetil, methotrexate, cyclosporine, pioglitazone, topical/oral Janus kinase inhibitor

 Severe disease:

·       Immunosuppressive: Dapsone, adalimumab, infliximab
For overlapping female/male pattern hair loss:

·       Oral low-dose minoxidil – promote hair growth

·       Oral spironolactone – block androgens that trigger hair loss
For specific types of scarring alopecia:

·       Dutasteride/finasteride – block androgens and stabilize FFA

·       Compounded topical 10% metformin cream – promote hair growth in CCCA

References:

  1. Ezemma O, Devjani S, Kelley KJ, Senna MM. Treatment modalities for lymphocytic and neutrophilic scarring alopecia.J Am Acad Dermatol. 2023;89(2S):S33-S35. doi:10.1016/j.jaad.2023.04.023