As mentioned above, primary scarring alopecia is classified by the predominant type of inflammatory cells that attack the hair follicles: i.e., lymphocytes, neutrophils, or mixed inflammatory cells. Treatment strategies are different for each of these three subtypes and detailed treatment options are beyond the scope of this discussion. However, certain general principles are reviewed below.
Treatment of the lymphocytic group of scarring alopecia (including lichen planopilaris, frontal fibrosing alopecia, central centrifugal cicatricial alopecia, pseudopelade (Brocq), chronic cutaneous lupus erythematosus, and keratosis follicularis spinulosa decalvans) involves use of anti-inflammatory medications. The goal of treatment is to decrease or eliminate the lymphocytic cells that are attacking and destroying the hair follicle. Oral medications may include hydroxychloroquine, doxycycline, mycophenolate mofetil, pioglitazone, cyclosporine, or corticosteroids. Topical medications may include corticosteroids, topical tacrolimus, Derma-Smoothe/FS scalp oil; triamcinolone acetonide (a corticosteroid) may be injected into inflamed, symptomatic areas of the scalp.
Treatment of the mixed group of scarring alopecia (dissecting cellulitis and folliculitis keloidalis) may include antimicrobials although culture often does not grow a pathogen. Isotretinoin, anti-inflammatory medications such as corticosteroids, and tumor necrosis factor inhibitors may be used. In dissecting cellulitis, incision and drainage of nodules may be needed. You should discuss any treatment with your dermatologist who will also explain potential side effects, as well as laboratory tests that are needed before starting medications and sometimes are monitored during treatment.
The course of scarring alopecia is usually prolonged and treatments are often given for 6 to 12 months or longer. Treatment is continued until the symptoms and signs of scalp inflammation are controlled. In other words, itching, burning, pain and tenderness have cleared and scalp redness, scaling, and/or pustules are no longer present.
Treatment may then be stopped. However, except for pioglitazone, current treatments do not usually influence the underlying process and may not arrest progression of hair loss even when symptoms and signs have cleared. Clinical activity often recurs, and treatment frequently needs to be repeated.
Because of the above last statement, surgical treatment is not an option in most cases except under certain circumstances. If the disease has been inactive for one or two years, then surgical removal of the scarred scalp and/or hair restoration surgery may be considered for cosmetic benefit. Folliculitis keloidalis is one exception in that excision of the affected scalp (scalp reduction) may provide relief for the patient.