Scarring Alopecia: Causes, Symptoms, and How To Manage It

Scarring alopecia, or cicatricial alopecia, is a serious form of hair loss where inflammation destroys hair follicles and replaces them with scar tissue. Unlike other types of alopecia, this damage is irreversible, making early diagnosis and treatment absolutely critical.

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This guide will help you understand what scarring alopecia is, how it differs from other forms of hair loss, what causes it, and—most importantly—what steps you can take to manage it effectively. 

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Whether you're newly diagnosed or seeking better answers, the information that follows will empower you to make informed, confident decisions about your scalp health.

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What Is Scarring Alopecia?

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Scarring alopecia, also known as cicatricial alopecia, is a group of rare hair loss disorders characterized by permanent destruction of hair follicles and replacement with scar tissue. 

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Unlike non-scarring types, where follicles remain intact and regrowth is possible, scarring alopecia causes irreversible damage. 

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The condition involves inflammation around the follicular stem cells, sebaceous glands, and bulge area, leading to follicular dropout and smooth, hairless scalp patches. 

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It may present gradually or rapidly and often includes symptoms such as itching, burning, tenderness, or redness. 

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Approximately 3% of all hair loss cases involve some form of scarring alopecia. Scarring alopecia can affect anyone, but is more prevalent in specific demographics, depending on the subtype. 

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Because hair loss is permanent once follicles are destroyed, early diagnosis and treatment are critical to slowing or halting disease progression.

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Types of Scarring Alopecia

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Scarring alopecia is classified into two main categories—primary and secondary—based on the origin of follicular destruction. 

Within these categories are several distinct subtypes, each with unique clinical features, progression rates, and treatment challenges. Identifying the specific type is essential for targeted management and improving long-term outcomes.

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Primary Scarring Alopecia

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In primary scarring alopecia, the hair follicle is the direct target of inflammation, often due to autoimmune or lymphocytic processes. 

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This group includes conditions such as lichen planopilaris (LPP), frontal fibrosing alopecia (FFA), and central centrifugal cicatricial alopecia (CCCA). These disorders typically cause progressive follicular destruction and irreversible hair loss. 

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Inflammation may be lymphocytic, neutrophilic, or mixed, which can influence treatment choice. Early symptoms may include scalp redness, itching, or burning, which are signs of active follicular damage requiring prompt intervention.

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Secondary Scarring Alopecia

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Secondary scarring alopecia occurs when external factors, such as infections, burns, trauma, or tumors, destroy the follicle and replace it with scar tissue. The follicle itself is not the initial target, but collateral damage from severe inflammation or injury leads to permanent loss.

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Common causes include deep fungal infections (e.g., kerion), bacterial folliculitis, surgical scars, or radiation therapy. Management typically involves treating the underlying condition and may require cosmetic or surgical solutions for areas of irreversible hair loss.

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Notable Subtypes

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Lichen planopilaris (LPP) is one of the most common forms of primary scarring alopecia. It is an autoimmune condition that typically affects middle-aged women and presents with patches of hair loss accompanied by redness and scaling around remaining follicles. 

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Patients often report intense itching or burning. The condition can also affect other body areas with a characteristic purple, flat rash.

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Central centrifugal cicatricial alopecia (CCCA) predominantly affects women of African descent. It starts at the crown and spreads outward in a circular pattern. The progression is usually slow but relentless without treatment. 

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Folliculitis decalvans causes pustules and crusting that destroy follicles. It's one of the more symptomatic forms, with patients experiencing pain, drainage, and odor from affected areas.

This type often requires aggressive treatment with antibiotics and anti-inflammatory medications. 

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How Scarring Alopecia Differs From Other Types of Hair Loss

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Scarring alopecia differs from non-scarring hair loss in both cause and outcome. In conditions such as androgenetic alopecia or telogen effluvium, hair follicles remain structurally intact, allowing for potential regrowth with appropriate hair growth treatment. 

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In contrast, scarring alopecia involves inflammation that permanently destroys the hair follicle and replaces it with fibrotic scar tissue. This damage is irreversible, meaning hair loss in affected areas cannot be reversed. 

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Clinically, scarring alopecia often presents with signs of inflammation, such as redness, pain, pustules, or scaling, alongside patchy or diffuse hair loss. Another key distinction is the loss of follicular openings (pores) on the scalp, which is a diagnostic clue. 

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Prompt medical evaluation is essential, as early intervention may prevent progression and preserve unaffected follicles.

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Main Causes of Scarring Alopecia

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Scarring alopecia can result from a wide range of underlying conditions that damage the hair follicle beyond repair. These causes generally fall into three categories: inflammatory and autoimmune disorders, infections and physical trauma, and damaging hair care practices. 

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Understanding the root cause is essential for selecting the right treatment and preventing further follicular destruction.

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Inflammatory and Autoimmune Disorders

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Autoimmune and inflammatory disorders are leading causes of scarring alopecia. In these conditions, the immune system mistakenly attacks healthy hair follicles, triggering chronic inflammation and tissue damage. 

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Common examples include lichen planopilaris, discoid lupus erythematosus, and frontal fibrosing alopecia. These disorders target the follicular stem cells in the bulge area, leading to irreversible scarring and hair loss. 

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Symptoms often include redness, scaling, pain, or burning, and early treatment is essential to control inflammation and preserve unaffected follicles.

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Infections and Physical Injury

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Certain bacterial, fungal, or viral infections can cause scarring alopecia when they result in deep or prolonged follicular inflammation. Examples include folliculitis decalvans, dissecting cellulitis, and severe tinea capitis. 

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Additionally, physical trauma, such as burns, radiation, or surgical scars, can destroy follicles and lead to localized scarring hair loss. 

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Infections often require antimicrobial therapy, while trauma-related cases may need surgical or cosmetic intervention. Prompt diagnosis and treatment can limit long-term follicular damage and minimize scarring.

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Hair Care Practices and Traction

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Traction alopecia, a form of scarring alopecia, develops from repeated tension on the hair, often due to tight hairstyles such as braids, weaves, or ponytails. 

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Prolonged stress on the follicle can cause inflammation, follicular damage, and eventually scarring. Chemical burns from harsh relaxers or straighteners may also contribute. 

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Though initially reversible, chronic mechanical or chemical trauma can lead to permanent follicle loss if left unaddressed. Modifying styling habits early is critical to preventing long-term damage.

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Common Symptoms and Early Warning Signs

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Scarring alopecia can begin subtly, making early recognition essential for preventing irreversible hair loss. 

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One of the earliest signs is patchy hair loss with smooth, shiny areas of scalp where follicles and pores are no longer visible. This may be accompanied by redness, scaling, or hyperpigmentation. 

Patients often report symptoms such as itching, burning, tenderness, or a sensation of tightness in the scalp, indicating active inflammation. In some subtypes, pustules, crusting, or follicular hyperkeratosis may be present, reflecting bacterial involvement or excessive scaling.

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Unlike more common forms of hair loss, scarring alopecia frequently involves discomfort or visible skin changes in addition to thinning. Because the condition is progressive, symptoms may worsen over time, with increasing hair loss and more extensive follicular destruction.

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Recognizing these early warning signs and seeking dermatologic evaluation promptly is necessary for preserving remaining hair and halting disease progression.

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How Scarring Alopecia Is Diagnosed

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Accurate diagnosis of scarring alopecia is essential because early intervention can preserve remaining hair and minimize permanent loss. The diagnostic process involves a detailed clinical evaluation, often supported by laboratory tests and scalp biopsy. 

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Identifying the specific type and pattern of inflammation is vital for selecting the most effective treatment plan and avoiding further follicular destruction.

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Physical Exam and Scalp Evaluation

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A dermatologist begins by examining the scalp for hallmark signs of scarring alopecia, such as smooth bald patches, loss of follicular openings, redness, scaling, pustules, or crusting.

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Dermoscopy (trichoscopy) enhances visualization of follicular structures and inflammatory patterns, helping to differentiate scarring alopecia from other hair loss disorders. 

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A detailed medical and hair care history is also essential, as it may reveal triggers such as autoimmune disease, traction, or infections. Clinical evaluation guides the need for further diagnostic testing.

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Biopsy and Other Tests

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A scalp biopsy is the gold standard for confirming scarring alopecia. 

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A small tissue sample is taken, ideally from an area with active inflammation, and analyzed histologically to identify the type of inflammatory cells (lymphocytic, neutrophilic, or mixed) and assess the extent of follicular destruction. 

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Additional tests, such as bacterial or fungal cultures, blood work for autoimmune markers, or imaging, may be used to identify underlying causes or rule out mimicking conditions. Accurate histopathologic diagnosis is critical for guiding treatment.

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Can Scarring Alopecia Be Treated Naturally?

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While natural approaches may support overall scalp health and help reduce inflammation, they cannot reverse scarring once the follicles are permanently destroyed. 

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However, these strategies may complement medical therapies and help slow disease progression, ease symptoms, and promote a healthier scalp environment. 

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It’s essential to use natural remedies under medical supervision to avoid worsening inflammation or delaying critical medical treatment.

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Natural Remedies for Scalp Health

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Some natural ingredients, such as aloe vera, rosemary oil, peppermint oil, and tea tree oil, have anti-inflammatory or antimicrobial properties that may soothe the scalp and reduce irritation. Gentle scalp massages with nourishing oils can also improve circulation. 

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Anti-inflammatory herbs such as turmeric and green tea contain compounds that might help reduce scalp inflammation when used topically. Creating rinses or masks with these ingredients can provide a soothing effect.

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However, not all “natural” products are safe—especially with active inflammatory conditions—so patients should consult a dermatologist before using any topical remedy to ensure it won’t aggravate symptoms or interfere with prescribed treatments.

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Diet and Lifestyle Changes

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Anti-inflammatory foods rich in omega-3 fatty acids, antioxidants, and vitamins A, D, and E may help reduce systemic inflammation that contributes to autoimmune scalp conditions. 

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Reducing stress through meditation, sleep hygiene, or light exercise can also help modulate the immune response. 

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Gentle hair care practices prevent additional trauma to affected areas. Using mild, sulfate-free shampoos, avoiding heat styling, and choosing loose hairstyles reduces mechanical stress on remaining follicles. 

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Protecting the scalp from sun exposure also matters, as scarred areas can be more sensitive to UV damage.

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While lifestyle changes cannot reverse follicle damage, they may support immune health and complement medical treatment by stabilizing inflammatory triggers and reducing flare-ups in some subtypes of scarring alopecia.

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Limitations of Natural Approaches

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Natural methods cannot regenerate scarred follicles or reverse permanent hair loss. Relying solely on alternative treatments may allow the disease to progress unchecked, leading to more extensive follicular destruction. Once scarring occurs, those follicles are gone forever. 

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Additionally, some natural products may cause allergic reactions or irritation, worsening inflammation. 

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For these reasons, natural remedies should be considered adjunctive—not primary—therapies. Early medical intervention remains the most effective strategy for preserving remaining hair and managing active inflammation in scarring alopecia.

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Medical Treatments for Scarring Alopecia

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Because scarring alopecia involves permanent follicular damage, the primary goal of treatment is to halt disease progression and preserve existing hair. 

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Medical therapies target the underlying inflammation or infection, depending on the subtype. Treatment plans are individualized based on biopsy findings, symptom severity, and response to previous therapies. 

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Early intervention offers the best chance of stabilizing the condition and preventing further hair loss.

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Anti-inflammatory Medications

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Anti-inflammatory agents are the cornerstone of treatment for most types of primary scarring alopecia. Topical corticosteroids, steroid injections, and calcineurin inhibitors (e.g., tacrolimus) are commonly used to reduce localized inflammation. 

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Minoxidil is being explored as a complementary treatment, as its anti-inflammatory effects around the hair follicles can slow or prevent hair loss.

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For more extensive or aggressive disease, systemic agents such as hydroxychloroquine, methotrexate, mycophenolate mofetil, or oral corticosteroids may be prescribed. 

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These medications help suppress immune activity and limit follicular destruction. Regular monitoring is essential to assess treatment response and manage potential side effects.

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Antibiotics and Other Prescriptions

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For scarring alopecias with neutrophilic inflammation or secondary infections, such as folliculitis decalvans, oral antibiotics such as doxycycline, rifampin, or clindamycin are commonly used to control bacterial overgrowth and inflammation. 

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Antimicrobial shampoos and antiseptic washes may be added for scalp hygiene. 

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In some cases, isotretinoin is prescribed to reduce sebaceous gland activity and inflammation. These medications can help stabilize the condition, but they must be carefully selected based on the inflammatory profile confirmed by biopsy.

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Personalized prescription formulas, such as Happy Head’s Topical SuperSolution™ ProBlend, combine multiple active ingredients, including minoxidil for growth stimulation, finasteride for hormonal support, and anti-inflammatory agents, in a single convenient treatment. 

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Hair Restoration and Transplant Options

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Hair restoration is generally considered only after scarring alopecia has been inactive for at least 12–24 months, as active inflammation can cause graft failure. 

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Follicular unit transplantation (FUT) or follicular unit extraction (FUE) may be viable for select patients with stable disease and adequate donor hair. 

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However, success rates vary, and not all individuals are candidates. A thorough evaluation, including scalp biopsy and inflammation markers, is essential before proceeding with surgical intervention.

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Living With Scarring Alopecia: Coping and Support

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Living with scarring alopecia can be emotionally challenging due to the permanent nature of hair loss and the visible changes to appearance. Support groups, both in-person and online, can provide emotional validation and practical advice. 

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Dermatologists may recommend counseling or therapy, especially for people experiencing anxiety or depression. Scalp prosthetics, wigs, or hairpieces offer cosmetic solutions, and some patients find confidence through medical tattooing or camouflage products. 

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Understanding the condition, pursuing stable treatment, and connecting with others who share similar experiences can significantly improve quality of life and emotional well-being.

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Preventing Further Hair Loss With Scarring Alopecia

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Preventing the progression of scarring alopecia begins with early diagnosis and strict adherence to treatment. Regular follow-ups with a dermatologist allow for monitoring of disease activity and medication adjustments as needed. 

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Patients should avoid scalp trauma from tight hairstyles, harsh chemicals, or aggressive brushing. Managing underlying triggers, such as autoimmune disease or infections, is also essential. 

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For some, dietary or lifestyle modifications may help reduce systemic inflammation. Educating patients on early warning signs of flare-ups can empower them to act quickly, helping to preserve as much hair as possible over the long term.

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Moving Forward With Scarring Alopecia

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While scarring alopecia can feel overwhelming, especially because of its permanent nature, it’s important to remember that you’re not alone and that effective care is possible. 

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With early diagnosis, expert medical guidance, and a personalized treatment plan, it’s often possible to halt the disease’s progression and preserve your existing hair. 

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Many people also find strength through community, self-care, and the use of cosmetic options that help restore confidence. 

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With the right support and timely action, you can take control of your scarring alopecia—taking that first step toward treatment today could make all the difference in preserving your hair for tomorrow.

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Talk to a board-certified dermatologist to discuss your goals and find the solution that is best for you.

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Frequently Asked Questions

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Can scarring alopecia go away?

Scarring alopecia causes permanent damage to hair follicles, so lost hair typically doesn’t grow back. However, early diagnosis and treatment can halt progression and reduce inflammation, helping preserve remaining hair and prevent further irreversible loss.

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What are the symptoms of scalp scarring?

Symptoms may include patchy hair loss, redness, burning, itching, pain, and a smooth or shiny scalp where follicles once were. As the condition progresses, hair follicles may disappear, and the skin can appear scarred or discolored in the affected areas.

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How rare is cicatricial alopecia?

Cicatricial (scarring) alopecia is relatively rare, accounting for about 3% of hair loss cases in dermatology clinics. It can affect anyone, but is more common in certain populations, depending on the subtype, such as black women with CCCA or middle-aged women with LPP.

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What autoimmune disease causes scarring alopecia?

Several autoimmune conditions can cause scarring alopecia, including lupus erythematosus and lichen planopilaris (LPP). In these disorders, the immune system attacks hair follicles, leading to inflammation, follicle destruction, and irreversible hair loss over time.

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