SCARRING - CICATRICIAL ALOPECIA

SCARRING/CICATRICIAL ALOPECIA

Definition and introduction

A large number of scalp disorders may destroy the hair follicles and result in scarring (cicatricial) alopecia. These include diseases that primarily affect the hair follicles as well as diseases that affect the deeper layers of skin (dermis) and secondarily cause follicular destruction.

Once established, cicatricial alopecia is a permanent condition that cannot be reversed by treatment. For this reason, it is very important to diagnose the hair or scalp disorders that may produce cicatricial alopecia as soon as possible in order to start a specific treatment and avoid diffuse follicular destruction.

The differential diagnosis between the diseases that cause cicatricial alopecia requires a biopsy (pathological examination). A scalp biopsy is therefore mandatory in all cases of cicatricial alopecia. The causes are summarized below:

Follicular diseases

·         Lichen planopilaris

·         Discoid lupus erythematosus

·         Keratosis follicularis spinulosa decalvans

·         Folliculitis decalvans

·         Traction alopecia

Dermal fibrosis

·         Localized  scleroderma

·         Radiodermeatitis

·         Pemphigoid

·         Chemical or physical injuries

·         Burns

The aim of treatment is to avoid further scarring and it is necessary to explain clearly to the patient that the hair that has been lost will not grow again. Surgical treatment of cicatricial alopecia includes excision of the scarring area tissue expansion or hair transplantation.

Lichen planopilaris

Lichen planolilaris is the most common cause of cicatricial alopecia.

Patients usually seek medical advice because they have noticed one or several patches of hair loss. A certain degree of itching is frequently reported. The clinical examination reveals a variable number of poorly circumscribed bald patches.

Discoid lupus erythematosus

Diagnosis of ‘discoid lupus erythematosus’ is strongly suggested by the presence of redness (erythema), prominent hair roots (follicular hyperkeratosis), thinning of skin (atrophy) and small blood vessels (telangiectasia).

 Folliculitis decalvans

This term is utilized a spectrum of scalp disorders characterized by painful acute inflammatory changes with or without pustules. Relapsing inflammatory episodes result in cicatricial alopecia and tufted folliculitis.

Although the bacteria Staphylococcus aureus may frequently be isolated from the pustules, folliculitis  decalvans is not an infective condition, but possibly represents an abnormal host response against staphylococcal antigens or toxins.

Keratosis follicularis spinulosa decalvans (KFSD)

This inherited condition usually becomes evident in infancy. Follicular papules are also evident on the eyebrows and cheeks. Alopecia, which is more prominent in the vertex, usually develops after puberty.

Its severity varies considerably in different patients.

Brocq pseudoarea

Brocq pseudoarea is not a separate entity, but represents the cicatricial outcome of lichen planopilaris. The scalp presents multiple irregular bald atropic areas, but no signs of inflammation.

 Involvement of the beard area has also been reported.

Localized scleroderma

Localized scleroderma of the scalp presents as a slowly progressing irregular patch of hair loss. The skin often shows a certain degree of erythema or pigmentation in the absence of follicular keratosis or scaling. The patch is often not completely bald, but presents some vellus or intermediate hairs.

                                        Serve atrophy with involvement of the hypodermis and muscles is a feature of fronotoparietal linear scleroderma (‘encoup de sabre’).  

Hair transplantation is a good treatment option for its management. However, there are some factors that reduce the chances of survival of the implanted grafts:

·         Poor blood supply

·         Fibrosis of deeper layers of skin

The following are the differences in hair transplant technique in such cases:

1.       The density of the implanted grafts is lesser

2.       A session of trial grafting of 100/150 grafts can be performed to look for the survival of implanted grafts. If the growth is good the transplanting the complete bald area can be attempted

3.       The angle of insertion of grafts is less acute

4.       The amount of tumescence anaesthesia administered is less

5.       Adrenaline is avoided in the anaesthetic solution.