Mission Possible? Managing Scarring Alopecia

Jerry Shapiro, MD provided a clinical deep dive into cicatricial (scarring) alopecias, underscoring the critical distinction between scarring and non-scarring hair loss: once follicles are destroyed, regrowth is no longer possible. He emphasized the importance of early recognition and aggressive intervention to prevent permanent hair loss. Advanced diagnostic tools were highlighted, including trichoscopy to identify hallmark features such as loss of follicular ostia, perifollicular scale, and blue-grey dots, as well as AI-driven trichometric analysis (HairMetrix) to objectively measure disease progression and guide individualized treatment plans.

The session reviewed key lymphocytic scarring alopecias, including lichen planopilaris (LPP), frontal fibrosing alopecia (FFA), and central centrifugal cicatricial alopecia (CCCA). Treatment algorithms for LPP incorporate intralesional triamcinolone acetonide, combination topical therapies, and systemic agents including JAK inhibitors. In FFA, which predominantly affects postmenopausal women and frequently involves eyebrow loss, Dr Shapiro discussed data linking certain sunscreens and moisturizers to increased risk and advised mineral-based alternatives. Facial papules associated with FFA were shown to respond well to oral isotretinoin. For CCCA, emerging data on topical and low-dose oral metformin demonstrated improvement in fibrosis by downregulating profibrotic gene pathways, representing a promising therapeutic advance.

Neutrophilic scarring alopecias, including folliculitis decalvans and dissecting cellulitis, were also addressed, with refractory cases responding to biologics such as adalimumab or baricitinib. Practical pearls included the use of low-dose doxycycline to reduce inflammation with fewer gastrointestinal side effects, adjusting intralesional steroid concentrations based on scalp location, and monitoring for rare complications such as central serous chorioretinopathy following steroid injections. Dr Shapiro concluded by cautioning that hair transplantation should only be considered after more than two years of disease quiescence to avoid disease reactivation, reinforcing that in scarring alopecia, success hinges on stopping progression early rather than restoring lost hair.