By Dr Neda Adibi Dermatologist and researcher of IUMS Cicatricial alopecia

Cicatricial or scaring alopecia means the replacement of the follicular epithelium by connective tissue All forms of alopecia that hair follicles are permanently lost Permanent injury to the follicular stem cell

Some hair disaeses are biphasic: Non scaring in the early stages and permanent hair loss in the late stages Examples like: Androgenic alopecia,traction alopecia,alopecia areata

subtypes 1)primary scaring alopecia :the hair follicle is the main target of injury 2)secondary: the hair follicle is inocent by stander like burn,radiation dermatitis,cutaneus TB,sarcoidosis,morphea

diagnosis Biopsy:at least 4 mm,it is better to be two for horizental and vertical section 6 main types 1)Central centrifugal cicatricial alopecia (CCCA) 2)Lichenplanopilaris 3)Chronic DLE 4)Acne keloidalis 5)Dissecting cellulitis 6)Cicatricial alopecia

Slowly progressive symetric cicatricial alopecia centered on the crown or vertex Most often in black woman of african descent Treatable in early and mild stage

1)chronic and progressive 2)predominant on the vertex 3)symetric progression and the priphery is active 4)more in women 5)they used chemical hair relaxers frequently 6)hair ironing and hot comb aggravate the Dx

No symptom except mild pruritus Tx:topical potent Cs +antibiotic (Doxy or mino)folliculitis decalvance :10 week oral rifampin and clindamycin(300 mg BID)

Lichenplano pilaris More in female,caucasians Most in 5 th decade Other types of LP In more than 50% Course:incidious or fulminant Scattered foci of partial hair loss and,perifollicular erythema,follicular spine and scarring Pruritus and tenderness often present

The alopecic area smaller, irregularly shaped and interconnected, which can lead to a reticulated clinical pattern as compared to DLE

Tx First line treatment: Intralesional triamcinolone each 4-6 week Oral cyclosporine, retinoids, antimalarials and griseofulvin have been shown to have a positive effect in patients with rapidly progressive LPP. Oral corticosteroids in the first weeks of treatment

DLE Adult specially women(20-40 y) Very few of patients may develop SLE Erythema,atrophy follicular pluggings Over 50% have lesions in the other parts except scalp Concurrent alopecia areata is frequent

Central hyperpigmentation,follicular pluging,erythema and scale

Antimalarials :like hydroxychloroquin mg daily in adults or 4-6 mg/kg in children In sever cases oral prednisolon 1 mg/kg for 8 weeks and corticosteroids (topical or intralesional)

Alopecia mucinosa indurated, well-demarcated erythematosus or skin colored patches of scarring or nonscarring alopecia Grouped follicular papules,follicular cysts and follicular hyperkeratosis may be present in some cases.

rule out an underlying malignancy such as mycosis fungoides and Sezary syndrome Oral corticosteroids,minocycline and isotretinoin have been shown to be effective. Topical and intralesional corticosteroids,dapsone, indomethacin and light therapy

Acne Keloidalis Most in blackmen small, smooth, firm papules admixed with occasional pustules on the occipital scalp and posterior neck the papules resolve and leave small zones of alopecia within a field of papular lesions. In many patients, the papules coalesce and form firm, hairless, keloid- like

Treat with topical corticosteroids and oral doxycyclines

Disecting cellulitis multiple, firm scalp nodules, most commonly on the mid and posterior vertex and upper occiput. The nodules rapidly develop into interconnecting,fluctuant, oval and linear ridges abcesses Pain and fuel smalling discharge

Treat with isotretinoin mg/kg and oral antibiotic and corticosteroid

Folliculitis decalvance Young and Middle aged specially male erythematous Cicatricial alopecia with inflamatory perifollicular papules and postules Pain,itching and burning Staphylococ areus and superantigens may be the cause

CMX,erythromycin,cephalosporin,Topical clindamycin Rifampin plus clindamycin Oral TC Topical fusidic acid,erythromycin 2%,mupirocin

Secondary cicatricial alopecia 1)traumatic alopecia 2)tractional alopecia 3)pressure alopecia 4)tricotillomania