Understanding Female Scarring Alopecia: Causes, Diagnosis and Treatment Options
What is Scarring Alopecia?
The term scarring alopecia, or (cicatricial alopecia), refers to a group of disorders that cause destruction of the hair follicles, resulting in permanent hair loss. The hair follicle becomes the main target of an inflammatory process, which often becomes a clinical and therapeutic challenge. (1) There are numerous types of cicatricial alopecias; however, the three most common afflicting women are: lichen planopilaris, frontal fibrosing alopecia, and central centrifugal cicatricial alopecia.
Scarring alopecia is the least common type of hair loss, accounting for only about 5% of all alopecias. (2) In non-scarring alopecia, the hair follicles are preserved, allowing for hair regrowth. Androgenic alopecia is the most common non-scarring alopecia, affecting approximately 30% of middle-aged women, and is characterized by miniaturization of hair follicles. (2)
Why It Matters: The Impact on Women's Health and Identity
Alopecia can be an emotional burden for many women and impact their quality of life. Hair loss for many is more than a cosmetic feature, it can have profound psychological and psychosocial consequences. It can result in lower self-esteem and fewer social interactions. Studies have shown that gender and age are associated with lower quality of life (QOL) scores on questionnaires such as the Patient-Reported Outcomes Measurement Information System (PROMIS) used by dermatologists. (3)
Younger and middle-aged people scored lower on QOL indexes and had higher anxiety levels than older adults in both scarring and non-scarring alopecias. Researchers believe this is especially true for younger generations because hair holds aesthetic and cultural identity that affects self-esteem. Women overall report higher anxiety levels than men regarding their hair loss. Findings suggest that psychological support could be a beneficial approach to overall hair loss management strategies. (3)
Types of Scarring Alopecia
Central Centrifugal Cicatricial Alopecia (CCCA)
Central Centrifugal Cicatricial Alopecia (CCCA) belongs to a group of scarring alopecias that destroy hair follicles, replacing them with scar tissue and resulting in permanent hair loss. The exact cause is unknown, but evidence suggests that a genetic or environmental factor plays a role in the inflammatory process. Women with CCCA typically develop thinning at the center of the scalp that slowly enlarges and spreads outward in a circular pattern. CCCA primarily affects African-American women between the ages of 25 and 65, but can present in women of other ethnic groups as well as men. Symptoms can range from asymptomatic to itching, burning, pain, and tingling. The relationship between certain hair styling practices, such as tight styles and extensions, is still being studied as a factor in CCCA development. (4)
Frontal Fibrosing Alopecia (FFA)
The inflammatory skin disorder Frontal Fibrosing Alopecia (FFA) causes permanent hair loss by destroying hair follicles. Hair loss occurs around the eyebrows and the front hairline and is most commonly seen in peri- and postmenopausal women, but also in teenagers and adult men. The cause of FFA is not well understood but is likely induced by genetic and environmental factors. Researchers have recently discovered a gene linked to estrogen formation, which could explain why women undergoing hormone fluctuations surrounding menopause are mostly afflicted. Additional studies have shown an association with many autoimmune conditions, such as thyroid disease. Evidence also suggests that FFA can be triggered by the use of cosmetics, sun exposure, and psychological stressors. FFA progresses slowly and can go unnoticed for years, but usually presents as a triad of sudden eyebrow loss, hairline recession, and hair loss of the upper and lower extremities. (5)
Lichen Planopilaris (LPP)
As with Central Centrifugal Cicatricial Alopecia and Frontal Fibrosing Alopecia, Lichen Planopilaris (LPP) is an inflammatory process that leads to the destruction of the hair follicles and permanent hair loss. LPP is thought to be induced by genetic and/or environmental factors; however, research has found that immune cells called lymphocytes attack part of the hair follicle known as the "bulge". This area of the hair follicle contains stem cells, which are essential for hair growth. The theory is that the immune system mistakes the hair follicles for foreign invaders and destroys them. LPP mostly affects middle-aged women but can occur in young adults, men, and, in rare cases, children. It is most common in lighter-skinned individuals compared to those with darker complexions, and there is an association between LPP and hypothyroidism (underactive thyroid). LPP usually affects the scalp's top and sides and can develop quickly or slowly over several years. Symptoms such as burning, itching, and scalp tenderness are common. (6)
Diagnosis and Treatment Options
A scalp biopsy is the gold standard in diagnosing and treating scarring alopecias. It provides crucial information on the degree of inflammation, the number of active hair follicles present, and the amount of scar tissue, all of which are essential for appropriate treatment.
For patients with Central Centrifugal Cicatricial Alopecia, treatments such as anti-inflammatories prevent further destruction. Mild cases can be treated with topical corticosteroids and non-steroidal agents such as tacrolimus. Steroid injections such as triamcinolone, can be administered for active symptoms related to inflammation. In more severe cases, oral medications like tetracycline antibiotics and hydroxychloroquine may be necessary. Topical minoxidil can help to keep hair follicles in the growing phase longer and stimulate growth. (4)
Management of Frontal Fibrosing Alopecia can be challenging because response to treatment is case by case and there is no consensus on treatment guidelines. In most cases, topical medications like corticosteroids are not sufficient, and steroid injections directly into the area of hair loss are necessary to promote hair growth. The problem with continuous steroid injections is the risk of skin breakdown (atrophy). For severe cases, Finasteride, a 5-alpha-reductase inhibitor, has been shown to be the most effective. Other medications that show promise include anti-inflammatories such as doxycycline and hydroxychloroquine. Immunosuppressants such as azathioprine, mycophenolate, and cyclosporine have also been part of treatment management. (5)
Treatment for Lichen Planopilaris is similar to FFA and CCCA, with the goal of reducing inflammation to prevent further hair loss. Mild cases can be managed with topical corticosteroids and anti-inflammatory products like tea tree oil and shampoos. For severe cases, oral corticosteroids, injections, and immunosuppressant drugs might be necessary. The anti-diabetic drug, Pioglitazone, has shown positive results in some patients. Other treatments such as minoxidil, tetracyclines and laser therapy have also shown promising results. (6) Hair transplantation is an option for some patients but generally not as successful with scarring alopecias. Because of the chronic, unpredictable inflammation process, new hair grafts can be destroyed even after successful transplantation. (7)
Navigating Scarring Alopecia
Women newly diagnosed with scarring alopecia might feel overwhelmed, uncertain and have many questions. The key is to gather resources, information and community to navigate this sometimes emotional journey. Tips for successful navigation include:
Understand your diagnosis: a scalp biopsy is crucial for accurate diagnosis.
Find a knowledgeable dermatologist who specializes in hair loss disorders and scarring alopecia.
Education: Organizations like the Scarring Alopecia Foundation have a wealth of information to help make informed decisions.
Connect with others experiencing similar hair loss issues.
Stay informed about the latest research and clinical trials.
Living with scarring alopecia in today's world, where societal pressures can be intense, can bring about unique challenges. The journey to acceptance can be difficult, and feelings of shame, anxiety, fear, and self-doubt can be expected. With the right support, resources, and knowledge, these challenges can be managed, leading to a happy and fulfilling life that moves beyond a self-image defined by hair loss.
References:
Abal-Díaz, L., et al. “Scarring Alopecia.” Actas Dermo-Sifiliográficas (English Edition), vol. 103, no. 5, June 2012, pp. 376–87. DOI.org (Crossref), https://doi.org/10.1016/j.adengl.2012.06.004.
Cardoso, Camila Oliveira, et al. “Topical Treatment for Scarring and Non-Scarring Alopecia: An Overview of the Current Evidence.” Clinical, Cosmetic and Investigational Dermatology, Volume 14, May 2021, pp. 485–99. DOI.org (Crossref), https://doi.org/10.2147/CCID.S284435.
McNulty, Rose. “Psychological Burden of Alopecia Significantly Impacts Quality of Life.” The American Journal of Managed Care [Published online], Oct. 2025, https://www.ajmc.com/view/psychological-burden-of-alopecia-significantly-impacts-quality-of-life.
Central Centrifugal Cicatricial Alopecia. https://scarringalopecia.org/central-centrifugal-cicatricial-alopecia. Accessed 24 Apr. 2026.
Frontal Fibrosing Alopecia. https://scarringalopecia.org/frontal-fibrosing-alopecia. Accessed 24 Apr. 2026.
Lichen Planopilaris. https://scarringalopecia.org/lichen-planopilaris. Accessed 24 Apr. 2026.
Queen, Dawn, and Marc R. Avram. “Hair Transplantation in Primary Cicatricial Alopecias: A Review and Update.” Surgeries, vol. 6, no. 4, Sept. 2025, p. 80. DOI.org (Crossref), https://doi.org/10.3390/surgeries6040080.
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