Medical Care
Few large, randomized, blinded, controlled studies are available. Most treatments are considered off label. Stimulating hair growth using options often considered for nonscarring alopecia has been attempted with mixed results, and these include finasteride, minoxidil topically, and bimatoprost injections. [47] In general, with both scarring and nonscarring alopecia, early intervention is best. [48]
Lichen planopilaris
Primary treatment is focused on anti-inflammatory modulation. More common medications used are monthly intralesional triamcinolone acetonide at 3-10 mg/mL, prednisone, and systemic retinoids, although hydroxychloroquine and other immune suppressants (particularly mycophenolate mofetil) are also used. Evidence suggests good results with mycophenolate mofetil. Evidence also suggests that while hydroxychloroquine may suppress symptoms, it may not prevent disease progression. [49] Novel approaches include attempting PPAR modulation. [22]
Central centrifugal cicatricial alopecia
No large randomized blinded controlled studies are available. Symptoms or histologic evidence of inflammation has been reported to improve with daily use of a potent topical corticosteroid and tetracycline.
Traction alopecia
Patient education and behavioral modification are most critical.
Discoid lupus
Sun avoidance is a common suggestion for lupus patients. Whether sun exposure plays a role in discoid lupus erythematosus is not clear because several authors have noted no correlation in discoid lupus erythematosus prevalence and patients with previous alopecia avoiding sun exposure.
Two randomized and controlled studies are available. These studies showed that class II corticosteroid creams are more efficacious than class VII preparations, and approximately half the patients have improvement with hydroxychloroquine. Acitretin has also shown good results, although with increased adverse effects.
Several other treatment modalities have been advocated. These include concurrent topical class I or class II steroids along with intralesional triamcinolone acetonide (10 mg/mL every 4-6 wk). Hydroxychloroquine is also commonly used as part of the treatment regimen. Clinical improvement is often seen within 4-8 weeks, with the full extent of benefit not evident for several months. Despite its good safety profile, prior to initiating therapy, a baseline ophthalmologic examination should be conducted, and patients who smoke should be encouraged to quit because cigarette smoking has been shown to reduce therapeutic responsiveness in a dose-dependent fashion. A bridge of anti-inflammatory prednisone orally is sometimes used for the first 3 months.
With recalcitrant disease, oral retinoids (acitretin or isotretinoin) have been used with good-to-excellent results. Immune-suppressing medications have been used for treatment of discoid lupus erythematosus, with largely mixed outcomes.
Acne keloidalis
Early disease can be controlled with topical steroids and topical antibiotics. Intralesional steroids, laser ablation, and retinoids have also been used. Surgical excision can also be effective.
Acne necrotica
Empiric oral tetracyclines or antistaphylococcal agents, antibacterial shampoos, and even oral retinoids may produce results.
Erosive pustular dermatosis
Topical steroids have been reported to be effective. Reports of treatment and aggravation have been noted with phototherapy. Traumatic manipulation also often aggravates the lesions. Topical psoriatic medications have been reported to be effective.
Pressure alopecia
No large randomized blinded controlled studies are available.
Trichotillomania
Psychiatric behavioral modulation is an option.
In a double-blind, placebo-controlled trial, N -acetylcysteine improved trichotillomania in adults (n = 50) with compulsive behavior. The dosage ranged from 1200-2400 mg/d. N -acetylcysteine restores extracellular glutamate concentration in the nucleus accumbens and therefore may be effective in reducing compulsive behavior. This study is thought to be the first to examine the effect of a glutamatergic agent for the treatment of trichotillomania. [50]
Alopecia mucinosa
Age-appropriate cancer screening should be undertaken. Small reports have included use of topical, intralesional, and oral corticosteroids; antibiotics; and topical/oral retinoids.
Keratosis pilaris atrophicans
Pustular flares should prompt bacterial cultures. Anecdotal reports have noted use of topical/oral steroids, topical/oral retinoids, and dapsone. Baseline and routine ophthalmologic examination may be warranted.
Folliculitis decalvans
Combination antibiotic treatment including rifampin can sometimes produce sustained disease-free remission. Rifampin (600 mg twice daily) and clindamycin (150-300 mg twice daily) are commonly used together. Sustained relief can also be obtained through the use of topical corticosteroids together with an oral tetracycline.
Perifolliculitis capitis abscedens et suffodiens
Oral antibiotics (eg, tetracyclines) and intralesional triamcinolone acetonide are most effective if used in combination. The response to oral isotretinoin is often disappointing, but some reports describe a response to the more potent antitumor necrosis factor biologic agents. Refractory dissecting cellulitis of the scalp was treated successfully employing risankizumab. [51]
Incision and drainage of painful nodules or excisional carbon dioxide laser treatment with secondary-intention healing are among several surgical techniques advocated.
Surgical Care
Despite the lack of multiple medical options for the treatment of end-stage scarring alopecia, achieving cosmetically acceptable correction of alopecia by means of surgical hair transplantation procedures (eg, punch grafting, flap rotation) is possible. [52]
However, koebnerization of the disease may occur. Additionally, surgical correction of alopecia should not be performed if the patient has any active scalp disease or inflammation.
Recent advances in follicle unit extraction have also led to improved survival and more natural outcomes in scarring alopecia patients. [53, 54, 55]
Scarring alopecia in children may be suitably treated by follicular unit hair transplantation. [56]
Finally, scalp reduction can be used in small areas (usually ≤1 cm).
Consultations
Stress and psychiatric morbidity are common considerations to evaluate. Often, consultation with a psychiatrist is of assistance. Patients often refuse this suggestion.
Diet
Sufficient levels of iron and protein in the diet may help promote normal hair growth. The exact role of diet with scarring alopecia has not been evaluated extensively in the medical literature. Diet and vitamins such as vitamin D are an established factor in normal hair growth and development but have not yet been strongly correlated with scar formation and inflammation. [57]
Prevention
Patients should discontinue any practices that exert traction on the hair, including the following:
-
Hairstyling practices such as braiding and chemical hair straightening
-
Use of tight curlers and nylon brushes
-
Wearing the hair in a chignon (bun)
-
Traction alopecia.
-
Alopecia due to primary cutaneous follicular center cell lymphoma. Used with permission, rights retained, courtesy of Rashid M. Rashid, MD, PhD, Morzak Research Collaborative.
-
Recalcitrant scarring pressure alopecia several years after an ICU stay. Used with permission, rights retained, courtesy of Rashid M. Rashid, MD, PhD, Morzak Research Collaborative.
-
End-stage scarring alopecia (ESSA) with prior history of itching and burning, along with a receding hairline. Started as the lichen planopilaris variant, frontal fibrosing alopecia. Used with permission, rights retained, courtesy of Rashid M. Rashid, MD, PhD, Morzak Research Collaborative.
-
Dissecting scalp cellulitis. Used with permission, rights retained, courtesy of Rashid M. Rashid, MD, PhD, Morzak Research Collaborative.
-
Armpit scarring alopecia in lichen planopilaris variant. Patient presented with frontal fibrosing alopecia. Used with permission, rights retained, courtesy of Rashid M. Rashid, MD, PhD, Morzak Research Collaborative.
-
Acne keloidalis. A misnomer term based on clinical examination findings. Used with permission, rights retained, courtesy of Rashid M. Rashid, MD, PhD, Morzak Research Collaborative.
-
Lichen planopilaris in its active stage presenting in a lighter-skinned patient. Courtesy of Rashid M Rashid, MD, PhD, and Ronald Rapini, MD.
-
Alopecic and aseptic nodules of the scalp (AANS) is a new entity reported first in Japan as "pseudocyst of the scalp." The main location of the nodules was the occiput. The associated alopecia was nonscarring. Histology is nonspecific but often shows deep granulomas. AANS reponds to tetracyclines. Photo courtesy of Sami Abdennader, MD (rights retained).
