scarring hair loss

Alopecia is not a diagnosis



Alopecia, latin for partial or complete absence of hair from an area which normally grows hair, is a diagnosis term but is not a final diagnosis. It is an umbrella term under which there are numerous subsets and reasons for hair loss. I often hear people tell me they were told by physicians and stylists that they have alopecia. This is a broad term similar to saying, “you would like a beverage.” There are many types of beverages of all variations, flavors, consistency, and contents. This also pertains to alopecia. Having a specific diagnosis is important for not only knowing the prognosis of your hair loss but also tailoring treatment towards the pathology, or reason, for the hair loss. For example, if you have hair loss secondary to an auto immune condition, treating with oral supplements and stopping all of your medications is not targeting the reason for the hair loss.

A large part of treating hair loss is education and increasing awareness so individuals present to a dermatologist earlier in their course with hopes to stop the progression and if possibly restore the hair. When I speak at salons and cosmetology schools I explain the umbrella term of alopecia. I also categorize hair loss into different types to show that not all hair loss is the same and should not be treated the same.

There are primary inflammatory conditions where the immune system is the initial cause of inflammation attacking the follicles/sebaceous glands (anatomy of hair follicle unit) causing permanent destruction.  Then there are secondary inflammatory conditions which there is an inciting trigger to cause inflammation, such as traction, chemicals, heat, and trauma. Another way to categorize hair loss is by scarring and non-scarring which helps with prognosis.  Scarring hair loss definitely requires medical intervention to stop the inflammatory process and to prevent progression of further follicle damage and hair loss.  Non-scarring conditions are usually environmental or changes in the body- hormones, stress, medications, infections, etc and are reversible sometimes on their own and sometimes with medical intervention.

In this series I will explain the following types of hair loss and the natural progression of each condition if it isn’t diagnosed and treated earlier in its course.


Scarring hair loss:

  1. Frontal fibrosing alopecia:
  2. Central centrifugal cicatricial alopecia:
  3. Lichen planopilaris
  4. Pseudopelade (Brocq)
  5. Discoid lupus erythematosus
  6. Dissecting cellulitis
  7. Acne keloidalis nuchae
  8. Folliculitis decalvans
  9. Traction alopecia


Non-Scarring hair loss:

  1. Alopecia areata
  2. Telogen effluvium
  3. Trichorrhexis nodosa
  4. Seborrheic dermatitis
  5. Lipedematous alopecia




My hair is thinning!

“I can see through my hair.” I often hear this as a dermatologist. The first question I always ask is whether short hairs versus long hairs are found on the pillows, on the bathroom floor, in the shower, or in the brush/comb. I ask this question primarily because short hairs equal breakage and if someone is experiencing breakage, I further ask about the hair care regimen and products.  A guide to infusing moisture back into the hair can be found here.


Hair grows at an average set rate and length is inevitable while retention of length depends on moisture content of hair and daily care. If your hair is processed, with color, perms, relaxers, texturizers, etc, this changes the inherent pH of the hair and can allow for dehydration and a dry, fragile hair shaft. Daily wear and tear on fragile hairs further lead to breakage and split ends. If enough hairs involved, the ends of your hair will appear uneven and the density will become thinner the further down the hair you travel. A quick way to test for breakage at home is to grab a strand of hair and do a quick bend and tug. If the hair snaps, there is a fragility factor. Also look at the entire length and at the end to assess for splitting and frayed areas. Lastly, place a sheet of white paper behind your hair and have someone take a photo. If you can see a large portion of white paper through your hair, that is breakage. The more breakage, the more visible the paper until it starts tracking up higher in the hair.


If long hairs are found on the brush, floor, pillow, clothing, etc, there may be a concern for a shedding condition called, telogen effluvium (learn about the natural hair cycle here). Telogen effluvium is an excessive shedding phase that is reversible and does not destroy the follicles (non-scarring). Triggers include starting and stopping medications especially hormones and supplements, health conditions (anemia, thyroid, malnutrition, pregnancy, birth), and sudden stressors (illnesses, surgeries, crash diets, stressful event).  My patients will report diffuse shedding and thinning hair all over the scalp. The solution is to find the stressor and remove it. If it was a one-time event, when the stressor has finished, the telogen effluvium must run its course and fade out. I always counsel patients it is an unknown amount of time when the hairs exit out of this effluvium and enter back into their normal cycles. If the shedding is occurring for a long time or if the patient feels more than 50% of the hair density has been lost,  I can intervene with medicine to stop or slow down the natural process and help prevent further shedding.

A similar story of long hairs shedding rapidly can also occur from another shedding condition called anagen effluvium, commonly seen with medications that stop rapid cell growth, such as chemotherapy and particular medications. This condition is also non-scarring and is reversible.  Interestingly, with regrowth after these medicines the hair may return a different color or have a new curl pattern.


Lastly, I evaluate for age, nutritional status, and family history. Male and female pattern baldness is prevalent and I not only ask about hair loss in male family members but also among female members.  I check hormone levels to make sure there are no internal factors driving this condition. There are a few topical and systemic (oral pills) regimens that will help. Often these regimens regrows hair and thickens the hair and holds the patient for years as long as they continue the treatment regimen.

Other reasons:

A close look at the scalp is necessary as all hair thinning is not due to breakage, shedding, or genetics.  There are inflammatory, scarring (follicles turn to scar tissue and cannot grow a hair) permanent hair loss conditions that do warrant medications to slow or stop the process and I specialize in diagnosing and treating these conditions. Early assessment and diagnosis is important to prevent diffuse permanent hair loss. Other permanent hair loss disorders can occur from tight braids, removing glue-in weaves, wraps or headbands around the edges, and chemical burns.  We will talk about these conditions and how to prevent them in future articles.

In conclusion, hair thinning is very common either through medical or cosmetic reasons.  If you’re experiencing hair thinning, seek guidance from your local cosmetologist and dermatologist for treatment of any medical conditions and to help correct moisture imbalance so you can regain your thick healthy hair.