Synopsis
Detect follicular destruction before it becomes irreversible, distinguish inflammatory, infective and traction patterns, and obtain correctly sited photographs, samples and biopsy without delaying specialist care.
- Primary cicatricial alopecia destroys follicular stem-cell regions and replaces follicles with fibrosis; treatment can preserve remaining hair but cannot reliably regenerate established scar.
- Look for absent follicular openings, shiny atrophy, perifollicular scale or erythema, pustules, crust, tufting and symptoms of pain, burning or itch.
- Lichen planopilaris often shows perifollicular scale and erythema; frontal fibrosing alopecia recedes the frontotemporal hairline and commonly reduces eyebrows.
Key red flags
Loss of follicular openings, perifollicular erythema or scale, scalp pain or burning, pustules, tufted hairs, shiny atrophy, a rapidly receding frontotemporal line or central crown expansion warrants expedited dermatology assessment because lost follicles cannot regrow.
Crust, pustules and several shafts emerging from one enlarged opening suggest folliculitis decalvans or another neutrophilic destructive process.
Investigation priorities
Map pattern, identify retained ostia and locate active inflammatory margins.
Management branches
Missing openings or perifollicular inflammation suggests an active scarring alopecia.
- Document symptoms, tempo, distribution, medicines and hair practices, then examine the entire scalp, brows, facial hair, skin, nails and mucosa for diagnostic clues.
- Take standardised photographs and use trichoscopy to mark an active margin; obtain fungal or bacterial samples when scale, pustules or exposure supports infection.