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.
- Central centrifugal cicatricial alopecia typically begins at the vertex and expands centrifugally, especially in women of African ancestry, but it is not caused by ethnicity and hair practice is only one possible modifier.
- Traction loss begins in sites under repeated tension and can be reversible early; longstanding tension produces permanent scar, so ask neutrally about styles, adhesives, chemicals, heat and pain.
- Pustules, crust and tufted multiple hairs suggest folliculitis decalvans or another infective-neutrophilic process and require bacterial sampling plus urgent specialist assessment.
- Trichoscopy and consented photographs map active margins. If biopsy is needed, sample an inflamed edge with remaining follicles rather than a smooth burned-out centre.
- Biopsy planning should specify site, orientation and clinical differential to dermatopathology and include bleeding, infection, scar and local permanent hair loss in consent.
- Do not wait for widespread baldness before referral: symptoms and inflammatory signs may precede obvious density loss.
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.
- Arrange expedited dermatology referral, stating pain, pustules, eyebrow loss, rate of recession and any systemic red flag rather than labelling the referral as nonspecific hair loss.