Does this look like scarring alopecia? (Photo)

Question

I have been shedding and itching for 7 months. Was diagnosed with seb derm, TE, and MPB. Used Keto 2%, clobetosol, doxycycline, and am trying 2.5% selenium sulfide. Nothing seems to work. I’ve noticed a completely bald spot that my derm suspects may be a scar. However, he noted no abnormalities in the rest of my hair. I’m skeptical since I’ve noticed a widening of my part and lots of hair on my pillow and in the shower. I’m desperate to stop the itching. Do the pictures look like it’s permanent?

Anna Chacon, MD, FAAD · Answer

I understand why you're worried, particularly with seven months of shedding and itching and now noticing a completely bald spot. The important thing is that shedding and a widening part do not automatically mean scarring alopecia. Telogen effluvium and androgenetic/pattern hair loss are both nonscarring conditions, meaning the follicles can remain intact and continue producing hair.

The most important question with the bald spot is whether the follicular openings are still visible. In scarring alopecia, inflammation destroys the follicle and replaces it with scar tissue, so the normal follicular openings disappear. The scalp may look smooth, shiny, pale, or otherwise altered. In nonscarring alopecia, the follicular openings are generally preserved.

Because you're describing one completely bald area plus more generalized shedding and a widening part, there could potentially be more than one process occurring at the same time. For example, seborrheic dermatitis can cause significant itching and inflammation, while telogen effluvium can cause diffuse shedding and androgenetic alopecia can contribute to progressive widening of the part. Telogen effluvium can also coexist with pattern hair loss.

The fact that your dermatologist did not see abnormalities elsewhere on the scalp is somewhat reassuring, but it doesn't completely settle the question. Persistent itching and a discrete bald patch deserve a closer look, particularly if the area is smooth or appears different in texture from the surrounding scalp.

The most useful next step

I would strongly consider trichoscopy (scalp dermoscopy). It is a noninvasive examination that can help distinguish scarring from nonscarring alopecia and can also provide clues about conditions such as androgenetic alopecia and telogen effluvium.

If the diagnosis remains uncertain—especially if the bald spot appears scarred—a scalp biopsy can be very helpful. Biopsy is specifically useful when persistent hair loss needs to be distinguished between scarring and nonscarring causes. When scarring alopecia is suspected, the biopsy is generally taken from an active area at the edge of the affected patch.

As for whether the bald area is permanent: I would not assume that from a photograph alone. If follicular openings are preserved, there is a much better possibility that the follicles remain capable of regrowth. If the follicles have actually been replaced by scar tissue, spontaneous regrowth from those destroyed follicles is unfortunately not expected.

Your itching is also important. I would focus on getting the underlying scalp inflammation properly controlled rather than simply adding more products. If the itching remains severe despite treatment, that is another reason to reassess the diagnosis rather than assuming everything is seborrheic dermatitis.

So, while I understand why you're feeling desperate, seven months of shedding does not by itself mean that you are developing permanent hair loss. The combination of trichoscopy and, if necessary, biopsy should give you a much clearer answer about whether that particular bald spot is scarred and what is driving the more diffuse shedding.

Jeff Rapaport, MD · Answer

The workup to rule out scarring alopecia with scaling of the scalp and hair loss typically involves a thorough clinical evaluation, diagnostic tests, and a biopsy to confirm the diagnosis. Here's a  breakdown: Diagnostic Tests-
   -Scalp Scraping : If there is scaling present, a sample of the scales may be collected and examined under a microscope to check for the presence of fungi, which could indicate a fungal infection like tinea capitis.
   -Blood Tests: Blood tests may be ordered to assess for underlying conditions such as autoimmune diseases (e.g., lupus), hormonal imbalances (e.g., thyroid disorders), or infections.
   -Trichoscopy:  Trichoscopy involves using a special handheld device to magnify and examine the scalp and hair follicles in detail. It can help identify specific features associated with scarring alopecia, such as follicular plugging, perifollicular erythema, or loss of follicular openings.
   -Skin Biopsy : A skin biopsy is necessary to confirm the diagnosis of scarring alopecia definitively. This involves removing a small sample of affected scalp tissue for examination under a microscope. The biopsy can reveal characteristic features such as destruction of hair follicles, inflammation, and fibrosis (scar tissue).
Once a diagnosis is confirmed, the dermatologist can develop a comprehensive treatment plan tailored to the specific type of alopecia identified. 
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Matt Tahsini, MD · Answer

Hello and thank you for your question. This could be early scarring alopecia but you'll need to see a dermatologist in order to be sure. Find a reputable doctor in order to get the proper diagnosis. Best of luck to you.

Dr. T

Dr. T

Wipawan Vathananai, MD · Answer

From the photos, I can see a well-defined hair loss patch which could be alopecia areata or early scarring alopecia. I think it is very important that you seek for a dermatologist specialized in hair diseases in order to get the right diagnosis and treatment. For the meantime, I would recommend you to use clobetasol on that bald patch if you still have it. Please try to book an appointment as soon as possible. I hope this help.

Jeff Donovan, MD, PhD · Answer

Thank you for the interesting question. It would be great to see more photos and up close ones. One thing is for sure: this is more than AGA, TE and SD. While it could be a scarring alopecia, there’s not enough evidence here to support this 100 %. A cyst is possible, for example. But if someone suspects a scarring alopecia, a biopsy might be considered. Pseudopelade and lichen planopilaris are in the differential of hair loss like this but so is alopecia and aseptic nodules of the scalp (AANS), alopecia areata and others. Be sure to continue your discussions with an expert!

Does this look like scarring alopecia? (Photo)

Answers (5)

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