Cicatricial alopecia: Working classification, treatment protocols bring hope

Key Points

"Clinicians should realize that a perfect therapy does not exist for cicatricial alopecia.

"However, much can be done towards treating the symptoms and signs, and also for slowing disease progression.

Resurgence in interest

Dr. Price says that cicatricial alopecia has been neglected for some time by dermatologists because these disorders are rare and little is known about them.

Recently, however, the interest in cicatricial alopecia has experienced resurgence, and it has become a hot topic at dermatology conferences and meetings.

According to Dr. Price, this resurgence is due in large part to two events: first, the establishment of a working classification that aided communication between physicians and treatment protocols that followed; and secondly, the formation of the Cicatricial Alopecia Research Foundation (CARF), which has greatly increased awareness of these disorders with educational materials, advocacy in Washington, patient conferences, and an award-winning Web site ( http://www.carfintl.org/).

Biopsy

Taking a biopsy is paramount when cicatricial alopecia is suspected, and the specimen should preferably be sent to a dermatopathologist who is familiar with scalp biopsies and with cicatricial alopecias.

A dermatologist must then correlate the biopsy results with the clinical findings.

Treatment is based upon the biopsy findings, which will identify the predominant cellular infiltrate - lymphocytic, neutrophilic/plasmacytic - and its location (around the isthmus and infundibulum), extent (sparse, moderate or dense), and the presence or absence of sebaceous glands.

Lymphocytic group

For the predominantly lymphocytic group, immunomodulating agents are used. Therapy consists of oral hydroxychloroquine, 200 mg twice daily, or doxycycline, 100 mg twice daily, or mycophenolate mofetil, 0.5 gm twice daily for the first month, then 1 gm twice daily for five months; or cyclosporine, 3 to 5 mg/kg/day, or 300 mg/day for three to five months.

Topical therapy may consist of high-potency corticosteroids, topical tacrolimus or pimecrolimus and Derma-Smoothe/FS scalp oil. Intralesional injections of triamcinolone acetonide, 10 mg/cc are often given in inflamed, symptomatic areas of the scalp.

Neutrophilic/plasmacytic group

For the predominantly neutrophilic/plasmacytic group, antimicrobial agents are used. For example, clindamycin, 300 mg twice daily for 10 to 12 weeks, along with oral rifampin, 600 mg daily.

This regimen can be substituted with ciprofloxacin, 500 to 750 mg twice daily, or cephalexin, 500 mg four times a day, or doxycycline, 100 mg twice daily, given with rifampin.

Topical therapy may consist of clindamycin solution or lotion, Derma-Smoothe/FS oil, topical corticosteroids and intralesional injections with triamcinolone acetonide.

"I use these treatments for approximately three months to see if there is improvement in symptoms, signs and spreading.

"If there is improvement, I continue the treatment for six to 12 months. If there is no improvement after three months, then another drug is selected.

"We use a standardized patient assessment chart to track response to treatment. These treatment suggestions are a rough guide for treating cicatricial alopecia.

"However, not every hair expert necessarily follows this protocol, which is fine, because until we know the cause of the different cicatricial alopecias, their management varies amongst the specialists," Dr. Price says.