Scalp Pathology Beyond Trichoscopy: CCCA, DLE Scalp, Cutaneous LSA, Scarring Alopecias

01Central centrifugal cicatricial alopecia (CCCA) is the most common scarring alopecia in women of African descent. Classical trichoscopy (Miteva 2014) shows a peripilar grey-white halo (an annular hypopigmented zone of 1 mm or so around emerging hair shafts), variable shaft caliber heterogeneity, pinpoint white dots representing fibrosed follicular ostia, and a honeycomb pigmented network on the surrounding scalp. Pohl-Pinkus constrictions (segmental shaft thinning) reflect intermittent hair growth disruption. Disease starts at the vertex and centrifugally extends. Histology shows premature desquamation of the inner root sheath and concentric perifollicular fibrosis. Management combines aggressive hair-care modification, topical and intralesional steroids, oral antifibrotic agents (doxycycline, hydroxychloroquine), and increasingly minoxidil to support residual non-scarring miniaturized hairs.

02Discoid lupus erythematosus on the scalp shows a distinctive trichoscopy: large, yellow to brown follicular keratin plugs, branching arborizing telangiectasias on the surrounding scalp, follicular red dots (especially in early disease and around residual hairs), and structureless red and blue-grey areas. Late disease shows white scarring patches, loss of follicular ostia, and milky-red areas. Early DLE can show all these features without complete loss of hairs, allowing time-window diagnosis and treatment with intralesional triamcinolone, topical or oral hydroxychloroquine, and immunosuppressants. Histology demonstrates basal vacuolar interface change, perivascular and perifollicular lymphocytic infiltrate, and dermal mucin.

03Lichen planopilaris (LPP) and its frontal fibrosing alopecia (FFA) variant are covered in detail in the dedicated trichoscopy topic. Briefly, LPP shows peripilar tubular casts (white-grey perifollicular scale) and absent follicular ostia in scarred zones; FFA adds vellus hair loss, pale pink to ivory atrophic scalp, and frequent eyebrow and body hair loss. Cross-reference to the trichoscopy topic for the full inflammatory pattern.

04Cutaneous lichen sclerosus (LSA) on the scalp is rare, but when it occurs trichoscopy shows ivory-white structureless areas, comedo-like openings (yellow follicular plugs), peripheral pigment network, and absent or fibrosed follicular ostia in advanced lesions. The hair-bearing extragenital LSA pattern is similar to that of vulvar and trunk LSA, with white sclerotic background and follicular plugging. Treatment is high-potency topical steroid and consideration of topical calcineurin inhibitor.

05Pseudopelade of Brocq is the so-called footprints in the snow pattern: irregular, atrophic, ivory-white patches without follicular ostia, scattered across the scalp of a middle-aged woman, with absent inflammation and absent perifollicular changes. Trichoscopy is dominated by white interfollicular structureless areas and absent follicular openings; vessels are minimal. Whether pseudopelade is a distinct entity or the burnt-out end stage of LPP or DLE is debated. Histology in active disease may show only mild perifollicular fibrosis and minimal lymphocytic infiltrate.

06Dissecting cellulitis of the scalp (Hoffman disease) is part of the follicular occlusion tetrad with hidradenitis suppurativa, acne conglobata, and pilonidal sinus. Trichoscopy shows yellow structureless areas and yellow dots over confluent boggy nodules, follicular pustules, sinus tracts, and three-dimensional yellow-brown blotches. Hair loss is patchy in early disease and scarring in chronic disease. Treatment escalates from topical and intralesional steroids and tetracyclines to isotretinoin, biologic therapy (TNF inhibitors, increasingly IL-17 inhibitors), and surgical drainage or excision for recalcitrant sinuses.

07Folliculitis decalvans is the prototypical primary neutrophilic scarring alopecia. Trichoscopy shows yellow structureless areas, perifollicular white-yellow scale, and the pathognomonic tufted hairs (polytrichia): clusters of 5 or more shafts emerging from a single dilated follicular ostium. Surrounding scalp shows follicular pustules and erosions. Bacterial culture (Staphylococcus aureus is the typical isolate) supports prolonged combination antibiotic therapy (rifampin plus clindamycin or rifampin plus other macrolides), with isotretinoin and biologic options for refractory disease.

08Acne keloidalis nuchae presents as firm follicular papules and pustules at the occipital scalp and posterior neck of young men, often skin of color, evolving into keloid-like plaques and tufted hairs. Trichoscopy shows perifollicular white-yellow scale, dilated follicular openings, polytrichia, and structureless red areas with arborizing vessels in chronic disease. Treatment combines mechanical hair-care advice (avoiding close shaves), topical and intralesional steroids, oral tetracyclines, isotretinoin, and laser hair reduction; surgical excision is reserved for severe keloid-like disease.

09Putting trichoscopy into a clinical workflow: examine the entire scalp first to identify pattern (vertex versus frontal versus occipital, single patch versus multifocal), then examine three or more representative areas under polarized dermoscopy, and document follicular density, ostia, peripilar findings, scale color, vessels, and tufting. Combine with clinical history and selectively biopsy the active edge for cases with diagnostic uncertainty or before high-cost or long-term therapy.