Management of Scarring Alopecia

In his presentation at Maui Derm NP+PA Fall 2021, Jerry Shapiro, MD, FAAD, shared his treatment protocols for lupus erythematosus, lichen planopilaris, folliculitis decalvans, and dissecting cellulitis.

In his presentation on hair disorders at the Maui Derm NP+PA Fall Conference, Jerry Shapiro, MD, FAAD, professor and director of disorders of hair and scalp, The Ronald O. Perelman Department of Dermatology, New York University Langone Medical Center, highlights the differences in scarring alopecia.1

Scarring alopecias are described, according to Shapiro, is a group of disorders characterized by a final common pathway of replacement of follicular structure by fibrous tissue, a loss of follicular ostia, and obliteration of the hair follicle.

Of the scarring alopecias, primary cicatricial alopecias are the preferential destruction of follicular epithelium with the sparing of interfollicular dermis.

The North American Hair Research Society consensus classification of primary cicatricial alopecias include:


  • Chronic cutaneous lupus erythematosus (DLE)
  • Lichen planopilaris
  • Classic psaudopelade (Brocq)
  • Central centrifugal cicatricial alopecia
  • Alopecia mucinosa
  • Keratosis follicularis spinulosa decalvans


  • Folliculitis decalvans
  • Dissecting cellulitis


  • Acne keloidalis
  • Acne necrotica
  • Erosive pustular dermatosis

For scarring alopecias, Shapiro shared his treatment protocol for lupus erythematosus, lichen planopilaris, folliculitis decalvans, and dissecting cellulitis.

Lupus Erythematosus

For patients with less than 10% lupus erythematosus coverage, he prescribes an ultra-potent topical steroid, and will also sometimes add an intralesional triamcinolone acetonide (IL-TAC) monthly. If no improvement is seen, he prescribes either hydroxychloroquine, isotretinoin, or tacrolimus 0.3% twice daily, corticosteroid twice daily, and 5% minoxidil solution twice daily (TCM).

For those with an extent of 10% or more, patients are given hydroxychloroquine 200 mg twice daily, along with the potential addition of an ultra-potent topical steroid, IL-TAC, or prednisone. With improvement, he recommends tapering dosage to the lowest that is effective. On the other hand, if no improvement is seen, Shapiro prescribes either isotretinoin or TCM.

Lichen Planopilaris

Lichen planopilaris treatment when the patient is experiencing less than 10% extent of disease involves IL-TAC 10 mg/ml monthly plus TCM twice daily. If no improvement is seen, the treatment moves to what is prescribed for 10% or more extent of disease. For that, IL-TAC 10 mg/ml monthly, TCM twice daily, and doxycycline 100 mg twice daily or hydroxychloroquine 100 mg twice daily is prescribed.

If a patien stabilizes after 3-6 months, taper to the lowest effective dose. If the patient does not stabilize, he adds pioglitazone 15 mg per day with the possible addition of naltrexone 3 mg per day. If the patient is still not stabilizing, more options include mycophenolate mofetil, methotrexate, cyclosporine, low dose isotretinoin, or Janus kinase (JAK) inhibitors.

Additionally, if the lichen planopilaris is rapidly progressive, Shapiro recommended a first line treatment of oral prednisone.

Folliculitis Decalvans

When treating folliculitis decalvans, Shapiro starts patients of on cephalexin 500 mg 4 times daily, doxycycline 100 mg twice daily, with the possible inclusion of IL-TAC monthly, and mupirocin cream.

If improvement is seen, he tapers the doses to the lowest possible and adds mupirocin cream if it is not already part of the regimen.

However, if there is no improvement, patients are prescribed rifampicin 300 mg twice daily and clindamycin 300 mg twice daily, or ciprofloxacin 500 mg twice daily and mupirocin cream. From there, if there is improvement, he tapers the dose to the lowest effective.

If there is still no improvement, Shapiro repeats the course. If remission is not sustained, he uses fusidic acid 500 mg 3 times daily and zinc 15 mg once daily.

Dissecting Cellulitis

Dissecting cellulitis treatment regimens include isotretinoin 0.5 to 1 mg/kg with a possible addition of IL-TAC monthly for 4 months. If improvement is seen, he continues isotretinoin for an additional 5 to 7 months. If no improvement is seen, Shapiro prescribes cephalexin 500 mg 4 times daily or doxycycline 100 mg twice daily and incisional drainage.


1. Shapiro J. Hair Disorders Update 2021. Session presented at: Maui Derm NP+PA Fall 2021 conference Program; October 1, 2021; Accessed October 1, 2021. Asheville, North Carolina.