Cicatricial vs Androgenetic Alopecia: How Scarring Changes the Hair’s Future

Disclaimer: This content is for educational purposes only and does not constitute medical advice. Always consult a qualified dermatologist or healthcare professional for diagnosis and treatment recommendations.

What signs, sensations, and scalp changes reveal whether hair loss is permanent

Hair loss is stressful. When it is happening to you, knowing which type you have can make all the difference in treatment and expectations. Two forms that are sometimes confused are cicatricial (scarring) alopecia and androgenetic (pattern) alopecia. Below, I explain how they differ, what to look for, how they behave over time, and when to see a dermatologist.

What each term means, and why the distinction matters

Alopecia is the medical word for hair loss. Androgenetic alopecia (AGA), also called male or female pattern hair loss, is the most common non scarring alopecia. In AGA, hair follicles remain present but gradually miniaturize. Miniaturization means the follicles shrink and produce progressively finer, shorter hairs. The pattern is usually slow and predictable.¹ ³ ⁷
Cicatricial alopecia, also called scarring alopecia, refers to a group of conditions in which inflammation or other injury destroys hair follicles and replaces them with scar tissue. Once scarring replaces a follicle, regrowth in that spot is not possible.¹ ² ⁴

The key difference is structural. In AGA, follicles are weakened yet still present. In cicatricial alopecia, follicles are permanently lost in the scarred zones.¹ ²

Clinical signs: what patients and clinicians actually see

Feature	Androgenetic Alopecia (Pattern Loss)	Cicatricial (Scarring) Alopecia
Pattern and progression	Gradual thinning in characteristic areas such as receding hairline or crown in men, widening part in women	May begin as focal patches or a central area that expands outward; does not always follow a classic pattern¹
Scalp appearance	Skin often looks normal, with visible follicular openings	Skin in affected areas can look smooth and shiny with loss of follicular openings²
Symptoms	Often minimal; many patients report no itch or pain	Itching, burning, tenderness, and visible redness or scale are common² ⁴
Follicular changes	Miniaturization with follicles still present¹ ³	Follicles destroyed and replaced by fibrosis; sebaceous glands often absent¹ ⁴
Regrowth potential	Possible with early and consistent therapy⁷	Very limited or absent once scarring has occurred² ⁴
Testing	Diagnosis often clinical with trichoscopy	Scalp biopsy commonly required to confirm and subtype⁴

A common confusion point: CCCA vs AGA in the crown

Central Centrifugal Cicatricial Alopecia (CCCA) is a scarring alopecia that more often affects women of African descent. It typically starts at the vertex and spreads outward. That location overlaps with female pattern thinning, which is why confusion happens. In CCCA, the scalp may show absent follicular openings, perifollicular scale, and symptoms such as itch or burning. A biopsy clarifies the diagnosis and prevents delay in anti inflammatory treatment.⁴ ⁵ ⁶

The natural course: how each condition behaves over time

Androgenetic alopecia

Androgenetic alopecia tends to progress slowly over years or decades. The rate can increase with age and hormonal changes such as menopause. Without treatment, thinning generally advances. With appropriate therapy, many patients achieve stabilization and some regrowth, especially when treatment begins early.³ ⁷

Cicatricial alopecia

Cicatricial alopecias can smolder quietly or flare more aggressively. During active inflammation, the scarred area can enlarge. Once a follicle is replaced by scar tissue, hair in that exact spot will not regrow. Timely recognition and treatment aim to calm inflammation, preserve remaining follicles, and reduce symptoms such as itch or pain.¹ ² ⁴

Diagnostic pathway: how a dermatologist separates scarring from pattern loss

• History and symptom review. Your clinician will ask about onset, pace of change, family history, hairstyling practices, chemical treatments, and scalp sensations such as itch or tenderness.
• Clinical exam and trichoscopy. Under magnification, we assess follicular openings, hair shaft caliber variation, scaling, redness, and pustules.
• Scalp biopsy when scarring is suspected. A 2 to 4 mm punch biopsy from the active edge and a nearby area can confirm whether follicles are present and miniaturized or destroyed with fibrosis. Pathology also identifies the inflammatory pattern, which guides therapy.⁴
• Selective laboratory testing. When indicated, we check thyroid status, autoimmune markers, and nutritional factors to rule in or out contributors.

Why misdiagnosis happens, and why it matters

Scarring alopecias can resemble common pattern thinning, especially at the crown. If a scarring process is mistaken for AGA and treated only with growth stimulators, inflammation can continue to destroy follicles. In CCCA, delayed recognition has real consequences for permanent density. Early biopsy and anti inflammatory therapy can prevent further loss and reduce symptoms.⁵ ⁶

What to do if you are not sure which one you have

Step 1: Scan for warning signs of scarring.

• The scalp in a thinning area looks unusually smooth or shiny.²

• You feel itch, burning, or tenderness in that spot.²

• You cannot see normal hair pores in the bare area.²

• Thinning began in a patch or a non typical pattern.

Step 2: Book a visit with a dermatologist who treats hair disorders. Bring a timeline, photos over time, current and past hair care practices, and any symptoms you notice.
Step 3: Ask whether trichoscopy or biopsy is appropriate. If there is any doubt, confirmation now prevents regret later.⁴
Step 4: Press pause on aggravating practices. Avoid tight styles, chemical relaxers, aggressive heat, and harsh scalp treatments while you are being evaluated.⁵
Step 5: Support the scalp gently. Use a mild, fragrance free shampoo, keep styles loose, protect from sunburn, and avoid scratching while symptoms are active.

Treatment goals and the typical options

For androgenetic alopecia

Goal: slow progression, maintain coverage, and stimulate regrowth where possible.
Options to discuss with your clinician:

• Topical minoxidil once or twice daily.⁷

• Oral finasteride for eligible men after a risk benefit discussion.³

• Low level laser therapy devices as an adjunct.³

• Procedures such as platelet rich plasma or microneedling in select cases.³

• Hair transplantation in stable disease when donor supply and expectations align.³

  
  

For cicatricial alopecia

Goal: suppress inflammation, halt further follicle destruction, relieve symptoms, and protect remaining hair.
Options to discuss with your clinician:

• Topical and intralesional corticosteroids to calm local inflammation.⁴

• Oral anti inflammatory or immunomodulatory agents such as doxycycline or hydroxychloroquine, depending on subtype.⁴

• Antimicrobials when pustules or secondary infection are present.⁴

• Surgical options such as transplantation only after the disease has been inactive and stable, typically for a prolonged period, and with careful expectations.⁴

  
  

Prognosis and expectation setting

With androgenetic alopecia, consistent treatment often slows loss and can thicken miniaturized hairs. Results depend on baseline density, duration, and adherence.³ ⁷ With cicatricial alopecia, the main win is stabilization. Hair rarely returns in scarred areas, yet many patients achieve comfort and disease control with the right regimen.¹ ² ⁴ Routine follow up with photographs and trichoscopy helps measure progress and informs when to adjust the plan.

Practical tips you can start today

• Create a simple hair diary with weekly photos in consistent lighting.

• Switch to gentle cleansers and avoid vigorous scrubbing if the scalp feels irritated.

• Loosen hairstyles and rotate part lines to minimize repeated tension.

• Protect the scalp from sun with hats or SPF sprays to reduce inflammation triggers.

• Bring your product list and devices to your appointment so your clinician can tailor advice.

  
  

When to act, and why timing matters

Seek care promptly if you notice rapid change, symptoms such as itch or pain, or shiny areas without visible pores. Early evaluation improves the odds of preserving hair in both conditions and is critical for scarring types where delay risks permanent loss.² ⁴ ⁶

Wrap up and encouragement

Cicatricial alopecia and androgenetic alopecia differ at the root. In pattern hair loss, follicles are still present and responsive to ongoing care. In scarring alopecia, follicles are lost, so the priority is to stop inflammation and protect what remains. If you are unsure which you have, do not panic. Book an evaluation, ask about dermoscopy or biopsy, and take small steps now to support a calmer, healthier scalp.

Glossary

• Androgenetic alopecia (AGA). Pattern hair loss caused by genetics and hormones, with follicle miniaturization.
• Cicatricial alopecia. Scarring hair loss in which follicles are destroyed and replaced with scar tissue.
• Miniaturization. Shrinking of hair follicles that produce finer, weaker hairs over time.
• Follicular ostia. The visible openings where hair emerges from the scalp.
• Trichoscopy. Magnified scalp examination using a dermoscope.
• Punch biopsy. A small cylindrical skin sample examined under a microscope.

Claims Registry

Citation #	Claim(s) supported	Source title + authors + year + venue	Accessed date (America/New_York)	Anchor extract	Notes
1	Non scarring alopecias preserve follicles; scarring alopecias destroy follicles	Diagnostic Evaluation of Hair Loss: A Clinician’s Guide; PMC review, 2019; Journal review	2025 10 15	"In non scarring alopecia, hair follicles are preserved; in scarring alopecia the follicle is irreversibly destroyed"	Histologic definitions used widely
2	Scarring areas appear smooth and shiny with loss of openings	Cleveland Clinic, Scarring Alopecia overview, 2024	2025 10 15	"Skin where hair used to be tends to look smooth and shiny"	Clear patient friendly description
3	AGA has predictable patterns; therapies can slow loss	AAFP Clinical Review on Hair Loss, 2017	2025 10 15	"Androgenetic alopecia typically presents in characteristic patterns"	Primary care guideline
4	Biopsy confirms scarring vs non scarring and guides therapy	Practical guide to scalp biopsy in alopecia; review article, 2020	2025 10 15	"Scalp biopsy remains the gold standard when scarring alopecia is suspected"	Diagnostic standard
5	CCCA more common in women of African descent and can mimic AGA at the crown	Review of CCCA, 2012; case series	2025 10 15	"CCCA often begins at the vertex and spreads centrifugally"	Epidemiology and pattern
6	Misdiagnosis or delayed diagnosis can lead to irreversible loss	Patient and clinician reports on CCCA delay; feature article	2025 10 15	"Delay in diagnosis may result in permanent hair loss"	Risk framing
7	Minoxidil is safe and effective for AGA in many patients	AAFP Clinical Review; FDA labeling	2025 10 15	"Topical minoxidil is safe and effective for androgenetic alopecia"	Therapy standard