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Review

Hair Transplantation in Primary Cicatricial Alopecias: A Review and Update

1
Department of Dermatology, Columbia University Irving Medical Center, New York, NY 10032, USA
2
Department of Dermatology, Weill Cornell Medicine, New York, NY 10021, USA
*
Author to whom correspondence should be addressed.
Surgeries 2025, 6(4), 80; https://doi.org/10.3390/surgeries6040080
Submission received: 28 August 2025 / Revised: 18 September 2025 / Accepted: 25 September 2025 / Published: 26 September 2025

Abstract

Background: Primary cicatricial alopecias (PCA) are inflammatory disorders that cause permanent hair loss through follicular destruction and fibrosis. Hair transplantation (HT) may restore coverage in stable or end-stage PCA cases. This review assesses the efficacy of HT in PCA including optimal timing, graft survival rates, and the risk of disease reactivation. Material & Methods: A PubMed literature search identified 33 studies of HT in lichen planopilaris (LPP), frontal fibrosing alopecia (FFA), discoid lupus erythematosus, central centrifugal cicatricial alopecia, pseudopelade of Brocq, morphea en coup de sabre, and folliculitis decalvans from the 1960s to present. Reviews were excluded. Results: Among 147 PCA patients, 87.8% had positive HT outcomes. LPP showed high graft survival (70–90%). In contrast, eyebrow FFA (75%), folliculitis decalvans (25%), and scalp FFA (8.6%) had the highest failure rates. Follicular unit extraction was used slightly more than follicular unit transplantation. Notably, 46 patients developed PCA post-HT for presumed androgenetic alopecia. Discussion: HT in PCA can succeed with careful patient selection and stable disease (ideally ≥12–24 months). Graft survival varies by subtype. LPP has consistently reported successful outcomes post-transplantation, whereas folliculitis decalvans and FFA had the poorest outcomes. Adjuncts like immunosuppressants, PRP, and minoxidil may enhance results. Conclusions: Hair transplantation is viable in quiescent PCA, but outcomes are subtype-dependent. Many surgeons already perform these surgeries, but the published literature is lacking, and more research is needed to establish standardized timing, improve long-term graft survival, and clarify the risk of post-HT PCA onset.

1. Introduction

Primary cicatricial alopecias (PCA) are a group of inflammatory hair disorders characterized by permanent hair loss resulting from the destruction of hair follicles and subsequent fibrosis. These conditions are often progressive and can significantly affect patients’ quality of life, contributing to both physical and psychological distress. PCAs represent approximately 7.3% of hair loss cases presenting to specialty hair clinics [1]. Hair transplantation (HT) has emerged as a potential treatment option for patients with stable or end-stage PCA, aiming to restore hair coverage and improve self-esteem. However, the underlying inflammation and fibrosis in PCA create challenges distinct from non-scarring alopecia cases. A critical concern among providers is determining the optimal waiting period to ensure disease quiescence before HT, given the risk of graft failure and disease reactivation. Another question is the growth rate and long-term stability of transplanted hair into these areas. Due to limited available publications, these questions remain up for debate. Herein, we review the literature to assess the efficacy of hair transplantation in PCA subtypes as well as the optimal timing of transplant, graft survival, and likelihood of disease reactivation.

2. Material & Methods

2.1. Search Strategy

A comprehensive literature search was conducted via PubMed using terms related to PCA and HT. Keywords included “hair transplantation” “hair transplant” “follicular unit extraction”, “cicatricial alopecia,” “scarring alopecia,” and specific PCA subtypes such as “lichen planopilaris”, “frontal fibrosing alopecia”, “discoid lupus erythematosus”, “central centrifugal cicatricial alopecia”, “pseudopelade of brocq”, “morphea en coup de sabre”, and “fibrosing alopecia in a pattern distribution”.

2.2. Inclusion/Exclusion Criteria

Only clinical studies, case reports, and original research articles were included; systematic reviews and studies on secondary scarring alopecias were excluded. Publications spanned from the 1960s to the present.

3. Results

3.1. Study Selection

The literature search yielded 1341 articles, which were narrowed to 33 relevant publications after screening. These studies covered 193 patients, with 147 undergoing hair transplantation for PCA.

3.2. Characteristics of Included Patients

Among these, three patients had central centrifugal cicatricial alopecia (CCCA), nine had discoid lupus erythematosus (DLE), 70 had frontal fibrosing alopecia (FFA), 39 had lichen planopilaris (LPP), five had unspecified FFA or LPP, 12 had folliculitis decalvans, two had morphea en coup de sabre, and seven had pseudopelade of Brocq. No original reports were found of HT in fibrosing alopecia in a pattern distribution (FAPD).

3.3. Outcomes by Subtype

Outcomes varied, with 129 patients (87.8%) experiencing positive hair growth ranging from mild (40% survival) to excellent growth (>90%), while 18 had unsatisfactory outcomes or disease recurrence. Of PCA subtypes, lichen planopilaris appears to have consistently high graft survival (ranging from 70 to 90%). Eyebrow FFA had a high long-term failure rate (75%), followed by folliculitis decalvans (25%) and scalp frontal fibrosing alopecia (8.6%). Notably, 46 cases were found of patients who received transplant for androgenetic alopecia (AGA) but developed a PCA post-transplant.

3.4. Surgical Techniques Used

Techniques included follicular unit extraction (FUE, 49.0%), follicular unit transplantation (FUT or strip method, 30.6%), punch grafts (9.5%), and unspecified methods (10.9%). A summary of each article included in this review is provided in Table 1 and Table 2. In light of heterogeneous outcome definitions and follow-up intervals across studies, we present qualitative outcome summaries in Table 1 and provide study-level survival percentages in Supplementary Tables S1 and S2.

4. Discussion

4.1. Pathophysiology

The pathophysiology of primary cicatricial alopecia creates a high-risk environment for hair transplantation, primarily due to the irreversible loss of follicular stem cells in the bulge and replacement with destructive fibrosis [2]. Even during clinical quiescence, a subclinical lymphocytic infiltrate, often with a Th1/IFN-γ skew in conditions like lichen planopilaris (LPP), can persist; this hostile microenvironment threatens new grafts via a collapse of immune privilege and risks provoking disease activity through the Koebner phenomenon from surgical trauma [3]. Furthermore, the associated microvascular compromise and tissue hypoxia inherent to scar tissue impair graft plasmatic imbibition and neovascularization, leading to significantly reduced survival rates compared to non-scarring alopecias [4]. These pathophysiological barriers necessitate strict patient selection, documented prolonged quiescence, test grafting, and adjunctive peri-operative anti-inflammatory therapies to mitigate risk and improve outcomes.

4.2. General Considerations

4.2.1. Patient Evaluation

The first step in treating PCA with HT occurs during the consultation visit. Patients may present with a history of PCA or may come in with a diagnosis of AGA. It is important that the surgeon not anchor in these diagnoses and instead evaluate clinically for themselves using clinical exam assisted by dermoscopy. If any question exists, the scalp should be biopsied. Accurate diagnosis of PCA and the subtype is important for predicting prognosis and tailoring treatment. Active disease may present with erythema, scaling, or pruritus but can also be subclinical or more insidious. Patients must understand the limitations of HT in PCA, including lower graft survival rates compared to AGA and the possibility of disease reactivation (Table 3). However, patients may still choose to proceed with transplant understanding the limitations given the marked psychological impact cicatricial alopecia may have on patients [5]. Indeed, hair transplant surgery in cicatricial alopecias is often reconstructive for patients and despite variable success, patients are often very grateful for restoring even some of their lost hair. For this reason, hair transplant surgery for patients with cicatricial alopecias with proper expectations can be highly satisfying for both patient and physician.

4.2.2. Timing

Based on limited reports, many providers suggest that clinical remission should be maintained for at least 12–24 months prior to HT [6,7,8]. A pre-procedural biopsy is generally recommended to provide histopathological confirmation of quiescence. Notably, several authors have reported successful procedures within active disease or with stability less than 6 months [9]. Some patients may require ongoing systemic or topical immunosuppressants perioperatively to prevent reactivation. Other adjuncts such as minoxidil or finasteride are also commonly used.

4.2.3. Test Transplant

Careful preoperative planning is essential to evaluate PCA’s unique challenges, including assessment of donor area quality, recipient site vascularity, and degree of fibrosis. A small test HT can be useful to predict overall graft survival, allowing larger procedures to follow if successful. This keeps the valuable donor resource from being wasted if the area cannot support growth. It is important to allow the test hair transplant site to grow for 8–12 months to fully judge its efficacy. Test hair transplants that are successful do not guarantee the success of a larger procedure but give both the surgeon and patient more confidence to proceed.

4.2.4. Factors Affecting Graft Survival

Once transplanted, there are multiple factors that affect graft survival. The degree of fibrosis can limit graft uptake, vascular supply may be insufficient to provide adequate support to transplanted follicles, and ongoing inflammation can lead to poor long-term outcomes. A systematic review by Ekelem et al. in 2019 found that 76% of scarring alopecia patients had moderate to good results post-HT, although with reduced graft survival rates (~50%) [4].

4.2.5. Techniques to Improve Graft Survival

Several technical considerations are important to optimize results. Follicular unit extraction (FUE) is often preferred over follicular unit transplantation (FUT) as smaller incisions minimize trauma in areas of compromised skin and may allow for better wound healing. However, both have been used with success. Lower initial graft densities (20–25 grafts/cm2) are recommended to minimize the risk of poor survival caused by compromised vascular supply [6]. Utilizing multi-haired follicular units can enhance visual density without increasing the number of grafts.
If successful, there is potential for secondary sessions. Intraoperative techniques should be adjusted based on the level of fibrosis. Atrophic areas may require more acute angle incisions whereas hypertrophic areas may require deeper incisions [6]. Limiting the use of epinephrine in the recipient area can help the surgeon as visible bleeding may be an indicator of vascular supply and allow the surgeon to make real-time adjustments [1].

4.2.6. Adjunctive Treatment

Adjunctive therapies play an essential role in optimizing transplant outcomes in PCA. Continuing systemic or topical immunosuppressive therapy perioperatively and postoperatively can prevent disease flares and improve outcomes. Reports have been made using agents such as platelet-rich plasma (PRP) [10] and minoxidil [7,11] to enhance graft survival and overall hair density in PCA. Finasteride and lasers may be effective adjuncts as well. Especially for the first few years post-HT, regular dermatology visits with scalp exams should be recommended to evaluate for subtle signs of early reactivation. If symptoms are noted, early medical intervention may be implemented and may prevent loss of grafts.

4.3. Subtype-Specific Considerations

4.3.1. Lichen Planopilaris (LPP)

Lichen planopilaris (LPP) is considered the most common type of primary cicatricial alopecia and therefore is the most well-studied. It presents with perifollicular erythema, scaling, and progressive patchy hair loss. The clinical course can vary from rapid progression to periods of dormancy. Studies suggest that LPP often burns out within a few years from the initial onset, although variability is common, and some patients experience chronic, low-grade activity beyond this timeframe. Graft survival rates post-HT are generally higher in LPP compared to other PCA subtypes, with consistently successful reports.
Individual outcomes remain variable with graft survival rates between 70% and 90% over follow-up periods ranging from six months to two years [7,10,11,12,13,14,15].

4.3.2. Frontal Fibrosing Alopecia (FFA)

Frontal fibrosing alopecia (FFA) is often thought to be a subtype of LPP which typically manifests as a progressive recession of the frontal hairline, often accompanied by eyebrow loss. It predominantly affects postmenopausal women. Clinically, patients may notice perifollicular erythema and scaling along the hairline. The disease trajectory is generally slow but progressive. HT outcomes in FFA are mixed. While some patients achieve satisfactory cosmetic results [13,16,17], graft survival is often compromised over time, with initial growth followed by disappearance of grafts by 4–5 years [18,19,20]. Of PCA subtypes, scalp FFA had the third highest report of HT failure over time (8.6% when excluding papers reporting on both FFA and LPP or eyebrow FFA). Even in cases of “successful” transplants, survival rate can be lower than that of other subtypes. Vano-Galvan reviewed 51 cases and found that only 41% survived by 5 years [21]. Eyebrow restoration in FFA is a common patient request but may be even more prone to suboptimal long-term results [22,23] with failure over time reported in 75% of cases. Maintenance of medical therapy post-HT is critical, given the tendency of FFA to display recipient site dominance and reactivate [24]. Given high risk of reactivation post-HT, it may be warranted for patients to maintain a longer period of disease quiescence, up to 5 years, prior to transplanting.

4.3.3. Central Centrifugal Cicatricial Alopecia (CCCA)

Central centrifugal cicatricial alopecia (CCCA) predominantly affects women of African descent and typically presents with central scalp thinning that spreads outward. Patients often report scalp tenderness, burning, and pruritus. CCCA is associated with certain hair grooming practices and genetic predisposition. Indeed, in 2019, a landmark paper associated a variant PADI3 gene with CCCA [25]. The disease trajectory is typically gradual but can progress to extensive scarring alopecia. HT outcomes in CCCA are variable, with success contingent upon achieving long-term disease stability. Specifics are lacking, but several cases report moderate graft survival, with one study noting approximately 60% growth [11] compared to non-scarring alopecia (>90%) [7,26]. Recurrence rates are not well-documented.

4.3.4. Discoid Lupus Erythematosus (DLE)

Discoid lupus erythematosus (DLE) presents with scaly, erythematous plaques that evolve into atrophic scars, often affecting sun-exposed areas of the scalp. The clinical course is unpredictable, with periods of activity interspersed with remission. Patients frequently experience dyspigmentation and permanent hair loss. HT in DLE is challenging due to underlying vascular compromise and the potential for immune reactivation. Nevertheless, several case series have documented favorable outcomes, with graft survival rates reaching up to 72% [27,28]. Patients usually require long-term immunosuppressive therapy. Recurrence of disease after HT remains a significant risk.

4.3.5. Folliculitis Decalvans

Folliculitis decalvans is characterized by recurrent pustules, crusting, and tufted folliculitis, leading to progressive scarring alopecia. Patients often report pain, pruritus, and drainage from the scalp. The disease trajectory is chronic and relapsing, making HT feasible only after prolonged periods of quiescence. Even with careful patient selection, graft survival is highly variable. Studies have reported a range of 40% at 6 months to 60% at two years, but long-term durability remains uncertain [11,29]. Out of 12 reported cases, 3 experienced significant disease reactivation post-transplant, leading to positive outcomes in only 75% of patients. Given possibility of disease reactivation even years after HT, these patients will often require ongoing medical management.

4.3.6. Morphea en Coup de Sabre

Morphea en coup de sabre presents as a linear, indurated plaque typically located on the forehead and scalp. The lesion often progresses from months to years, causing skin atrophy, pigmentation changes, and underlying bone involvement in some cases. Early intervention with systemic immunosuppressive therapy is essential to halt progression. HT in patients with stable disease has been successful as disease rarely reactivates, with two case reports in quiescent disease >1 year noting over 86% graft survival at 10 to 12 months post-procedure [30,31].

4.3.7. Pseudopelade of Brocq

Pseudopelade of Brocq is a diagnosis of exclusion, characterized by smooth, flesh-colored patches of alopecia that give a “footprints in the snow” appearance. The disease course is typically slow and insidious, with most patients unaware of hair loss until significant scarring has occurred. Pseudopelade is often considered “end-stage” and has lower likelihood of reactivation. HT outcomes are generally favorable in quiescent disease, with reports citing over 60% graft survival at six months [7,11,32,33].

4.3.8. Fibrosing Alopecia in a Pattern Distribution (FAPD)

Fibrosing alopecia in a pattern distribution (FAPD) is a newly recognized subtype of PCA that presents with progressive hair loss in a pattern resembling androgenetic alopecia (AGA) but has the lichenoid inflammatory infiltrate of LPP. Given the shared features of both conditions, it is especially important to use trichoscopy to assess for loss of follicular openings and biopsy in borderline cases as lichenoid inflammatory infiltrates could make HT less efficacious. The literature is lacking on the success rates of HT in FAPD. Gómez-Zubiaur et al. suggest a “test transplant” surgery that involves 400–500 follicular units, 2–5 years of monitoring, followed by a regular hair transplant if indicated [34].

4.3.9. PCA Post-Transplant

Notably, 46 patients have been reported to develop a “new” PCA post-transplant for androgenetic alopecia (Table 2). Most commonly, LPP was diagnosed (89.1% of cases) 3 months up to 9 years post-transplant [35,36,37,38]. It is unclear in these cases if LPP was previously unrecognized, developed de novo, or if it was triggered by the procedure itself. Some authors posit that all hair transplants may cause some degree of inflammation, or that traumatic injury induces a Koebner phenomenon [39]. Interestingly, Alcantara et al. performed a prospective study of eight patients receiving HT for AGA and found that all patients post-transplant on scalp biopsy had some degree of inflammation and fibrosis, suggesting that some reports may represent overdiagnoses of LPP [35]. In Alcantara’s eight patients, there was no loss of grafts. They emphasize that clinical exam, presence of symptoms, and noticeable graft loss are important to make an accurate diagnosis of true LPP. Importantly, with treatment, it may be possible to salvage the transplant and maintain a favorable outcome.

4.3.10. Other Subtypes

Less commonly, erosive pustular dermatosis (n = 2) [38], FFA (n = 1) [40], folliculitis decalvans (n = 1) [41], and dissecting cellulitis (n = 1) [42] have been diagnosed. Of note, the case of folliculitis decalvans was reported to occur 20 years post-HT. The length of time between diagnosis and HT suggests that onset may be unrelated.

5. Conclusions

Hair transplantation can be effective in quiescent primary cicatricial alopecias, but outcomes are subtype-dependent and generally inferior to non-scarring alopecia. In 33 studies (147 PCA patients), 87.8% had positive growth outcomes. LPP showed the most consistent graft survival (~70–90%), whereas FFA—particularly eyebrows—and folliculitis decalvans had the highest long-term failure/reactivation rates. Most experts target ≥12–24 months of clinical stability, with biopsy confirmation when uncertain; small test grafts and low initial densities (20–25 grafts/cm2) help reduce risk. Technique (FUE vs. FUT) is less important than careful patient selection, atraumatic handling, and adjunctive therapy during and following the peri-operative window. Vigilant follow-up in the first few years is essential to detect reactivation early. Reports of post-HT PCA exist, but causality remains unclear and may reflect latent disease or overdiagnosis; prospective studies are needed.
Clinical takeaways: (i) choose candidates with documented quiescence; (ii) set conservative density/expectations; (iii) anticipate subtype-specific risks (avoid eyebrow FFA or counsel on high failure); (iv) maintain medical therapy and follow-up. Future work should standardize stability criteria by subtype, define durable graft-survival benchmarks, and clarify mechanisms of post-HT inflammation.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/surgeries6040080/s1, Table S1: Detailed reports of hair transplantation in primary cicatricial alopecia (all individual studies, n = 33); Table S2: Detailed report of primary cicatricial alopecia cases noted post-transplantation.

Author Contributions

Conceptualization, D.Q. and M.R.A.; methodology, D.Q. and M.R.A.; formal analysis, D.Q. and M.R.A.; investigation, D.Q.; resources, D.Q.; data curation, D.Q.; writing—original draft preparation, D.Q.; writing—review and editing, M.R.A.; visualization, D.Q. and M.R.A.; supervision, M.R.A.; project administration, D.Q. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The authors confirm that the ethical policies of the journal, as noted on the journal’s author guidelines page, have been adhered to. No ethical approval was required as this is a review article with no original research data.

Data Availability Statement

No new data were created or analyzed in this study.

Conflicts of Interest

The authors declare no conflicts of interest.

References

  1. Dahdah, M.J.; Iorizzo, M. The Role of Hair Restoration Surgery in Primary Cicatricial Alopecia. Ski. Appendage Disord. 2016, 2, 57–60. [Google Scholar] [CrossRef]
  2. Harries, M.J.; Paus, R. The pathogenesis of primary cicatricial alopecias. Am. J. Pathol. 2010, 177, 2152–2162. [Google Scholar] [CrossRef]
  3. Harries, M.J.; Meyer, K.; Chaudhry, I.; Kloepper, J.E.; Poblet, E.; Griffiths, C.E.; Paus, R. Lichen planopilaris is characterized by immune privilege collapse of the hair follicle’s epithelial stem cell niche. J. Pathol. 2013, 231, 236–247. [Google Scholar] [CrossRef] [PubMed]
  4. Ekelem, C.; Pham, C.; Atanaskova Mesinkovska, N. A Systematic Review of the Outcome of Hair Transplantation in Primary Scarring Alopecia. Ski. Appendage Disord. 2019, 5, 65–71. [Google Scholar] [CrossRef] [PubMed]
  5. Chiang, Y.Z.; Bundy, C.; Griffiths, C.E.; Paus, R.; Harries, M.J. The role of beliefs: Lessons from a pilot study on illness perception, psychological distress and quality of life in patients with primary cicatricial alopecia. Br. J. Dermatol. 2015, 172, 130–137. [Google Scholar] [CrossRef] [PubMed]
  6. Unger, W.; Unger, R.; Wesley, C. The surgical treatment of cicatricial alopecia. Dermatol. Ther. 2008, 21, 295–311. [Google Scholar] [CrossRef]
  7. Madura, C.; Vinay, N.; Kusuma, M.R.; Harsha, S.; Chandrashekar, B.S. The assessment of Hair Transplantation Outcomes in Cicatricial Alopecia. Int. J. Trichol. 2020, 12, 164–167. [Google Scholar] [CrossRef]
  8. Singh, S.; Muthuvel, K. Role of Hair Transplantation in Scarring Alopecia-To Do or Not to Do. Indian J. Plast. Surg. 2021, 54, 501–506. [Google Scholar] [CrossRef]
  9. Scribel, M.; Dutra, H.; Trüeb, R.M. Autologous Hair Transplantation in Frontal Fibrosing Alopecia. Int. J. Trichol. 2018, 10, 169–171. [Google Scholar] [CrossRef]
  10. Saxena, K.; Saxena, D.K.; Savant, S.S. Successful Hair Transplant Outcome in Cicatricial Lichen Planus of the Scalp by Combining Scalp and Beard Hair Along With Platelet Rich Plasma. J. Cutan. Aesthetic Surg. 2016, 9, 51–55. [Google Scholar] [CrossRef]
  11. Tyagi, V.; Singh, P.K. A new approach to treating scarring alopecia by hair transplantation and topical minoxidil. Indian J. Dermatol. Venereol. Leprol. 2010, 76, 215. [Google Scholar] [CrossRef]
  12. Kuka Epstein, G.; Epstein, J.; Nikolic, J. Successful Short-Term Hair Transplantation Results in Two Patients With Primary Scarring Alopecia of the Scalp Pretreated With Autologous Fat Grafting. Dermatol. Surg. 2021, 47, 729–731. [Google Scholar] [CrossRef] [PubMed]
  13. Podda, M.; Spieth, K.; Kaufmann, R. Er:YAG laser-assisted hair transplantation in cicatricial alopecia. Dermatol. Surg. 2000, 26, 1010–1014. [Google Scholar] [CrossRef] [PubMed]
  14. Daruwalla, S.B.; Dhurat, R.; Ghate, S.; Bhatt, K. Long-Term Utility of Follicular Unit Excision in Lichen Planopilaris-Correlation of Graft Survival With Histopathological and Ultrasound Biomicroscopic Parameters. Dermatol. Surg. 2021, 47, 1243–1248. [Google Scholar] [CrossRef] [PubMed]
  15. Cevasco, N.C.; Bergfeld, W.F.; Remzi, B.K.; de Knott, H.R. A case-series of 29 patients with lichen planopilaris: The Cleveland Clinic Foundation experience on evaluation, diagnosis, and treatment. J. Am. Acad. Dermatol. 2007, 57, 47–53. [Google Scholar] [CrossRef]
  16. Liu, Y.S.; Jee, S.H.; Chan, J.L. Hair transplantation for the treatment of lichen planopilaris and frontal fibrosing alopecia: A report of two cases. Australas. J. Dermatol. 2018, 59, e118–e122. [Google Scholar] [CrossRef]
  17. Gurfinkiel, A.; Igarza, H.G.; Casas, J.; Kaminsky, A. Hair transplantation in a patient with frontal fibrosing alopecia associated with lichen scleroatrophicus vulvae. Dermatol. Argent. 2010, 17, 110–115. [Google Scholar]
  18. Jiménez, F.; Poblet, E. Is hair transplantation indicated in frontal fibrosing alopecia? The results of test grafting in three patients. Dermatol. Surg. 2013, 39, 1115–1118. [Google Scholar] [CrossRef]
  19. Nusbaum, B.P.; Nusbaum, A.G. Frontal fibrosing alopecia in a man: Results of follicular unit test grafting. Dermatol. Surg. 2010, 36, 959–962. [Google Scholar] [CrossRef]
  20. Rogers, N. Imposters of androgenetic alopecia: Diagnostic pearls for the hair restoration surgeon. Facial Plast. Surg. Clin. N. Am. 2013, 21, 325–334. [Google Scholar] [CrossRef]
  21. Vañó-Galván, S.; Villodres, E.; Pigem, R.; Navarro-Belmonte, M.R.; Asín-Llorca, M.; Meyer-González, T.; Rodrigues-Barata, R.; Moreno-Arrones, Ó.M.; Saceda-Corralo, D.; Bouhanna, P.; et al. Hair transplant in frontal fibrosing alopecia: A multicenter review of 51 patients. J. Am. Acad. Dermatol. 2019, 81, 865–866. [Google Scholar] [CrossRef]
  22. Epstein, J.; Kuka, G. Commentary on Eyebrow Hair Transplantation in Frontal Fibrosing Alopecia. Dermatol. Surg. 2020, 46, 926–927. [Google Scholar] [CrossRef] [PubMed]
  23. Audickaite, A.; Alam, M.; Jimenez, F. Eyebrow Hair Transplantation in Frontal Fibrosing Alopecia: Pitfalls of Short- and Long-Term Results. Dermatol. Surg. 2020, 46, 922–925. [Google Scholar] [CrossRef] [PubMed]
  24. Mendes-Bastos, P.; Camps-Fresneda, A. Hair Transplantation for Frontal Fibrosing Alopecia: Part of the Solution? Actas Dermosifiliogr. 2016, 107, 3–4. [Google Scholar] [CrossRef] [PubMed]
  25. Malki, L.; Sarig, O.; Romano, M.T.; Méchin, M.C.; Peled, A.; Pavlovsky, M.; Warshauer, E.; Samuelov, L.; Uwakwe, L.; Briskin, V.; et al. Variant PADI3 in Central Centrifugal Cicatricial Alopecia. N. Engl. J. Med. 2019, 380, 833–841. [Google Scholar] [CrossRef]
  26. Callender, V.D.; Lawson, C.N.; Onwudiwe, O.C. Hair transplantation in the surgical treatment of central centrifugal cicatricial alopecia. Dermatol. Surg. 2014, 40, 1125–1131. [Google Scholar] [CrossRef]
  27. Nordström, R.E. Hair transplantation. The use of hairbearing compound grafts for correction of alopecia due to chronic discoid lupus erythematosus, traumatic alopecia, and male pattern baldness. Scand. J. Plast. Reconstr. Surg. Suppl. 1976, 14, 1–37. [Google Scholar]
  28. Taylor, K.F.; Cooley, J. Successful Allogeneic Hair Transplantation in a Patient With Extensive Cicatricial Alopecia. Dermatol. Surg. 2024, 50, 1225–1227. [Google Scholar] [CrossRef]
  29. Cova-Martín, R.; Perez-Bootello, J.; Hermosa-Gelbard, A.; Gomez Zubiaur, A.; Pigem Gasos, R.; Vaño-Galvan, S.; Saceda-Corralo, D. Hair transplantation in folliculitis decalvans: Outcome description in a multicentre series of 11 patients. J. Eur. Acad. Dermatol. Venereol. 2025. [Google Scholar] [CrossRef]
  30. Park, S.W.; Wang, H.Y. Survival of grafts in coup de sabre. Dermatol. Surg. 2002, 28, 763–766; discussion 766–767. [Google Scholar] [CrossRef]
  31. Dai, Y.; Xu, A.E.; He, J. A case report of coup de sabre patient with hair transplantation. J. Dermatol. Treat. 2017, 28, 546–548. [Google Scholar] [CrossRef]
  32. Stough, D.B., 3rd; Berger, R.A.; Orentreich, N. Surgical improvement of cicatricial alopecia of diverse etiology. Arch. Dermatol. 1968, 97, 331–334. [Google Scholar] [CrossRef]
  33. Moreno-Arias, G.A.; Izento-Menezes, C.M.; Camps-Fresneda, A.; Carrasco, M.A. Scarring alopecia: Case study. Dermatol. Surg. 2002, 28, 360–362. [Google Scholar] [CrossRef]
  34. Gómez-Zubiaur, A.; Valenzuela, C.; Andrés-Lencina, J.J.; Rodríguez-Villa, A.; Ricart, J.M. Algorithm proposal for hair transplantation in fibrosing alopecia pattern distribution. J. Cosmet. Dermatol. 2022, 21, 5543–5545. [Google Scholar] [CrossRef]
  35. Alcântara, A.S.; Donati, A.; Suárez, M.V.; Pereira, I.J.N.; Valente, N.Y.S.; Michalany, N.S.; de Lima, C.L.H., Jr.; Contin, L.A. Histopathological Findings of Uncomplicated Hair Transplant for Male Androgenetic Alopecia: Can Lichen Planopilaris Features Be Present? Ski. Appendage Disord. 2020, 6, 224–228. [Google Scholar] [CrossRef] [PubMed]
  36. Crisóstomo, M.R.; Crisóstomo, M.C.; Crisóstomo, M.G.; Gondim, V.J.; Crisóstomo, M.R.; Benevides, A.N. Hair loss due to lichen planopilaris after hair transplantation: A report of two cases and a literature review. An. Bras. Dermatol. 2011, 86, 359–362. [Google Scholar] [CrossRef] [PubMed]
  37. Donovan, J. Lichen planopilaris after hair transplantation: Report of 17 cases. Dermatol. Surg. 2012, 38, 1998–2004. [Google Scholar] [CrossRef] [PubMed]
  38. Saad, S.; Cavelier-Balloy, B.; Smadja, J.; Assouly, P.; Reygagne, P. Inflammatory complications after hair transplantation: Report of 10 cases. J. Cosmet. Dermatol. 2022, 21, 5938–5941. [Google Scholar] [CrossRef]
  39. Chiang, Y.Z.; Tosti, A.; Chaudhry, I.H.; Lyne, L.; Farjo, B.; Farjo, N.; Cadore de Farias, D.; Griffiths, C.E.; Paus, R.; Harries, M.J. Lichen planopilaris following hair transplantation and face-lift surgery. Br J Dermatol 2012, 166, 666. [Google Scholar] [CrossRef]
  40. Kossard, S.; Shiell, R.C. Frontal fibrosing alopecia developing after hair transplantation for androgenetic alopecia. Int. J. Dermatol. 2005, 44, 321–323. [Google Scholar] [CrossRef]
  41. Otberg, N.; Wu, W.Y.; Kang, H.; Martinka, M.; Alzolibani, A.A.; Restrepo, I.; Shapiro, J. Folliculitis decalvans developing 20 years after hair restoration surgery in punch grafts: Case report. Dermatol. Surg. 2009, 35, 1852–1856. [Google Scholar] [CrossRef]
  42. Guerrero-González, G.A.; González-Martínez, G.; Valdez-Zertuche, J.A. Dissecting Cellulitis Presenting After Hair Restoration Surgery. Cureus 2024, 16, e74304. [Google Scholar] [CrossRef]
Table 1. Reported outcomes of hair transplantation in patients with primary cicatricial alopecia (by subtype, treatment, and follow-up). N = Number of patients, LPP = lichen planopilaris, FFA = frontal fibrosing alopecia, DLE = discoid lupus erythematosus, CCCA = central centrifugal cicatricial alopecia, ECDS = en coup de sabre, yr = year, FUT = follicular unit transplantation, FUE = follicular unit extraction.
Table 1. Reported outcomes of hair transplantation in patients with primary cicatricial alopecia (by subtype, treatment, and follow-up). N = Number of patients, LPP = lichen planopilaris, FFA = frontal fibrosing alopecia, DLE = discoid lupus erythematosus, CCCA = central centrifugal cicatricial alopecia, ECDS = en coup de sabre, yr = year, FUT = follicular unit transplantation, FUE = follicular unit extraction.
SubtypeNRemission PeriodMethodsOutcomes
LPP390.5–3.6 yrFUE, punchMostly positive; 70–90% survival *
FFA580–5 yrFUT, FUEMixed; early growth, frequent loss by 4–5 yr
Eyebrow FFA12Not specifiedFUT, FUEShort-term positive; majority lost by 3–4 yr
DLE90–2 yrPunch, FUTPositive
CCCA3<1–>2 yrPunch, FUEPositive; modest survival (~60%)
Folliculitis decalvans12>0.5 yrFUEPositive in 9; 3 failures with reactivation
Morphea (ECDS)21 yrFUEPositive
Pseudopelade70–3.6 yrFUE, punchPositive; generally favorable in end-stage disease
* Footnote: An additional 5 patients were reported in studies where the diagnosis was unspecified between LPP and FFA; quantitative survival percentages are not shown here due to heterogeneity in outcome definitions and follow-up timepoints and are provided in Supplementary Table S1.
Table 2. Reported cases of primary cicatricial alopecia diagnosed after hair transplantation (subtype, timing, and outcomes). PCA = primary cicatricial alopecia, N = Number of patients, HT = Hair transplantation, LPP = lichen planopilaris, FFA = frontal fibrosing alopecia, EPD = erosive pustular dermatosis, mo = month, yr = year, FUT = follicular unit transplantation, FUE = follicular unit extraction.
Table 2. Reported cases of primary cicatricial alopecia diagnosed after hair transplantation (subtype, timing, and outcomes). PCA = primary cicatricial alopecia, N = Number of patients, HT = Hair transplantation, LPP = lichen planopilaris, FFA = frontal fibrosing alopecia, EPD = erosive pustular dermatosis, mo = month, yr = year, FUT = follicular unit transplantation, FUE = follicular unit extraction.
PCA Subtype Post-HTNMethods UsedInterval Post-HTOutcome Summary
LPP41FUE, FUT, punch3 mo–9 yrVariable: <5% to 80% survival, some stabilization, frequent graft loss
FFA1Punch/minigraft>5 yrLoss of follicles
Folliculitis decalvans1Punch grafts20 yrLoss of follicles
EPD2FUE or FUT~12 mo<50% graft survival, repeat HT successful
Dissecting cellulitis1FUE4 moRegrowth with medical therapy
Table 3. Differences between hair transplantation in non-scarring and scarring alopecia. FUE = follicular unit extraction, FUT = follicular unit transplantation, HT = hair transplantation.
Table 3. Differences between hair transplantation in non-scarring and scarring alopecia. FUE = follicular unit extraction, FUT = follicular unit transplantation, HT = hair transplantation.
CharacteristicNon-Scarring AlopeciaScarring Alopecia
DefinitionHair loss without permanent follicular destruction; follicles remain intactHair loss due to permanent follicular
destruction and fibrosis
EtiologyCommonly androgenetic alopecia, telogen effluvium, alopecia
areata
Autoimmune, inflammatory, or infectious conditions (e.g., lichen planopilaris, frontal fibrosing alopecia, discoid lupus erythematosus, central centrifugal cicatricial alopecia,
folliculitis decalvans)
Follicular unit survivalHigh; follicles viableLower; destruction and fibrosis
Scalp vascularityPreservedCompromised
InflammationMinimal to noneActive or subclinical
Risk of progression
post-HT
LowModerate to high; risk of reactivation
Candidate selectionMost AGA patients are candidates;
outcomes usually satisfactory
Very selective; depends on disease stability and donor availability
Recommended stability periodNot required12–24 months (some success with <6 months)
Test areaNot requiredAlways recommended
Donor harvestingFUT or FUE both optionsFUT or FUE both options; FUE often
preferred
Recipient site optimal
density
Density 20–35 grafts/cm2Lower density (20–25 grafts/cm2); angle adjustments often needed
Number of proceduresUsually 1 (sometimes 2–3)Often multiple staged sessions
Transplant success rate>90% graft survival50–80% graft survival (subtype-dependent)
Patient satisfactionVery highVery high (with appropriate counseling)
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Queen, D.; Avram, M.R. Hair Transplantation in Primary Cicatricial Alopecias: A Review and Update. Surgeries 2025, 6, 80. https://doi.org/10.3390/surgeries6040080

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Queen D, Avram MR. Hair Transplantation in Primary Cicatricial Alopecias: A Review and Update. Surgeries. 2025; 6(4):80. https://doi.org/10.3390/surgeries6040080

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Queen, Dawn, and Marc R. Avram. 2025. "Hair Transplantation in Primary Cicatricial Alopecias: A Review and Update" Surgeries 6, no. 4: 80. https://doi.org/10.3390/surgeries6040080

APA Style

Queen, D., & Avram, M. R. (2025). Hair Transplantation in Primary Cicatricial Alopecias: A Review and Update. Surgeries, 6(4), 80. https://doi.org/10.3390/surgeries6040080

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