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Lichen planopilaris
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Lichen planopilaris (LPP), also known as follicular lichen planus , is a clinical syndrome consisting of lichen planus (LP) associated with cicatricial scalp alopecia. The condition is more common in women and presents with perifollicular erythema and keratotic plugs at the margins of the expanding alopecia. The follicular involvement is limited to the infundibulum and the isthmus, both demonstrating lichenoid inflammation. The main complications of follicular LP are atrophy and scarring, with permanent hair loss. Three forms of LPP are recognized: classic LPP; Graham–Little syndrome, characterized by the triad of multifocal scalp cicatricial alopecia, non-scarring alopecia of the axilla and/or groin, and keratotic follicular papules; and frontal fibrosing alopecia that affects mainly postmenopausal women and appears as cicatricial alopecia of the frontoparietal hairline and is associated with non-scarring alopecia of the eyebrows.
Management Strategy
Therapeutic management for LPP is challenging. However, if the associated inflammation can be controlled in its early stages, follicular units could be preserved, and hair regrowth may be possible. A good therapeutic response aims to halt disease activity and would include a reduction in associated symptoms along with stabilization of the disease and some regrowth of hair in the active perimeter of the alopecic patch. Treatment recommendations vary and tend to be multifaceted due to the lack of high-quality data on therapies. High-potency topical corticosteroids are used to control the inflammation in early lesions. Intralesional injections of 3–5 mg/mL of triamcinolone acetonide are effective in well-developed lesions and especially at the edge of the patches. Systemic therapy includes short courses of oral corticosteroid for active and progressive disease. Hydroxychloroquine and tetracycline antibiotics may be efficacious and are commonly considered as second-line therapy. Other agents such as ciclosporin and mycophenolate mofetil are reported to be useful in refractory cases; attention must be paid to monitoring for side effects and relapse posttreatment is also prevalent. More recently, antiandrogens (5α-reductase inhibitors) were found to be effective. There is some rationale for trying biologic agents such as tumor necrosis factor (TNF)–blocking agents for this condition. Finally, cosmetic measures can be helpful in camouflaging hair loss on the scalp or eyebrows. These include wigs, hairpieces, microfiber powder, cosmetic makeup, semipermanent makeup, and tattoos. A cosmetic camouflage expert is a useful resource.
A histologic review of 27 patients with lichen planopilaris
Tandon YK, Somani N, Bergfeld WF. J Am Acad Dermatol 2008; 59: 91–8.
Characteristic features of LPP include the absence of arrector pili muscles and sebaceous glands, a perivascular and perifollicular lymphocytic infiltrate, mucinous perifollicular fibroplasia with absence of interfollicular mucin, and superficial perifollicular wedge-shaped scarring.
Dermoscopy guided scalp biopsy in cicatricial alopecia
Miteva M, Tosti A. J Eur Acad Dermatol Venereol 2013; 27(10): 1299–303.
Obtaining the biopsy from the correct site is essential for accurate pathologic interpretation in scarring alopecia, as the disease may be focal and difficult to appreciate with the naked eye. In this study of 80 patients, 95% of the dermoscopic-guided biopsies yielded correct pathologic diagnosis. Dermoscopic features of reduced follicular ostia, perifollicular scale, and white dots are suggestive of LPP.
Immunofluorescence abnormalities in lichen planopilaris
Ioannides D, Bystryn JC. Arch Dermatol 1992; 128: 214–6.
Direct immunofluorescence studies were performed on biopsied lesions of patients with LPP and LP. All of the LPP studies demonstrated abnormal linear deposits of immunoglobulin, consisting of IgG or IgA restricted to the basement membrane. The biopsies from those with LP demonstrated fibrillar deposits.
These different appearances suggest different disease processes for LPP and LP .
Dermoscopy: alternative uses in daily clinical practice
Micali G, Lacarrubba F, Massimino D, et al. J Am Acad Dermatol 2011; 64: 1135–46.
Video dermoscopy is performed with a video camera equipped with lenses providing magnification ranging from ×10 to ×1000 and shows the reduction to total absence of orifices, hyperkeratotic perifollicular scales, and erythema. In addition, perifollicular arborizing vessels, pigmented networks, and white pale or blue–gray dots in dark-skinned individuals, corresponding to focal decrease in melanin content.
The use of anti-keratin 903 antibodies to visualize colloid bodies and diagnose lichen planopilaris
Lanoue J, Yanofsky VR, Mercer SE, et al. Am J Dermatopathol 2016; 38: 353–8.
CK-903 is a useful adjunctive tool that will allow for a quicker, less costly, and more accurate diagnosis of LPP given its ability to identify colloid bodies even in the setting of significant inflammation and fibrosis and its advantages over direct immunofluorescence of low cost, short preparation time, and lack of need for a specialized fluorescent microscope.
Lichen planopilaris: report of 30 cases and review of the literature
Chieregato C, Zini A, Barba A, et al. Int J Dermatol 2003; 42: 342–5.
This retrospective case series of 30 patients with LPP reports good therapeutic benefit from early treatment with high-potency topical steroids. Only four patients did not respond to the therapy and needed other treatments.
A case-series of 29 patients with lichen planopilaris: the Cleveland Clinic Foundation experience on evaluation, diagnosis, and treatment
Cevasco NC, Bergfeld WF, Remzi BK, et al. J Am Acad Dermatol 2007; 57(1): 47.
In this retrospective case series, 20 patients were treated with intralesional corticosteroid injections. A good response was documented in 40% of patients; 50% of patients stabilized and 10% worsened. This study also commented on the benefit of using tetracyclines (1 g/day), contrary to what was thought before.
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