Lichen planopilaris - Hair and Scalp
Alerts and Notices
SynopsisLichen planopilaris (LPP), also referred to as follicular lichen planus (LP), lichen follicularis, and lichen planus acuminatus, is characterized by perifollicular erythema and scale that can progress to cicatricial (scarring) alopecia over time. As in lichen planus, LPP is thought to be caused by dysfunction in cell-mediated immunity. In LPP, the immune privilege of the hair follicle bulge is felt to be lost, resulting in loss of hair stem cells after attack by activated T-lymphocytes targeting follicular antigens and an inability of hair to regrow. LPP may present in association with LP, although it is often seen alone. LPP affects women more commonly than men. Those with lighter skin phototypes are more often affected than individuals with darker skin phototypes. The onset of LPP is frequently between age 40 and 60, although the condition has been described in children. LPP is very uncommon in children.
The condition may have an insidious or fulminant onset with hair loss in variable patterns. There are several variants of LPP: classic LPP, frontal fibrosing alopecia, and Graham-Little-Piccardi-Lassueur (Graham-Little) syndrome. Classic LPP presents with follicular violaceous erythema and perifollicular fine scale. Interfollicular erythema may also be seen, and in severe cases, confluent scale may be evident. The perifollicular erythema is usually seen at the periphery of patches of alopecia, which corresponds to active areas of disease. As the disease progresses, permanent cicatricial alopecia or Brocq alopecia occurs. Frontal fibrosing alopecia, as the name implies, clinically appears as a band-like scarring alopecia of the frontal hairline that commonly affects women. Graham-Little syndrome consists of the triad of cicatricial alopecia of the scalp, a lichenoid follicular eruption, and noncicatricial pubic and axillary hair loss. In addition, a diffuse variant was recently described. It presents with diffuse scalp itching with widespread hair thinning and erythema. This variant has no gender predilection.
Increased hair shedding, severe itching, scaling, burning, and tenderness are common symptoms associated with LPP.
Related topics: oral lichen planus, lichenoid drug eruption
L66.1 – Lichen planopilaris
64540004 – Lichen planopilaris
Differential Diagnosis & Pitfalls
- Seborrheic dermatitis – Scaling with erythema of the scalp can be confused with early LPP before alopecia occurs.
- Discoid lupus erythematosus – Scarring patches of alopecia with inflammation; erythema not confined to perifollicular areas. Dyspigmentation is more commonly seen.
- Central centrifugal cicatricial alopecia – Scarring alopecia of the vertex of the scalp expanding centrifugally, usually in Black women.
- Alopecia areata – Nonscarring circular patches of alopecia with little or no inflammation. Exclamation-point hairs and yellow dots on dermoscopy can help aid in diagnosis.
- Trichotillomania – Nonscarring patches of alopecia with angulated, irregular borders. Broken hairs of different lengths are seen.
Patient Information for Lichen planopilaris - Hair and Scalp
OverviewLichen planopilaris (LPP) is an uncommon inflammatory scalp disorder that results in scarring (cicatricial) hair loss. It is considered a variant of lichen planus, a chronic inflammatory condition that can affect the skin, hair, nails, and mucous membranes.
The cause (pathogenesis) of LPP is poorly understood. It is considered to be an autoinflammatory disorder in which immune cells attack antigens (proteins) in the hair follicles.
There are 3 clinical variants of LPP:
- Classic LPP
- Frontal fibrosing alopecia (FFA)
- Graham-Little-Piccardi-Lasseur syndrome
Who’s At RiskLPP occurs more often in women, usually between the ages of 40 and 60 years.
Signs & SymptomsLPP is characterized by redness (erythema) and scaling around the hair follicles, and permanent hair loss.
Symptoms include itching, burning, pain, and tenderness at sites of hair loss.
The most common sites of hair loss in LPP are the crown (vertex) and middle (parietal) areas of the scalp.
Frontal fibrosing alopecia, a type of LPP, is characterized by recession of the hairline with scarring along the front of the scalp and sometimes the sides of the scalp. Eyebrow involvement is common.
Graham-Little-Piccardi-Lasseur syndrome is characterized by scarring alopecia of the scalp, nonscarring alopecia involving the underarm (axillary) and pubic areas, and rash (follicular eruption) on the trunk, limbs, face, or eyebrows.
- Avoid chemicals (hair coloring or perming).
- Minoxidil helps maximize hair growth of remaining follicles.
- Consider joining a hair loss support group.
- You may wear hair pieces, wigs, or hair powder that does not irritate the scalp.
When to Seek Medical CareYou should see a doctor if the hair loss becomes bothersome or if hair loss does not subside after self-care or over-the-counter measures. LPP can lead to irreversible hair loss, so it is important to visit a dermatologist if you are experiencing hair loss.
TreatmentsYour physician may:
- Prescribe topical corticosteroids and intralesional corticosteroid injections.
- Prescribe oral corticosteroids.
- Prescribe tacrolimus or hydroxychloroquine.
- Offer information about hair transplantation.
- Recommend removing a small piece of skin to further evaluate under a microscope (biopsy) if the diagnosis is in question.
Lichen planopilaris - Hair and Scalp