Lichen Planopilaris

Lichen planopilaris (LPP) is a primary lymphocytic scarring alopecia caused by T-cell attack on the follicular bulge stem cells, representing the follicular variant of lichen planus.

• Incidence is 1 to 5 per 100,000. Mostly women aged 40 to 60. Variants: classic LPP, frontal fibrosing alopecia (FFA, post-menopausal), Graham-Little-Piccardi-Lassueur syndrome.
• Associated with thyroid disease, autoimmune conditions, and sometimes oral or nail lichen planus.
• Scarring is permanent; early diagnosis preserves hair.

• Patchy scarring alopecia of the vertex and parietal scalp, with perifollicular erythema and scale, tufting, and burning or itching.
• FFA: band like recession of frontotemporal hairline, loss of eyebrows, eyelashes, and body hair, facial papules, "lonely hairs".
• Graham-Little: scarring alopecia plus non-scarring axillary and pubic loss, and follicular spinous papules.
• Active disease: pull test positive at margins.

• Trichoscopy: perifollicular scale and erythema, loss of follicular openings, and blue grey dots.
• Biopsy (4 mm punch from the active margin, horizontal sections): lichenoid interface infiltrate around the infundibulum, apoptotic keratinocytes, and concentric perifollicular fibrosis.
• Exclude discoid lupus, folliculitis decalvans, central centrifugal cicatricial alopecia, alopecia areata, and tinea capitis.
• Check thyroid function, ANA, and vitamin D in selected patients; examine mouth, nails, and skin.

• Early treatment halts progression but cannot restore scarred follicles.
• Topical: clobetasol 0.05% solution once daily for 4 to 8 weeks, tacrolimus 0.1%, and ketoconazole shampoo.
• Intralesional triamcinolone 5 to 10 mg/mL (up to 20 mg per session) every 4 to 8 weeks.
• Oral therapy for moderate to severe disease:
  • Hydroxychloroquine 200 mg twice daily for 6 to 12 months.
  • Doxycycline 100 mg twice daily.
  • Methotrexate 10 to 25 mg weekly.
  • Mycophenolate 1 to 1.5 g twice daily.
  • Ciclosporin 3 to 5 mg/kg for short courses.
  • Pioglitazone 15 to 30 mg daily.
  • Prednisolone 0.5 mg/kg for 4 to 8 weeks as a bridge.
• JAK inhibitors (tofacitinib 5 mg twice daily, baricitinib) are emerging options.
• FFA: finasteride 2.5 to 5 mg or dutasteride 0.5 mg daily, topical or oral minoxidil, and avoidance of facial sunscreens with irritants.
• Hair transplantation only after 2 years of inactive disease; psychological support and wigs.