By Gary M. White, MD
Lichen planopilaris (LPP) is an uncommon inflammatory disorder of the hair follicle, most common in women, that usually results in a scarring alopecia. Perifollicular erythema is characteristic. A higher incidence of hypothyroidism has been associated with LPP. See also frontal fibrosing alopecia, pseudopelade, and Graham Little Piccardi Lassueur Syndrome.
Perifollicular erythema along with a scarring alopecia of the scalp is characteristic. Itching, burning and pain may be present. Onset can be rather acute, mimicking alopecia areata but more commonly it is gradual over many years. Involvement of the nails, oral mucosa and skin with more typical lesions of lichen planus may occur. The disease is more common in women. The diagnosis may be confirmed with a scalp biopsy, preferably a 4 mm punch biopsy. Frontal fibrosing alopecia is felt to be a variant of LPP. Pseudopelade may represent end stage LPP.
Isolated linear lichen planopilaris limited to the scalp has been reported [Cutis 2013;92;303].
Patients with androgen excess may have seborrheic dermatitis, hirsutism, polycystic ovary syndrome and/or ovarian cysts. Blood workup may include 17-hydroxyprogesterone, androstenedione, DHEAS, follicle stimulating hormone, fasting glucose, insulin, luteinizing hormone prolactin, ferritin, testosterone and vitamin D.
The goal of therapy is to prevent further hair loss and to reduce symptoms. Regrowing hair that has already been lost is unlikely. IL steroids combined with a class I topical steroid, e.g. clobetasol cream for 3-4 months has been recommended. Second line therapy might add in hydroxychloroquine 200 BID for 4 months along with the topical and intralesional steroids. An alternative is minocycline but good studies are lacking. Oral cyclosporin 3-5 mg/kg/day for 6-12 months can be considered [JAAD 2003;49;669] as well as mycophenolate mofetil. Oral retinoids are generally ineffective [JAAD 2014:71:1016].
Pioglitazone (Actos) lowers blood sugar and has been studied in the treatment of LPP. See frontal fibrosing alopecia for a discussion.
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