The Impact of Lichen Planopilaris

This blog series highlights conditions that have a strong impact on people of color and appears as part of Project IMPACT: Improving Medicine’s Power to Address Care and Treatment.

Lichen planopilaris (LPP) is a type of cicatricial (scarring) alopecia that is characterized by perifollicular erythema and scale that can progress to scarring alopecia over time. It is categorized into 3 distinct groups: classic LPP, frontal fibrosing alopecia (FFA), and Graham-Little-Piccardi-Lassueur syndrome (also known as Graham-Little syndrome). Classic LPP presents with perifollicular erythema and scaling around the hair follicles of the scalp. It is considered a follicular variant and scarring form of lichen planus, and patients may present with lichen planus of the skin at any time before, after, or in conjunction with it. FFA presents as a progressive scarring alopecia of the frontal hairline. Graham-Little syndrome is characterized by cicatricial alopecia of the scalp, nonscarring hair loss in the axilla and pubic region, and lichen planus of the skin.

It is thought that cell-mediated immunity may play a significant role in triggering LPP. It is likely that a reaction initiated by a medication, virus, or contact sensitizers may lead to the binding of keratinocytes and hair follicles, making them the target of inflammation.

How does lichen planopilaris impact people of color?

There have been reports of an association between FFA, LPP, and facial papules in women of color. In Hispanic and Black patients, FFA may be misdiagnosed as traction alopecia. Patients presenting with features of FFA should be assessed for other cutaneous associations such as depressed frontal veins, facial papules, and glabellar red dots.

The lesions of LPP can sometimes be subtle with mild flaking and erythema. In darker skin colors, perifollicular erythema may appear dark violet or slate gray and may be difficult to discern. Early scarring is marked by follicular dropout but early on may be more difficult to appreciate.

What to look for:

Patients will typically present with a history of spreading hair loss. When assessing the scalp, one may be able to appreciate erythema around the hair follicles, hyperkeratotic follicular papules, and the absence of follicular orifices (scarring). Patients may also report pain, pruritus, and/or burning.

Differential:

 

Diagnostic pearls:

Dermoscopy can be clinically useful to better visualize distinctive features on the scalp such as scaling and erythema. Additionally, a positive pull test, in which anagen hairs are easily pulled from the scalp, can serve as an indicator of active disease.

However, making the distinction between all the forms of primary cicatricial alopecia can be very difficult to do solely based on clinical evaluation. Histopathologic and immunohistopathologic studies are required for definitive diagnosis.

Treatment:

The management of LPP begins with getting any underlying inflammation under control and preventing further spread. Treatment options for localized disease include topical and intralesional corticosteroids. In patients with more widespread disease and those who are not responsive to topical or intralesional corticosteroids, oral hydroxychloroquine can be used. Other oral alternatives include doxycycline and mycophenolate mofetil. Oral corticosteroids such as prednisone can be used for more rapidly progressive or recalcitrant disease.

 

Sources:

Blume-Peytavi U, Whiting DA, Trüeb RM, eds. Hair Growth and Disorders. Springer; 2008.

Desai NS, Mirmirani P. Lichen planopilaris. In: Mirmirani P, ed. Alopecia. Elsevier; 2019: 143–150.

Farah RS, Ferguson NN, Swick BL. Lichen planopilaris. Cutis. 2013;92(1):11, 17-18. https://pubmed.ncbi.nlm.nih.gov/23961528/

Kang H, Alzolibani AA, Otberg N, Shapiro J. Lichen planopilaris. Dermatol Ther. 2008;21(4):249-256. https://pubmed.ncbi.nlm.nih.gov/18715294/

Khan Mohammad Beigi P, ed. Alopecia areata: A clinician’s guide. Springer; 2018.

Krueger L, Svigos K, Brinster N, Elbuluk N. Frontal fibrosing alopecia: cutaneous associations in women with skin of color. Cutis. 2018;102(5):335-338.

Mackay I, Rose NR, Diamond B, Davidson A, eds. Encyclopedia of Medical Immunology. Springer: 2014.

Morais KL, Martins CF, Anzai A, Valente NYS, Romiti R. Lichen planopilaris with pustules: a diagnostic challenge. Skin Appendage Disord. 2018;4(2):61-66. https://pubmed.ncbi.nlm.nih.gov/29765960/

Otberg N, Wu WY, McElwee KJ, Shapiro J. Diagnosis and management of primary cicatricial alopecia: part I. Skinmed. 2008;7(1):19-26. https://pubmed.ncbi.nlm.nih.gov/18174797/

Raffi J, Suresh R, Agbai O. Clinical recognition and management of alopecia in women of color. Int J Womens Dermatol. 2019;5(5):314-319. https://pubmed.ncbi.nlm.nih.gov/31909150/

Stefanato CM. Histopathology of alopecia: a clinicopathological approach to diagnosis. Histopathology. 2010;56(1):24-38. https://pubmed.ncbi.nlm.nih.gov/20055903/

This Project IMPACT blog series was created to highlight dermatologic conditions that disproportionately affect people of color. By improving diagnosis in skin of color we can reduce racial disparities in healthcare.

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