Lichen planopilaris, a common form of scarring alopecia, typically occurs in middle age and is twice as common in women as in men. It most often affects the central scalp but may be present in other sites in up to half of cases. Key symptoms of lichen planopilaris (LPP) include hair loss, scalp pruritus, and pain/tenderness, often a burning sensation at the site of hair loss. On dermoscopy, most LPP cases appear as reduced hair density with scalp erythema and perifollicular scale, also called peripilar casts.
Courtesy Dr. Jeff Donovan
Lichen planopilaris (LPP) in a 68-year-old woman. The central scalp is a typical location for the disease.
The goal of LPP treatment is to reduce symptoms and shedding and to stop the disease from occurring in new sites. "Regrowth is not possible in most scarring alopecias," said Dr. Donovan, who leads the University of Toronto’s program in hair transplantation and hair loss. "Treatments help to halt the underlying disease process. Disease activity may recur."
Treatment options for localized/limited LPP include intralesional triamcinolone acetonide and/or several treatments at home, including 0.05% clobetasol propionate lotion or foam, clobetasol propionate shampoo to help decrease itching and burning, fluocinolone acetonide oil one time per week to help with removal of scales, and topical 0.1% tacrolimus ointment (or compounded lotion) as needed.
Systemic treatment of LPP is also an option, and he said he relies on the dermatopathology report to guide his treatment decisions. If biopsy reveals minimal lymphocytic infiltrate, Dr. Donovan said he recommends doxycycline 100 mg b.i.d. as his first-line approach. If biopsy reveals moderate lymphocytic infiltrate, he turns to hydroxychloroquine 6 mg/kg.
Courtesy Dr. Jeff Donovan
Dermoscopy of lichen planopilaris (LPP). Perifollicular scale and reduced hair density in a background of scalp erythema is typical of the condition.
His recommended second-line systemic treatment is mycophenolate mofetil 500 mg b.i.d. for 1 month, then 1,000 mg b.i.d. thereafter. Third-line systemic treatment options include cyclosporine 3-5 mg/kg per day and retinoids such as isotretinoin, but fewer than 20% of patients benefit from retinoids, he said. Once the disease becomes quiet, hair transplant surgery can sometimes be an option to restore hair density.
Dr. Donovan disclosed that he is the cofounder of Okavana Laboratories, a privately held company devoted to hair.