Published on 19/03/2015 by admin
Filed under Dermatology
Last modified 19/03/2015
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Anwar Al Hammadi and Eric Berkowitz
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Lichen planopilaris (LPP), also known as follicular lichen planus, is a clinical syndrome consisting of lichen planus (LP) associated with cicatricial scalp alopecia. The condition is more common in women, and presents with perifollicular erythema and keratotic plugs at the margins of the expanding alopecia. The follicular involvement is limited to the infundibulum and the isthmus, both demonstrating lichenoid inflammation. The main complications of follicular lichen planus are atrophy and scarring, with permanent hair loss. Three forms of LPP are recognized, including classic LPP; Graham–Little syndrome, characterized by the triad of multifocal scalp cicatricial alopecia, non-scarring alopecia of the axilla and/or groin, and keratotic follicular papules; and frontal fibrosing alopecia that affects mainly postmenopausal women and appears as cicatricial alopecia of the frontoparietal hairline and is associated with non-scarring alopecia of the eyebrows.
Therapeutic management for LPP is challenging. However, if the associated inflammation can be controlled in its early stages, follicular units may be preserved and hair regrowth may be possible. A good therapeutic response would include a reduction in associated symptoms along with stabilization of the disease and some regrowth of hair in the active perimeter of the alopecic patch. For the most part, therapeutic reports are anecdotal. Oral antihistamines may be used to control pruritus, and high-potency topical corticosteroids are used to control the inflammation in early lesions. Intralesional injections of 3–5 mg/mL of triamcinolone acetonide are effective in well-developed lesions. Hydroxychloroquine may be efficacious. Retinoids have demonstrated some effect in the treatment of LP and therefore provide a possible alternative to corticosteroid treatment. Other agents that have been reported to be of use are cyclosporine and mycophenolate mofetil. There is some rationale for trying biologic agents such as tumor necrosis factor (TNF)-blocking agents for this condition.
Skin biopsy
Immunofluorescence studies
Dermoscopy
Tandon YK, Somani N, Bergfeld WF. J Am Acad Dermatol 2008; 59: 91–8.
Characteristic features of LPP include: the absence of arrector pili muscles and sebaceous glands; a perivascular and perifollicular lymphocytic infiltrate; mucinous perifollicular fibroplasia with absence of interfollicular mucin; and superficial perifollicular wedge-shaped scarring.
Ioannides D, Bystryn JC. Arch Dermatol 1992; 128: 214–16.
Direct immunofluorescence studies were performed on biopsied lesions of patients with LPP and LP. All of the LPP studies demonstrated abnormal linear deposits of immunoglobulin, consisting of IgG or IgA restricted to the basement membrane. The biopsies from those with LP demonstrated fibrillar deposits.
These different appearances suggest different disease processes for LPP and LP.
Micali G, Lacarrubba F, Massimino D, Schwartz R. J Am Acad Dermatol 2011; 64: 1135–46.
Video dermatoscopy is performed with a video-camera equipped with lenses providing magnification ranging from ×10 to ×1000, and shows the reduction to total absence of orifices, hyperkeratotic perifollicular scales, and erythema. In addition, perifollicular arborizing vessels, pigmented networks, and white pale or blue-gray dots in dark-skinned individuals, corresponding to focal decrease in melanin content, can also be observed
Treatment of Skin Disease Comprehensive Therapeutic Strategies 4e
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High-potency corticosteroids
