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Lichen Planopilaris in the Androgenetic Alopecia Area: A Pitfall for Hair Transplantation - how to detect it?

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  • Senior Member

Sadly i cannot find many pictures on the matter but is there a visual thumbrule how to distinguish between normal male pattern baldness and Lichen Planopilaris in the Androgenetic Alopecia Area? Something you can detect with your eyes without using a biopsy?



Classic lichen planopilaris (LPP) is a patchy form of primary lymphocytic cicatricial alopecia localized on the vertex of the scalp. It is important, however, to be aware of other, less recognized presentations that may be missed without dermatoscopy and pathology.

Methods and Results

We report 26 patients with LPP presenting with subtle erythema and scaling colocalized in the area of patterned thinning (androgenetic alopecia, AGA). All patients had been treated for seborrheic dermatitis in the past. Dermatoscopy showed the presence of 2-4 hairs emerging as a tuft from the same ostium surrounded by erythema, peripilar casts and interfollicular scaling associated with hair miniaturization. Histopathology obtained from those areas corresponded to LPP with concomitant follicular miniaturization.


Subtle or focal cases of LPP may be missed for seborrheic dermatitis when overlapping with AGA. Dermatoscopy-guided biopsy from the affected scalp is the best approach to make a timely diagnosis. This is particularly important in patients with AGA evaluated to undergo hair transplantation, as active LPP is a contraindication for these patients.“







„Background: Lichen planopilaris (LPP) is a scarring alopecia rarely described in men.

Objective: To investigate the clinical and histopathologic features of LPP in men.

Methods: We performed a retrospective cohort study of male patients with LPP seen at Mayo Clinic between 1992 and 2016.

Results: Nineteen men with biopsy-confirmed LPP were included. The disease most commonly presented with diffuse (42.1%) or vertex scalp (42.1%) involvement. None of the patients had eyebrow or body hair involvement. Perifollicular erythema (94.7%) and pruritus (57.9%) were the most frequent clinical findings. Androgenetic alopecia (AGA) co-occurred in 26.3% of patients. Mucosal lichen planus was found in four patients (21.1%). Thyroid disease occurred in three patients (15.8%). Disease improvement (47.3%) occurred with combination topical and systemic therapy, topical clobetasol monotherapy, and minocycline monotherapy.

Conclusions: LPP in men has similar clinical and histologic presentations as reported in women. Nonscalp hair loss appears less likely in men with classic LPP than reported in men with frontal fibrosing alopecia, while mucosal lichen planus and thyroid disease appear to be more common in classic LPP. Men with AGA can present with new-onset concomitant LPP. Limitations included small study size, variable follow-up, and lack of standardized clinical assessment due the study's retrospective nature.“





Of the 182 men studied, 7 men, with a median age of 53 when they were diagnosed, were diagnosed with FFA. Following biopsies, they were all also found to have lichen planopilaris. 

FFA causes a different type of receding hairline to that commonly seen in patients with Male Pattern Hair Loss. Instead of gradually thinning or causing a widow's peak, FFA leads to a wide band of smooth bald skin around the entire frontal hairline. "



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  • Senior Member

some pictures i found so far

Frontal Fibrosing Alopecia (FFA)




The skin along the receding hairline is generally pale and appears as a band that may progress above and behind the ears. The recession of the hair may be fast or slow – sometimes it is self-limiting




This 30-year-old woman has noticeable hair loss, which looks like a band of lighter skin, on her forehead and temples. This is a common sign of FFA.




Along with a receding hairline, some people develop small, raised bumps on their face. The pimple-like spots on this man’s face are due to FFA.


A, Hairline that is evidently receding from the forehead in a patient with no underlying androgenetic alopecia. B, Intense erythema and perifollicular hyperkeratosis. C and D, Bald patches on both arms.











Lichen Planus



A, Receding hairline with erythema and perifollicular hyperkeratosis. B, Patches of parietal scarring alopecia typical of follicular lichen planus.






  • Lesions can be single, multiple or diffuse, circular to oval shaped or have finger-like projections 
  • The early classically complete lesions are characterised by a follicular violaceous erythema and keratotic plugs, which are commonly located at the periphery of expanding areas of alopecia. Some hair affected by the inflammation process can persist in the centre of the bald area  
  • Perifollicular inflammation or scaling can be very discreet in some cases, which makes the diagnosis more difficult
  • As with other cases of scarring alopecia tufted hairs may be seen
  • A positive pull test of anagen hairs is commonly present at the margin of alopecia, indicating the disease activity
  • After inflammation and hair shedding, atrophic scarring of areas without follicular units replaces all the other lesions
  • Typical papules of lichen planus are not observed on the scalp
  • Differentiation from discoid lupus erythematosus (DLE) of the scalp can sometimes be difficult. In DLE, inflammation is not restricted to surrounding hairs, and the affected skin can become telangiectatic. Although follicular LP and DLE can be seen in the same patient, this is very rare




„Lichen planopilaris (LPP) is a type of scarring hair loss condition. Patients frequently present with scalp itching, and sometimes scalp burning and tenderness. Increased hair shedding is common in the early stages. Hair loss is generally permanent and treatment helps stop the disease or at least slow down progression.
Clinically, dermoscopy (trichoscopy) of LPP often shows (follicular keratosis) perifollicular erythema and perifollicular scale.
These findings are not present in all forms of LPP. A less common presentation of LPP is shown in the photo. Patients have hair loss with scalp itching. However, by dermoscopy they have many single hair follicles growing in a base of redness. This is what I have termed the "sea of singles" (SOS) appearance to describe the numerous single hairs and absence of hair follicle units containing 2 and 3 hairs. This form of LPP is similar to Abbasi's subtype described in 2016 and fibrosing aloepcia in a pattern distribution described by Zinkernagel in 2000. The "SOS" trichoscopic appearance is important to remember and provides a clue that the patient may have a scarring alopecia.“




What is perifollicular erythema and perifollicular scale exactly?

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  • Regular Member

Terrifying infection. What's the worst about LPP is that in its milder form it just looks like AGA. A significant percentage of people who think they're just suffering from typical male pattern balding actually have a chronic fungus.

Think about that next time you're at the gym and about to lay your head on that sweaty bench press.

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