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

[mr_peanutbutter]

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?

 

„Background

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.

Conclusion

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.“

 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4857822/

 

 

 

 

„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.“

 

https://pubmed.ncbi.nlm.nih.gov/33128471/

 

 

„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. "

 

https://www.belgraviacentre.com/blog/study-finds-frontal-fibrosing-alopecia-hair-loss-also-occurs-in-mendas 

[mr_peanutbutter]

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.

 

https://www.actasdermo.org/es-frontal-fibrosing-alopecia-in-men-articulo-S1578219016302359

 

https://www.bernsteinmedical.com/hair-loss/scarring-cicatricial-alopecia/

 

https://www.aad.org/public/diseases/hair-loss/types/frontal-fibrosing-alopecia/symptoms

 

 

 

 

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

https://www.pcds.org.uk/clinical-guidance/lichen-planus-follicular-lichen-planus

 

 

„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.“

https://static1.squarespace.com/static/5243dccde4b08fd9e4fc92ef/t/59dc4ffbe3df281768aefc59/1507610636185/lpp.pdf

 

 

What is perifollicular erythema and perifollicular scale exactly?

[mr_peanutbutter]

could the poster of this thread might suffer from Frontal Fibrosing Alopecia (FFA)

 

comparison

 

[consequence]

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.

Edited June 1, 2023 by consequence

[mcr7777]

On 6/1/2023 at 12:34 PM, consequence said:

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.

Agree LPP is not nice - but it's not contagious.  It's an autoimmune condition - it's not a fungus/bacterial/viral and not something you can catch from others or at the gym.

[consequence]

On 9/9/2023 at 3:44 PM, mcr7777 said:

Agree LPP is not nice - but it's not contagious.  It's an autoimmune condition - it's not a fungus/bacterial/viral and not something you can catch from others or at the gym.

That's a really good point and I know that's the party line, but as we don't know what actually causes it I don't think this is something we can unequivocally state.

For example, it has been reported in association with hepatitis C and sure as heck acts a lot like a skin infection. My hunch is down the line we'll realize there's an underlying bug (or bugs) that some people have an immune response to and others do not. Like it's odd that ketoconazole works for hairloss, and I know there's a mechanistic explanation but it always makes me wonder about occult fungal infections.

But yes, I think the "lichen" in it made me stray into broscience more than I intended to in my post -- you are correct, as far as we know it's not infectious in the classical sense.

Tinea capitis, on the other hand, is infectious and can cause hair loss, so my caution about sweaty gym benches stands though. 😅😅

Edited September 11, 2023 by consequence

[mr_peanutbutter]

here is a case of a failed ht due to an undected lpp

 

 

50k down the drain…

 

 

[DrMunibAhmad]

On 5/26/2023 at 2:02 PM, mr_peanutbutter said:

could the poster of this thread might suffer from Frontal Fibrosing Alopecia (FFA)

 

comparison

 

No, day and night difference 😜
 

FFA is easy detected with a good eye. 

[mr_peanutbutter]

3 minutes ago, DrMunibAhmad said:

No, day and night difference 😜
 

FFA is easy detected with a good eye. 

thank a lot for the answer doctor, can you say the same about lpp? are there certain signs that a patient himself can watch out for?

[DrMunibAhmad]

21 hours ago, mr_peanutbutter said:

thank a lot for the answer doctor, can you say the same about lpp? are there certain signs that a patient himself can watch out for?

For a patient is can be quite difficult. I guess it's just the experience and the gut feeling that a good doctor should have. I recently catched one after she visited 5 clinics and all of them we're already to pick a date for the surgery. When she walked in my office, I saw it immediately. 

[mr_peanutbutter]

here is an interesting article regarding the matter

 

https://dru.com/what-is-lpp-aka-lichen-planopilaris/

„

LPP Symptoms to Look Out For:

Although LPP symptoms may be similar to what may be interpreted as common genetic balding or pattern baldness, there are specific LPP symptoms that should be noted:

1. Itching on the scalp
2. Bumps on the scalp
3. Pain around the scalp
4. Redness of the scalp
5. Increased hair loss
6. Patchy hair loss

 

It is essential to look out for itching, bumps, pain, or redness on the scalp, mainly if hair loss appears patchy and less patterned, as this is a signifier of LPP (Lichen Planopilaris).“

 

 

 

 

 

 

[ScottishGuy21]

Hi Everyone 

I’ve been shedding for around 3-4 weeks and orignally put it down to seasonal shed or a finasteride type cycle shed

However in the last 7 days my scalp has become very irritated and inflamed too. I am due to see a Dr here Wednesday but in the mean time can anyone give me any pointers on if this is potentially LLP or Foliciltis? There is definitely some sort of issue going on that’s gradually becoming worse. It’s impacting all over not just in my transplanted area and has become very noticeable rapidly.  I must have shed 50% of my hairs within the last few weeks , pretty terrifying😔

Edited October 8, 2023 by ScottishGuy21