Lichen Planopilaris – Clinical Features
There are several clinical presentations of lichen planopilaris. Some patients present with small areas of scarring alopecia that often involve the vertex. There are minute red follicular papules with fine scaling at the base of the terminal hairs at the periphery of the areas of scarring. These papules indicate active inflammation that will eventually lead to scarring and loss of the affected follicles. Extremely early LPP presents as plaques of these minute red scaling follicular papules without associated hair loss. Other patients with LPP have a large area of central scarring alopecia on the crown, so-called central centrifugal cicatricial alopecia (CCCA). The area of hair loss slowly expands centrifugally. The active edges of the lesion again demonstrate minute red follicular scaling papules.
Patients with LPP often complain of pain, stinging or burning in the areas of active disease. A rare presentation of LPP is fulminant disease that can result in complete scalp alopecia in months to a year’s time. These patients have very inflamed red scaling plaques, which on biopsy show changes of LPP. Some patients with LPP have concomitant cutaneous and/or oral lichen planus. Vulvar lichen planus has coexisted with scalp LPP in some of my patients. However, in my experience, most patients with LPP do not have lichen planus elsewhere on the body. Frontal fibrosing alopecia (FFA) is felt to be a distinctive clinical variant of LPP. Patients with FFA are usually postmenopausal women with scarring alopecia of the frontal scalp margin and associated eyebrow loss. The advancing edge of the area of alopecia may demonstrate minute perifollicular papules at the bases of terminal hairs. Biopsy findings are that of LPP.