The punch biopsies were consistent with lichen planopilaris, an idiopathic, immune-mediated scarring alopecia that largely affects women between the ages of 40 and 70 years. In this variant of lichen planus, T cells target hair bulbs and cause destruction with scarring and permanent hair loss. Distribution may be patchy or may be more concentrated on the crown or involve the frontal scalp—a subtype called frontal fibrosing alopecia. Early recognition and intervention may save hair follicles and minimize disease severity.
The differential diagnosis includes traction alopecia, discoid lupus erythematosus, alopecia areata, centrifugal cicatricial alopecia, and folliculitis decalvans. The diagnosis may be confirmed with a scalp biopsy of actively inflamed follicles. Biopsy of scarred areas is likely to be nonspecific and unhelpful.
Treatment is targeted at slowing progression and symptom management. First-line therapy often includes potent corticosteroids (intralesional, topical, or systemic). Longer courses of steroid-sparing agents may be considered, including hydroxychloroquine, tacrolimus, ciclosporin, methotrexate, or acitretin. Hair styling and coloring, as well as hairpieces, often are used to conceal patches of hair loss. Hair transplantation is expensive but can be used to increase hair density in scarred areas once disease is controlled.
In this case, the patient was started on clobetasol solution 0.05% to be applied nightly to affected areas of the scalp. This treatment helped with the itching, but the inflammation and hair loss continued to worsen after 2 months. At that point, hydroxychloroquine 200 mg bid was added to the regimen, and hair loss and associated symptoms stopped. The patient remained on this therapy for 16 months. The hydroxychloroquine was then stopped, and the patient was advised to use the topical clobetasol, as needed.
Text courtesy of Tristan Reynolds, DO, Maine Dartmouth Family Medicine Residency, and Jonathan Karnes, MD, medical director, MDFMR Dermatology Services, Augusta, ME. Photos courtesy of Jonathan Karnes, MD (copyright retained).