Lichen Planopilaris (LPP) is a rare, chronic inflammatory condition that primarily affects the scalp, leading to progressive scarring alopecia. It is considered a follicular variant of lichen planus and is believed to be autoimmune in nature, where the immune system mistakenly attacks the hair follicles. The condition often presents with symptoms such as itching, burning, tenderness, and scalp redness, eventually leading to permanent hair loss in the affected areas.

While the scalp is the primary site, LPP can also affect other hair-bearing areas such as the eyebrows, pubic region, and axillae, though these are less commonly involved. The hallmark of LPP is scarring (cicatricial) alopecia, meaning that once the hair is lost, it does not grow back due to destruction of the hair follicle. The global standardized prevalence of LPP is approximately 13.4 per 100,000 individuals.¹ Untreated LPP eventually leads to complete hair loss. Therefore, timely diagnosis and treatment are crucial. Doctors usually use immune-modulatory medications to alleviate symptoms.

Types Of Lichen Planopilaris

Researchers have identified different forms of the disease:

Classic Lichen Planopilaris:

It is also known as follicular lichen planus and is characterized by scarring of the skin that leads to the development of bald patches on the scalp. Most patients with this type present with bald patches (with permanent hair loss) at the vertex or the parietal scalp. The hair loss is attributed to irreversible scarring.² The disease is histologically marked by perifollicular lymphocytic infiltrates and hyperkeratotic follicular papules—hallmarks of follicular lichen planus.

Frontal Fibrosing Alopecia (FFA):

Unlike the classic LPP, the frontal fibrosing type affects the skin of your hairline at the front, the forehead region. It may also affect the hair of your eyebrows and eyelashes. Eyebrow alopecia is present in the vast majority of patients (63-83% of individuals). It is most commonly seen in post-menopausal women from Asian/Caucasian backgrounds. Multiple factors like environmental toxins, surgery, and stress play a role in the development of FFA. Autoimmunity is also believed to contribute to hair loss.³

Frontal and patchy hair loss areas — A) Hair loss on the forehead region and eyebrows is a presentation of the frontal fibrosing alopecia. B)Alopecia patches seen on the vertex in a classic lichen planopilaris patient. Image courtesy of Fechine, C. O. C., Valente, N. Y. S., & Romiti, R. (2022). Lichen planopilaris and frontal fibrosing alopecia: review and update of diagnostic and therapeutic features. *Anais brasileiros de dermatologia*, 97(3), 348–357. https://doi.org/10.1016/j.abd.2021.08.008 made available by PubMed under CC.

Graham-Little-Piccardi-Lassueur Syndrome (GLPLS).

In addition to the scarring and bald patches, patients also report thinning of hair in the groin and the armpit region. Studies show that this syndromic type of scarring alopecia is an immune-mediated disorder, characterized by:⁴

Scarring (cicatricial) alopecia of the scalp
Non-scarring (non-cicatricial) alopecia of the groin
Non-scarring alopecia (non-cicatricial) of the axilla
Follicular lichen planus eruption

In some patients, rough skin bumps are also present around affected hair follicles.

Lichen Planopilaris Symptoms

Patients experience the following symptoms:

Bald Patches:

While it can affect any hair-bearing region of the body, the main target is the scalp. Female patients start noticing bald patches with scarring that spread and increase in size with time. The most common clinical presentation of the disease is diffuse or patchy hair loss on the scalp.⁵ It is the leading cause of scarring alopecia.⁶ Individuals suffering from lichen planopilaris complain that their hair is very easily pulled out. Many notice an absence of hair follicle openings.

Red & Scaly Skin:

Scalp analysis of LPP patients reveals perifollicular erythema (redness around the hair follicles) with scaliness on the skin in the early stages of lichen planopilaris. Patients feel spiny and scaly skin around the hair follicles. There is evident hyperpigmentation of the scalp in several cases.⁷

Inflamed scalp with follicular scaling — Trichoscopy analysis of a patient reveals erythematous (red) lesions on the scalp with perifollicular scaling skin. Image courtesy of Góes, H. F. O., Dias, M. F. R. G., Salles, S. A. N., Lima, C. D. S., Vieira, M. D. S., & Pantaleão, L. (2017). Lichen planopilaris developed during childhood. *Anais brasileiros de dermatologia*, 92(4), 543–545. https://doi.org/10.1590/abd1806-4841.20174890 made available by PubMed under CC.

Scalp Discomfort:

A lot of patients experience discomfort mainly on the scalp. Pururitis (itching) is a significant problem for most patients, for which they take medications. It is believed that scalp purpuritis results from the release of chemicals like substance P and calcitonin gene-related peptide (CGRP) from the inflamed bulge region (area within the hair follicle which has the epithelial stem cells).⁸ Pain and burning sensations may accompany purpuritis. This scarring alopecia disorder presents with burning pain and itching.

Lichen Planopilaris Causes

The exact cause of this disorder is not known. However, experts believe that it is an autoimmune disorder where T-cells (immune cells) mistakenly attack your hair follicles. The cytotoxic effects seen in LPP can be attributed to an unknown antigen present in the hair follicles, which are targeted by immune cells. Moreover, the strong link between the autoimmune disorder lichen planus and lichen planopilaris makes it more likely to be an autoimmune disorder. Around 17-28% of cases of LPP are associated with lichen planus lesions (in mucous membranes and nails).⁹

Risk Factors/Groups:

Postmenopausal adult women, people of the black race, and lichen planus patients are at a greater risk of developing lichen planopilaris.

Is LPP Contagious?

No, it is an autoimmune disease that is not contagious.

Lichen Planopilaris Diagnosis

After taking the history of symptoms, your health provider will perform a physical examination to check the inflammation, redness, and scaliness on your scalp. He might question you about a diagnosis (or symptoms) of lichen planus.
Tests specifically done to diagnose lichen include:

Dermoscopy: It is a non-invasive diagnostic test in which the doctor uses a magnifying device under light to look at your skin and hair closely.
Trichoscopy: This is similar to dermoscopy, but in this test, doctors focus on the scalp and hair. Trichoscopy analyses play an important part in LPP diagnosis.¹⁰
Skin biopsy: Your doctor may take a small sample of your skin and send it to the lab for analysis. The presence of lymphocytic folliculitis (lymphocyte-based damage of hair follicles) in lab testing points towards lichen planopilaris.

Differential Diagnosis:

Lichen Planopilaris Vs Alopecia Areata

Both are characterized by hair loss, but there are differences in the nature and progression of the disease. LPP attacks the hair follicles with autoimmune cells and leads to permanent damage, while alopecia areata‘s damage is reversible (with potential for regrowth). Moreover, LPP causes scarring of the skin, but no scarring is seen in alopecia areata.

Lichen Planopilaris Vs Discoid Lupus Erythematosus

Both are autoimmune disorders characterized by inflammation of the scalp. However, a notable difference lies in the region of inflammation. In LPP, you will see perifollicular inflammation, i.e., around the hair follicle, while in DLE, inflammation is also found around the vessels (perivascular area).

Lichen Planopilaris Treatment

LPP is a slowly progressing condition and won’t cause complete baldness overnight. However, untreated lichen planopilaris can eventually end up with a head void of hair. Treatment involves different types of therapies. Some patients respond to a specific treatment modality while others report improvement with another one. Most commonly employed therapies for lichen planopilaris include:

Anti-Malarial Drugs:

Drugs like hydroxychloroquine help reduce inflammation in autoimmune patients. Clinical studies show that hydroxychloroquine and immunosuppressants (like cyclosporine) work well in reducing immune-mediated inflammation of the scalp follicles.¹¹

Immune Modulatory Drugs:

Immune modulatory drugs are advised for patients suffering from autoimmune disorders. Methotrexate has shown positive results in LPP management. When compared with hydroxychloroquine, methotrexate has a lower failure rate, which makes it a more feasible choice as first-line therapy for LPP.¹²

Janus kinase inhibitors (JAK inhibitors) like baricitinib are effective in managing symptoms of rheumatoid arthritis. Its use in lichen planopilaris has shown promising results.¹³ Adalimumab is a tumor-necrosis factor alpha inhibitor that has been effective in some cases.
Most of the time, doctors advise oral corticosteroids along with immunosuppressants to curb the inflammation and improve symptoms.

Topical Therapy:

Minoxidil application helps people with hair loss. It can help slow down the progression of lichen planopilaris. Topical application of immune modulatory drugs like tacrolimus and cyclosporine shows alleviation of symptoms (itching, pain, and inflammation).¹⁴

PRP Therapy:

Modern therapies like platelet-rich plasma (PRP) therapy are proving to be helpful in managing numerous inflammatory conditions. Its application in LPP patients reduces pain and is readily accepted by patients.¹⁵

Antibiotics like tetracycline and doxycycline may also work for LPP sufferers. Pioglitazone is a drug mainly used for diabetes management. Clinical trials show that pioglitazone effectively controlled LPP signs and symptoms and was well tolerated by patients. ¹⁶

Laser Therapy:

Your doctor may also use low-level laser therapy that utilizes special light waves to reduce skin inflammation and alleviate symptoms.
Shifting to a Mediterranean diet also helps flush out inflammation from the body. However, there is no specific lichen planopilaris diet that can aid you with disease progression or stop your hair fall.

Conclusion

Lichen planopilaris is an autoimmune disorder closely related to lichen planus, which is characterized by scarring of the skin and irreversible hair loss (especially on the scalp). In most cases, there is perifollicular erythema, and patients complain of pain, burning, and itching. Doctors use trichoscopy to diagnose the condition and manage the progression of the disease with a variety of drugs. Antimalarial drugs (hydroxychloroquine) and corticosteroids help with inflammation, while immune modulatory drugs (like methotrexate, baricitinib, adalimumab, etc.) evidently reduce symptoms. Modern research focuses on the use of PRP therapy to alleviate LPP symptoms.

Refrences

1
El Toro, N. P., Strunk, A., Garg, A., & Han, G. (2024). Prevalence and treatment patterns in patients with lichen planopilaris. JAMA dermatology, 160(8), 865-868.
2
Svigos, K., Yin, L., Fried, L., Lo Sicco, K., & Shapiro, J. (2021). A practical approach to the diagnosis and management of classic lichen planopilaris. American Journal of Clinical Dermatology, 22, 681-692.
3
Porriño-Bustamante, M. L., Fernández-Pugnaire, M. A., & Arias-Santiago, S. (2021). Frontal fibrosing alopecia: a review. Journal of Clinical Medicine, 10(9), 1805.
4
Piya, S., Bhusal, M., Thapa, D. P., & Shrestha, J. (2024). Graham-Little-Piccardi-Lassueur Syndrome: Two Case Reports. Nepal Journal of Dermatology, Venereology & Leprology, 22(2), 28-31.
5
Chew, A., Stefanato, C. M., Savarese, I., Neill, S. M., Fenton, D. A., & Lewis, F. M. (2014). Clinical patterns of lichen planopilaris in patients with vulval lichen planus. British Journal of Dermatology, 170(1), 218-220.
6
Naeini, F. F., Saber, M., & Faghihi, G. (2021). Lichen planopilaris: A review of evaluation methods. Indian Journal of Dermatology, Venereology and Leprology, 87(3), 442-445.
7
Plata, G. T., Cortez de Almeida, R. F., & Tortelly, V. D. (2024). Trichoscopy of Lichen Planopilaris in Black Scalp: A Literature Review. Skin Appendage Disorders, 10(5), 391-395.
8
Senna, M. M., Peterson, E., Jozic, I., Chéret, J., & Paus, R. (2022). Frontiers in lichen planopilaris and frontal fibrosing alopecia research: pathobiology progress and translational horizons. JID innovations, 2(3), 100113.
9
Kang, H., Alzolibani, A. A., Otberg, N., & Shapiro, J. (2008). Lichen planopilaris. Dermatologic therapy, 21(4), 249-256.
10
Orlando, G., Rapparini, L., & Bruni, F. (2024). Lichen Planopilaris Trichoscopy in Caucasian Scalp: A Review. Skin Appendage Disorders, 10(6), 459-462.
11
Stege, H., Haist, M., Schultheis, M., Pawlowski, J., Wittmann, M., Grabbe, S., & Butsch, F. (2024). Treatment of Lichen Planopilaris and Frontal Fibrosing Alopecia: A Retrospective, Real-Life Analysis in a Tertiary Center in Germany. Journal of Clinical Medicine, 13(16), 4947.
12
Williams, J., Ranpariya, V. K., & Pichardo, R. O. (2022). 34084 Treatment patterns for hydroxychloroquine, methotrexate, and mycophenolate mofetil in lichen planopilaris. Journal of the American Academy of Dermatology, 87(3), AB122.
13
Moussa, A., Bhoyrul, B., Asfour, L., Kazmi, A., Eisman, S., & Sinclair, R. D. (2022). Treatment of lichen planopilaris with baricitinib: a retrospective study. Journal of the American Academy of Dermatology, 87(3), 663-666.
14
Jafarzadeh, A., Salami, N., Bazargan, A. S., Ghassemi, M., Salehi, S., & Goodarzi, A. (2025). Successful treatment of lichen planopilaris with topical cyclosporine: A case series. JAAD Case Reports.
15
Behrangi, E., Akbarzadehpasha, A., Dehghani, A., Zare, S., Ghassemi, M., Zeinali, R., … & Lotfi, Z. (2024). Platelet‐rich plasma as a new and successful treatment for lichen planopilaris: A controlled blinded randomized clinical trial. Journal of Cosmetic Dermatology, 23(8), 2547-2555.
16
Lajevardi, V., Ghiasi, M., Balighi, K., Daneshpazhooh, M., Azar, P. M., Kianfar, N., … & Peymanfar, A. A. (2022). Efficacy and safety of oral pioglitazone in the management of lichen planopilaris in comparison with clobetasol: a randomized clinical trial. Dermatologic Therapy, 35(11), e15868.

Lichen Planopilaris: How to Identify and Manage It Early

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