Lichen planopilaris is a rare, inflammatory condition that affects the scalp, causing hair loss in a patchy distribution. It is a disease that typically worsens over time. It occurs when lichen planus, which is a reasonably common condition affecting the skin, nails and mucous membranes (eg. the lining inside your mouth) affects the scalp. Lichen planopilaris causes hair loss by destroying the hair follicles and causing scarring of the surrounding scalp. Women are two times more likely to be affected than men. The onset is usually during adulthood, with a peak onset at around the age of 50. Lichen planopilaris tends to affect the back of the scalp close to the neck, as well as the front and sides of the scalp.
Signs & Symptoms
The main feature of lichen planopilaris is patchy loss of hair on the scalp. The underlying patches are white; but on the border of the patches, it is common to see redness and scaling, especially around the remaining hair follicles. The patches often feel smooth because the underlying hair follicles have been destroyed. The patches may also appear shiny. Patients may notice that the hairs easily fall out, particularly when brushing or combing the hair. Unfortunately, hair loss in the affected regions of the scalp is permanent.
Not all patients experience any other symptoms; however, some people may experience the following:
- Burning sensation
- Tenderness to touch
Over time, different, smaller patches of hair loss may merge into a larger patch. It does not typically result in complete loss of the hair on the head.
This is a rare form of lichen planopilaris that tends to predominantly affect females, especially those who are middle-aged and post-menopausal. The cause of Graham-Little syndrome is unknown. Graham-Little syndrome has the same scalp manifestations of lichen planopilaris. In addition, patients also experience non-scarring alopecia affecting the eyebrows, armpits and groin/pubic region. Additionally, patients also have the lesions of keratosis pilaris affecting their arms, legs and torso. Keratosis pilaris produces red, painless and non-itchy lumps that resemble acne on the skin. It is also referred to informally as “chicken skin”. It can affect any part of the skin except for the palms of the hands and the soles of the feet. The bumps of keratosis pilaris are associated with the hair follicles.
Frontal Fibrosing Alopecia
Frontal fibrosing alopecia is another form of lichen planopilaris which is most common in post-menopausal women. Frontal fibrosing alopecia affects a band of the scalp, typically along the front and sides of the scalp and may also affect the eyebrows. There are typically a few sparse hairs remaining in the bad area. Otherwise, the underlying skin is generally of normal appearance, but there may be some scarring or redness in the area. The cause is unknown, but due to its association with post-menopausal females, hormones are thought to play a role. Frontal fibrosing alopecia may also affect women who have female pattern baldness.
The precise cause of lichen planopilaris is not known. It is not a hereditary condition. It is thought to be an autoimmune disease, where the body’s immune system recognises its own normal tissues as foreign or potentially dangerous and destroys them. Lichen planopilaris is a disorder of the T- cells, which are a specialised type of white blood cell that are involved in the immune response. It is not a contagious disorder – you cannot catch it from somebody who is affected. In some cases, certain medications can trigger lichen planopilaris. The main medications implicated in this phenomenon are anti-malarial drugs, Captopril and Gold, which is used in the treatment of several rheumatologic disorders.
Medicated creams and gels, as well as oral medications can be used in the treatment of lichen planopilaris; however, there is no treatment that is one hundred percent effective and the rates of success with different treatments are highly variable. Treatments cannot lead to re-growth of lost hair, but they may help to prevent loss of any additional hair.
Steroids may be used in the treatment of lichen planopilaris. In general, the steroids are applied topically to the affected area in the form of a gel, cream, or ointment to reduce the likelihood of developing side effects. Steroid creams are helpful in removing any sense of itchiness and can reduce the appearance of any rashes. Care needs to be taken to apply the treatment only to the affected area of scalp. This is because one of the key side effects of steroids is thinning of the skin. This is particularly important if the affected area of scalp is close to the skin of the face and neck; the scalp is much thicker than the skin on the rest of the body and is more resistant to thinning. Steroids are also available as injections. These can be administered directly into the affected patches. The main drawback of this is that the injections are uncomfortable and delivering the treatment in this way increases the risk of developing side effects. In severe cases, steroids may be considered in an oral (tablet) form because they are quite effective at reducing the amount of inflammation on the scalp. However, oral steroids have an array of side effects which impact upon almost all body systems. Some of the common side effects of steroid use include weight gain, glucose intolerance, osteoporosis, hypertension, muscle weakness, changes in mood, increased duration of wound healing and an increased skin bruising tendency.
Another medication that can be used is hydroxychloroquine. This is a medication that was originally used as an anti-malarial tablet, but it has been found to be effective in delaying the progress of autoimmune disorders, including rheumatologic conditions such as rheumatoid arthritis and lupus. The mechanism by which hydroxychloroquine works to dampen the immune response is unknown, but it may be an effective treatment for lichen planopilaris. Hydroxychloroquine tends to be used at low doses and it is not advised as a long-term treatment (ie. >5 years in duration). This is because a potential side effect is retinal toxicity which can lead to blindness. This is a very, very rare side effect, and the risk of developing this complication is increased in patients who have been receiving the treatment for long periods of time at higher doses. Regular monitoring by an ophthalmologist is recommended whilst receiving this treatment.
If you have any questions or concerns about lichen planopilaris and its treatments, you are welcome to contact us today.