There are different health conditions that can cause hair loss. One example is follicular lichen planopilaris, a rare medical condition that affects the scalp and sometimes other hair-bearing areas, causing hair loss.
This kind of hair loss can be distressful as the exact cause of the problem is not known. Additionally, this disorder can cause permanent damage to the hair follicles, which is usually irreversible. Before seeking treatment for its symptoms, you should understand lichen planopilaris.
What Is Lichen Planopilaris?
Lichen planopilaris (LPP) is a type of lichen planus – an inflammatory disorder – that affects the skin of the scalp and damages the hair follicles, resulting in scarring or cicatricial alopecia. The hair loss is sudden and irregular and can progress diffusely or in patches. Following the loss of hair, atrophic (indented) scars are left on the skin with no hair follicles in them.
Although the condition is rare, it is the most common cause of scarring alopecia. Other than causing inflammation of the skin, it can also affect the nails and mucous membranes. Still, the scalp remains one of the most commonly affected areas, particularly the vertex (top of the scalp) and crown (highest point of the scalp) regions.
It should be noted that although the exact prevalence is not known, lichen planopilaris affects more women than men, usually between the ages of 40 and 60. But rarely, it can also affect children. It is not contagious.
Types of Lichen Planopilaris
There are two other variants of lichen planopilaris, which are as follows:
- Frontal Fibrosing Alopecia (FFA) – It is a type of alopecia that usually affects the hairline and causes permanent loss of hair. It is rarely seen in men. Most commonly, it occurs in post-menopausal women. Earlier treatment can stop the progression of hair loss.
- Graham-Little-Piccardi-Lasseur Syndrome (GLPLS) – It is also a type of scarring alopecia that’s more commonly seen in women. It exists as a triad affecting different areas of the body: scarring alopecia occurs on the scalp, non-scarring alopecia occurs in the armpits and groin, and spiny papules appear on the base of hair follicles on the scalp and body.
What Does Lichen Planus On Scalp Look Like?
There are some people who are asymptomatic, but others can experience the following lichen planopilaris scalp symptoms:
- Burning sensation
- Tiny, red bumps
- Hair loss
According to DermNet NZ, no hair follicle opening can be seen in the bald patch caused by lichen planopilaris. Also, the hair at the edges of these bald patches has redness and scaliness at the base of their follicles. This gives them a rough texture. Moreover, the area where the hair has been lost permanently will appear smooth. Atrophic scarring occurs slowly.
What Causes Lichen Planopilaris Of the Scalp?
The exact cause of lichen planopilaris of the scalp is not known. It is not an inherited disorder. However, it is believed to be autoimmune, where the immune system cells start attacking healthy hair follicles.
At a biological level, it is thought that lichen planopilaris occurs due to a defect in a protein that preserves the stem cells in the hair follicles along with the sebaceous glands. Because the normal protein isn’t present, excessive oil is produced by the sebaceous glands, which results in a toxic buildup of lipids. This triggers inflammation, which permanently damages the stem cells, rendering the hair follicle barren.
Lichen Planopilaris Triggers
There are certain factors that can trigger lichen planopilaris. These are as follows:
- Infection (hepatitis C, HIV, herpes)
- Certain medications (beta blockers, painkillers, thiazide diuretics)
- Skin sensitisers (substances – metal and dyes – that can trigger an allergic reaction )
According to a study published in the Journal of the American Academy of Dermatology, more than 70% of the people with lichen planopilaris and frontal fibrosing alopecia were allergic to one or more ingredients in personal care products for the scalp and neck.
The study showed that 26% of the people with LPP/FFA were allergic to a preservative – gallate – commonly used in personal hygiene products like shampoos and soaps. The fragrance linalool also acted as an allergen. Therefore, you need to consult your doctor about the kind of products you should use.
How Is Lichen Planopilaris Diagnosed?
For lichen planopilaris diagnosis, the medical practitioner will perform a biopsy. In this, small tissue will be taken from the scalp from the symptomatic areas. This takes place under anaesthesia, so you will not feel any pain.
A hair pull test may also be a helpful indicator of scarring alopecia as the hair that falls out is in the anagen phase, which is the growing phase of the hair growth cycle. It is the exogen phase in which the shedding normally happens.
To avoid misdiagnosis of lichen planopilaris, doctors perform a differential diagnosis as the symptoms of this condition may be similar to that of alopecia areata, seborrheic dermatitis, or discoid lupus erythematosus (DLE), among other health conditions.
What Is The Treatment For Lichen Planopilaris?
Lichen planopilaris is a chronic condition, so it cannot completely be cured; the treatment is aimed at managing the different symptoms of the condition, including slowing down hair loss. Different medications that are used to treat lichen planopilaris include:
- Topical and oral steroids
- Antimalarial hydroxychloroquine
- Immunosuppressants (Methotrexate, Ciclosporin, Azathioprine)
- Oral retinoids
According to the British Hair & Nail Society (BHNS), in most cases, lichen planopilaris eventually “burns out” and doesn’t get any worse. The condition essentially becomes inactive. Once that happens, it is possible to undergo surgical procedures that reduce the size of the scarred areas or remove them entirely. You should further discuss with your doctor whether or not you’re suitable for such a surgical procedure.
Can Hair Grow Back After Lichen Planopilaris?
Lichen planopilaris will cause permanent hair loss in areas where atrophic scarring has occurred. The hair cannot grow through scar tissue. It is not possible to regrow the hair that has already been lost to the condition.
Unfortunately, since lichen planopilaris is progressive, you will lose more hair with time. Medications can help slow down the progression of this disorder, which is why it’s important to get early treatment.
There are some case studies that show hair regrowth in lichen planopilaris is possible with platelet-rich plasma, low-level light therapy, or a combination of antimalarial drugs. Usually, minoxidil is used to promote the growth of the hair follicles that are remaining on the scalp. You should further consult your doctor before deciding to get any treatment.
Lichen Planopilaris and Hair Transplant: Is It Possible?
It is possible to have a hair transplant if you have lichen planopilaris but only after the condition has been inactive for 1-2 years. If lichen planopilaris is still active, a hair transplant cannot take place. To determine the candidacy for a hair transplant, the doctor will check for any symptoms of the condition and may even perform a pull test.
You should not be experiencing any pain, burning, or itching. Additionally, the base of the hair follicles should not be red or scaly, as this is a sign of active lichen planopilaris. For the hair transplant to take place, the condition should be “burnt out.” Still, the patient should have a strong donor area (hair on the back and sides of the scalp) to undergo the surgery. This may not always be the case, so a hair transplant may not be recommended.
Here, you should also keep in mind that it is not possible to predict the success rate of the surgery in this case. That’s because there’s a risk of hair transplant “reactivating” the disorder. If this happens, the results of the surgery may be permanently damaged. You should make sure to discuss all the potential risks and complications of this procedure with your surgeon beforehand if you have lichen planopilaris.
What Else Can You Do?
Some people who have lost hair due to lichen planopilaris choose to wear wigs or other hairpieces. While that can work, one case study published in the International Journal of Trichology reported that a woman who had frontal fibrosing alopecia developed lichen planopilaris on the site of wig attachment.
That is why before wearing a wig, you should make sure to consult with your doctor so that the problem is not worsened. Other than wearing wigs, some people also use scarves and hats to hide their scalps.
It’s important that you take good care of your health. A study published in Skin Appendage Disorders shows that “meat, fish, vegetables, fruit, coffee, or alcohol” do not influence lichen planopilaris. Therefore, you can have a healthy diet.
If you’re in the habit of smoking, it’s better to quit it early on. That’s because smoking can affect the normal functioning of the immune system and poor healing of wounds. It can also cause increased and severe scarring.
Lichen planopilaris on the scalp can cause permanent damage to the hair follicles and leave you with scar tissue. It is one of the most common scarring alopecias, and unfortunately, it cannot be cured. However, different medications are prescribed for the management of its symptoms.
Keep in mind that hair regrowth in this condition is not usually possible. There are surgical procedures for the removal of scar tissue. Or you can consider getting a hair transplant, but it also has certain risks. In any case, you should make sure to consult a medical practitioner for an accurate diagnosis and treatment plan.
Reviewed and Approved by Dr. Hassan Soueid.