Lichen planopilaris and its variants

Antonella TostiFredric Brandt Endowed Professor of

Dermatology & Cutaneous Surgery

Antonella Tosti, MD• S023 Lichen planopilaris and its variants

DISCLOSURES

CRC Press: RoyaltiesTrichoscopyonline: Royalties

Fotofinder :ConsultantKarger : Editor in chief

DISCLOSURE OF RELATIONSHIPS WITH INDUSTRY

Lichen Planopilaris

Most common cause of cicatricial alopecia

• Severe scalp itching

• Multiple irregular areas of scarring alopecia

Lichen Planopilaris

Diagnostic features

Loss of follicular openings

Peripilar casts

Hair tufting

Lichen Planopilaris

Loss of follicular openings

May or may not be associated with inflammatory changes

Inflammatory changes indicate disease activity

Lichen Planopilaris

Peripilar casts

White concentric scales surrounding the hair shaft at its emergency

Thickness is variable

Sign of disease activity

Lichen Planopilaris

Always use polarized dermoscopy to look for casts !!

Don’t use interface solution!!

Lichen Planopilaris

Hair tufting

Tufts of 2 or more hairs surrounded by a peripilar cast are very typical of LPP.

Lichen Planopilaris

Hair tufting

The V sign : two hairs surrounded by a peripilar cast

Lichen Planopilaris

Other features

Scalp erythema

Broken hairs

Pili torti

Black dots

Absence of vellus hairs

Lichen PlanopilarisBlack scalp

Loss of follicular openings is not very evident due to the pinpoint white dots.

Irregular distribution of pinpoint white dots suggests scarring.

Lichen Planopilaris

Blue- gray dots

Due to pigment incontinence

Arranged in a target pattern around the follicular ostia

Duque-Estrada B, Tamler C, Sodré CT, Barcaui CB, Pereira FB. Dermoscopy patterns of cicatricial alopecia resulting from discoid lupus erythematosus andlichen planopilaris. An Bras Dermatol. 2010 85(2) 179-83.

Lichen PlanopilarisRole of dermoscopy for pathological diagnosis

Miteva M, Tosti A. Dermoscopy guided scalp biopsy in cicatricial alopecia. J EurAcad Dermatol Venereol. 2013 Oct;27(10):1299-303.

Use the dermatoscope to select the biopsy site!

Select an area that include hair tufts surrounded by peripilar casts.

Frontal Fibrosing Alopecia

Most common in post-menopausal women

Partial or complete loss of the eyebrows

Facial papules

Hair loss in the limbs

Scarring alopecia causing progressive recession of the fronto-temporal hairline

Frontal Fibrosing AlopeciaAlways use polarized dermoscopy to evaluate the hairline for presence of peripilar casts !

Diagnostic features

Absence of vellus hairs

Peripilar casts

Frontal Fibrosing Alopecia

Lacarrubba F, Micali G, Tosti A. Absence of vellus hair in the hairline: a videodermatoscopic feature of frontal fibrosing alopecia.Br J Dermatol. 2013Aug;169(2):473-4

Peripilar casts

In FFA peripilar castsare usually thin and can be very subtle

Frontal Fibrosing Alopecia

Other featuresLoss of follicularopenings

Scalp erythema

Pili torti

Broken hairs

Black dots

Frontal Fibrosing Alopecia

Frontal Fibrosing Alopecia

Eyebrows

Loss of vellus hairs

Peripilar casts

Frontal Fibrosing Alopecia

Hair loss on limbs

Thin peripilar casts

Miteva M, Camacho I, Romanelli P, Tosti A. Acute hair loss on the limbs in frontal fibrosing alopecia: a clinicopathological study of two cases. Br JDermatol. 2010 Aug;163(2):426-8.

Frontal Fibrosing AlopeciaAssociated with lichen pigmentosus in patients with dark phototypes

Pirmez R, Duque-Estrada B, Donati A, Campos-do-Carmo G, Valente NS, Romiti R, Sodré CT, Tosti A. Clinical and dermoscopic features of lichen planus pigmentosus in 37 patients with frontal fibrosing alopecia. Br J Dermatol. 2016 May 28.

Frontal Fibrosing AlopeciaRole of dermoscopy for pathological diagnosis

Use the dermatoscope to select the biopsy site!

Select an area including hairs surrounded by peripilar casts.

Frontal Fibrosing AlopeciaFrequently associated with traction alopeciain patients of African descent

Frontal Fibrosing vs TractionCheck presence/absence of vellus hairs

Frontal fibrosing alopecia

Absence of vellus hairs

Peripilar casts

Frontal Fibrosing vs TractionCheck presence/absence of vellus hairs

Traction alopecia

Vellus hairs are preserved

Frontal Fibrosing AlopeciaMen can be affected

Absence of vellus hairsPeripilar castsBroken hairsAbsence follicular openings

Frontal Fibrosing AlopeciaMen can be affected

Beard and body hair frequently involved

Thin peripilar castsAbsence follicular openingsErythema

First described by Zinkernagel &Trueb in 2011

Pathology :miniaturization (as in androgenetic alopecia) and lichenoid perifollicular inflammation

Fibrosing alopecia with a pattern distribution

Zinkernagel MS, Trüeb RM. Fibrosing alopecia in a pattern distribution: patterned lichen planopilaris or androgenetic alopecia with a lichenoid tissue reaction pattern? Arch Dermatol. 2000 Feb;136(2):205-11.

Fibrosing alopecia with a pattern distribution

Thinning of centroparietalscalp with a pattern that resembles androgenetic alopecia

Scalp itching

Fibrosing alopecia with a pattern distribution

Dermoscopy

Hair shaft variability

Peripilar casts

Hair tufting

V sign

Fibrosing alopecia with a pattern distribution

Dermoscopy

Hair shaft variability

Peripilar casts

Tufts of 2 or more hairs emerging together surrounded by a casts

Fibrosing alopecia with a pattern distribution

Diagnosis confirmed by

Pathology

Need take biopsy in the right place!

Need horizontal sections!

Need experienced pathologist!

Fibrosing alopecia with a pattern distribution vs lichen planopilaris

FAPD :miniaturization LPP : vellus hairs areis a specific feature lost

Dermoscopy in the diagnosis of LPP ,FFA FAPDDo not miss early cases!

Take home message

Check temporal scalp and eyebrows!

Anzai A, Donati A, Valente NY, Romiti R, Tosti A. Isolated eyebrow loss in frontal fibrosing alopecia: relevance of early diagnosis and treatment. Br J Dermatol. 2016 May 13.

Dermoscopy in the diagnosis of LPP ,FFA FAPDDo not miss early cases!

Take home message

Always use dry dermoscopy to evaluate the scalp of patients with patterned alopecia and scalp itching

Take home messageAbsence of vellus hairs is a key to recognize FFAIn androgenetic alopecia vellus hair are preserved

Take home messageAbsence of vellus hairs is a key to recognize FFAIn traction alopecia vellus hair are preserved

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