Lichen Planopilaris

The cause of lichen planopilaris is unknown, but it may be linked with the body’s immune system. T-lymphocytes, a type of white blood cell, are known to be involved; however, the trigger is unknown. The hair loses its protection from the immune system. The immune system then starts to attack the hair follicle.

Is lichen planopilaris hereditary? No, lichen planopilaris is not inherited. However, there may be genes responsible for increasing the risk of developing the condition. These genes affect the immune system and its responsiveness.

Lichen planopilaris typically causes an itchy scalp. The crown and vertex (top of the scalp) are most commonly affected, and symptoms of pain, burning, and scalp tenderness may occasionally be experienced.

Gradually, areas of hair loss may be noticed. Lichen planus can also affect the skin, mouth, genitals, and nails (for further information, please see Patient Information Leaflet on lichen planus).

Lichen planopilaris causes redness and scaling of the skin around the base of a hair and blocking of the hair follicle, which may give the scalp a rough texture. Where hairs have been destroyed, the scalp may appear smooth and shiny. Any part of the scalp can be involved; lichen planopilaris often occurs in patches but may involve more extensive areas. Facial and body hair may rarely be affected.

A biopsy is often required to confirm the diagnosis. This procedure may involve removing at least two small areas of affected scalp skin under local anesthetic and will leave small scars.

Lichen planopilaris is a long-term disorder; however, in most cases, the condition does eventually become inactive. The hair loss is usually permanent. Although the disease cannot be cured, treatment aims to preserve the remaining hair and help control symptoms but cannot cause regrowth of hair that has already been lost.

Lichen planopilaris can be treated with topical medication, such as creams and gels, and also orally with tablets, although success rates can be very variable. Unfortunately, there is no single proven effective treatment for this condition, and despite trying many medications, some people fail to respond.

Treatments to the skin may include Topical corticosteroid preparations. Potent steroid based preparations (e.g., lotions, gels, or mousses) can help localized areas of affected skin. Care must be taken to apply the correct amount of steroid to the affected areas to avoid any unaffected skin.

Scalp skin is much thicker than facial skin and tolerates steroid applications better than delicate skin, such as that on the face and around the eyes. Steroids can cause thinning of the skin if misused. Topical steroid preparations can be incredibly helpful in improving itch and may also reduce the rash.

Steroid injections into the affected area (known as ‘intralesional steroids’) can be a more effective treatment for a small area; however, steroid injections are often painful or uncomfortable and have a higher risk of causing adverse effects such as thinning of the skin (atrophy) or dimpling of the skin. (For further information, please see Patient Information Leaflet on intralesional steroid therapy). 

Topical calcineurin inhibitor creams and ointments. Although not usually prescribed for lichen planopilaris, these topical treatments can settle local inflammation. They do not have the potential to cause thinning of the skin, as seen with topical steroids. Side-effects include stinging on initial application (this usually improves with time). Excessive sun exposure, sunbathing, and sunbeds should be avoided while using this treatment (see Patient Information Leaflet on calcineurin inhibitor). 

Corticosteroids. A short course of steroid tablets may quickly reduce inflammation in severe cases, hoping to stop hair loss. However, side effects such as high blood pressure, diabetes, osteoporosis, and weight gain can limit long-term use. Sometimes steroid tablets are given as a bridge while waiting for another longer-acting treatment to take effect (for further information, please see Patient Information Leaflet on oral treatment with corticosteroids).

Hydroxychloroquine. Although slow to start working, this drug can be very useful in treating lichen planopilaris. Usually, a minimum trial of 4-6 months is required to see whether the drug is effective. If helpful, it may be continued for longer until the condition goes into remission. It is not sure how the drug works to stop hair loss. Very rarely, hydroxychloroquine may damage the retina (the layer of cells in the back of the eye that detects light and allows you to see), particularly in those needing treatment for more than five years. This risk is generally prevented by keeping the dose low and limiting the overall length of time on this treatment. While you are taking hydroxychloroquine, annual eye tests may be recommended (see Patient Information Leaflet on hydroxychloroquine for further information). 

Immunosuppressive drugs. Several different tablets are used to treat lichen planopilaris by suppressing the immune system, with varying degrees of success. These are usually safer than taking steroid tablets in the long term but have side effects and require close monitoring, with periodic clinical reviews and regular blood tests. It is not recommended for women to become pregnant while on these medications.

The immunosuppressive drugs include azathioprine, ciclosporin, methotrexate, and mycophenolate mofetil (please see the relevant Patient Information Leaflets for further information).

Other tablets:

• Acitretin and isotretinoin are other drugs that have been used; however, isotretinoin is preferred as acitretin itself can cause hair loss. There are crucial risks concerning pregnancy when taking acitretin or isotretinoin. Please see the relevant Patient Information Leaflets for further information.
• Tetracycline or doxycycline are antibiotics commonly used in the treatment of acne but can also be used to treat lichen planopilaris. These drugs have few side-effects and do not require any monitoring by blood tests.
• There is some evidence to show that the off-license use of a diabetes drug called pioglitazone, might also help the treatment of lichen planopilaris. This treatment is generally well-tolerated, but there have been some safety concerns with long term use, including a possible association with bladder cancer.

Lichen planopilaris usually stabilizes eventually and stops getting worse. Once it has been stable for several years, it may be possible for permanent areas of hair loss to be removed or reduced in size by a small operation. Your doctor can let you know whether you might be suitable for such a procedure. Hair transplantation is another option that can be considered once the condition has stabilized but is also not available on the NHS and, unfortunately, is not always successful if the condition reactivates.