Lichen Planopilaris / Frontal Fibrosing Alopecia

Lichen planopilaris (LPP) and its clinical subtype, frontal fibrosing alopecia (FFA), are scarring (cicatricial/permanent) hair-loss conditions in which the immune system targets the hair follicles and which run an inflammatory course. Because permanent damage to the follicles can develop if left untreated, early diagnosis and appropriate treatment are very important.

In LPP, patches of hair loss appear on the scalp, and the number of these patches can gradually increase. The loss is often accompanied by itching, burning, stinging, pain or tenderness; redness and scaling can be seen around the hair follicles. In some patients, signs of lichen planus in the mouth, on the nails or on other parts of the body may accompany the condition.

In FFA, the most typical finding is slow recession of the frontal hairline and thinning at the temples. In addition, thinning or complete loss of the eyebrows and sometimes a reduction in the eyelashes, sideburns and body hair may be seen. In some patients, skin findings such as very small skin-coloured bumps on the face (facial papules), prominent blood vessels and brown marks may also accompany FFA.

Some LPP variants described in recent years can run a course that differs from the classic picture. In these patients, patchy loss and recession of the frontal hairline are not seen; instead there is diffuse shedding and thinning that mimics androgenetic alopecia or telogen effluvium. If these types of LPP are not diagnosed correctly, appropriate treatment can be delayed and the condition can progress, making the hair loss permanent.

Detailed clinical assessment and trichoscopic examination are very important in diagnosis. Trichoscopy allows the activity of the condition to be assessed, the differential diagnosis from other types of hair loss to be made, and the course of treatment to be followed closely. A scalp biopsy is performed in patients where it is needed to confirm the diagnosis.

The main aim of treatment is to bring the inflammatory process in the follicles under control, halt the progression of the condition and preserve the existing hair. The treatment plan is tailored to the extent and activity of the condition. Today, topical and systemic treatments — together with supportive procedures where needed — can bring the condition largely under control.