Lichen Planopilaris

Hair 
  • Reduced hair density

  • Absent vellus hairs 

  • Broken hairs 

  • Pili torti (occasionally)

  • Hair tufting (polytrichia) occasionally

Scalp 
  • Cloudy red-white erythema (strawberry icecream)

  • Atrophic pale plaques 

  • Slightly leathery textural change

Interfollicular Space 
  • Blue-grey dots arranged in target pattern around follicular ostia 

  • Follicular openings absent

  • Peripilar casts/perifollicular hyperkeratosis

  • Peripilar erythematous ring 

Differential Diagnosis:
  • Discoid lupus erythematosus

  • Frontal fibrosing alopecia

Description:

Lichen planopilaris (LPP) trichoscopy reveals a number of findings that can be highly variable between individuals. The most common area affected is the crown and vertex, but occasionally extends to the occipital, temporal and parietal scalp.  The findings can be subtle and close trichoscopic and tactile examination is necessary to establish the diagnosis, and often circumvents the need for a biopsy. Typically, there are accompanying symptoms of trichodynia, pruritus, of paresthesia, especially in the active phase.  In affected areas, expect to see a reduction in hair quality and density. Peripilar casts and erythema are classic findings and may indicate disease activity, but LPP can progress insidiously without out hallmark visible signs or symptoms. Broken hairs, pili torti, and decreased number or absence of vellus hairs are seen. The color of the scalp is a tell-tale sign, often appearing as cloudy red-white erythema (strawberry ice cream) admixed within scarred plaques. On palpation, the scalp will sometimes possess a firmer, more leather-like texture than normal scalp. An “atrophic sheen” is sometimes appreciable with the naked eye.  Pinpoint white dots are visible in patients with darker skin. Interfollicular space is characterized by lack of follicular openings. Additionally, blue-grey dots, arranged in a target-like pattern, appear around the follicular ostia. Biopsies are typically taken from areas with affected hairs showing peripilar erythema and scaling identified by trichoscopy.

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