Content uploaded by Daniela Pinto
Author content
All content in this area was uploaded by Daniela Pinto on Dec 18, 2017
Content may be subject to copyright.
Annals of Dermatological Research
Open Access
HTTPS://www.HEIGHPUBS.ORG
Abstract
Lichen Planopilaris is known as the form of Lichen Planus typical of the scalp. It is classifi ed as a lymphatic
disease and is characterized by chronic infl ammation which leads to cicatricial alopecia. Its causes are not yet
well characterized but its etiology seems to strongly correlates with infection, sensitization and pollution. A clear
and objective diagnosis of Lichen Planopilaris is not simple but the evolution and strongly negative outcomes on
scalp of people affected by, pose the need of an early diagnosis.
In this work we report the case of a 27-year-old male and a 54-year-old female, respectively, in which a correct
diagnosis of Lichen Planopilaris, followed the incorrect previous ones, was made by means of dermatoscopy
and histopathological analysis, decisive tools for the diagnosis of this kind of pathology.
Case Report
It is not invisible! A case report of 2
patients with scalp Lichen Planopilaris
mimicking Androgenic Alopecia
Sorbellini Elisabetta1, Pinto Daniela2, Marzani Barbara2 and
Fabio Rinaldi1*
1Studio Rinaldi & Associati, Milan, Italy
2International Hair Research Foundation (IHRF), Milan, Italy
*Address for Correspondence: Fabio Rinaldi,
Studio Rinaldi & Associati, Milan, Italy, Tel.: +39-2-
76006089; Email: fabio.rinaldi@studiorinaldi.com
Submitted: 24 November 2017
Approved: 06 December 2017
Published: 08 December 2017
Copyright: 2017 Sorbellini E, et al. This is an
open access article distributed under the Creative
Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly
cited
Abbreviations: LP: Lichen Planus; LPP: Lichen
Planopilaris; FFA: Frontal Fibrosing Alopecia;
FAPD: Fibrosing Alopecia in a Pattern Distribution;
VAS: Visual Analogue Scale; AGA: Androgenetic
Alopecia
How to cite this article: Sorbellini E, Pinto D, Marzani B, Rinaldi F. It is not invisible! A case report of 2 patients with scalp
Lichen Planopilaris mimicking Androgenic Alopecia. Ann Dermatol Res. 2017; 1: 012-017.
Introduction
Lichen planopilaris (LPP), a morphological variant of Lichen Planus known as
speciic of the scalp, is a rare, dificult-to-treat, chronic, inlammatory skin condition
resulting in cicatricial alopecia, which can be eventually permanent irreversible [1]. It
has been described for the irst time by Pringle in 1895 [2] and placed in the lymphocytic
disease group by the North American Hair Research Society (NAHRS) [3]. The causes
of this disease are not well clariied but it seems to act as an autoimmune disorder
probably triggered by drugs, metal exposure, stress, pollution, contacts sensitizers
or infection [4]. Epidemiological data report that about 0.5-1% of the population is
affected by Lichen Planus and in particular, adult women result as the most affected
population by LPP (ratio 1.8:1) [5,7], on people aged between 40-60 years and more
frequently in Caucasian and Indian population than Asian ones [7,8] Its typical
manifestation is multifocal areas of alopecia on the central scalp, usually accompanied
by perifollicular erythema, hyperkeratosis, and subjective symptoms such as pruritus
or pain [9]. Three different variants of LPP are normally recognized [3,9]: classic LPP,
frontal ibrosing alopecia (FFA) [10] and Graham-Little Piccardi Lassueur Syndrome
[11]. A fourth variant, known as ibrosing alopecia in a pattern distribution (FAPD)
could be added if considering some cases of patients with androgenetic alopecia in
which lesions identical to those seen in LPP were found [12].
The main therapy for LPP is topical treatment with class I or II, high-potency topical
corticosteroids such as clobetasol propionate or intralesional triamcinolone injection
[13]. Some other topical therapeutics approaches can include calcineurin inhibitors
(cyclosporine, tacrolimus), even if limited data are reported. More recently also the use
of mycophenolate mofetil has been proposed [13-16]. Driven by recent evidences on
the role of peroxisome-proliferator-activated receptor (PPAR)-γ on the pathogenesis of
It is not invisible! A case report of 2 patients with scalp Lichen Planopilaris mimicking Androgenic Alopecia
Published: December 08, 2017 13/17
LPP [17], also PPAR-γ antagonist, pioglitazone, has been recently included as effective
therapy. In presence of severe not responsive cases, systemic and/or intralesional
costicosteroids have been largely recommended [6] and tipically used in combination
with topical corticosteroid treatment, with limitations as regards side-effects.
As typical when referring to scalp disease to make a clear and objective diagnosis is
not easy. LPP manifestations evolve with the disease: early LPP can be easily confused
with seborrheic dermatitis, on the other side, in the late stages, LPP can be confused
with central centrifugal cicatricial alopecia (CCCA) and folliculitis decalvans [1]. The
approach of differential diagnosis reveals to be crucial in order to counteract the
progressive and chronic course of the pathology and to establish the correct therapy
as well as the use of dermatoscopy and histological evaluation in condition in which
LPP could result invisible at the clinical evaluation.
Case Report
Case report 1
A 27-year-old male (Milan, Italy), outdoor worker, reported a history of scalp
thinning and hair loss for 1 year. Other symptoms reported were moderate pruritus,
≥4 according to VAS scale [18], erythema and scaling. No evidence of Lichen Planus in
other body sites. All these symptoms were evaluated by the previous dermatologist
as compliant with androgenetic alopecia associated with seborrheic dermatitis.
Consequently, the patient was invited to treatment with Minoxidil 5% solution for
three months. The therapy was then suspended because of erythema and itching
worsening. Patient came to our examination because in his opinion hair loss and
symptoms did not disappear. Physical examination of scalp conirmed erythema and
localized thinning both in vertex and frontal area (Figure 1).
The area affected was also analyzed by a Dermatoscope with a 100x polarized
magniication (Molemax HD, DermaInstrument, Vienna, Austria). The Molemax
integrated software was used for images acquiring (Figure 2). Dermatoscopic
examination conirmed the presence of erythema and scalp scaling mainly at
perifollicular site but reported also the absence of signiicant miniaturization, which
is typical of androgenetic alopecia. Dermatoscopy showed also the presence of tubular
casts at the perifollicular level. Taking together the history of the patient and the latest
evaluations, a preliminary diagnosis of LPP was made, subsequently conirmed by
histopathological evaluation.
The analysis of histological section highlighted reduction in epidermis thickness,
presence of skin sclerosis, vasodilatation, melanin pigment residues in the supericial
dermis, vertical ibrotic bands and residues of pre-existing hair follicles (Figure 3). A
dense peripheral lymphocytic iniltration was also found. All these observations were
clearly consistent with LPP.
Figure 1: Localized scaling on vertex and parietal/mild frontal area of case report 1.
It is not invisible! A case report of 2 patients with scalp Lichen Planopilaris mimicking Androgenic Alopecia
Published: December 08, 2017 14/17
Case report 2
A 54-year-old female came to our clinic reporting a history of therapy for telogen
efluvium 2 years before. Patient went through menopause three years before and
reported important symptoms such as sever osteoporosis, hot lush, insomnia, mood
swings. Any hormone replacement therapy has been suggested to the patient because
breast cancer familiarity.
Clinical evaluation showed scalp thinning both in vertex and frontal area (Figure 4).
Patient referred also a persistent trichodinia. Also in this case no evidence of Lichen
Planus in other body sites were found.
Patient anamnesis and clinical evaluation suggested the dermatologist to proceed
further with dermatoscopic analysis. Images observation (Figure 5) revealed, among
the rest, arborized vasodilatation, which is a typical manifestation of LPP. This
diagnosis was inally conirmed by histology (Figure 6).
Tre a t m e n t
After LPP diagnosis, both patients were treated with clobetasol propionate foam
0.05% on affected area once a day for 30 days, following by 15 days of resting and
further 30 days of treatment once a day. Treatment succeeded into reduce inlammatory
symptoms, also alleviating erythema, itching and ibrosis too. This contribute to
stabilize LPP avoiding further evolution of the pathology as demonstrated by the
following histopathological analysis.
Discussion
LPP is an uncommon scalp disease which diagnosis remains a challenge due to
epidemiological data lacking and especially to the increasing number of patients in
which lesions and symptoms are not clearly visible or evaluable if limited to patient
Figure 2: Dermatoscopic analysis on case report 1 showing perifollicular tubular casts (arrow).
*
Figure 3: Histopathological analysis on case report 1, showing melanin incontinence on superfi cial dermis (red
arrow), perifollicular infi ltrates (asterisk).
It is not invisible! A case report of 2 patients with scalp Lichen Planopilaris mimicking Androgenic Alopecia
Published: December 08, 2017 15/17
clinical history and clinical observations. This led, in most cases, to a wrong diagnosis,
preferably of androgenetic alopecia (AGA) with which LPP shares some macroscopic
features. Some authors report these situations as “invisible LPP” [19,20]. The prognosis
for LPP is worse than AGA, evolving into bulge stem cells disruption and scarring
[6,21,22], leading to irreversible baldness. Therefore, LPP is often accompanied with
persistent trichodynia, a burning scalp syndrome strongly affecting quality of life of
patients, which are affected by [23]. From this the importance of an immediate and
correct diagnosis for reducing LPP discomfort and stopping pathology evolution by
early therapeutic intervention.
In the cases reported in the present work, we made a diagnosis of LPP, apparently
invisible and following a previous wrong diagnosis, by means of dermatoscopic
analysis coupled with histopathological examination. Patients were then submitted
to treatment with clobetasol foam and this led the inlammation to be stabilized and
at the same time hair loss stopping and trichodynia disappearance. Therapy with
Figure 4: Localized scaling on vertex of case report 1.
Figure 5: Dermatoscopic analysis on case report 2 showing perifollicular casts (arrow).
Figure 6: Histopathological analysis on case report 2.
It is not invisible! A case report of 2 patients with scalp Lichen Planopilaris mimicking Androgenic Alopecia
Published: December 08, 2017 16/17
topical corticosteroid with mid-to high-potency is generally preferred as irst-line the
treatment of LPP with a resolution of the patology higher than 66% [5,6,23] conirming
as the mainstay therapy for LPP.
According to our experience [24] LPP incidence is increasing with respect to
reported statistics and this, probably, due to the impact on the pathology of etiological
factors such as hair dying or microbioma dysbiosis [25]. There are also some studies
demonstrating the involvement of environment in skin pathology including LPP [26,
27]. Pollution may act as oxidant agent and induce oxidative stress by increasing the
production of reactive oxygen species (ROS) directly or indirectly [28]. LPP incidence
is growing also because an improvement in diagnostic by means of dermatoscopy
and histopathology that revel themselves as essential tools for make “visible” the
“invisible”.
Informed consent
Written informed consent was obtained from the patient for the publication of this
case report and accompanying images.
Confl ict of interest
R.F. serves as a consultant for Giuliani S.p.A. P.D. and M.B. are employed by Giuliani
S.p.A.
References
1. Assouly, Philippe; Reygagne, Pascal. Lichen planopilaris: update on diagnosis and treatment. Semin
Cutan Med Surg. 2009; 28: 3-10. Ref: https://goo.gl/hQEsUa
2. Pringle JJ. Lichen pilaris spinulosus. Br J Dermatol. 1905; 17: 78-97.
3. Olsen EA, Bergfeld WF, Cotsarelis G, Price V, Shapiro R, et al. Workshop on cicatricial alopecia.
Summary of North American Hair Research Society (NAHRS)-sponsored workshop on cicatricial
alopecia, Duke University Medical Center, February 10 and 11, 2001. J Am Acad Dermatol. 2003;
48:103-110. Ref: https://goo.gl/2xKT8p
4. Cooper S. Lichen planopilaris. Orphanet. 2011; Ref: https://goo.gl/DhtZSB
5. Chieregato C, Zini A, Barba A, Magnanini M, Rosina P. Lichen planopilaris: report of 30 cases and
review of the literature. Int J Dermatol. 2003; 42: 342-345. Review. Ref: https://goo.gl/S2xHx1
6. Nathaniel C. Cevasco, Wilma F. Bergfeld, Berna K. Remzi, Haydee Ramirez de Knott. A case-series
of 29 patients with lichen planopilaris: the Cleveland Clinic Foundation experience on evaluation,
diagnosis, and treatment. J Am Acad Dermatol. 2007; 57: 47-53. Ref: https://goo.gl/QBGnmV
7. Hoon Kang, Abdullateef A. Alzolibani, Nina Otberg, Jeery Shapiro. Lichen planopilaris. Dermatol Ther.
2008; 21: 249-256. Ref: https://goo.gl/EfGFqh
8. Lehman JS, Tollefson MM, Gibson LE. Lichen planus. Int J Dermatol. 2009; 48: 682-694. Ref:
https://goo.gl/FH4R2u
9. Weston G, Payette M. Update on lichen planus and its clinical variants. Int J Womens Dermatol.
2015; 16:140-149. Ref: https://goo.gl/3oMJ1N
10. Samrao A, Chew AL, Price V. Frontal fi brosing alopecia: a clinical review of 36 patients. Br J Dermatol.
2010; 163: 1296-1300. Ref: https://goo.gl/ivZ831
11. Odom RB, James WD, Berger TG, editors. Andrews’ Diseases of the skin. 9th ed. Philadelphia:
WB Saunders Elsevier, Lichen planus and related Conditions; pp. 2006; 274-275. Ref:
https://goo.gl/M8FbAp
12. 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; 136: 205-
211. Ref: https://goo.gl/WVnqba
13. Whiting D. Cicatricial alopecia: clinico-pathological fi ndings and treatment. Clin Dermatol. 2001; 19:
211-225. Ref: https://goo.gl/72CpDr
14. Mehregan DA, Van Hale HM, Muller SA. Lichen planopilaris: clinical and pathologic study of forty-fi ve
patients. J Am Acad Dermatol. 1992; 27: 935-942. Ref: https://goo.gl/iPJsYo
It is not invisible! A case report of 2 patients with scalp Lichen Planopilaris mimicking Androgenic Alopecia
Published: December 08, 2017 17/17
15. Tan E, Martinka M, Ball N, Shapiro J. Primary cicatricial alopecias: clinicopathology of 112 cases. J
Am Acad Dermatol. 2004; 50: 25-32. Ref: https://goo.gl/CJ7igP
16. Tursen U, Api H, Kaya T, Ikizoglu G. Treatment of lichen planopilaris with mycophenolate mofetil.
Dermatol Online J. 2004; 10: 24. Ref: https://goo.gl/BC6BNF
17. Mirmirani P, Karnik P. Lichen planopilaris treated with a peroxisome proliferator-activated receptor
gamma agonist. Arch Dermatol. 2009; 145: 1363-1366. Ref: https://goo.gl/ft26KW
18. Reich A, Heisig M, Phan NQ, Taneda K, Takamori K, et al. Visual analogue scale: evaluation of
the instrument for the assessment of pruritus. Acta Derm Venereol. 2012; 92: 497-501. Ref:
https://goo.gl/JGdR1s
19. Nirmal B, George R, Kodiatte TA. Invisible lichen planopilaris unmasked by dermatoscopy. Int J
Trichol. 2017; 9: 76-78. Ref: https://goo.gl/Gt1VVB
20. Grupper MC, Buisson J, Durepaire R, Edelson Y. [Gougerot’s invisible lichen planus]. Bull Soc Fr
Dermatol Syphiligr. 1971; 78: 598-599. French. Ref: https://goo.gl/B5eGVt
21. d’Ovidio R, Sgarra C, Conserva A, Angelotti UF, Erriquez R, Foti C. Alterated integrin expression in
lichen planopilaris. Head Face Med. 2007; 3: 11. Ref: https://goo.gl/PZrmkS
22. Baquerizo Nole KL, Nusbaum B, Pinto GM, Miteva M. Lichen Planopilaris in the Androgenetic
Alopecia Area: A Pitfall for Hair Transplantation. Skin Appendage Disorders. 2015; 1: 49-53. Ref:
https://goo.gl/f7BmaQ
23. Chiang C, Sah D, Cho BK, Ochoa BE, Price VH. Hydroxychloroquine and lichen planopilaris: effi cacy
and introduction of Lichen Planopilaris Activity Index scoring system. J Am Acad Dermatol. 2010;
62: 387-392. Ref: https://goo.gl/opaHBT
24. Sorbellini E, Pinto D, Marzani B, Rinaldi F. Considerations about Lichen Planopilaris and the correct
diagnosis. JPD. 2018 in press.
25. He Y, Gong D, Shi C, Shao F, Shi J, at. Dysbiosis of oral buccal mucosa microbiota in patients with
oral lichen planus. Oral Dis. 2017; 23: 674-682. Ref: https://goo.gl/Mqv6Fo
26. Srivastava K. Urbanization and mental health. Ind Psychiatry J. 2009; 18:75-76. Ref:
https://goo.gl/7grFsr
27. Dlova N, Goh CL, Tosti A. Familial frontal fi brosing alopecia. Br J Dermatol. 2012; 168: 220-2.Ref:
https://goo.gl/7grFsr
28. Bickers DR, Athar M. Oxidative stress in the pathogenesis of skin disease. J Invest Dermatol. 2006;
126: 2565-2575. Ref: https://goo.gl/xXW3TJ
