Perifollicular Scale: A Clue to the Diagnosis of Lichen Planopilaris

The photo on the left is from a patient with a normal healthy scalp. The hair follicles are all similar size and spacing between them is similar. There is no redness, and no flaking in the scalp.

The patient on the right has redness in the scalp. The hair density is decreased.  Another striking feature is also present - the white “scale” around many of the hair follicles. The medical term for this scale hugging each of the hair follicles is known as ‘perifollicular scale.’  Perifollicular scale is a potentially important clue to the diagnosis of a certain scarring hair loss conditions, especially a condition known as lichen planopilaris (LPP).

When I see perifollicular scale in a patient with a red itchy scalp, I suspect that the patient has a scarring hair loss condition and usually do a scalp biopsy to confirm the diagnosis. Lichen planopilaris is a cause of permanent hair loss.  When the condition first starts, patients may have itching, burning or pain in the scalp and possibly increased hair shedding too. It is important to diagnose this condition in the early stages in order to try to prevent further hair loss.