Lasers for Lichen Planopilaris (LPP) and Frontal Fibrosing Alopecia (FFA): Which ones ?

Lasers for FFA and LPP: A Closer Look at 308 nm Excimer Laser and Low level Laser Therapy (LLLLT)

I’m often asked if lasers can be used in treating the scarring alopecia frontal fibrosing alopecia and lichen planopilaris. Here, we’ll take a look together at an interesting 2017 study examining the use of low level laser (LLLT) as well as some older 2006 and 2011 studies with the excimer laser.

For those not familiar with these laser, excimer laser is a special type of ultraviolet B (UVB) laser. These are 308 nm wavelength lasers. Low level laser therapy (LLLT) involves the use of red light laser of around 650 nm.

Fonda-Pascual and colleagues, 2017

In 2017, Fonda-Pascual and colleagues from Spain set out to examine the benefits of a laser known as “low level laser” in patients with lichen planopilaris. The study was small with 8 patients (3 males 5 females). Patients had LPP for an average of 3-4 years (mean 44.25 months). A laser helmet based device with 246 LEDs was used (each with a wavelength of 630 nm and fluency of 4 J/cm2). Interestingly, all patients had a reduction in symptoms, redness and scaling and there was a decrease in the disease activity after 6 months.
This was an interesting preliminary study. More studies are needed on the potential benefits of LLLT in LPP and especially in FFA where we really have no information. The inflammation in LPP is generally quite high up in the skin and these laser devices only penetrate a short distance into the skin making them potentially effective agents to target the inflammation in these scarring alopecias.

The above study pertained to treating LPP. For FFA specifically, we really have little information about low level red lasers. We don't know if low level laser would do much - or whether it would do alot. Many with FFA also have LPP in the middle of the scalp so it might do something for that area. Some laser devices are expensive as you say but some are not very expensive. Some are a few hundred US dollars and some are a few thousand US dollars. Do we know that the more expensive ones work better in FFA and LPP? No, not at all.

In fact, one of my concerns in using laser in FFA is making sure the chosen device actually covers the front of the scalp. Some more expensive devices do a wonderful job targeting the middle and crown of the scalp but less effectively target the middle of the scalp.

So, the main point about low level laser is that we have a hint of benefit in LPP, but less is known for FFA.

Vavricka and colleagues 2006

Now let’s move on to excimer lasers. In a 2006 study by Vavricka et al , 13 LPP patients were treated with an average of 10 excimer laser treatments. Only 3 responded. Two had more hair growth and 1 showed less activity. A small proportion of responders.

Navarini an colleagues, 2011

In 2011, Navarini et al also treated patients with LPP with twice weekly excimer laser. Some of the patients had FFA too. The authors found the treatment was successful in all 13 patients.

Conclusion

Lasers of various types may be an option for scarring alopecia. I have not consistently found excimer or LLLT to consistently help all our patients. But they do help some. The key point in all this discussion is that for FFA lasers are probably less effective than the leading treatments which include finasteride/dutasteride, isotretinoin, and steroid injections. For LPP, lasers are probably less effective that immunosuppressants live cyclosporine and methotrexate but for some may be on par with agents like topical calcineurin inhibitors, pioglitazone etc.

I suspect that low level laser therapy or excimer laser if it helps might have an important role as an “add on” therapy. For now, finasteride and dutaseride and isotretinoin and steroid injections are probably first line in FFA and topical steroids, doxycycline, steroid injections and hydroxychloroquine are probably first line in LPP.

That does not mean they must be used for any patient but it does mean they should be discussed before moving on to other therapies.

For a patient with newly diagnosed LPP who wants in the door, it’s probably not ideal to say “hey we can do laser for you.” Other treatments should be discussed.

REFERENCE

Fonda-Pascual P, et al. Effectiveness Of Low-Level Laser Therapy In Lichen Planopilaris. J Am Acad Dermatol. 2017.

Navarini A, Kolios A, Prinz-Vavricka B. Low-dose excimer 308-nm laser for treatment of lichen planopilaris. Arch Dermatol. 2011;147(11):1325–1326.

Vavricka BP, Haug S, Eliades I, Trueb R. 308-nm excimer laser treatment of lichen planopilaris of the scalp. Dermatology. 2006;213:74.