Peripilar casts (Perifollicular scale) in LPP

Scaling in Lichen Planopilaris (LPP)

Lichen planopilaris (LPP) is a scarring alopecia that has the potential to cause permanent hair loss. Many patients first develop symptoms such as itching or burning or tenderness un the affected area. Some patients have all three. 

Clinical examination can sometimes look fairly normal. However, in more active LPP, the scalp is red to varying degrees. There is redness around the follicles (called perifollicular erythema) and there is often whitish scale around follicles too. The whitish scale is known by many names including “perifollicular scale” and “peripilar casts” and “follicular hyperkeratoses.” All these terms mean the same thing for the most part. Perifollicular erythema and perifollicular scale are signs the disease is active. 

Perifollicular scale (white color around follicles) in a patient with LPP.

Treatments for LPP have been discussed in other posts but include agents such as topical steroids, steroid injections, topical calcineurin inhibitors, low level laser therapy, oral doxycycline, oral hydroxychloroquine, mycophenolate mofetil, methotrexate, cyclosporine, low dose naltrexone, oral tofacitinib. Successful treatment stops symptoms and more importantly stops hair loss.