Can I Use Minoxidil When My Lichen Planopilaris (LPP) is Active?

Using Minoxidil in Cases of Active Lichen Planopilaris (LPP)

I’m often asked if minoxidil can be used for patients who have active scarring alopecia. The answer really depends on the patient and other specific details. Before we tackle the question, we need to take a look at what constitutes ‘active’ scarring alopecia.

What is active scarring alopecia?

Active scarring alopecia refers to hair loss caused by an overactive immune system process. The patient may have scalp itching, have increased scalp burning and may be shedding more and more hair. All of these things point to active scarring alopecia. What do we do when scarring alopecia is deemed active? Well, we increased the amount of immunosuppressive and immunomodulatory treatments we are using.

Here are just come examples of how we change treatment is we feel LPP is active

Example 1: instead of using steroid injections, we might use steroid injections AND topical steroids.

Example 2: Instead of using topical steroids, we might ADD oral doxycycline.

Example 3: Instead of using oral doxycycline, and topical steroids, a patient might be started on oral doxycycline PLUS oral hydroxychoroquine

In other words, once the LPP is determined to be active (or still active) we are going to make some pretty important decisions about increasing treatment. These are indeed big decisions because treatments have potential side effects, cost money

What is are the potential side effects of minoxidil?

Now , let’s focus on minoxidil and the potential side effects. In addition to side effects like headaches, dizziness and heart palpitations and hair growth on the face, minoxidil can cause two important side effects for patients with scarring alopecia: 1) Minoxidil can cause increased hair shedding and 2) Minoxidil can cause scalp itching for some people. These two side effects can make it difficult to figure out if the itching and shedding are coming from the active LPP or coming from the minoxidil.

So can I use minoxidil if I have LPP or not?

I always advise that patients review use of any medication with their dermatologist. In general, if a patient was using minoxidil for a very long time (without any problem) before the LPP even started, it’s usually fine to continue. In these situations, it’s unlikely any increased shedding or scalp symptoms the patient experiences is going to be attributable to the minoxidil. But starting up or initiating the use of minoxidil when one has active LPP is active is not usually a good idea. If the patient gets more shedding or more scalp symptoms, it will impossible to tell if they are coming from active LPP or coming from the minoxidil. In the worse case scenario, one can imagine a situation where the doctor increases the dose of medications thinking that the change in clinical symptoms or signs was due to increased activity of the LPP when really it was just the minoxidil. Imagine if the patient developed a side effect of the new mediation - and it never needed to be started in the first place.