Perifollicular Scaling in Lichen Planopilaris (Follicular Hyperkeratoses)

Perifollicular Scaling in Lichen Planopilaris (LPP)

Lichen planopilaris (LPP) is a scarring alopecia. Affected patients frequently develop hair shedding in the initial stages and this is often accompanied by itching, burning and/or tenderness in the scalp.

Areas of permanent scarring hair loss can be visualized on the scalp as the disease progresses. However, in the early stages, findings such as scalp redness, or redness around hair follicles (perifollicular erythema) or scaling around hair follicles (perifollicular scaling) may be the only signs of the disease. This patient has LPP and the scaling was initially mistaken for dandruff. The intense itching, burning and tenderness she was experiencing were among the clues that another condition besides dandruff might be present.

Trichoscopic image of lichen planopilaris showing typical scale around hairs (ie. perifollicular scale)

A biopsy is not always needed to diagnose LPP. If all the pieces of the puzzle fit, and the clinician is confident the diagnosis is indeed LPP, a biopsy does not add anything further and may not be necessary. However, if there is any uncertainty with the diagnosis or something just does not seem clear, a 4 mm punch biopsy should be performed to evaluate further.