Scarring Alopecia - LPP

Sea of single hairs in LPP

Lichen planopilaris is a scarring alopecia which destroys hair follicles. The result is permanent hair loss. Affected individuals with LPP often develop scalp symptoms like itching and burning and classical findings are often present when one examines the scalp.

Typical findings of LPP include perifollicular scale (follicular hyperkeratosis), perifollicular erythema. and areas of scarring.  In other cases of LPP, the findings can be quite subtle. 15 % (to as high as 30 %) of patients with LPP in some studies have minimal symptoms so concerns about itching and burning are not present. 

Furthermore, in some patients with LPP, classic findings of perifollicular scale and redness may not be there. These photos shows two patients with lichen planopilaris with minimal findings except a reduction in hair density (ie hair loss), slight redness/pinkness in the scalp and a marked alteration in follicular architecture such that mostly single hairs are seen in the affected region.

While this can be seen in other conditions including genetic hair loss, it is an important finding to be aware of in (lymphocytic) scarring alopecias such as lichen planopilaris. I frequently refer to this finding as the "sea of singles".