Treatment of Lichen planopilaris (LPP): What's available?

Treating Lichen Planopilaris (LPP)

I'm often asked how lichen planopilaris is best treated. There are many treatments for lichen planopilaris. These include topical, injection forms, oral (pill) forms and laser. Patients should always keep in mind that the main goal of treatment is to stop the condition- regrowth or improvements in hair density do not often occur.

1. TOPICAL TREATMENTS

Topical steroids and topical calcineurin inhibitors are two important topical treatments to consider when treating lichen planopilaris. 

Topical steroids range from weak to very strong (potent). Generally potent topical steroids are needed for a period of time and one of the most common such ones is Clobetasol. Topical steroids are available as creams, lotions, sprays, foams and shampoos. Side effects include thinning of the skin, dilatation of blood vessels and others.

Topical calcineurin inhibitors are not generally as effective but have a distinct benefit in that they do not thin the skin. Tacrolimus (Protopic) and Pimecrolimus (Elidel) are two examples.

2. STEROID INJECTIONS

Steroid injections can be very helpful in LPP. Choosing the appropriate concentration for a given patient is important as one of the side effects of excessive steroid is atrophy or "dents/depressions" in the scalp. These can even happen when the right concentration was used and the patient's scalp is just sensitive to the medications. Other side effects are possible (but fairly rare) but one should review all side effects with their physician. Some women for example may notice irregular periods for a month of two after.

3. ORAL TREATMENTS (Pills)

Oral treatments are among the most important to carefully review with one's dermatologist. Not everyone needs them but in my opinion a high proportion do require them for various periods of time. The exact oral treatment to start with depends on several factors but may include oral doxycycline/tetracycline, or oral hydroxychloroquine. Treatments such as mycophenolate mofetil, methotrexate, cyclosporine, prednisone may be needed. Side effects differ according to which treatment is used - so all patients considering starting these medications should review side effects with their dermatologist.

4. LASERS

The 308 nm excimer laser can also be considered in some forms of LPP. Other laser devices, such as the 655 nm red (low level laser therapy) lasers may also benefit but not likely to the same degree as the 308 nm lasers.

Conclusions

There are many treatments for lichen planopilaris. Topical steroids and steroid injections are important for individuals with very limited disease. However, more advanced disease requires oral treatments, in combination with topical and/or injections. If disease improves and stabilizes, one may reduce medications. If the conditions worsens more aggressive treatments are needed.  For example if a patient using topical steroids is still loosing hair I often move up to doxycycline + topical steroids. If the patient using doxycycline or hydroxychloroquine is still not improving, we may start methotrexate or mycophenolate.