Hydroxychloroquine for Lichen Planopilaris (LPP): Should I change?

Hydroxychloroquine for Lichen Planopilaris.

I’ve selected this question below for this week’s question of the week. It allows us to review some concepts in the use of hydroxychloroquine for scarring alopecia.

Question

I have been on hydroxychloroquine for three months and it’s not working. Is this long enough? Should I change to methotrexate? My scalp is still red!

Answer

Well, to offer some solid thoughts I would need to ideally review your entire story and examine your scalp. But let’s review a couple of key points here.

I’m not so worried if your scalp is red. What I’m more concerned about is whether your scarring alopecia is active (Of course, I’m always concerned whether or not scarring alopecia is the correct diagnosis but I will assume it is for the sake of the question).

If your redness is from allergic contact dermatitis rather than LPP, then no MTX sure is not the ideal plan. The goal in that case is to stop allergens! If redness is from seborrheic dermatitis and not LPP, then the plan would be to bring on board some dandruff shampoos! If the redness is from overuse of topical steroids (like in the photo below), the goal is to get off the steroids ASAP.

Dilated blood vessels (steroid telangiectasias) in a patient using excessive amounts of the topical steroids clobetasol.

But let’s return to assuming the redness is from the scarring alopecia. Hydroxychloroquine can take 6-9 months to figure out if it’s working so you’ll want to be closely followed by your doctor. One month on a new dose means little. We need to give it longer. I don’t know your full story but I’d be hesitant to switch to MTX yet. Be sure to check the dosing as too many people are on the wrong dose. Steroid injections, cetirizine, doxycycline, low dose naltrexone, clobetasol, doxycycline, tacrolimus may be options before starting MTX but again I don’t know enough about your story. Be sure to get an expert review!

Here is my general treatment approach to lichen planopilaris (first-line options, second-line options and third line options).