Lichen planopilaris (LPP) is an inflammatory scalp condition that leads to patchy scarring hair loss . LPP overlaps with other syndromes and conditions such as the previously-discussed Frontal fibrosing alopecia (FFA article) and Graham Little syndrome which is characterized by progressive scarring hair loss on the scalp, non-scarring hair loss in the underarm and groin, and spiky bumps located over hair follicles. LPP can also overlap with lichen planus, a similar inflammatory process that affects the skin on the body and develops purplish, flat, itchy bumps called lichen planus.
LPP affects woman more often than men. The FFA type affects primarily postmenopausal women while the Graham Little Syndrome affects primarily Caucasian women between ages 30-60 years1. There are studies looking at the correlation between LPP and thyroid disorders but further information is needed to make a definite link between the two conditions2.
The early stage of LPP typically presents as scaling or red bumps around each follicle on the frontal and crown of the scalp. Other symptoms experienced include tenderness, burning, and itching. As the condition progresses the inflammatory process starts destroying follicles, leaving behind scarred, white, patches of hair loss. Initially these patches may be small and diffuse but can spread wider and become connected with more severe disease.
Diagnosis is through an examination and sometimes biopsy. The scalp is assessed for scaling and redness around the follicels, the hairs are pulled to see if they remove easily. Trichoscopy (trichology) is used to assess if the follicles are present and to assess the root of the hair to determine which phase the hair is in (life cycle of hair). A full body exam is also performed to assess for lichen planus lesions on the skin, in the mouth, genitals, or nails. A biopsy can be helpful to assess for deeper inflammation of the scalp and show if activity is present or absent.
Treatment aims at reducing the inflammatory process. Topical steroids and non-steroidal agents are used at home. In-office steroid injections can help calm down inflammation at the site without the side effects of taking an oral steroid and can penetrate deeper than topical steroids. Oral medications are usually initiated for more advanced disease to help reduce inflammation. Close follow up is warranted to assess for symptoms and monitor for slowing and halting the progression of the condition.
- LászlóFG. Graham-Little-Piccardi-Lasseur syndrome: case report and review of the syndrome in men. Int J Dermatol. 2014;53(8):1019.
- Atanaskova Mesinkovska N, Brankov N, Piliang M et al. Association of lichen planopilaris with thyroid disease: a retrospective case-control study. Kyei A, Bergfeld WF. J Am Acad Dermatol. 2014;70(5):889.
Central centrifugal cicatricial alopecia (CCCA) is a primary inflammatory condition that previously held the names of “hot comb alopecia,” “follicular degeneration syndrome,” “pseudopelade” and “central elliptical pseudopelade.” CCCA primarily affects the vertex/crown scalp and progressively spreads down the top of the scalp over time.
The causes of CCCA have been speculated but not proven. One study performed by Dr. McMichael1 showed patients affected by CCCA had a history of hair weaving and a long duration of chemical relaxer usage compared to unaffected individuals. However, a more recent study in 2011 by Olsen et al showed no obvious association of general central hair loss with relaxer or hot comb use, history of seborrheic dermatitis (dandruff article) or a reaction to a hair care product, bacterial infection, or male pattern hair loss in fathers of those affected2.
CCCA can mimic other hair loss disorders including female pattern hair loss and requires definitive diagnosis and medical intervention. CCCA typically affects women but also men of primarily African descent. Patients present with an itchy, tender, and scaly scalp with areas of tight shiny skin where hair follicles have been destroyed and replaced with scar tissue. The condition is slowly progressive and severe cases can progress to involve the entire scalp. Awareness of this condition is important due to symptoms going unnoticed for a long time. The most common early signs are hair breakage, itching, scalp tenderness in the affected area.
If diagnosed early, medical intervention can stop the progression of the condition. Topical steroids, antibiotics and other anti-inflammatory medications are used to calm down the inflammation targeting the follicles and the sebaceous glands (anatomy of a follicular unit).
- Review Ethnic hair update: past and present. McMichael AJ. J Am Acad Dermatol. 2003 Jun; 48(6 Suppl):S127-33.
- Olsen EA, Callender V, McMichael A, Sperling L, Anstrom KJ, Shapiro J, et al. Central hair loss in African American women: Incidence and potential risk factors. J Am Acad Dermatol. 2011;64:245–52.
Frontal Fibrosing Alopecia (FFA) is a primary inflammatory condition where lymphocytes (a type of white blood cells) target and destroy fine and vellus hairs on the scalp, face, and less commonly, the body.
FFA is common amongst postmenopausal women with early symptoms presenting around 50-60 years of age. Initially this condition was only seen in Caucasian women but over the past few years cases have emerged amongst African American and Hispanic women.
FFA presents as a band of hairline recession along the scalp. Itching may or may not be present. The skin on the forehead and temples is thinner and blood vessels appear prominent in fairer skin. With the use of a dermatoscope, one can appreciate fine bumps around hair follicles. In areas of long-term or permanent hair loss, the follicles scar over and the follicular openings cannot be visualized.
Women suffering from FFA also notice thinning or complete loss of facial and body hair including eyebrows, sideburns, eyelashes, arms, legs, and underarm hair. The skin surrounding eyebrow hairs may also be affected and can appear red and inflamed.
The cause of FFA is still unknown. FFA is responsive to topical anti-inflammatories and medications that block androgens prompting speculation that there may be a hormonal influence to this condition. The inflammation destroys the stem cells located near the sebaceous glands (article on anatomy of hair follicle) which are needed to regenerate hair. Early diagnosis and treatment is important to halt the progression and if caught early enough, can salvage follicles not yet destroyed by the lymphocytes.
FFA requires a detailed history from the patient, a thorough exam, and if warranted, a biopsy. The work up for FFA is necessary because other hair loss conditions such as traction alopecia and lichen planopilaris can look similar to FFA but require different treatments. It is also important to know that more than one hair disorder can present in the same individual.
Below are photos of individuals with FFA involving the scalp and/or eyebrows.
Alopecia, latin for partial or complete absence of hair from an area which normally grows hair, is a diagnosis term but is not a final diagnosis. It is an umbrella term under which there are numerous subsets and reasons for hair loss. I often hear people tell me they were told by physicians and stylists that they have alopecia. This is a broad term similar to saying, “you would like a beverage.” There are many types of beverages of all variations, flavors, consistency, and contents. This also pertains to alopecia. Having a specific diagnosis is important for not only knowing the prognosis of your hair loss but also tailoring treatment towards the pathology, or reason, for the hair loss. For example, if you have hair loss secondary to an auto immune condition, treating with oral supplements and stopping all of your medications is not targeting the reason for the hair loss.
A large part of treating hair loss is education and increasing awareness so individuals present to a dermatologist earlier in their course with hopes to stop the progression and if possibly restore the hair. When I speak at salons and cosmetology schools I explain the umbrella term of alopecia. I also categorize hair loss into different types to show that not all hair loss is the same and should not be treated the same.
There are primary inflammatory conditions where the immune system is the initial cause of inflammation attacking the follicles/sebaceous glands (anatomy of hair follicle unit) causing permanent destruction. Then there are secondary inflammatory conditions which there is an inciting trigger to cause inflammation, such as traction, chemicals, heat, and trauma. Another way to categorize hair loss is by scarring and non-scarring which helps with prognosis. Scarring hair loss definitely requires medical intervention to stop the inflammatory process and to prevent progression of further follicle damage and hair loss. Non-scarring conditions are usually environmental or changes in the body- hormones, stress, medications, infections, etc and are reversible sometimes on their own and sometimes with medical intervention.
In this series I will explain the following types of hair loss and the natural progression of each condition if it isn’t diagnosed and treated earlier in its course.
Scarring hair loss:
- Frontal fibrosing alopecia:
- Central centrifugal cicatricial alopecia:
- Lichen planopilaris
- Pseudopelade (Brocq)
- Discoid lupus erythematosus
- Dissecting cellulitis
- Acne keloidalis nuchae
- Folliculitis decalvans
- Traction alopecia
Non-Scarring hair loss:
- Alopecia areata
- Telogen effluvium
- Trichorrhexis nodosa
- Seborrheic dermatitis
- Lipedematous alopecia