Lichen planopilaris and its variants. Antonella Tosti. Fredric Brandt Endowed Professor of Dermatology & Cutaneous Surgery

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1 Lichen planopilaris and its variants Antonella Tosti Fredric Brandt Endowed Professor of Dermatology & Cutaneous Surgery

2 DISCLOSURE OF RELATIONSHIPS WITH INDUSTRY Antonella Tosti, MD S023 Lichen planopilaris and its variants DISCLOSURES CRC Press: Royalties Trichoscopyonline: Royalties Fotofinder :Consultant Karger : Editor in chief

3 Lichen Planopilaris Most common cause of cicatricial alopecia Severe scalp itching Multiple irregular areas of scarring alopecia

4 Lichen Planopilaris Diagnostic features Loss of follicular openings Peripilar casts Hair tufting

5 Lichen Planopilaris Loss of follicular openings May or may not be associated with inflammatory changes Inflammatory changes indicate disease activity

6 Lichen Planopilaris Peripilar casts White concentric scales surrounding the hair shaft at its emergency Thickness is variable Sign of disease activity

7 Lichen Planopilaris Always use polarized dermoscopy to look for casts!! Don t use interface solution!!

8 Lichen Planopilaris Hair tufting Tufts of 2 or more hairs surrounded by a peripilar cast are very typical of LPP.

9 Lichen Planopilaris Hair tufting The V sign : two hairs surrounded by a peripilar cast

10 Lichen Planopilaris Other features Scalp erythema Broken hairs Pili torti Black dots Absence of vellus hairs

11 Lichen Planopilaris Black scalp Loss of follicular openings is not very evident due to the pinpoint white dots. Irregular distribution of pinpoint white dots suggests scarring.

12 Lichen Planopilaris Blue- gray dots Due to pigment incontinence Arranged in a target pattern around the follicular ostia Duque-Estrada B, Tamler C, Sodré CT, Barcaui CB, Pereira FB. Dermoscopy patterns of cicatricial alopecia resulting from discoid lupus erythematosus andlichen planopilaris. An Bras Dermatol (2)

13 Lichen Planopilaris Role of dermoscopy for pathological diagnosis Use the dermatoscope to select the biopsy site! Select an area that include hair tufts surrounded by peripilar casts. Miteva M, Tosti A. Dermoscopy guided scalp biopsy in cicatricial alopecia. J Eur Acad Dermatol Venereol Oct;27(10):

14 Frontal Fibrosing Alopecia Scarring alopecia causing progressive recession of the fronto-temporal hairline Most common in postmenopausal women Partial or complete loss of the eyebrows Facial papules Hair loss in the limbs

15 Frontal Fibrosing Alopecia Always use polarized dermoscopy to evaluate the hairline for presence of peripilar casts!

16 Frontal Fibrosing Alopecia Diagnostic features Absence of vellus hairs Peripilar casts Lacarrubba F, Micali G, Tosti A. Absence of vellus hair in the hairline: a videodermatoscopic feature of frontal fibrosing alopecia. Br J Dermatol. 2013Aug;169(2):473-4

17 Frontal Fibrosing Alopecia Peripilar casts In FFA peripilar casts are usually thin and can be very subtle

18 Frontal Fibrosing Alopecia Other features Loss of follicular openings Scalp erythema Pili torti Broken hairs Black dots

19 Frontal Fibrosing Alopecia Eyebrows Loss of vellus hairs Peripilar casts

20 Frontal Fibrosing Alopecia Hair loss on limbs Thin peripilar casts Miteva M, Camacho I, Romanelli P, Tosti A. Acute hair loss on the limbs in frontal fibrosing alopecia: a clinicopathological study of two cases. Br JDermatol Aug;163(2):426-8.

21 Frontal Fibrosing Alopecia Associated with lichen pigmentosus in patients with dark phototypes Pirmez R, Duque-Estrada B, Donati A, Campos-do-Carmo G, Valente NS, Romiti R, Sodré CT, Tosti A. Clinical and dermoscopic features of lichen planus pigmentosus in 37 patients with frontal fibrosing alopecia. Br J Dermatol May 28.

22 Frontal Fibrosing Alopecia Role of dermoscopy for pathological diagnosis Use the dermatoscope to select the biopsy site! Select an area including hairs surrounded by peripilar casts.

23 Frontal Fibrosing Alopecia Frequently associated with traction alopecia in patients of African descent

24 Frontal Fibrosing vs Traction Check presence/absence of vellus hairs Frontal fibrosing alopecia Absence of vellus hairs Peripilar casts

25 Frontal Fibrosing vs Traction Check presence/absence of vellus hairs Traction alopecia Vellus hairs are preserved

26 Frontal Fibrosing Alopecia Men can be affected Absence of vellus hairs Peripilar casts Broken hairs Absence follicular openings

27 Frontal Fibrosing Alopecia Men can be affected Beard and body hair frequently involved Thin peripilar casts Absence follicular openings Erythema

28 Fibrosing alopecia with a pattern distribution First described by Zinkernagel &Trueb in 2011 Pathology :miniaturization (as in androgenetic alopecia) and lichenoid perifollicular inflammation Zinkernagel MS, Trüeb RM. Fibrosing alopecia in a pattern distribution: patterned lichen planopilaris or androgenetic alopecia with a lichenoid tissue reaction pattern? Arch Dermatol Feb;136(2):

29 Fibrosing alopecia with a pattern distribution Thinning of centroparietal scalp with a pattern that resembles androgenetic alopecia Scalp itching

30 Fibrosing alopecia with a pattern distribution Dermoscopy Hair shaft variability Peripilar casts Hair tufting V sign

31 Fibrosing alopecia with a pattern distribution Dermoscopy Hair shaft variability Peripilar casts Tufts of 2 or more hairs emerging together surrounded by a casts

32 Fibrosing alopecia with a pattern distribution Diagnosis confirmed by Pathology Need take biopsy in the right place! Need horizontal sections! Need experienced pathologist!

33 Fibrosing alopecia with a pattern distribution vs lichen planopilaris FAPD :miniaturization is a specific feature LPP : vellus hairs are lost

34 Take home message Dermoscopy in the diagnosis of LPP,FFA FAPD Do not miss early cases! Check temporal scalp and eyebrows! Anzai A, Donati A, Valente NY, Romiti R, Tosti A. Isolated eyebrow loss in frontal fibrosing alopecia: relevance of early diagnosis and treatment. Br J Dermatol May 13.

35 Take home message Dermoscopy in the diagnosis of LPP,FFA FAPD Do not miss early cases! Always use dry dermoscopy to evaluate the scalp of patients with patterned alopecia and scalp itching

36 Take home message Absence of vellus hairs is a key to recognize FFA In androgenetic alopecia vellus hair are preserved

37 Take home message Absence of vellus hairs is a key to recognize FFA In traction alopecia vellus hair are preserved

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