Lichen planopilaris and its variants Antonella Tosti Fredric Brandt Endowed Professor of Dermatology & Cutaneous Surgery
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
Lichen Planopilaris Most common cause of cicatricial alopecia Severe scalp itching Multiple irregular areas of scarring alopecia
Lichen Planopilaris Diagnostic features Loss of follicular openings Peripilar casts Hair tufting
Lichen Planopilaris Loss of follicular openings May or may not be associated with inflammatory changes Inflammatory changes indicate disease activity
Lichen Planopilaris Peripilar casts White concentric scales surrounding the hair shaft at its emergency Thickness is variable Sign of disease activity
Lichen Planopilaris Always use polarized dermoscopy to look for casts!! Don t use interface solution!!
Lichen Planopilaris Hair tufting Tufts of 2 or more hairs surrounded by a peripilar cast are very typical of LPP.
Lichen Planopilaris Hair tufting The V sign : two hairs surrounded by a peripilar cast
Lichen Planopilaris Other features Scalp erythema Broken hairs Pili torti Black dots Absence of vellus hairs
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.
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. 2010 85(2) 179-83.
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. 2013 Oct;27(10):1299-303.
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
Frontal Fibrosing Alopecia Always use polarized dermoscopy to evaluate the hairline for presence of peripilar casts!
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
Frontal Fibrosing Alopecia Peripilar casts In FFA peripilar casts are usually thin and can be very subtle
Frontal Fibrosing Alopecia Other features Loss of follicular openings Scalp erythema Pili torti Broken hairs Black dots
Frontal Fibrosing Alopecia Eyebrows Loss of vellus hairs Peripilar casts
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. 2010 Aug;163(2):426-8.
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. 2016 May 28.
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.
Frontal Fibrosing Alopecia Frequently associated with traction alopecia in patients of African descent
Frontal Fibrosing vs Traction Check presence/absence of vellus hairs Frontal fibrosing alopecia Absence of vellus hairs Peripilar casts
Frontal Fibrosing vs Traction Check presence/absence of vellus hairs Traction alopecia Vellus hairs are preserved
Frontal Fibrosing Alopecia Men can be affected Absence of vellus hairs Peripilar casts Broken hairs Absence follicular openings
Frontal Fibrosing Alopecia Men can be affected Beard and body hair frequently involved Thin peripilar casts Absence follicular openings Erythema
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. 2000 Feb;136(2):205-11.
Fibrosing alopecia with a pattern distribution Thinning of centroparietal scalp with a pattern that resembles androgenetic alopecia Scalp itching
Fibrosing alopecia with a pattern distribution Dermoscopy Hair shaft variability Peripilar casts Hair tufting V sign
Fibrosing alopecia with a pattern distribution Dermoscopy Hair shaft variability Peripilar casts Tufts of 2 or more hairs emerging together surrounded by a casts
Fibrosing alopecia with a pattern distribution Diagnosis confirmed by Pathology Need take biopsy in the right place! Need horizontal sections! Need experienced pathologist!
Fibrosing alopecia with a pattern distribution vs lichen planopilaris FAPD :miniaturization is a specific feature LPP : vellus hairs are lost
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. 2016 May 13.
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
Take home message Absence of vellus hairs is a key to recognize FFA In androgenetic alopecia vellus hair are preserved
Take home message Absence of vellus hairs is a key to recognize FFA In traction alopecia vellus hair are preserved
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