Follicular Lichen Planus: Diagnosis, Forms & Treatment

Follicular Lichen Planus (FLP) is a rare, chronic inflammatory condition that affects hair follicles. Unlike other forms of hair loss that are reversible, follicular lichen planus belongs to the group of “scarring alopecias,” which means the inflammation permanently destroys the hair follicle, leading to irreversible hair loss. This condition, although rare, causes significant psychological distress due to its permanent nature.

The purpose of this article is to provide a comprehensive overview of follicular lichen planus, including its etiology, its various forms, diagnostic methods, and modern therapeutic approaches. Early recognition and prompt intervention are crucial for successful treatment and the prevention of further, irreparable damage.

What is Follicular Lichen Planus?

Follicular lichen planus is an autoimmune condition, considered a variant of skin lichen planus, that instead of affecting the epidermis, exclusively targets the hair follicles. Essentially, the body’s immune system mistakenly attacks the hair follicles, treating them as foreign invaders. This immunological attack causes intense inflammation that surrounds the follicle, leading to the gradual destruction of the hair’s stem cells. As the inflammation subsides, the follicle is replaced by fibrous tissue (scar tissue), so the hair can no longer grow. This process is called “scarring alopecia.”

The condition occurs most often in middle-aged women but can affect any person, regardless of age or gender. It is not contagious, and its exact cause remains unknown, though it is believed to be a combination of genetic factors and environmental triggers.

Forms of Follicular Lichen Planus

Follicular lichen planus is not a single condition but appears in various clinical forms, the most common being:

• Classic Lichen Planopilaris (LPP): This is the most common form. It is characterized by the appearance of small, red, inflammatory bumps (papules) around the hairs, often accompanied by intense itching, pain, or a burning sensation. Over time, the hairs fall out and are replaced by redness, scaling, and finally a smooth, scarred surface without hair follicles. The pattern of loss can be diffuse or create small, scattered patches.
• Frontal Fibrosing Alopecia (FFA): This is a distinct and increasingly common variant that primarily affects postmenopausal women. It is characterized by a progressive, symmetrical receding of the frontal hairline and eyebrows. It is often accompanied by the appearance of small, flesh-colored papules on the face. The loss of eyebrows is a classic diagnostic sign.
• Graham-Little Syndrome: A rarer variant that combines the appearance of alopecia on the scalp, hair loss in the armpits and thighs, and the appearance of keratotic follicular papules.

Diagnosis: A Challenging Path

The diagnosis of follicular lichen planus is often difficult and delayed, as the symptoms can resemble other forms of hair loss. However, early and accurate diagnosis is vital to prevent permanent hair loss. A specialized dermatologist will use a combined approach:

1. Clinical Examination: The doctor will carefully examine the scalp for signs of inflammation (redness, scaling, swelling around the hairs) and for the presence of scarred areas, where hair follicles have been destroyed. The absence of hair follicle openings in the affected areas is a key sign.
2. Trichoscopy: This non-invasive method allows for magnification of the scalp image and the observation of details not visible to the naked eye. In follicular lichen planus, trichoscopy reveals specific signs, such as perifollicular erythema and scaling, as well as the absence of hair follicles in the scarred areas.
3. Skin Biopsy: A scalp biopsy is the “gold standard” for confirming the diagnosis. A small tissue sample is taken from an active, inflamed area and examined under a microscope by a pathologist. The histopathological examination will highlight the characteristic findings of the disease, such as lymphocytic infiltration around the hair follicle and signs of fibrosis.

Management and Treatment: The Goal is Inhibition

The treatment of follicular lichen planus does not aim to regenerate hair in the scarred areas, as the damage is permanent. The main goal is to inhibit the inflammation to stop the disease’s progression and prevent further hair loss. The treatment must be personalized and aggressive, especially in the early stages.

Topical Medication

• Topical Corticosteroids: In the form of creams, ointments, or lotions, they are the first line of defense to combat inflammation.
• Intralesional Corticosteroid Injections: Injections directly into the inflamed areas of the scalp. They are particularly effective for controlling local inflammation.

Systemic Medication

• Immunosuppressants: In cases of more widespread or resistant disease, a dermatologist may prescribe systemic medications such as Hydroxychloroquine, Cyclosporin, or Methotrexate. These drugs work by suppressing the overactivity of the immune system.
• Androgen Antagonists: In frontal fibrosing alopecia, drugs like Finasteride may be used to stop the hormonal effect believed to be associated with the disease.

Complementary and Supportive Therapies

• Low-Level Laser Therapy (LLLT): It can be used to stimulate existing, undamaged hair follicles, although it does not treat the underlying inflammation.
• Platelet-Rich Plasma (PRP): Although there is insufficient evidence of its effectiveness in treating follicular lichen planus itself, it may help to strengthen surrounding hairs and minimize inflammation.
• Hair Transplant: Generally, transplantation is not recommended for patients with active follicular lichen planus, as the new hair follicles will also be destroyed by the disease. It may only be considered when the disease has been in complete remission for several years, and even then, with great caution.

Living with Follicular Lichen Planus

The diagnosis of follicular lichen planus can be emotionally difficult. However, managing the condition involves not only medical treatment but also caring for mental health.

• Psychological Support: Contact with a psychologist or participation in support groups can help patients manage anxiety and loss of self-confidence.
• Scalp Protection: Sun protection is essential, as ultraviolet radiation can worsen inflammation.
• Health Enhancement: Adopting a healthy lifestyle, with a balanced diet and stress management, can contribute to overall body health and, consequently, better management of inflammation.

Conclusion

Follicular lichen planus is a serious and chronic condition that requires immediate and specialized care from a dermatologist. Early diagnosis through clinical examination, trichoscopy, and biopsy is the only way to confirm the disease. Although there is no definitive cure for regenerating destroyed follicles, modern therapeutic approaches can effectively control inflammation, halt the disease’s progression, and prevent further permanent hair loss. Proper management, at both a medical and psychological level, is the key to a better quality of life.