What is the best treatment approach for a patient with lichen planopilaris?

Treatment of Lichen Planopilaris

Start with high-potency topical corticosteroids—specifically clobetasol propionate 0.05% applied to the scalp once daily for 2-3 months—combined with hydroxychloroquine 200-400 mg daily for systemic control, as this combination achieves the highest remission rates in lichen planopilaris. 1, 2

First-Line Treatment Protocol

• Apply clobetasol propionate 0.05% ointment or solution to affected scalp areas once daily for 2-3 months. 1 The ointment formulation provides better penetration for scalp lesions compared to gel formulations used for oral disease.

• Add hydroxychloroquine 200-400 mg orally daily as systemic therapy, as the combination of hydroxychloroquine with topical corticosteroids produces the highest remission rate (33% at 18 months) compared to other treatment regimens. 2

• Consider intralesional triamcinolone (10-20 mg/mL) injections every 4-6 weeks for localized, treatment-resistant areas, as this achieves the highest rate of symptomatic improvement in active disease. 3, 2

• After the initial 2-3 month treatment period, taper clobetasol to alternate days for 1 month, then twice weekly for maintenance therapy. 1 Never abruptly discontinue—gradual tapering over 3 weeks prevents rebound flares. 1, 4

Adjunctive Therapies for Symptom Control

• Prescribe oral antihistamines for moderate to severe pruritus, which is the most common presenting symptom (present in 60.8% of patients). 1, 2

• Use emollients as soap substitutes and advise patients to avoid all irritant and fragranced hair products that may exacerbate inflammation. 3, 5

• For acute severe flares, consider a short course of oral prednisone 15-30 mg for 3-5 days. 1

Treatment Algorithm Based on Disease Response

At 3-Month Follow-Up:

• If symptoms improve and inflammation decreases (reduced erythema, scaling, and follicular hyperkeratosis): Continue current regimen and begin tapering topical corticosteroids as outlined above. 1, 6

• If no improvement or progression continues: Add or switch to alternative systemic agents while maintaining topical therapy. 6, 2

For Treatment-Resistant Disease:

• Consider platelet-rich plasma (PRP) injections monthly for 3 sessions in patients failing topical clobetasol alone, as PRP combined with topical corticosteroids shows significantly lower disease activity scores at 2 and 6 months compared to topical therapy alone. 7

• Consider ixekizumab (anti-IL-17A/F biologic) 160 mg initial dose, then 80 mg every 2-4 weeks for severe, refractory cases, as complete hair regrowth has been documented at 12 weeks with sustained efficacy at 12 months. 8

• Low-level light therapy (LLLT) can be added as adjunctive treatment, with evidence showing reduction of inflammation, symptom resolution, and hair regrowth without side effects. 9

Critical Management Principles

• The primary goal is halting disease progression and preventing further permanent hair loss, not hair regrowth—no treatment consistently produces visible hair regrowth in scarred areas. 6, 2

• 50% of patients who achieve remission require continuous maintenance treatment to prevent relapse, so plan for long-term therapy rather than expecting cure. 2

• Remission rates are time-dependent: only 6.5% achieve remission at 3 months, but 33% achieve remission by 18 months with combination hydroxychloroquine and topical corticosteroid therapy. 2

Important Pitfalls to Avoid

• Never use gel formulations on the scalp—these are designed for oral mucosal adherence and are inappropriate for hair-bearing areas; use ointment or solution formulations instead. 1, 4

• Educate patients on proper hand washing after application to prevent inadvertent transfer to eyes or other sensitive areas. 3, 4

• Monitor for corticosteroid side effects including cutaneous atrophy, adrenal suppression, and hypopigmentation, especially with prolonged use. 3, 5

• Avoid potent steroids in pediatric patients due to increased risk of systemic absorption and adverse effects. 3

Follow-Up Protocol

• Schedule follow-up at 3 months to assess treatment response, verify proper medication application technique, evaluate compliance, and monitor for adverse effects. 1, 4

• Perform scalp examination documenting: extent of erythema, follicular hyperkeratosis, scaling, symptoms (pruritus, burning, tenderness), and progression of scarring alopecia. 3, 6

• If satisfactory response at 3 months, continue treatment and reassess at 6 months before considering maintenance therapy adjustments. 4

• Biopsy any atypical or non-responsive areas to confirm diagnosis and rule out alternative diagnoses or malignant transformation. 1