How should lichen planopilaris causing scarring alopecia be managed?

Management of Lichen Planopilaris Causing Scarring Alopecia

The primary goal in managing lichen planopilaris (LPP) is to halt disease progression and prevent further permanent hair loss through early aggressive anti-inflammatory therapy, as hair regrowth is rarely achievable once scarring has occurred. 1, 2

First-Line Treatment Strategy

Combination therapy with hydroxychloroquine plus high-potency topical corticosteroids achieves the highest remission rates and should be initiated immediately upon diagnosis. 2

• Start hydroxychloroquine 200-400 mg daily orally as the systemic anchor therapy, as this combination led to the highest remission rate (33% at 18 months) in clinical series 2
• Apply clobetasol propionate 0.05% solution to the affected scalp twice daily for 2-3 months, as solution formulations are specifically designed for scalp application 3, 4
• Administer intralesional triamcinolone acetonide injections (5-10 mg/mL) to active areas of inflammation every 4-6 weeks, as this provides the highest rate of symptomatic improvement among topical interventions 2, 3

Critical Treatment Principles

• Begin treatment aggressively at disease onset, as 50% of patients who achieve remission require continuous maintenance therapy to prevent relapse 2
• Taper topical corticosteroids gradually over 3 weeks once symptoms improve to Grade 1 to prevent rebound flares 3, 4
• Set realistic expectations with patients that visible hair regrowth is unlikely even with successful treatment, as no patients in published series achieved regrowth despite achieving disease control 2

Second-Line and Adjunctive Options

For patients who fail first-line therapy or cannot tolerate hydroxychloroquine:

• Consider tacrolimus 0.1% ointment as an alternative topical agent, particularly for patients concerned about corticosteroid side effects 3
• Add oral antihistamines for symptomatic relief of pruritus in moderate to severe cases 3
• Trial narrow-band UVB phototherapy if available, though evidence is limited to case reports 3

Emerging Targeted Therapies

• Ixekizumab (anti-IL-17A/F antibody) achieved complete hair regrowth at 12 weeks in a case of linear LPP refractory to multiple conventional treatments, with sustained efficacy at 12 months 5
• Low-level light therapy (LLLT) demonstrated dramatic response in four patients, including reduction of inflammation, symptom resolution, and evident hair regrowth with no side effects 6

Monitoring Protocol

• Assess treatment response at 3 months to evaluate symptom control (pruritus, tenderness, scalp irritation, hair shedding) and signs of active inflammation (perifollicular erythema, follicular hyperkeratosis) 1, 2
• Recognize that remission rates are only 6.5% at 3 months but increase to 33% at 18 months, requiring patience and treatment persistence 2
• Continue maintenance therapy indefinitely in patients who achieve remission, as 50% will relapse without ongoing treatment 2

Common Pitfalls to Avoid

• Do not delay treatment initiation while awaiting biopsy confirmation if clinical features are characteristic, as early intervention is critical to prevent irreversible scarring 1
• Avoid abrupt discontinuation of topical corticosteroids, which causes rebound flares; always taper gradually over 3 weeks 3, 4
• Do not use cream or ointment formulations on the scalp; only solution formulations provide appropriate application for hair-bearing areas 3
• Never promise hair regrowth as a treatment outcome, as this is rarely achieved even with disease control 2

Treatment-Refractory Disease

For patients failing conventional therapy after 6-12 months:

• Consider steroid-sparing immunosuppressants including methotrexate, mycophenolate mofetil, or cyclosporine in consultation with dermatology 3
• Evaluate for targeted biologic therapy with ixekizumab, particularly in severe or rapidly progressive cases 5
• Trial botanical formulations (topical and oral phytoactive preparations) as emerging evidence shows response in treatment-refractory cases with high patient satisfaction and no adverse effects 7