Scarring alopecia and lichen planopilaris: why early care matters

Most hair loss is not scarring. In pattern hair loss, shedding after illness or alopecia areata, the follicles survive. In a smaller group of conditions, called scarring or cicatricial alopecias, inflammation destroys the follicles and replaces them with scar tissue. This changes everything about the approach: the aim is not to bring lost hair back, but to protect the hair that remains.

What is lichen planopilaris?

Lichen planopilaris (LPP) is an uncommon inflammatory condition considered a form of lichen planus that affects hair follicles ¹. It causes patchy, progressive hair loss, mainly on the scalp, though eyebrows and body hair can also be affected ¹. Although rare, it is one of the common causes of scarring hair loss on the scalp ¹.

Recognised forms include classic LPP, frontal fibrosing alopecia, which affects the front hairline, and a rarer form called Graham-Little syndrome ¹. Frontal fibrosing alopecia is considered a variant of LPP because the findings under the microscope are similar ². See frontal fibrosing alopecia.

Who gets it?

LPP usually affects young adult women, but the age range is wide and men can be affected ¹. It often occurs together with lichen planus on the skin, inside the mouth or on the nails ¹. The exact cause is unknown; it is thought to be an immune reaction directed at the hair follicle ¹.

Signs to look for

According to DermNet, LPP typically shows ¹:

• smooth, white patches of hair loss where no follicle openings can be seen
• redness and scale around hairs at the edges of the patches
• hairs at the edge that pull out easily
• small patches that may merge into larger irregular areas, often on the sides, front and lower back of the scalp

Some people have no symptoms; others feel itch, pain, tenderness or burning ¹. The condition is usually slowly progressive.

These signs can be subtle in the early stages. Itching or burning in a spot where hair is thinning deserves a doctor's look, especially if there is redness around the hairs.

How is it diagnosed?

A dermatologist will look for lichen planus elsewhere, including in the mouth, on the nails and skin ¹. Trichoscopy may show missing follicle openings and scale around the hairs ¹. A scalp biopsy taken from an active edge is the standard test for a definite diagnosis ². A biopsy is not always conclusive, especially if only old scarring is present without active inflammation ¹.

Other conditions that can look similar include discoid lupus, central centrifugal cicatricial alopecia, folliculitis decalvans and alopecia areata ¹. Getting the right diagnosis matters because treatment differs.

Why early care matters

The most important message: no treatment restores hair that has already been replaced by scar ¹. Every month of active, untreated inflammation may mean more follicles lost. That is why DermNet advises that treatment be sought and given early ¹.

What treatment aims to do

The goals are to slow or stop the disease and relieve symptoms such as itch and burning. Hair loss may continue, but at a slower rate ¹. There are currently no validated treatments or formal guidelines, and recommendations vary with each person's situation ².

Options a dermatologist may consider include ¹:

• strong steroid creams or lotions, or steroid injections into active areas
• other anti-inflammatory creams
• tablets that calm inflammation or the immune system
• newer medicines that are still under investigation

Response varies, and studies do not always agree on which treatments work best ¹.

Follow-up and photos

Because the aim is to stop progression, careful monitoring is essential. Clinical examination, trichoscopy and photographs help the dermatologist judge whether the disease is active and whether treatment is working ². Expect regular reviews, often every few months ¹. Keeping your own photos in the same light and position can help too. See photo tracking.

Camouflage and surgery

• Camouflage: careful styling, hair colouring and hairpieces such as wigs can help ¹. See camouflage options.
• Hair transplant: has been used in long-standing, inactive disease, but it is not always successful, because grafts may survive less well in scarred skin and the disease can flare in treated areas ¹. It is not suitable while the condition is active.

Coping

Losing hair in a way that cannot be reversed can be distressing, and DermNet lists psychological distress and reduced quality of life as complications ¹. Talking to your doctor about how you feel, and seeking counselling or peer support, is a normal part of care.

When to see a doctor

See a doctor promptly if you have patchy hair loss with redness, scaling, itching, pain or burning, or smooth shiny patches where hair used to grow. See seeing a dermatologist and what to do first.

Frequently asked questions

Can hair grow back in lichen planopilaris?

Hair already replaced by scar tissue does not grow back. Treatment aims to slow the disease and protect remaining hair ¹.

How is lichen planopilaris confirmed?

By examination, trichoscopy and usually a scalp biopsy from an active edge, which is the standard test ^{2 1}.

Is frontal fibrosing alopecia the same as LPP?

It is considered a variant of lichen planopilaris because the microscope findings are similar ².

Can I have a hair transplant for scarring alopecia?

Sometimes, in long-standing inactive disease, but results are less reliable and it is not suitable while the disease is active ¹.

Educational content. Not medical advice.