Dear Editor,
Lichen planopilaris (LPP) is a primary lymphocytic cicatricial alopecia that can closely mimic female pattern hair loss (FPHL), especially in its low-inflammatory stages. This diagnostic overlap may delay appropriate management, resulting in irreversible follicular damage.
We report the case of a 42-year-old female who presented with progressive hair loss and thinning over the frontal and vertex area of the scalp for 6 months. She was provisionally diagnosed and treated as a case of FPHL and started on 5% topical minoxidil. However, despite complying with this line of management for nearly 6 months, she reported no significant improvement, which prompted further evaluation. There was no known family history of hair loss, systemic illnesses, or autoimmune disorders.
On clinical examination, a diffuse patch of hair loss was seen over the frontal and vertex of scalp, with sparing of the frontal hairline. Multiple hyperpigmented macules coalesced to form diffuse grayish patches over the affected alopecic area. Atrophy of the skin on the vertex, along with a shiny thinned-out appearance, was suggestive of scarring alopecia [Figure 1a and b].
Figure 1.
(a) Frontal hairline preserved, commonly seen in female pattern hair loss. (b) Patterned hair loss with shiny, atrophic skin over the frontal and vertex scalp
Dermoscopy demonstrated multiple perifollicular blue–gray dots (black arrow), sparing of the interfollicular area suggestive of pigment incontinence (blue arrow), areas of eccrine gland loss suggestive of scarring (green arrow), and lone terminal hairs at the periphery with perifollicular scaling (red arrow) [Figure 2].
Figure 2.
Black arrow: Perifollicular blue–gray dots suggestive of pigment incontinence. Blue arrow: Sparing of the interfollicular area. Green arrow: Loss of eccrine gland openings, indicating scarring. Red arrow: Lone terminal hairs with perifollicular scaling and blue–gray dots
Histopathology showed hyperkeratosis, follicular plugging, and atrophy. Basal cell vacuolation and a dense lymphocytic infiltrate were seen at the dermoepidermal junction hallmark findings consistent with LPP [Figure 3].[1]
Figure 3.
Dense band-like lymphocytic infiltrate at the dermoepidermal junction (black arrow) and follicular plugging with epithelial disruption and fibrosis (green arrow)
The patient was started on oral methotrexate (7.5 mg/week) with folic acid supplementation, along with intralesional corticosteroids every 3 weeks. She was counseled regarding the chronic nature of LPP, its potential to cause irreversible hair loss, and the possible adverse effects of methotrexate. At the 3-month follow-up, she showed stabilization of progressive hair loss, with dermoscopy revealing reduced perifollicular inflammation.
FPHL is a nonscarring alopecia with progressive follicular miniaturization and >20% hair diameter variability.[2] LPP, however, is scarring and inflammatory. Dermoscopy and biopsy remain critical to early diagnosis. Methotrexate, through inhibition of purine/pyrimidine synthesis and T-cell suppression, is effective in LPP management due to its immunosuppressive and anti-inflammatory effects.[3]
This case illustrates a critical diagnostic challenge where LPP may masquerade as FPHL and underscores the need for a high index of suspicion while assessing patterned hair loss, particularly in patients unresponsive to conventional treatments. However, dermoscopy is invaluable in identifying early signs of scarring alopecia.
A systemic approach involving clinical history taking, dermoscopic, and histopathologic examination offers ample opportunity to identify subtle yet critical features, thereby enhancing diagnostic accuracy and optimizing patient management.[4,5]
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initial will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
Conflicts of interest
There are no conflicts of interest.
Acknowledgment
The authors thank the patient for consenting to the use of clinical information for academic purposes.
Thank you for the opportunity to share this observation with your readers.
Funding Statement
Nil.
REFERENCES
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