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Presentation

Diagnosis and Treatment of Lichen Planopilaris and Frontal Fibrosing Alopecia

Description

The talk reviewed diagnosis and treatment of lichen planopilaris (LPP) and frontal fibrosing alopecia (FFA), emphasizing that most therapies are off-label because no treatments are formally approved. LPP was described as a scarring inflammatory alopecia that often causes itching, burning, and pain, with substantial quality-of-life impact, especially in women over 60. Trichoscopy findings include perifollicular scaling, loss of follicular units, and early perifollicular erythema with arborizing vessels; diffuse scales between follicles suggest another diagnosis. Current practical recommendations stratify LPP into mild, moderate, and severe disease: mild cases may start with topical clobetasol or intralesional triamcinolone; moderate disease often uses hydroxychloroquine, with doxycycline or retinoids as alternatives; severe disease may require methotrexate or mycophenolate, with short-term prednisone only as a bridge. JAK inhibitors are promising but lack formal approval and robust data, though baricitinib had good real-world responses in the speaker’s experience. Cetirizine and low-dose naltrexone may help itch symptoms. For FFA, key clinical features include frontal hairline recession, eyebrow loss, and facial papules; trichoscopy helps distinguish it from androgenetic alopecia by the absence of vellus hairs. Treatment is variable, but common first-line approaches combine finasteride or dutasteride with an anti-inflammatory agent such as hydroxychloroquine, tetracyclines, isotretinoin, or intralesional corticosteroids, with retinoids particularly useful for facial papules. The speaker stressed that cicatricial alopecia is a dermatologic emergency because follicular loss is permanent and inflammation should be treated early.

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Conclusions

Lichen planopilaris and frontal fibrosing alopecia are inflammatory cicatricial alopecias that can cause substantial quality-of-life burden, especially from itch, burning, and pain, and should be treated early to prevent permanent follicular loss.
Trichoscopy is central to diagnosis, with perifollicular scaling as a hallmark of LPP and loss of vellus hairs helping distinguish FFA from androgenetic alopecia.
Disease severity should guide therapy, with topical clobetasol or intralesional triamcinolone used for mild LPP, hydroxychloroquine often used for moderate disease, and methotrexate or mycophenolate favored in severe disease.
Methotrexate appears to have the strongest overall evidence and highest response rates among commonly used systemic treatments for LPP, and may deserve consideration as a first-line systemic option.
Cyclosporine can be effective but is often limited by side effects and discontinuation, while doxycycline is safer and practical but likely less effective.
JAK inhibitors are promising for both LPP and FFA, but evidence remains limited, they are not yet approved for these indications, and their benefit may take months to appear.
For FFA, a combination approach is typical, often centered on finasteride or dutasteride plus an anti-inflammatory agent, with intralesional triamcinolone, hydroxychloroquine, tetracyclines, or isotretinoin used as adjuncts depending on the case.
Retinoids seem particularly useful for facial papules in FFA, and isotretinoin may have comparatively favorable response rates in some series.
Metformin is an intriguing but still unproven option for FFA and LPP because published efficacy data are lacking despite some supportive mechanistic rationale and anecdotal expert experience.
Because these disorders are chronic, progressive, and irreversible once follicles are lost, the overall message is that cicatricial alopecia is a dermatologic emergency requiring timely, individualized, multimodal management.

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