A histologic review of 27 patients with lichen planopilaris

Diffuse Lichen Planopilaris Masquerading as Diffuse Alopecia Areata

Introduction

Lichen planopilaris (LPP) is a primary lymphocytic cicatricial alopecia that represents a form of follicular lichen planus.

Case Presentation

We describe a case of coexisting diffuse LPP and female pattern hair loss masquerading as diffuse alopecia areata in a 32-year-old female.

Discussion

In complex cases such as this, dermoscopy-guided vertical and horizontal biopsies from androgen sensitive and insensitive areas are helpful in increasing diagnostic yield. Prompt initiation of treatment is key to halting disease progression. Long-term follow-up is important as resolution of clinical signs does not always correlate with the absence of disease progression.

Patterns of Mucin Deposition in Lichen Planopilaris: A Journey From Follicular "Bubbles" to Perifollicular Fibroplasia

ABSTRACT

Lichen Planopiolaris (LPP) is a scarring alopecia characterised by a perifollicular lymphoid cell infiltrate at the level of the infundibulum and isthmus. While perifollicular mucinous fibroplasia is an established finding in LPP, intrafollicular mucin deposition has not been previously reported. We describe two cases with this histopathology and suggest it may represent a helpful clue to the diagnosis of LPP, in the appropriate clinical setting.

Cross-sectional study to evaluate the utility of elastic tissue staining in primary cicatricial alopecia

BACKGROUND AND AIMS

Diagnosing end-stage primary cicatricial alopecia (PCA) on routine histology is challenging since the major diagnostic feature (inflammatory infiltrate) may be minimal or absent. This study aimed to assess various staining patterns and diagnostic utility of elastic tissue staining by Verhoeff-Van Gieson (VVG) method and trichoscopy in PCA.

STUDY DESIGN

Cross-sectional study.

METHODS

Fifty-three patients clinically diagnosed with PCA underwent biopsy and trichoscopy in this cross-sectional study. Clinically active edge, if present, was biopsied. Twenty serial tissue sections were stained using H&E and VVG stain. Clinicopathological diagnoses were lichen planopilaris (LPP), discoid lupus erythematosus (DLE), folliculitis decalvans and unclassified PCA (UPCA) in 30 (56.6%), 11 (20.75%), 1 (1.9%) and 11 (20.75%) patients, respectively. Utility of VVG stain was ascertained considering clincopathological correlation (CPC) as the reference standard. Association of characteristic trichoscopic and VVG staining patterns was ascertained.

RESULTS

Diagnostic definition was achieved on VVG staining in 19/30 sections of LPP (wedge-shaped pattern) with 63.33% sensitivity; 7/11 cases of DLE (absent upper and mid dermal elastic fibres) with 63.64% sensitivity and 7/11 cases of UPCA (wedge-shaped pattern-3/7; recoil pattern-4/7). Routine histology suggested diagnosis only in 13/53 sections (24.52%). However, diagnosis on VVG staining corresponded with diagnosis on CPC in 33/53 cases (62.3%). Comparison of H&E versus VVG stain both overall and in the LPP and UPCA cohorts proved utility of VVG staining using Fisher's exact test (p<0.05). Statistical significance was also noted when trichoscopy was correlated with patterns on VVG staining (p<0.05).

CONCLUSION

Increased diagnostic yield is noted with trichoscopy and VVG stain in PCA especially when routine histopathology is non-diagnostic.

Comparative Efficacy Study Combination of Oral Methotrexate and Prednisolone versus Oral Methotrexate in Patients with Lichen Planopilaris

Background

Lichen planopilaris (LPP) is a rare inflammatory disorder of the scalp that causes cicatricial alopecia. No therapeutic approach has been approved for this disease due to the rare frequency. Methotrexate and corticosteroid are commonly considered second- or third-line therapy. The efficacy of a combination of methotrexate and corticosteroid has been reported in some dermatological and immunological diseases. However, the efficacy of this combination in LPP is not clear. Therefore, this study aimed to compare the impact of methotrexate alone and in combination with corticosteroid on LPP.

Materials and Methods

This randomized clinical trial was performed on 28 patients who referred to the dermatology clinic affiliated with Isfahan University of Medical Sciences, Isfahan, Iran during February 2015-December 2016, and 24 of them completed the trials. Fourteen patients received 15 mg methotrexate per week alone and the other fourteen subjects received 200 mg prednisolone plus 15 mg methotrexate per week. The primary outcome was Lichen planopilaris activity index (LPPAI) score. Moreover, we evaluated photographic changes and symptoms during the study.

Results

The mean of LPPAI in both groups decreased during the follow-up with a similar pattern of LPPAI changes in both groups. No statistically significant difference was found between the two intervention groups regarding the LPPAI score. We found no difference in the symptoms and photographic assessments in methotrexate and combination therapy groups during follow-up. In both groups, exclusively one adverse effect was reported.

Conclusions

Our results showed that methotrexate therapy with and without corticosteroids had similar efficacy and safety.

Clinicopathological Features of Alopecia With an Emphasis on Etiology and Histopathological Characteristics of Scarring Alopecia

Introduction

Alopecia is a common dermatological condition with varied etiologies based on age, gender and geographic location. Non-cicatricial (non-scarring) alopecia is more common but often not biopsied. Alternatively, primary cicatricial (scarring) alopecia is diagnostically more challenging and more commonly biopsied to determine the etiology. In this study, we evaluated the clinicopathological characteristics of alopecia in our population.

Methods

We conducted a retrospective study at the Department of Histopathology, Liaquat National Hospital and Medical College, Pakistan. A total of 104 patients were enrolled in the study who underwent scalp biopsy for alopecia over a period of 11 years. Clinical data were obtained from clinical referral forms, which included age, sex of the patients and duration of the lesions. Three hematoxylin and eosin-stained tissue sections, along with periodic acid-Schiff (PAS), PAS with diastase and collagen stains were examined, and histopathological diagnosis was rendered.

Results

Our study demonstrated that alopecia was more prevalent among females, accounting for 73.1% of cases. Most of the patients belonged to the age group of <35 years (53.8%). The type of alopecia in 88.5% of the cases was scarring, while there were 11.5% cases of non-scarring alopecia. The most common diagnoses were discoid lupus erythematosus (DLE) (23.1%) and pseudopelade of Brocq (PB) (23.1%), followed by lichen planopilaris (LPP) (15.4%). A significant association was noted between the histological features and the diagnosis, as epidermal atrophy was the most common histological feature in most cases of DLE, followed by periadnexal infiltrates, lymphocytic infiltrates, follicular plugging and basement membrane thickening. In LPP, the most common histological features were perifollicular infiltrates and fibrosis. In PB, the frequently recurring histological features in most cases were the loss of sebaceous glands, dermal fibrosis and epidermal thinning.

Conclusion

In this study, we demonstrated the key role of skin punch biopsy and histology in determining the accurate etiology of scarring alopecia. We found discoid lupus erythematosus and pseudopelade of Brocq to be the most common causes of scarring alopecia, followed by lichen planopilaris.

Lichen planopilaris arising between two linear surgical scars

Lichen planopilaris (LPP) is a type of lymphocytic cicatricial alopecia, which can occur at unusual sites. It can be difficult to diagnose at an early stage and may be misdiagnosed as seborrheic dermatitis or psoriasis in early stages before alopecia occurs. We report a rare case in which alopecia occurred between two long surgical scars on the scalp several years after surgery. Dermoscopy and biopsy led to a diagnosis of LPP. The localization of the lesions in our case suggests that oxidative stress from the failure of lymph flow might have induced LPP. Oral roxithromycin, a macrolide antibiotic, with anti-oxidative and anti-inflammatory was effective at stopping its progression.

Evaluation of ocular psoriasis with meibography

Background

Previous studies has shown that dry eye test abnormalities, meibomian gland dysfunction (MGD), may occur in psoriasis.

Objectives

The authors aimed to evaluate the dry eye disease (DED), MGD, in psoriasis patients with meibography which is a current, objective, noninvasive method for patients with meibomian gland diseases, to investigate the relationship between disease severity and ocular involvement.

Methods

This study included 50 participants with psoriasis and 50 healthy individuals. All subjects were examined by the same dermatologist and referred for ophthalmological examination including meibomian gland obstruction, lid margin alterations assessment, ocular surface disease index assessment, tear film break-up time test, Schirmer test, corneal conjunctival fluorescein staining assessment. Additionally, upper and lower lids were evaluated for meibomian gland loss with meibography.

Results

MGD (28%), meibomian gland loss (MGL) (29.5%), upper meiboscore (0.61 ± 0.81), lower meiboscore (0.46 ± 0.61), DED (22%) were significantly higher in the psoriasis group compared with the control group (p = 0.008, p < 0.001, p = 0.027, p = 0.041, p = 0.044, respectively). There was a significant relationship between MGD and psoriasis area severity index (PASI) (p = 0.015, Odds Ratio = 1.211). There was a significant positive relationship between MGL with PASI (p < 0.001, r = 608) and psoriasis duration (p < 0.001, r = 0.547).

Study limitations

Smaller study group and inability to detect quality changes of meibum with meibography were limitations of the study.

Conclusions

Psoriasis may affect the meibomian gland morphology, may cause structural changes in meibomian glands, and as a result of these may cause MGD and DED. Therefore, ophthalmologists and dermatologists should be aware of this situation and co-evaluate the patients in this respect.

Flushing episodes in the context of frontal fibrosing alopecia with facial papules

Frontal fibrosing alopecia (FFA) is a progressive frontotemporal hairline recession with eyebrow loss. Facial papules are present in up to 14% of FFA cases and can start with facial flushes. Nevertheless, these flushes are commonly associated with rosacea, a much more prevalent disease. In this case, a woman with FFA had, at first, clinical and histopathological findings of rosacea and was treated with ivermectin 1% cream with no improvement. She returned reporting new papules in the frontal region, reaching the frontotemporal hairline. Trichoscopy of the scalp showed mild perifollicular erythema and follicular scale. The new skin biopsy was compatible with FFA, and oral finasteride (5 mg/day) and hydroxychloroquine were introduced to stabilise the disease.

Evaluation of corneal densitometry changes in patients with lichen planus

PURPOSE

To investigate the corneal topography and densitometry changes in patients with lichen planus (LP).

METHODS

Anterior segment parameters and corneal densitometry of patients with LP and age- and gender-matched individuals with healthy eyes were evaluated using Scheimpflug corneal topography. A 12 mm corneal area was divided into 4 annular zones and 3 regions-in-depth anterior, central and posterior-for densitometry evaluation.

RESULTS

The study included 45 patients with LP and 50 individuals with healthy eyes. The two groups were similar in age and gender, and they showed no significant differences in anterior segment corneal topography parameters. Schirmer's I test results were significantly lower in the patients with LP than in the control group (P ˂ .001). The total corneal densitometry was higher in patients with LP than in the control group (P = .030). The anterior, central and posterior corneal densitometry in the 0-2 mm and 2-6 mm annular zones was higher in the LP group than in the control group. Correlation analysis between disease duration and corneal densitometry values showed a strong positive correlation in the anterior segment and a moderate positive correlation in the central and posterior segments (r = 0.632, P ˂ .001; r = 0.572, P ˂ .001; and r = 0.562, P ˂ .001, respectively).

CONCLUSIONS

Corneal densitometry values were higher in patients with LP than in individuals with healthy eyes, even if the patients had a clinically transparent cornea. More studies are needed to evaluate the changes that may occur in corneal transparency in patients with LP and other autoimmune dermatologic diseases that may affect the eye.

Lichen planus - a clinical guide

Lichen planus (LP) is a chronic lichenoid inflammatory disorder of the skin, mucosa and of the appendages. LP is classically characterized by the presence of a rich infiltration of inflammatory T cells, which migrate in the upper part of the dermis, arranged in a band-like pattern. Different sub types of the disease have been so far described. Albeit LP is clinically well defined, the disease still represents a therapeutic enigma. Especially with regard to mucosal or scalp affecting LP types, which often present a recalcitrant and treatment unresponsive course, efficacious therapeutic options are still lacking. Thus, LP represents a disease with a high psychosocial burden. Yet, development in the deciphering of LP pathogenesis reveals possible new druggable targets, thus paving the way for future therapeutic options. In this clinical guide, we summarize the current clinical knowledge and therapeutic standards and discuss the future perspective for the management of LP.

Lichen planopilaris in men: a retrospective clinicopathologic study of 19 patients

BACKGROUND

Lichen planopilaris (LPP) is a scarring alopecia rarely described in men.

OBJECTIVE

To investigate the clinical and histopathologic features of LPP in men.

METHODS

We performed a retrospective cohort study of male patients with LPP seen at Mayo Clinic between 1992 and 2016.

RESULTS

Nineteen men with biopsy-confirmed LPP were included. The disease most commonly presented with diffuse (42.1%) or vertex scalp (42.1%) involvement. None of the patients had eyebrow or body hair involvement. Perifollicular erythema (94.7%) and pruritus (57.9%) were the most frequent clinical findings. Androgenetic alopecia (AGA) co-occurred in 26.3% of patients. Mucosal lichen planus was found in four patients (21.1%). Thyroid disease occurred in three patients (15.8%). Disease improvement (47.3%) occurred with combination topical and systemic therapy, topical clobetasol monotherapy, and minocycline monotherapy.

CONCLUSIONS

LPP in men has similar clinical and histologic presentations as reported in women. Nonscalp hair loss appears less likely in men with classic LPP than reported in men with frontal fibrosing alopecia, while mucosal lichen planus and thyroid disease appear to be more common in classic LPP. Men with AGA can present with new-onset concomitant LPP. Limitations included small study size, variable follow-up, and lack of standardized clinical assessment due the study's retrospective nature.

Lichen Planopilaris in Women: A Retrospective Review of 232 Women Seen at Mayo Clinic From 1992 to 2016

OBJECTIVE

To characterize the clinicopathologic findings, comorbidities, and treatment outcomes of women with lichen planopilaris (LPP).

METHOD

In this retrospective review of women with LPP at Mayo Clinic from 1992 to 2016, we searched for scarring alopecia in all female patients aged 1 to 100 years from January 1, 1992, through December 31, 2016. Men were excluded from this study to more accurately determine the association of hormonal factors in LPP pathogenesis. Two hundred thirty-two patients were included as they met diagnostic criteria for LPP based on clinicopathologic correlation, with 217 having confirmatory biopsies.

RESULTS

We identified 232 women with LPP (mean age, 59.8 years). Of those, 92.7% (215) presented with hair loss; 23.7% (55) had preceding inflammation; 30.6% (71) had thyroid disease, including hypothyroidism (23.2%; 54); and 9.4% (22) had vitamin D deficiency. Incidence of depression and anxiety was 45.7% (106) and 41.8% (97), respectively. History of total abdominal hysterectomy/bilateral salpingo-oophorectomies and hormone replacement therapy was found in 16.8% (39) and 16.4% (38), respectively. Lichen planus at other body sites occurred in 16.4% (38) of patients; and 53.2% (123) had slowing of disease progression or disease stabilization, often requiring combination therapies. In those who achieved slowing or stabilization of disease, mean time to recurrence was 1.8 year. The mean time to remission was 1.1 year.

CONCLUSION

The typical LPP patient is a 60-year-old female with vertex scarring alopecia who presents with burning, erythema, inflammation, and scale. Almost half of patients will have comorbid autoimmunity. As previously reported, LPP is associated with thyroid disease. We also found higher rates of depression, anxiety, nutritional deficiencies, and skin cancer than reported in the general population.

Pathomechanisms of immune-mediated alopecia

The hair follicle (HF) is a complex mini-organ that constantly undergoes dynamic cycles of growth and regression throughout life. While proper progression of the hair cycle requires homeostatic interplay between the HF and its immune microenvironment, specific parts of the HF, such as the bulge throughout the hair cycle and the bulb in the anagen phase, maintain relative immune privilege (IP). When this IP collapses, inflammatory infiltrates that aggregate around the bulge and bulb launch an immune attack on the HF, resulting in hair loss or alopecia. Alopecia areata (AA) and primary cicatricial alopecia (PCA) are two common forms of immune-mediated alopecias, and recent advancements in understanding their disease mechanisms have accelerated the discovery of novel treatments for immune-mediated alopecias, specifically AA. In this review, we highlight the pathomechanisms involved in both AA and CA in hopes that a deeper understanding of their underlying disease pathogenesis will encourage the development of more effective treatments that can target distinct disease pathways with greater specificity while minimizing adverse effects.

Utility of horizontal and vertical sections of scalp biopsies in various forms of primary alopecias

BACKGROUND:

This study was performed to demonstrate the usefulness of horizontal and vertical sections of scalp biopsies in diagnosing various forms of primary alopecias and to highlight the importance of error-free grossing.

MATERIALS AND METHODS:

A retrospective analytical review of 228 scalp biopsies was done, noting down the diagnostic histopathological features evident in horizontal and vertical sections of each cases. The idealness of the sections, especially horizontal section, was also analyzed.

RESULTS:

Out of the 228 cases, 44 scalp biopsies were classified histologically as cicatricial alopecias and the remaining 162 as noncicatricial alopecia. 22 cases were inconclusive owing to erroneous grossing. We found horizontal sections to be more useful in cases of noncicatricial alopecias, whereas vertical sections proved superior in cicatricial alopecias.

CONCLUSION:

Combining both horizontally and vertically sectioned scalp biopsies maximizes the diagnostic yield. When a single biopsy is submitted, the choice between horizontal and vertical section should depend on clinical diagnosis/suspicion.

Lichen planopilaris: retrospective study on the characteristics and treatment of 291 patients

Lichen planopilaris (LPP) is an immune-mediated cicatricial alopecia. The main clinical presentations of LPP include classic form, frontal fibrosing alopecia (FFA), and Graham-Little-Piccardi-Lassueur syndrome (GLPLS). We reviewed medical records of all 291 patients diagnosied with LPP from 2006 to 2017 in Department of Dermatology, Tehran University of Medical Sciences. LPP was more common in women than men. Lichen planus (LP) was seen in 59 of patients (20.3%). Parietal lesions (69.75%), frontal (27.14%), occipital (23.71%), and temporal (21.64%) were frequently seen in LPP patients. However, trunk hair involvement (15.4% vs. 2.7%; p = .011) and eyebrow involvement (57.7% vs. 0%; p < .0001) were high in FFA patients. The response rates of cyclosporine (CSP) and methotrexate (MTX) were highest, 100% and 85%, respectively. Those treated with CSP achieved partial remission (PR) and complete remission (CR) faster than MTX-treated group. Moreover, MTX was more effective than MMF but not different in time to reach PR (p = .23) or CR (p = .56). However, CSP and MTX were less safe compared with MMF. 5-alpha reductase inhibitors, systemic retinoids (isotretinoin) or their combination were the most effective therapeutic options for FFA patients.

Lichen Planopilaris with Pustules: A Diagnostic Challenge

Introduction

Lichen planopilaris (LPP) is a lymphocytic primary cicatricial alopecia presenting with scarring hair loss and variable degrees of perifollicular erythema and scaling. Pustules are infrequent and may mimic folliculitis decalvans (FD) and other forms of neutrophilic alopecia. We present a series of LPP cases with pustules and discuss the importance of differentiating them from primary neutrophilic folliculitis.

Materials and Methods

Demographic, clinical, histopathological, and follow-up data of 13 cases of LPP with pustules followed at the Department of Dermatology of the University of São Paulo Medical School were described.

Results

Seven females and 6 males were included. Onset of signs and symptoms ranged from 23 to 61 years of age. Previous diagnoses were FD in 3 patients, pityriasis amiantacea in 2 cases, and folliculitis keloidalis nuchae in 1 case. Other 7 cases presented typical clinical features of LPP.

Discussion

There is limited data concerning LPP with pustules. Our analysis shows that LPP should be considered a differential diagnosis in patients with refractory folliculitis. Cautious examination of the entire scalp with dermoscopy and/or reevaluation after a course of antibiotics can avoid misdiagnosis. Further studies are required to establish the etiology of pustules in the setting of LPP.

Lichenoid and interface dermatoses

The terms 'lichenoid' and 'interface' dermatitis are often used interchangeably to describe an inflammatory pattern characterized histologically by damage to the basal keratinocytes in the epidermis. The mechanism of cell damage of such cells is now best understood as apoptosis, or programmed cell death. This inflammatory pattern of dermatoses, is also accompanied frequently by a band of lymphocytes and histiocytes in the superficial dermis, that often obscures the dermal-epidermal junction, hence the term 'lichenoid'. A discussion of the more common lichenoid/interface dermatitides encountered in the routine clinical practice encompasses the following entities: lichen planus, lupus erythematosus, dermatomyositis, erythema multiforme, graft versus host disease, fixed drug reactions, and multiple others.

Primary scalp alopecia: new histopathological tools, new concepts and a practical guide to diagnosis

The diagnosis of primary scalp alopecia remains one of the most challenging fields in dermatopathology. In this review, we would like to connect the established classification of primary alopecia into scarring (cicatricial) and non-scarring (non-cicatricial) with current concepts. We introduce a simplified pathway for the diagnosis of the most common causes of alopecia, including a discussion of tissue processing techniques and use of immunohistochemistry.

The Use of Anti-Keratin 903 Antibodies to Visualize Colloid Bodies and Diagnose Lichen Planopilaris

Cytokeratins are a major component of colloid bodies that are essentially diagnostic of lichen planopilaris (LPP). Here, the authors assess the ability of the cytokeratin 903 antibody (CK-903) to stain colloid bodies and differentiate LPP from other histologically similar appearing primary cicatricial alopecias. A retrospective review of all specimens submitted to the dermatopathology department over a 2-year window identified 18 cases of LPP and 20 cases of histologically similar appearing entities (discoid lupus erythematosus or central centrifugal cicatricial alopecia) through a combination of H&E, elastic van gieson, and periodic acid-schiff stains. All 38 samples were then prospectively stained with CK-903. Colloid bodies were identifiable in 3 of the 18 LPP cases based on H&E alone but were seen in 9 of 18 cases when CK-903 was used. There were no cases where colloid bodies were seen on H&E but not subsequently identified with CK-903. Additionally, there was no CK-903 staining in any of the 20 cases of similar appearing entities except 1 case of discoid lupus erythematosus, which is known to occasionally show colloid bodies. The authors conclude that CK-903 is a useful adjunctive tool that will allow for a quicker, less costly, and more accurate diagnosis of LPP given its ability identify colloid bodies even in the setting of significant inflammation and fibrosis and its advantages over direct immunofluorescence of low cost, short preparation time, and lack of need for a specialized fluorescent microscope.

Clinical, Trichoscopic, and Histopathological Features of Primary Cicatricial Alopecias: A Retrospective Observational Study at a Tertiary Care Centre of North East India

BACKGROUND

The primary cicatricial alopecias (PCAs) are a rare group of diseases where hair follicle is the primary target of destruction. There are a few studies on histopathological and trichoscopic features of PCA.

AIMS

To study the clinical, trichoscopic, and histopathological characteristics of PCAs of the scalp and to find out the concordance between trichoscopic and histopathological diagnosis.

MATERIALS AND METHODS

We retrospectively analyzed the clinical, trichoscopic, and histopathological features of 24 PCA patients. Fisher's Chi-square exact test was done to find the significant trichoscopic and histopathological features. Cohen's kappa coefficient was used to determine the agreement between histopathological and trichoscopic diagnosis.

RESULTS

A total of 24 patients of PCA were seen with a male: female ratio of 2:1. There were 10 (41.7%) patients of discoid lupus erythematosus (DLE), 5 (20.8%) of lichen planopilaris (LPP), 3 (12.5%) of dissecting cellulitis of scalp, and 2 (8.3%) each of pseudopelade of brocq, folliculitis decalvans, and frontal fibrosing alopecia. The important histopathological findings of DLE were follicular plugging, vacuolar changes in the basal layer, necrotic keratinocytes, and superficial and deep perifollicular and perivascular lymphocytic infiltrate. Histopathology of LPP showed vacuolar changes in the basal layer and lichenoid infiltrate involving the infundibulum and isthmus. Trichoscopy of DLE showed follicular plugging, yellow dots, and thick arborizing blood vessels. The peripilar cast was important finding in LPP. The characteristic yellow dot with three-dimensional structure was noted in dissecting cellulitis of the scalp. The Cohen's kappa agreement was 0.89 between histopathological and trichoscopic diagnosis.

CONCLUSION

The diagnosis of PCA is challenging because of overlapping features clinically and histopathologically. Trichoscopy may provide quick and reliable diagnosis and obviate the necessity of scalp biopsy in busy clinics.

Update on lichen planus and its clinical variants

Lichen planus (LP) is an inflammatory skin condition with characteristic clinical and histopathological findings. Classic LP typically presents as pruritic, polygonal, violaceous flat-topped papules and plaques; many variants in morphology and location also exist, including oral, nail, linear, annular, atrophic, hypertrophic, inverse, eruptive, bullous, ulcerative, lichen planus pigmentosus, lichen planopilaris, vulvovaginal, actinic, lichen planus-lupus erythematosus overlap syndrome, and lichen planus pemphigoides. Clinical presentation of the rarer variant lesions may be largely dissimilar to classic LP and therefore difficult to diagnose based solely on clinical examination. However, histopathological examination of LP and LP-variant lesions reveal similar features, aiding in the proper diagnosis of the disease. Management of LP and LP variants aims to control symptoms and to decrease time from onset to resolution; it often involves topical corticosteroids, but varies depending on the severity and location of the lesion. The literature contains an array of reports on the variations in presentation and successful management of LP and its variants. A familiarity with LP and its variants is important in achieving timely recognition and management of the disease.

Pediatric Lichen Planopilaris: Clinicopathologic Study of Four New Cases and a Review of the Literature

Lichen planopilaris (LPP) is a rare form of cicatricial alopecia that has occasionally been reported in children. Because of the limited number of patients reported, little information is available about demographic characteristics, clinical presentation, or treatment options for these patients. A retrospective chart review of LPP cases in patients under 18 years of age from 1976 to 2013 was performed to further define clinicopathologic features of pediatric LPP. Four pediatric LPP patients ages 13 to 16 years were identified (three male, one female). One patient had scalp pruritus and one had other cutaneous findings of lichen planus (LP). Perifollicular scale and scarring were the most common physical examination findings, although changes mimicking those of alopecia areata were observed. Three patients were treated with topical or intralesional steroids. One patient was treated with minocycline. Histopathologic findings included perifollicular interface and perifollicular fibrosis in all cases. There was focal interfollicular interface in two cases and mild dermal mucin in one case. LPP is exceedingly rare in children. It may be misdiagnosed as alopecia areata in children because of the lack of symptoms and other features of LP. There should be a high index of suspicion for LPP in children with alopecia that is unresponsive to standard treatment or who have findings that are atypical for more common childhood alopecias.

Comparison of systemic mycophenolate mofetil with topical clobetasol in lichen planopilaris: a parallel-group, assessor- and analyst-blinded, randomized controlled trial

INTRODUCTION

Lichen planopilaris (LPP) is the most common cause of inflammatory immune-mediated cicatricial alopecia. If not diagnosed and treated properly, it may lead to irreversible hair loss with a devastating impact on quality of life. However, treatment can be a challenge. In an area lacking these sorts of studies, we conducted a randomized controlled trial (RCT) to study the tolerability and therapeutic effects of topical clobetasol versus systemic mycophenolate mofetil (MMF).

METHODS

A randomized, assessor- and analyst-blinded controlled trial was conducted in 60 patients with LPP in Razi Dermatology Hospital, Tehran, Iran, between February and December 2013. Patients were treated with clobetasol lotion 0.05 % applied at night or oral MMF 2 g/day and were followed for 6 months. The Lichen Planopilaris Activity Index (LPPAI) was the primary measure of response to treatment.

RESULTS

Systemic MMF and topical clobetasol were equally effective in reducing the LPPAI over 6 months of treatment. Treatment tolerability was excellent in both groups and no serious irreversible adverse effects were detected. Satisfaction with treatment rose in the MMF group over time; however, it declined in the clobetasol group.

CONCLUSION

Given the similar efficacy profiles, topical clobetasol seems to be a more suitable and reasonable choice for treatment of LPP than MMF.

Elastin staining patterns in primary cicatricial alopecia

BACKGROUND

Most biopsy specimens of cicatricial (scarring) alopecia can be readily subclassified as lymphocytic versus neutrophilic, but specific diagnosis remains difficult, particularly when a late stage of the disease is sampled.

OBJECTIVE

We sought to document patterns of scarring highlighted by elastic tissue staining in primary cicatricial alopecia.

METHODS

We documented Verhoeff elastic van Gieson staining patterns in 58 routinely embedded (vertical) biopsy specimens of cicatricial alopecia. Patterns of fibrosis included perifollicular (wedge-shaped vs broad tree trunk-shaped) and diffuse. The patterns were compared against the diagnosis obtained by independent expert clinical review, including central centrifugal cicatricial alopecia (CCCA), lichen planopilaris, traction alopecia, frontal fibrosing alopecia, discoid lupus erythematosus, and tufted folliculitis.

RESULTS

Wedge-shaped perifollicular fibrosis was seen in lichen planopilaris but also in CCCA. Broad tree trunk-shaped perifollicular fibrosis was most commonly encountered in CCCA.

LIMITATIONS

The retrospective nature of the study precluded temporal staging of the disease process.

CONCLUSIONS

Patterns of fibrosis highlighted by elastin staining in primary cicatricial alopecia appear to be disease specific. Superficial wedge-shaped perifollicular fibrosis is associated with but may not be specific for lichen planopilaris. Broad tree trunk-like perifollicular fibrosis is specific for CCCA but not present in many cases. Elastin staining represents a useful ancillary study for the evaluation of late-stage scarring alopecia in routinely oriented punch biopsy specimens.

Clinical variants of lichen planus

Lichen planus is characterized by lichenoid, polygonal papules with fine white lines, called Wickham striae. Lesions most commonly occur on the limbs and on the dorsal aspect of the trunk. At the same time often leukoplakia of mucous membranes as well as nail disorders are seen. There are numerous variants of lichen planus which can be distinguished from the classical form on the basis of morphology and distribution of the lesions. The typical primary lesion of lichen planus may be replaced by other forms, such as patches, hyperkeratoses, ulcerations, or bullous lesions. Moreover, distribution patterns of these lesions may vary and include erythrodermic, inverse or linear arrangements. In contrast to these numerous clinical features, histologic findings remain characteristic in the variants, so that the diagnosis can be made securely. Differential diagnoses of lichen planus include diverse dermatoses such as bullous pemphigoid or paronychia.

Perda pilosa por líquen plano pilar após transplante capilar: relato de dois casos e revisão da literatura

Alopecia androgenética é tratada com frequência por meio de microtransplante capilar, téc nica em que os fios transplantados geralmente não caem, pois mantêm características da área doadora, mais resistente. O líquen plano pilar é uma alopecia cicatricial com permanente destruição pilosa. Este artigo relata dois casos de lesões compatíveis com líquen plano pilar em áreas receptora e doadora póstransplante. A dominância da área doadora foi aparentemente sobrepujada pelo líquen plano pilar, que deve ter gerado a queda dos fios. Relatos semelhantes são raros. À suspeita de líquen plano pilar, devese biopsiar o couro cabeludo e evitar o transplante durante a atividade da doença.

A study of serial vertical sectioning of scalp biopsies to increase the histological diagnostic yield in alopecias

BACKGROUND

This study was performed to determine whether serial vertical sectioning of scalp biopsies increases the histological diagnostic yield in alopecias.

MATERIALS AND METHODS

The study group included 100 consecutively referred patients with scalp alopecias. The formalin-fixed paraffin-embedded specimens of the scalp alopecias were completely serially sectioned in a vertical orientation and stained with haematoxylin and eosin. The histological diagnosis rendered in the initial slide harbouring three to six sections was compared with the diagnosis in the following vertical serial sections (30-116 serial sections per specimen, mean 53).

RESULTS

A total of 55 scalp biopsies were classified histologically as non-cicatricial alopecia, 35 as cicatricial alopecia and 10 as 'others'. Diagnostic histological findings were present in the initial sections of 50 (50%) cases of alopecia, and only in the following serial sections in 48 (48%) cases. Two cases (2%) lacked differentiating diagnostic histological features in all of the vertical sections. The diagnostic yield of the serial vertical sections compared with the initial sections was higher in the non-cicatricial alopecias (52.7%) than in the cicatricial alopecias (48.5%) and the 'others' category (10%).

CONCLUSIONS

Serial vertical sectioning of scalp alopecias increases the histological diagnostic yield, substantially.

Lichen planopilaris: update on diagnosis and treatment

Lichen planopilaris (LPP), a follicular form of lichen planus, is a rare inflammatory lymphocyte mediated disorder. Although the physiopathology is unclear, an autoimmune etiology is generally accepted. Women are affected more than men, and the typical age of onset is between 40 and 60 years. LLP is a primary cicatricial alopecia whose diagnosis is supported in the early stage by both clinical and histopathological findings. Within the margins of the expanding areas of perifollicular violaceous erythema and acuminate keratotic plugs, the histology can show the lichenoid perifollicular inflammation. LPP can be subdivided into 3 variants: classic LPP, frontal fibrosing alopecia (FFA), and Lassueur Graham-Little Piccardi syndrome. With the exception of FFA, the hairless patches of the scalp can be unique or can occur in multiples and can present with a reticular pattern or as large areas of scarring. This condition can have major psychological consequences for the affected patients. The therapeutic management often is quite challenging, as relapses are common after local or systemic treatments. Further research is needed on the pathogenesis, and randomized controlled trials of treatment with scientific evaluation of the results are necessary to appreciate the proposed treatment.