Lichen planopilaris : the importance of early diagnosis

Lichen planopilaris is a rare disorder that belongs to the primary scarring alopecia type. The present study describes the case of a female patient bearing desquamative erythematous plaques and follicular plugs bilaterally in the frontoparietal region, associated with positive pull test. The biopsy’s result was consistent with lichen planopilaris and the patient was treated with prednisone associated with clobetasol, with regrowth of the hair in the affected area. The treatment of this pathology is a challenge due to the lack of data on efficacy of therapies and constant recurrence. The picture is irreversible if not treated early. This paper describes a classic case of a case of lichen planopilaris with good therapeutic response, highlighting the importance of early diagnosis, due to the fact that most cicatricial alopecias do not produce scarring in their initial stage and should for this reason be managed as an emergency in trichology.


INTRODUCTION
2][3] It is classified as a primary lymphocytic cicatricial alopecia 1,3,4 the same classification received by discoid erythematosus lupus (DEL), central centrifugal cicatricial alopecia, pseudopelade of Brocq (PBB) among others. 1The destruction of the hair follicle and replacement by fibrosis is a natural development in cicatricial alopecias. 1,2ichen planopilaris has chronic course, unpredictable development and, probably, autoimmune pathogenesis, 2,3 with an unknown inflammatory process against an autoantigen.infections, genetic factors and immunological abnormalities are described as possible triggering factors. 1 The authors of the present paper describe a case with classic manifestations of LPP, highlighting the importance of early diagnosis.

CASE REPORT
A 43-year-old female patient reported erythema and desquamation on the scalp with onset three months before, and intense pruritus associated with hair loss.She described previous use of clobetasol without improvement, denying comorbidities or use of any other medications.Dermatological examination showed erythematous-desquamative plaques with follicular plugs in the frontoparietal region bilaterally, (Figure 1) and positive pull test.Perifollicular and interfollicular erythema associated with tubular perifollicular scales were observed using trichoscopy (Figure 2).There were no nail or mucosal alterations at examination.The hypotheses of LPP and seborrheic dermatitis were raised.The lesion's biopsy yielded an anatomopathological study compatible with LPP (Figure 3).General laboratory tests were requested, resulting in serologies with absence of alterations.The patient started to use 40 mg/day oral prednisone, associated with 0.05% topical clobetasol twice daily, in addition to hydration.The patient progressed with great clinical improvement 30 days after the beginning of the treatment (Figure 4).The weaning off of the corticoid was then started up until it could be suspended.The patient is being follow-up and experienced hair regrowth of the affected area, at present with four months of remission, after the total suspension of systemic and topical corticosteroids (Figure 5).

DISCUSSION
2][3] These forms are differentiated by their distribution on the scalp and the patient's age group, however they have overlapping characteristics, such as perifollicular inflammation, follicular hyperkeratosis, and cicatricial alopecia. 2n FFA, there is a characteristic involvement of the frontotemporal area of postmenopausal women with an association of eyebrow lesion in a percentage that ranges from 50 to 83% of the cases. 1,3In GLPLS, it is possible to observe the triad of cicatricial alopecia in the scalp preceding non-cicatricial alopecia in the axillae and groins, accompanied by generalized lichenoid follicular papules.The case reported is compatible with classical LPP, the most common variant affecting women, 1-3 which frequently has its onset between the fifth and the seventh decades of life.2,3The involvement of the scalp is irregular and occurs in the form of plaques, mainly in the apex1- 3,5,6 and in the parietal region, as observed in the studied patient.Nevertheless, any region of the scalp can be affected. 2,3e first observed clinical signs are hyperkeratosis, follicular plugs and perifollicular erythema, 3,5,6 associated with a positive pull test.3Trichoscopy of early stages evidence perifollicular and interfollicular erythema associated with tubular perifollicular scales.Many patients are misdiagnosed with seborrheic dermatitis at this stage, 5 entailing a delay in the treatment and worsening of the prognosis.5,6 Complaints of pruritus and burning sensation are common, 1,3,5,6 as well as the association with the skin, nail and mucosal LP lesions. 1 It is estimated that at the time of diagnosis 17 to 28% of patients have evidence of LP 3 in other places of the body, meaning a complete physical examination is of paramount importance. 1,3,5ifferential diagnosis is performed with seborrheic dermatitis, DEL and PBB. 1 Biopsy of the lesions is necessary to differentiate them at the initial stage. 3,62][3] The peripheral lymphocytic infiltrate mainly affects the region that lays between the infundibulum and the isthmus, coursing with the destruction of the bulge. 2,3,5,6If LPP is not expanding with perifollicular inflammation and hyperkeratosis, it is impossible to differentiate it from PBB, 1-3 which some authors do not consider a different entity, but the final stage of LPP.

Figure 1 :
Figure 1: Erythematous-desquamative plaques with follicular plugs in the scalp's frontoparietal region bilaterally.The follicular plugs are more evident inside the black circle

Figure 2 :
Figure 2: Trichoscopy allowed to observe perifollicular and interfollicular erythemas associated with tubular perifollicular scales.The scales are more evident in the areas in Figures A, B and C. In D it is possible to observe through the trichoscopy of the hair that fell when performing the pull test.It is also possible to observe the tubular perifollicular scaling.

Figure 3 :Figure 5 :
Figure 3: A -HE20x It is possible to observe a discrete epithelial hyperplasia, hyperkeratosis and lymph histiocytic infiltrate of perifollicular lichenoid pattern compatible with lichen planopilaris.B -HE100x.Also, it was possible to observe an inflammatory infiltrate centered on the hair follicle.C -HE400x detail of the inflammatory infiltrate centered on the hair follicle

Figure 4 :
Figure 4: After one month of therapy it was possible to observe improvement, with the reduction of perifollicular and interfollicular erythema and scaling of the scalp