LPP Is a Scarring Alopecia That Destroys Hair Follicles Permanently
Lichen planopilaris (LPP) is a form of scarring (cicatricial) alopecia that destroys hair follicles permanently, making early detection and tracking critical. LPP causes lymphocytic inflammation that attacks the upper portion of the hair follicle, eventually replacing it with scar tissue. Once a follicle is destroyed, no treatment can restore it.
LPP can affect anyone but is most commonly diagnosed in women between 40 and 60 years old. It is closely related to lichen planus (a condition that can affect skin, nails, and mucous membranes) and is sometimes called the "follicular form" of lichen planus. Frontal fibrosing alopecia (FFA) is now considered a variant of LPP.
Recognizing LPP: Signs and Symptoms
Perifollicular Erythema and Scaling
The hallmark clinical signs of active LPP are visible around individual hair follicles:
- Perifollicular erythema: Redness encircling the base of individual hairs. This is the inflammation actively attacking the follicle.
- Perifollicular scaling: A keratotic (scaly) plug or "sleeve" around the hair shaft at the scalp surface. These scales may look like small collars of dead skin gripping individual hairs.
- Follicular hyperkeratosis: Thickened, rough texture around follicle openings in the active zone.
These signs are most visible at the border between scarred and healthy scalp and may require close-up photos or trichoscopy to see clearly.
Symptoms
LPP is not always asymptomatic. Patients commonly report:
- Itching (pruritus) at or near active areas, ranging from mild to severe
- Pain or tenderness on the scalp, especially when touching or pressing on active areas
- Burning sensation at the active margin
- Tightness or a pulling feeling in the scalp
Symptom intensity often correlates with disease activity. Increasing symptoms can signal a flare before visible progression appears in tracking photos.
Patterns of Involvement
LPP can present in several ways:
- Patchy: One or more discrete patches of hair loss, each with a smooth, scarred center and an active inflammatory border
- Diffuse: More widespread thinning across larger areas of the scalp
- Frontal pattern: When LPP primarily affects the frontal hairline, it is classified as frontal fibrosing alopecia (FFA), a recognized LPP variant. See our frontal fibrosing alopecia guide for FFA-specific information.
How LPP Differs from Other Conditions
| Feature | LPP | AGA | Alopecia Areata |
|---|---|---|---|
| Scarring | Yes (permanent) | No | No |
| Follicular ostia | Lost in scarred areas | Preserved | Preserved |
| Perifollicular signs | Erythema, scaling | None | None (or exclamation point hairs) |
| Symptoms | Itching, pain, burning | None | Usually none |
| Pattern | Patchy or diffuse | Patterned (Norwood/Ludwig) | Round patches |
| Hair pull test | Positive at active margin | Usually negative | Positive at margins |
| Recovery potential | Scarred follicles: none | With treatment: good | Spontaneous possible |
Confirming the Diagnosis
The Role of Scalp Biopsy
A clinical suspicion of LPP should be confirmed with a scalp biopsy. The biopsy is typically taken from the active margin (where inflammation meets healthy hair), not from the scarred center (where follicles are already destroyed and diagnostic features may be lost).
Characteristic biopsy findings in LPP:
- Lichenoid (band-like) lymphocytic inflammation at the infundibulum (upper follicle)
- Perifollicular fibrosis (scar tissue around follicles)
- Destruction of sebaceous glands
- Wedge-shaped scarring replacing follicles
Why Biopsy Matters
Several conditions can mimic LPP clinically. Biopsy distinguishes LPP from:
- Discoid lupus erythematosus (DLE)
- Central centrifugal cicatricial alopecia (CCCA)
- Pseudopelade of Brocq
- Alopecia areata (which can sometimes look similar but is non-scarring)
The treatment approach differs significantly between these conditions, making accurate diagnosis essential.
Tracking Protocol for LPP
Monthly Photo Documentation
Consistent tracking serves two purposes in LPP: detecting progression and evaluating treatment response.
Photo protocol:
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Overview photos of each affected area: Capture the full patch including surrounding healthy hair. Same angle, distance, and lighting every session.
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Close-up photos of the active margin: This is the most informative zone. Zoom in on the border where scarred skin meets hair-bearing scalp. Document perifollicular redness and scaling.
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Measurement photos: Place a small ruler or reference marker near the affected area to track patch size over time. Measure the longest diameter and perpendicular width of each patch.
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Any new areas: Photograph any new suspicious spots, even small ones. LPP can develop new patches while existing ones are being treated.
Symptom Tracking
Alongside photos, maintain a symptom log:
- Itching intensity (0-10 scale) at each tracking session
- Pain or tenderness (0-10 scale)
- Burning sensation (present/absent)
- Location of symptoms (which area is most active)
Increasing symptoms between tracking photos may prompt an earlier dermatologist visit before the next scheduled appointment.
What AI Tracking Can and Cannot Do for LPP
AI-powered density tracking can measure density changes in the zones surrounding active patches, helping detect expansion before it becomes visually obvious. However, AI tracking has limitations with scarring alopecias:
- It measures surface density, not the inflammatory activity underneath
- It cannot replace trichoscopy for assessing perifollicular signs
- Scarred areas may register as "zero density" without distinguishing the cause
Use AI tracking as a complement to clinical assessment, not a replacement. For understanding the difference between what AI tracking detects in non-scarring versus scarring conditions, see miniaturization vs. scarring.
Treatment Options
First-Line Treatments
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Hydroxychloroquine (200-400mg daily): An antimalarial with immunomodulatory properties. Commonly used as first-line systemic treatment. Takes 3-6 months to assess response. Requires baseline and annual ophthalmologic exams due to rare retinal toxicity risk.
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Doxycycline (100-200mg daily): Used for its anti-inflammatory (not antibiotic) properties. Often combined with topical treatments. Generally well-tolerated.
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Topical corticosteroids: High-potency steroids (clobetasol propionate) applied to active areas. Effective for localized disease but limited by skin thinning with prolonged use.
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Intralesional corticosteroids: Triamcinolone acetonide injected directly into the active margin. Provides concentrated anti-inflammatory effect. Repeated every 4-8 weeks during active disease.
Second-Line Treatments
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Topical tacrolimus (0.1%): A calcineurin inhibitor that suppresses local immune activity without the thinning effects of steroids. Applied directly to the active margin.
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Mycophenolate mofetil: An immunosuppressant used for resistant LPP that does not respond to first-line therapies. Requires blood monitoring.
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Pioglitazone: A PPAR-gamma agonist with anti-inflammatory and anti-fibrotic properties. Emerging evidence suggests benefit in some LPP patients.
Combination Therapy
Most dermatologists use combinations of systemic and topical treatments. For example, hydroxychloroquine plus intralesional steroids plus topical tacrolimus at the active margin. The specific combination is tailored to disease severity, location, and treatment response as documented by tracking data.
Treatment Goals
The goal of LPP treatment is disease control, not cure. Success means:
- Halting the expansion of affected areas
- Reducing symptoms (itching, pain)
- Suppressing visible inflammation (perifollicular redness and scaling)
- Preserving remaining hair follicles
Treatment is typically continued long-term. Premature discontinuation often leads to relapse.
When to Seek Urgent Evaluation
Contact your dermatologist promptly if you experience:
- Rapid expansion of existing patches
- New patches developing despite treatment
- Significant increase in itching, pain, or burning
- Visible worsening of perifollicular redness in tracking photos
These signs suggest active, uncontrolled disease that may need treatment escalation.
Start Monitoring Today
For anyone diagnosed with or concerned about LPP, consistent tracking data is your most valuable tool for guiding treatment decisions. The earlier you detect changes, the more effectively your dermatologist can respond.
Begin your scalp analysis at myhairline.ai/analyze and establish the baseline documentation that supports your care.
Medical disclaimer: This article is for informational purposes only and does not constitute medical advice. Lichen planopilaris is a complex condition requiring diagnosis and management by a board-certified dermatologist, ideally one experienced in scarring alopecias. Scalp biopsy is necessary for definitive diagnosis. Do not delay clinical evaluation if you suspect a scarring alopecia.