Journal of Cosmetics, Dermatological Sciences and Applications, 2013, 3, 35-39 Published Online September 2013 ( 35
Lichen Planopilaris is a Common Scarring Alopecia among
Iraqi Population*
Khalifa E. Sharquie1#, Adil A. Noaimi2, Ammar F. Hameed2
1Scientific Council of Dermatology & Venere ology-Iraq i Board for Medic al Specializations, Baghdad, Iraq; 2Department of Derma-
tology & Venereology, College of Medicine, University of Baghdad, Baghdad, Iraq.
Email:, adilnoaimi@,
Received May 18th, 2013; revised June 20th, 2013; accepted June 30th, 2013
Copyright © 2013 Khalifa E. Sharquie et al. This is an open access article distributed under the Creative Commons Attribution Li-
cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background: Scarring alopecia like discoid lupus erythematosus, lichenplanopilaris and scarring folliculitis are com-
mon skin problems where differentiations between them are often difficult in many cases. Objective: To report, study
and evaluate cases of lichen planopilaris and characterize the different clinical points in favor of this disease. Patients
and Methods: This case series descriptive study was done at Department of Dermatology-Baghdad Teaching Hospital
from January 2010 to November 2012. Sixty seven patients were included where histological and dermatological ex-
aminations were carried o ut to all patients regarding all relevant points related to the disease. Punch biopsies were per-
formed from ten patients for histopathological study. Results: The mean age of onset of the disease was 36.7 ± 5 years
with a mean duration of the disease being 4.4 ± 3 years. The male to female ratio was 1.4:1. The characteristic lesions
were pigmented scarring moth eaten alopecia surrounded by pigmented hyperkeratotic follicular papules involving
mainly the fronto-vertical and parietal scalp. Conclusions: Lichen planopilaris is a common cause of scalp scarring
alopecia in adult and it has many characteristic clinical features which can facilitate differentiation from other patho-
logic scalp conditions like discoid lupus erythematosus.
Keywords: Cicatricial Alopecia; Lichen Planopilaris; Moth Eaten Alopecia
1. Introduction
Lichen planopilaris (LPP) is a chronic inflammatory dis-
ease characterized by lymphocytic destruction of the hair
follicle resulting in progressive scalp scarring alopecia.
The cause is unclear but autoimmune pathology seems to
be the most accepted theory [1]. Women are affected
more than men and clinical presentation includes grouped
keratotic follicular papules surrounded by erythema.
Early disease is usually confirmed by histological ex-
amination, however a late disease often has no more spe-
cific signs making it hard to separate from other scarring
scalp conditions even with utilizing the h istopathological
examination [2].
The North American Hair Research Society (NAHRS)
placed LPP in the lymphocytic group. Although, LPP is
consid ered a rar e dise ase but it is the mo st frequ ent ca use
of adult primary scarring alopecia. According to the
NAHRS classification, LPP has been subdivided into 3
variants: classic LPP, frontal fibrosing alopecia (FFA),
and Lassueur Graham-Little Piccardi syndrome [3].
Scarring alopecia is considered as one of the most dis-
figuring problems that cause great cosmetic concern for
the patients. In our daily practice the most common cau-
ses of scaring alopecia are trauma (including burn), LPP,
discoid lupus erythematosus (DLE), fungal infection (ker-
ion) and striae di st ensae-li ke lesi ons scarring alopecia [4].
The aim o f th e presen t stud y was to stud y and ev alua te
the characteristic clinical features which can differentiate
classic LPP from other scarring scalp diseases.
2. Patients and Methods
This case seris descriptive study involved a total of 67
patients diagnosed as LPP and registered at the Depart-
ment of Dermatology and Venerology-Baghdad Teach-
ing Hospital between January 2010 to November 2012.
Clinical data including demographics: gender, age of
patient at onset of the disease, duration of the disease,
symptoms and signs of LPP in the scalp and other body
*Disclosure: This study was an independent study and not funded
any pharmaceutical company.
#Corresponding author.
Copyright © 2013 SciRes. JCDSA
Lichen Planopilarisis a Common Scarring Alopecia among Iraqi Population
sites, site and extent of the disease. Medical photographic
documentation of the lesions were done using Canon
Digital IXUS 85IS camera. The extent of disease was
adapted from Dr. Pric’s visual aid for estimating per-
centage of scalp hair loss in which one can divide the
scalp into 4 quadrants and estimate the percentage of the
scalp surface that all the alopecic areas would occupy if
placed together [5]. Histopathological examination was
achieved in 10 patients. Six mm punch biopsies were
taken from the scaly follicular border of the lesion to be
submitted for vertical sectioning and Haematoxylin-Eo-
sin staining. Formal consent was obtained from each pa-
tient after full explanation of the goals and the nature of
the study to them and the study was approved by the eth i-
cal committee of Iraqi Board for Medical Specializations.
Simple descriptive statistical analysis was carried out.
3. Results
Sixty seven patients with LPP were evaluated. Their ages
ranged between 20 to 65 years with a mean age ± SD of
onset of the disease was 36.7 ± 5 years. The mean dura-
tion of their disease was 4.4 ± 3 years with a range of 0.5
- 15 years. The male to female ratio was 1.4:1 (39 men
versus 28 women). Fifty five (79%) patients were symp-
tomatic with increased hair shedding observed in 45
(67%) patients, pruritus in 40 (59.7%) patients and scalp
tenderness in 36 (53.7%) patents.
Parietal and fronto-vertical scalp areas were the most
commonly involved parts where it was affected in 50
(74%) patients and in 41 (61%) patients respectively
(Table 1).
Twenty nine (43%) patients having 51% - 75% of their
scalp involved by pigmented patchy scarring hair loss
which is surrounded at its periphery by acuminate pig-
mented hyperkeratotic follicular papules. This pattern of
hair loss was irregular in all cases simulating the so
called moth eaten alopecia seen in seco ndary syph ilis and
alopecia areata (Figure 1). Extra-cranial lichen planus
was found in 18 (26.8%) patients with the trunk being the
most commonly affected part in 7 (10%) patients.
The follicular truncal involvement was asymptomatic
and often unnoticed by the patients (Figure 2). Other
extra-cranial involvements are shown in Table 1.
Histology of the examined patients were almost diag-
nostic of LPP through demonstration of lymphocytic
lichenoid infiltration of the upper part of follicular epi-
thelium with vacuolar chang es in its basal layer, presence
of colloid bodies and melanophages, the inflammatory
process was found to affect the upper permanents seg-
ment of the hair follicle at the attachment of erector pilli
muscle (bulge region) causing dermal fibrosis while the
lower segment of the hair follicle including hair matrix
was not aff ec t e d by this pathologic p rocess.
Table 1. Clinical characteristics of the LPP patients.
Clinical findings No. (%)
Site of the LPP
Frontal scalp
Parietal scalp
Temporal scalp
Occipital scalp
Symptoms of LPP
Hair shedding
Extent of scalp involvement
1% - 25%
26% - 50%
51% - 75%
76% - 100%
Extra-cranial LP
Mucous membrane
Axilla and groin
41 (61)
50 (74)
17 (25)
35 (52)
45 (67)
40 (60)
36 (54)
9 (13.4)
22 (33)
29 (43)
7 (10)
19 (28)
11 (16)
7 (10)
1 (1.5)
1 (1.5)
1 (1.5)
1 (1.5)
1 (1.5)
Figure 1. Pigmented scarring moth eaten alopecia involving
the occipital and parietal scalp of an elderly man with li-
chen planopilaris.
Figure 2. Pigmented lichenoidfollicular papules distributed
in the anterior trunk of male patient with lichen planopi-
Copyright © 2013 SciRes. JCDSA
Lichen Planopilarisis a Common Scarring Alopecia among Iraqi Population 37
4. Discussion
Scarring alopecia represents a challenge for both patient
and the treating dermatologist where early diagnosis is
essential to provide a guide for the initiation of an early
and effective therapy to save the follicular apparatus
from the irreversible damage caused by a variety of dis-
eases. From the daily clinical practice, we think that LPP
is the commonest cause of adult scarring alopecia in the
present time. Many Iraqi dermatologists are unaware
about this clinical observation and they often misdiag-
nosed LPP as DLE. The main objective of the present
study is to characterize the main clinical features of LPP
that can differentiate it from other similar scarring co ndi-
tions like DLE.
The mean age of onset inpatients of the present work
was 36.7 ± 5 years which is considered younger than that
reported by Tan et al. [5] where the mean age was 47.4
years and that of Cevasco et al. with a mean age was
48.9 years [6].
The present study showed that males were more af-
fected than males with a ratio of 1.4:1.These differences
in age and sex distribution can be attributed to the racial
differences as the present study was mainly among Arab
while previous studies were mainly among Caucasian
Parietal and fronto-vertical regions were the most fre-
quently involved part of the scalp in the present study
which is comparable to what had been reported in the
medical literatures [6,9,10].
Scarring alopecia was severe in 43% of patient as 51%
- 75% of their scalp surface area was affected by the
scarring process. This can be explained partly by the de-
layed or misdiagnosis with other similar conditions.
All patients had prominent and characteristic multifo-
cal irregular areas of patchy scarring hair loss resembling
moth eaten alopecia which is similar to what has been
seen in secondary syphilis and alopecia areata [11,12]
( Figures 3 and 4).
However, loss of follicular orifices can readily dis-
criminate the scarring moth eaten alopecia of LPP from
that of non scarring moth eaten alopecia in secondary
syphilis or alopecia areata [12]. This observation was not
well documented in the medical literature.
Scarring alopecia of the scalp can be associated with
other regional involvements as the present work showed
that 26.8% of patients had extracranial involvement
which was in agreement with many published reports [7,
8]. Most patients were unaware about the presence of
these small asymptomatic truncal follicular papules
unless it closely looked for by the examining dermatolo-
gist (Figure 2). Hence careful examinations of all body
regions are mandatory in evaluation of scarring scalp
All patients had prominent and characteristic multi-
Figure 3. The non-scarringmoth eaten alopecia in male pa-
tient with alopecia areata.
Figure 4. Typical moth eaten alopecia of secondary syphilis
in male patient.
focal irregular areas of patchy scarring hair loss resem-
bling moth eaten alopecia which is similar to what has
been seen in secondary syphilis and alopecia areata [12,
13] (Figures 3 and 4).
However loss of follicular orifices can readily discri-
minate the scarring moth eaten alopecia of LPP from that
of non scarring moth eaten alopecia of secondary syphilis
or alopecia areata [13].
The main diagnostic challenge for LPP is DLE. How-
ever there are many clinical and histopathological points
which can help the dermatologists to differentiate be-
tween these two primary lymphocytic cicatricial condi-
tions as follows:
The early lesions of LPP are pigmented follicular
papules while the early presentation of scalp DLE is
single or multiple scaly erythematous patches (Fig-
ure 5).
The scarring process in LPP is early and pigmented
while scarring in DLE is usually late and erythema-
Copyright © 2013 SciRes. JCDSA
Lichen Planopilarisis a Common Scarring Alopecia among Iraqi Population
Figure 5. Erythematous scarring alopecia in female patient
with discoid lupus erythematosus.
Irregular scarring areas that simulate moth eaten
alopecia are characteristic feature of LPP scarring and
can be considered as the most important differentiat-
ing point between DLE and LPP.
The activity of the disease is mainly central in DLE
lesions while the activity of LPP is mainly at the pe-
riphery of the scarring patch in the form of hyperk-
eratotic follicular papules [6].
The associated manifestation of other body regions
also can help approach the diagnosis; The lesions in
DLE commonly affect the sun exposed parts, particu-
larly on the cheeks, nose and the ears [13,14] with
typical discoid lesions, while LPP lesions, as demon-
strated by the present work, commonly present with a
symptomatic truncal follicular papules which might be
scarring or not (Figure 2).
Although both conditions sh are lichenod lymphocytic
infiltration of basal ep ithelium and follicular structure
with vacuolar interface dermatitis, but DLE lesions
are characterized by deeper follicular inflammation
and perieccrine lymphocytic infiltration while the
perifollicular inflammation in LPP is more superficial
and limited to the upper segment of the hair follicle [8]
(Figure 6).
The pathologic changes in active LPP are mainly fol-
licular without affection of the epidermis while in
DLE the changes are both epidermal (vacuolar inter-
face dermatitis) and dermal (interfollicular mucin
deposition) [15]. We also noticed an important ob-
servation where the inflammatory process involved
the area of bulge region causing fibrosis and leaving
the lower segment of the hair follicle intact. This
pathologic finding may be responsible for the perma-
nent damage to the hair organ and support the theory
that the bulge region is the site of hair regeneration
Figure 6. Lichen planopilaris showing follicular hyperkera-
tosis and superficial perifollicularlichenoid lymphocytic in-
filtrations causing dermal fibrosis. (H&E stain × 40).
Thickening of basement membrane and mucin depo-
sition in the dermis is a feature of DLE [17].
Other laboratory abnormalities like antinuclear factor
are frequently positive in DLE but not in LPP [14].
Accordingly DLE represents a systemic disease with
follicular involvement while LPP can be considered
as localized skin problem.
Early treatment of DLE can induce rapid hair re-
growth with little or no scarring while in LPP, the
scarring is aggressive from the start and the aim of the
medical intervention is to stop the early progress of
the disease. Hence very early diagnosis is mandatory.
In conclusion, scarring alopecia is a common problem
among adult population which can end by Pseudopelade
of Brocq. Although LPP and DL E can be so similar both
clinically and histologically, still a careful clinical ex-
amination remains the gold standard in establishing the
final diagnosis. Scarring moth eaten alopecia is the main
clinical differentiating point from other scarring scalp-
conditions like DLE.
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