Clinical Challenge: Hair and Nail Changes


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A 38-year-old African man is referred for evaluation of localized areas of hair loss and accompanying nail changes. The hair loss was first noted approximately 2 years ago, at which time the patient says the sites were dotted with multiple pinpoint pimples that did not drain but were tender on occasion. Over time, the pimples were replaced with a firm scale devoid of hair. No additional skin findings are identified except for deformity of all fingernails. The patient states that the nail changes coincided with the onset of his scalp dermatitis.

Lichen planopilaris (LPP) is considered a morphologic variant of lichen planus that involves the hair follicles and is classified as a primary lymphocytic cicatricial alopecia.1 Involvement of the scalp begins with the appearance of small papules and clinical symptoms may include...

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Lichen planopilaris (LPP) is considered a morphologic variant of lichen planus that involves the hair follicles and is classified as a primary lymphocytic cicatricial alopecia.1 Involvement of the scalp begins with the appearance of small papules and clinical symptoms may include itching and burning. The inflammatory infiltrate causes localized destruction of hair follicles that eventuates in scarring.

The etiology is unknown but the condition has been associated with a number of diverse factors such as bacterial infection, exposure to metal, stress, and hair transplantation.2-4 Differential diagnosis of LPP includes other causes of cicatricial alopecias such as discoid lupus erythematosus, scleroderma, sarcoidosis, and inflammatory tinea.

Nail involvement is a common manifestation of disseminated lichen planus but rarely accompanies LPP. Nails may show longitudinal depressions and crests, onychoschizia, onychomadesis, longitudinal ridging, and thinning of the nail plate.5,6 A pterygium may result from the fusing.

Histologic findings associated with LPP include a band-like mononuclear infiltrate that obscures the interface between follicular epithelium and the dermis. The dermal-epidermal junction typically shows signs of vacuolar degeneration with apoptotic keratinocytes. Late stages of LPP reveal perifollicular fibrosis.7 Dermoscopic findings vary according to the stage of evolution and the degree of disease activity. The most frequent signs on the scalp are irregular areas of alopecia, perifollicular whitish-gray scaling, perifollicular erythema, absence of follicular openings, and follicular plugging.8

Comorbidities associated with LPP include Hashimoto thyroiditis and hypothyroidism.9  No therapy that has proven universally successful at treating LPP and the clinical course is highly variable. Therapeutic options include potent topical corticosteroids, intralesional corticosteroids, oral antibiotics, hydroxychloroquine, methotrexate, oral retinoids, cyclosporine, Janus kinase inhibitors, and oral minoxidil.10-12

Nejib Doss, MD, is head of the department of dermatology, Military Hospital of Tunis, Tunisia. Ibrahim Almukahal, MD, is head of dermatology at Benghazi Medical Centre in Libya. Stephen Schleicher, MD, is director of the DermDox Dermatology Centers in Pennsylvania, associate professor of medicine at Commonwealth Medical College, and clinical instructor of dermatology at Arcadia University and Kings College.


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7. Tandon KT, Somani N, Cevasco NC, Bergfeld WF. A histologic review of 27 patients with lichen planopilarisJ Am Acad Dermatol. 2008;59(1):91-98. doi:10.1016/j.jaad.2008.03.007

8. Friedman P, Cohen Sabban E, Marcucci C, Peralta R, Cabo H. Dermoscopic findings in different clinical variants of lichen planus. Is dermoscopy useful? Dermatol Pract Concept. 2015;5(4):51-55. doi:10.5826/dpc.0504a13

9. Brankov N, Conic RZ, Atanaskova-Mesinkovska N, Piliang M, Bergfeld WF. Comorbid conditions in lichen planopilaris: a retrospective data analysis of 334 patientsInt J Womens Dermatol. 2018;4(3):180-184. doi:10.1016/j.ijwd.2018.04.001

10. Fatemi Naeini F, Saber M, Asilian A, Hosseini SM. Clinical efficacy and safety of methotrexate versus hydroxychloroquine in preventing lichen planopilaris progress: a randomized clinical trialInt J Prev Med. 2017;8:37. doi:10.4103/ijpvm.IJPVM_156_17 11

11. Yang CC, Khanna T, Sallee B, Christiano AM, Bordone LA. Tofacitinib for the treatment of lichen planopilaris: a case seriesDermatol Ther. 2018;31(6):e12656. doi:10.1111/dth.12656 

12. Vañó-Galván S, Trindade de Carvalho L, Saceda-Corralo D, et al. Oral minoxidil improves background hair thickness in lichen planopilarisJ Am Acad Dermatol. 2021;84(6):1684-1686. doi:10.1016/j.jaad.2020.04.026