Clinical and Histopathological Findings of Frontal Fibrosing Alopecia-Associated Lichen Planus Pigmentosus

Coexistence of Lichen Planus Pigmentosus and Classic Lichen Planopilaris: A Case Report and Literature Review

Lichen planus (LP) is a common inflammatory skin disorder with multiple variants. The coexistence of lichen planus pigmentosus (LPPigm) and frontal fibrosing alopecia is well-established in the literature. However, the coexistence of LPPigm and classic lichen planopilaris (LPP) is rare. We report a case of LPPigm and classic LPP in a postmenopausal woman with a literature review.

Case Series of Frontal Fibrosing Alopecia and Fibrosing Alopecia in a Pattern Distribution: Is There a Familial Correlation?

Introduction

Frontal Fibrosing Alopecia (FFA) and Fibrosing Alopecia in a Pattern Distribution (FAPD) are two distinct entities of cicatricial pattern hair loss that share histological features of perifollicular lichenoid inflammation associated with concentric fibrosis. Although the pathophysiology of FFA and FAPD are still unknown, recently published reports of familial cases indicate a possible genetic correlation.

Case Presentation

We report 6 cases of familial alopecia composed of mothers and daughters: five with FFA and one with FAPD. We describe clinical, trichoscopy and histological correlation in cases of familial alopecia.

Conclusions

These cases of mother and daughter disease association suggest a potential benefit of and role for performing systematic scalp examinations of all first-degree relatives of patients with pattern cicatricial alopecia.

Sensitization to benzyl salicylate and other allergens in patients with frontal fibrosing alopecia

BACKGROUND

Contact sensitization is frequent among patients with frontal fibrosing alopecia (FFA) (52%-76%).

OBJECTIVE

To evaluate the frequency of sensitization/photosensitization in an FFA population.

METHODS

A population of FFA patients were patch tested (Spanish Contact Dermatitis Research Group [GEIDAC] baseline; cosmetic and fragrance series), and photopatch tested (sunscreen series).

RESULTS

Thirty-six patients (mean age: 64.6 years; 35/36: women) were studied. A history of dermatitis was recorded in 69.4% (frequently involving the face). Overall, 80.5% patients showed positive patch-test reactions. The most frequently positive allergens were nickel sulfate (25%), benzyl salicylate (22%), gallates (16.6%), propolis (16.6%), and limonene hydroperoxides (13.8%). Benzyl salicylate was likely relevant to the dermatitis (labeled on personal care products and most patients reporting clinical improvement with allergen avoidance). Patch tests with sunscreens showed positive reactions to 11 materials (five patients). Photopatch tests were positive in one case.

CONCLUSION

We speculate a possible relationship between sensitization to benzyl salicylate and FFA. Hypothetically, the most likely explanation is that sensitization to benzyl salicylate involving FFA patients is a consequence of increased exposure to it. It is unclear whether allergen avoidance may impact the prognosis of alopecia. However, it seems to significantly improve the patients´ quality of life by lessening dermatitis and pruritus.

Association of Frontal Fibrosing Alopecia with Facial Papules and Lichen Planus Pigmentosus in a Caucasian Woman

Introduction

Frontal fibrosing alopecia (FFA) is a lymphocytic primary cicatricial alopecia typically involving the frontotemporal hairline. It may be associated with the presence of facial papules (FP) that clinically appear as noninflammatory, monomorphic, white-yellowish papules. Lichen planus pigmentosus (LPPigm) is characterized by the presence of asymptomatic grayish pigmented macules, predominantly in sun-exposed and flexural areas.

Case Report

A 58-year-old, Caucasian, phototype III woman presented with a symmetrical, band-like, frontotemporal alopecia with regression of the hairline; bilateral eyebrow loss; diffuse, symmetrical hyperpigmentation of the face; and some asymptomatic, flesh-colored, monomorphic papules on the chin. Based on clinical, dermoscopic, and histological findings, the diagnosis of FFA associated with FP and LPPigm was established.

Discussion/Conclusion

The peculiarity of our report is represented by the triple association of FFA, FP, and LPPigm in a Caucasian skin type III woman, as it has been rarely reported. Clinicians should be aware of this association also in subjects with phototype ≤III, as its recognition may be useful for diagnostic and prognostic purposes: the observation of LPPigm of the face may suggest to check for early FFA, and in case of FFA associated with FP, a poorer FFA prognosis may likely be expected.

Frontal fibrosing alopecia: a disease that remains enigmatic

Frontal fibrosing alopecia (FFA) is recognized to represent a generalized process of inflammatory scarring alopecia. Apart from the classic form affecting the frontal hairline, there are a range of disease manifestations involving loss of eyebrows and of eyelashes, loss of peripheral body hair, fibrosing alopecia in a pattern distribution, facial and extrafacial skin, mucous membrane, and nail involvement. Classic linear, diffuse “zigzag”, pseudo “fringe sign”, androgenetic alopecia-like, cockade-like, ophiasis-like and incomplete patterns are distinguished. The aetiology of FFA remains obscure, but a number of pathogenetic hypotheses and treatments to halt disease progression have been proposed.

Frontal Fibrosing Alopecia Associated with Lichen Planus Pigmentosus: Not Only in Dark Phototypes

The association between frontal fibrosing alopecia and lichen planus pigmetosus was first described in African women. Later, most reports about this association involved dark-skinned patients. Here, we describe 5 cases of frontal fibrosing alopecia associated with lichen planus pigmentosus in light-skinned women from Argentina. Our communication highlights the strength of both entities' association also in lower Fitzpatrick phototypes.

Ashy Dermatosis and Lichen Planus Pigmentosus: The Histopathological Differences

Background

Ashy dermatosis (AD) and lichen planus pigmentosus (LPP) are both acquired macular pigmentation of uncertain aetiology. Despite the controversy surrounding their entities, recent global consensus has concluded that they are 2 different diseases with distinct clinical presentations. Nevertheless, there are limited data on their histopathological comparisons.

Objective

To evaluate the differences in histopathological findings between AD and LPP.

Methods

Electronic records and photographs of patients with the diagnosis of AD or LPP from January 2008 to December 2018 were retrospectively reviewed by a dermatologist. Patients were then classified into groups with AD and LPP, based on the clinical descriptions from the recent consensus. Those with history/clinical presentations suggestive of other causes of macular pigmentation were excluded. The histopathological diagnosis of AD and LPP was then reevaluated by a blinded dermatopathologist.

Results

One hundred and twenty-four patients with acquired macular pigmentation were identified; 24 were excluded due to clinical history or photographs being inconsistent with AD or LPP. Of the remaining 100 patients, 71 had clinical findings consistent with LPP while 29 had AD. The prevalence of epidermal hyperkeratosis was significantly higher in LPP when compared to AD (33.8% vs. 0%, p < 0.001), as well as epidermal hypergranulosis (35.2% vs. 0%, p < 0.001), lichenoid dermatitis (49.3% vs. 7.1%, p < 0.001), perifollicular infiltration (47.9% vs.10.3%, p < 0.001), and perifollicular fibrosis (35.2% vs. 10.3%, p=0.01). In addition, the degree of pigmentary incontinence was more severe in LPP (21.1% vs. 3.5%, p=0.015). For AD, vacuolization of the epidermal basal cell layer was more common (96.4% vs. 77.5%, p=0.02).

Conclusions

Although most cases of AD and LPP can be diagnosed clinically, in doubtful cases, histopathological findings of lichenoid dermatitis, epidermal hyperkeratosis/hypergranulosis, and moderate to severe pigmentary incontinence can help distinguish LPP from AD.

Biophysical and ultrasonographic changes in lichen planus compared with uninvolved skin

BACKGROUND

Lichen planus (LP) is a chronic inflammatory disease of the skin. Currently, noninvasive techniques are used to evaluate biophysical properties of the skin in vivo.

OBJECTIVE

In this study, we aimed to evaluate skin biophysical properties in patients with LP and make a comparison between involved and uninvolved skin to provide a better understanding of the pathogenesis of LP.

METHODS

The stratum corneum hydration, transepidermal water loss, pH, erythema, melanin, sebum, friction, temperature, elasticity parameters (R0, R2, R5), and thickness and echo-density of the epidermis, dermis, and subepidermal low echogenic band were measured on lesions of classic LP in 21 patients and compared with the average of perilesional and symmetrical uninvolved skin (as control) with a paired t test.

RESULTS

Stratum corneum hydration (p = .002), sebum (p = .04), R0 (p = .005), and echo-density of the dermis (p = .005) were significantly lower, but pH (p = .007), melanin content (p < .001), erythema (p < .001), temperature (p = .01), thickness of dermis (p = .02), and subepidermal low echogenic band (p < .001) were significantly higher in LP lesions.

CONCLUSION

An evaluation of its biophysical, biomechanical, and ultrasonographic characteristics showed that the skin is an objective, noninvasive, and quantitative measuring tool that can be used to provide valuable information about skin changes in classic LP.

Lichen planopilaris and frontal fibrosing alopecia cannot be differentiated by histopathology

BACKGROUND

Lichen planopilaris (LPP) and frontal fibrosing alopecia (FFA) represent 2 entities that cause primary cicatricial alopecia. These entities are clinically different; nevertheless, the literature suggests that FFA represents a form of LPP. The main argument in support of this hypothesis is that previous studies comparing the histologic findings have not found obvious differences between these diseases.

METHODS

Our objective was to more critically compare and contrast 20 histologic findings of these diseases in a large number of patients in order to determine any significant histologic differences between LPP and FFA.

RESULTS

We found 3 parameters that were statistically different, namely the presence of terminal catagen-telogen hairs (50% FFA vs 23.5% LPP; P = .020); a severe perifollicular inflammatory infiltrate (29.4% LPP vs 4.6% FFA; P = .010) and a zone of concentric lamellar fibroplasia (85.3% LPP vs 63.6% FFA; P = .041).

CONCLUSIONS

Although a few histologic features differ between FFA and LPP, we believe that these differences are too subtle or non-specific to distinguish between them with confidence. Therefore, clinical correlation is essential to establish the diagnosis.