Graft versus Host Disease Presenting as Fibrosing Alopecia in a Pattern Distribution: A Model for Pathophysiological Understanding of Cicatricial Pattern Hair Loss

Early recognition of chronic rejection in a face allotransplant patient with alopecia

The features of chronic rejection (CR) in full-face vascularized composite allotransplantation (VCA) are not well-known. Herein, we report a full-face transplant patient that experienced two episodes of acute rejection (AR) and three episodes of AR/CR over the course of 6-years. The patient noticed a small, round patch of hair loss in his beard 9 months after the second AR episode, which occurred 21 months post-transplantation. Biopsy of the alopecic patch showed lichen-planopilaris-like features, which was suggestive of early CR. Despite an increase in immunosuppressive dosages, the alopecia progressed. Following the second and third AR/CR episodes, the alopecia became more pronounced, with the addition of hyperpigmentation as well as sclerosis and telangiectasia. The findings of multiple biopsies showed CR. Based on these findings we think that alopecia with lichen-planopilaris-like histopathological features similar to grade III AR features, particularly in hair follicles appears to be an early finding of CR in the presented patient. The findings further indicate that follicular involvement may be a significant feature of CR in VCA patients and that it can present prior to sclerosis, vasculopathy, or loss of adnexa. The present case is uniquely important because of the distinctive presentation of CR, with hair follicles clinically and histopathologically affected, leading to progressive and irreversible alopecia with lichen-planopilaris-like histopathology.

Lichen Planopilaris Caused by Wig Attachment: A Case of Koebner Phenomenon in Frontal Fibrosing Alopecia

Frontal fibrosing alopecia (FFA) represents a distinctive condition with a marginal scarring alopecia along the frontal and temporal hairline. Since its original description, the condition has been recognized to represent a more generalized than localized process, with extension beyond the frontotemporal hairline to include the parieto-occipital hairline and involve peculiar facial papules as evidence of facial vellus hair involvement and loss of peripheral body hair. Finally, the association of FFA with oral lichen planus, nail involvement, and concomitant lichen planopilaris (LPP) points to a close relationship to lichen planus. The Koebner phenomenon or isomorphic reaction has been described in lichen planus, LPP, and ultimately FFA, with face-lift procedures and hair restoration surgery having been implicated as the culprits in the latter. We report the first case of FFA in whom LPP developed at the sites of wig attachments, providing the evidence for Koebner phenomenon. Therefore, wigs are to be included to the list of procedures for hair restoration at risk of eliciting an isomorphic reaction in patients with FFA. Ultimately, the association of Koebner phenomenon with LPP-type lesions in FFA may provide further insight into the underlying pathology and nosology of the condition.