Lichen planopilaris

Key takeaways

• Lichen planopilaris (LPP) is an immune-mediated scarring hair loss, mainly on the crown and sides of the scalp, in which immune T cells attack the follicle and permanently destroy it (Seyed Jafari 2026).
• Symptoms are the clue: itching, burning or tenderness, scale around hair shafts and redness, with patchy loss that can look smooth and shiny. Not everyone has symptoms.
• Early treatment matters, because lost follicles are not recoverable (Seyed Jafari 2026).
• There is no cure and few randomized trials. The 2026 EADV task-force statement says first-line treatment often means potent topical and injected steroids, with systemic or combination therapy for moderate-to-severe, resistant or fast-progressing disease, and there are no head-to-head trials (Seyed Jafari 2026).
• Pioglitazone looked non-inferior to hydroxychloroquine in a 2026 prospective non-randomized study of 82 patients (activity index fell from 3.32 to 0.95 vs 3.64 to 1.13), but groups were allocated by extent of disease, so it is not a clean comparison (Kapetanovic 2026).
• LPP and frontal fibrosing alopecia sit on the same spectrum; frontal fibrosing alopecia is the hairline-predominant variant (Starace 2025; see frontal fibrosing alopecia).
• Transplant only when the disease is quiet, and expect late graft loss (Palacios-Diaz 2026).

What it is

A lymphocyte attack concentrated on the follicle region where stem cells live destroys its ability to regrow. Look-alikes include discoid lupus and folliculitis decalvans, and a scalp biopsy at the active edge is the usual confirmation.

What the studies show

All treatment evidence is low certainty.

• Steroids, topical and injected: first-line; they reliably stabilize disease but objective regrowth is inconsistent (Tanha 2025).
• Systemic treatments such as hydroxychloroquine, pioglitazone, methotrexate, mycophenolate, doxycycline and oral retinoids are used in practice, named as categories in the EADV statement without per-drug effect sizes.
• JAK inhibitors: case-level reports only. Baricitinib is approved only for alopecia areata, so use in LPP is off-label.
• Procedures: in 38 studies (411 patients) of LPP, frontal fibrosing alopecia and discoid lupus, platelet products reduced activity scores most consistently, low-level light gave modest gains, and transplantation worked early in quiet disease with progressive graft loss by 3 to 5 years (Tanha 2025). In the transplant review, survival fell below 41% after year 2 (Palacios-Diaz 2026).

Hair type notes

LPP can affect any hair type. In dark or tightly curled hair it is easily mistaken for dandruff, seborrhoeic dermatitis, CCCA or traction alopecia, because scale and redness are harder to see and misdiagnosis of hair and scalp disorders in adults with skin of colour is documented (McMullen 2026). Persistent scalp burning with patchy loss merits a biopsy whatever the curl pattern. Stubborn scale stuck to hair shafts with itch and patchy loss is not dandruff.

Bottom line

Painful or itchy patches, smooth bald spots or scale around hair shafts need a dermatologist and likely a biopsy soon. Treatment aims to stop activity, not to regrow hair. No supplement has LPP data. Avoid tight styles and harsh treatments on active areas as a precaution, ask about monitoring for any systemic drug, and discuss transplant only after months of documented quiet disease. See also CCCA and when to see a dermatologist. Discuss with a doctor.