International Journal of Trichology

: 2022  |  Volume : 14  |  Issue : 3  |  Page : 112--114

Lichen planopilaris arising between two linear surgical scars

Hiroko Sawada, Yukiyasu Arakawa, Norito Katoh, Jun Asai 
 Department of Dermatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan

Correspondence Address:
Yukiyasu Arakawa
Department of Dermatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465, Kajii-Cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566


Lichen planopilaris (LPP) is a type of lymphocytic cicatricial alopecia, which can occur at unusual sites. It can be difficult to diagnose at an early stage and may be misdiagnosed as seborrheic dermatitis or psoriasis in early stages before alopecia occurs. We report a rare case in which alopecia occurred between two long surgical scars on the scalp several years after surgery. Dermoscopy and biopsy led to a diagnosis of LPP. The localization of the lesions in our case suggests that oxidative stress from the failure of lymph flow might have induced LPP. Oral roxithromycin, a macrolide antibiotic, with anti-oxidative and anti-inflammatory was effective at stopping its progression.

How to cite this article:
Sawada H, Arakawa Y, Katoh N, Asai J. Lichen planopilaris arising between two linear surgical scars.Int J Trichol 2022;14:112-114

How to cite this URL:
Sawada H, Arakawa Y, Katoh N, Asai J. Lichen planopilaris arising between two linear surgical scars. Int J Trichol [serial online] 2022 [cited 2022 Aug 14 ];14:112-114
Available from:

Full Text


Lichen planopilaris (LPP) is a type of primary lymphocytic cicatricial alopecia, which can occur at unusual sites and can be difficult to diagnose at an early stage.[1] Here, we report a case in which LPP arose between two linear surgical scars several years after surgery. Oral roxithromycin was effective at stopping its progression. No similar cases have been reported previously.

 Case Report

The patient was a 20-year-old female with a history of pilocytic astrocytoma of the left basal ganglia. She had undergone two surgical procedures, which had left two long linear scars on her scalp. Three years after the surgery, itchy erythema with perifollicular scales developed between the two linear scars. Seborrheic dermatitis and psoriasis had been suspected by previous dermatologists, and treatment with topical corticosteroid therapy and ketoconazole cream was initiated. However, the erythematous plaque gradually enlarged, and hair loss developed. The patient was referred to our department. Clinically, the scalp exhibited an erythematous plaque with alopecia, containing tufted hair and perifollicular scales but no erosive lesions, crusts, or pustules [Figure 1]a. Perifollicular erythema, hyperkeratosis, and loss of follicular ostia were seen on dermatoscopy [Figure 1]b. A histopathological examination showed band-like lymphocytic infiltrates surrounding the hair follicles, together with marked dermal fibrosis [Figure 2]a and [Figure 2]b. Direct immunofluorescence produced a negative lupus band test result [Figure 2]c. These clinical, dermoscopic, and histopathological findings led to a diagnosis of LPP. Oral roxithromycin was started in addition to the topical corticosteroids. The patient's erythema was gradually ameliorated, and there has been no enlargement of the scarring alopecia for 11 months [Figure 3].{Figure 1}{Figure 2}{Figure 3}


LPP is a form of cicatricial alopecia of unknown etiology, which results in permanent alopecia and the replacement of hair follicles with scar-like fibrous tissue.[2] Its clinical course can be chronic and slow, or active and progressive. Early diagnosis is the key to achieving cosmetically satisfactory hair regrowth.[3] The classical clinical features of LPP include an erythematous plaque with perifollicular scales and follicular hyperkeratosis on dermatoscopy.[4] Most patients complain of itching, pain, or burning during the active stage. Hair loss develops rapidly and chronically. In early-stage lesions, i.e., before alopecia appears, the scaling inflammation can be misdiagnosed as seborrheic dermatitis or psoriasis.[4] Histopathologically, in the active stage, perifollicular band-like infiltrates of lymphocytes are present, which spare the lower portions of the follicles. In the later stages, dermal fibrosis replaces the destroyed hair follicles, and LPP can be difficult to distinguish from folliculitis decalvans (FD) and discoid lupus erythematosus (DLE).[5],[6] In our case, FD was ruled out, as the patient did not have any pustules or crusts, and no neutrophil infiltration was seen during a histological examination. As there was neither keratin plugs nor vacuolar interface change and the lupus band test produced a negative result, DLE could also be ruled out. Drugs, infections, genetic factors, and immunological abnormalities have been suggested as factors that might trigger LPP.[5] In recent years, LPP has been reported to occur after hair transplantation.[7],[8] It has been suggested that the Koebner phenomenon, an autoimmune process targeting a hair follicle antigen that is liberated during surgery, which induces the collapse of hair follicle immune privilege and follicular damage in susceptible individuals, might be caused by surgical trauma.[7],[8] However, our case occurred 3 years after surgery, and the scaling erythema and hair loss only arose on one side of each linear scar. Thus, it is difficult to believe that the abovementioned explanation fully accounts for the present case. The failure of lymph flow is known to occur after surgery, leaving linear scars, and can induce oxidative stress long after surgery.[9],[10] In addition, this phenomenon can be aggravated by neighboring linear scarring. The localization of the lesions in our case suggests that oxidative stress from the failure of lymph flow might have prolonged/induced the Koebner phenomenon and the collapse of hair follicle immunity. Roxithromycin normalizes the levels of markers of oxidative stress (GSH and TBARS) and has anti-inflammatory effects.[11] Furthermore, it ameliorated the erythema and halted the progression of the scarring alopecia in our case.

Thus, clinicians should consider early-phase LPP when erythema with follicular scaling occurs between or only on one side of surgical scars, and oral roxithromycin might be a useful treatment option for such cases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Olsen EA, Bergfeld WF, Cotsarelis G, Price VH, Shapiro J, Sinclair R, et al. Summary of North American hair research society (NAHRS)-sponsored workshop on cicatricial alopecia, duke university medical center, February 10 and 11, 2001. J Am Acad Dermatol 2003;48:103-10.
2Whiting DA. Cicatricial alopecia: Clinico-pathological findings and treatment. Clin Dermatol 2001;19:211-25.
3Lyakhovitsky A, Amichai B, Sizopoulou C, Barzilai A. A case series of 46 patients with lichen planopilaris: Demographics, clinical evaluation, and treatment experience. J Dermatolog Treat 2015;26:275-9.
4Assouly P, Reygagne P. Lichen planopilaris: Update on diagnosis and treatment. Semin Cutan Med Surg 2009;28:3-10.
5Tandon YK, Somani N, Cevasco NC, Bergfeld WF. A histologic review of 27 patients with lichen planopilaris. J Am Acad Dermatol 2008;59:91-8.
6Ankad BS, Beergouder SL, Moodalgiri VM. Lichen planopilaris versus discoid lupus erythematosus: A trichoscopic perspective. Int J Trichol 2013;5:204-7.
7Chiang YZ, Tosti A, Chaudhry IH, Lyne L, Farjo B, Farjo N, et al. Lichen planopilaris following hair transplantation and face-lift surgery. Br J Dermatol 2012;166:666-70.
8Donovan J. Lichen planopilaris after hair transplantation: Report of 17 cases. Dermatol Surg 2012;38:1998-2004.
9Grada AA, Phillips TJ. Lymphedema: Pathophysiology and clinical manifestations. J Am Acad Dermatol 2017;77:1009-20.
10Siems WG, Brenke R, Beier A, Grune T. Oxidative stress in chronic lymphedema. Q J Med 2002;95:803-9.
11Ahmad H, Verma S, Kumar VL. Effect of roxithromycin on mucosal damage, oxidative stress and pro-inflammatory markers in experimental model of colitis. Inflamm Res 2018;67:147-55.