Trichoscopic Features of Lichen Planopilaris versus Frontal Fibrosing Alopecia: A Systematic Review
Keywords:
dermoscopy, Lichen planopilaris, trichologyAbstract
Introduction: Lichen planopilaris (LPP) and frontal fibrosing alopecia (FFA) are primary scarring alopecias that few authors consider the same entity, and some consider them different.
Objective: We describe and summarize the trichoscopy features of both conditions.
Methods: We performed extensive literature search using the PubMed and Google Scholar databases. The Chi-square test was applied to for calculating the proportions of dermoscopic features in LPP and FFA. P- values less than 0.05 were considered statistically significant.
Results: Out of 60 articles, 33 (16 LPP, 17 FFA) were considered for quantitative analysis due to availability in English literature with full text. We found that peripilar cylindrical casts and perifollicular redness with arborizing vessels were predominant features suggesting early LPP. In contrast, yellow dots, perifollicular erythema, and scattered pigmentation suggested active FFA. Shiny white area was seen in both groups in the inactive stages. The target arrangement of blue-grey dots, milky-red areas, and irregularly arranged white fibrotic dots were seen in late LPP, and black dots, lonely hairs, and loss of vellus hairs were detected in the later stages of FFA. Features such as blue-grey structureless areas, blue-white veil, and variability in morphologies of hair shafts were nonspecific.
Conclusion: This article provides a comprehensive literature review, correlating dermoscopic features with histopathological findings and the similarities, differences, and peculiarities of LPP and FFA.
References
Gowda SK, Errichetti E, Thakur V, Panda M, Dash S, Agarwal A, Sethy M, Ayyanar P, Behera B. Trichoscopic Features of Scalp Discoid Lupus Erythematosus versus Lichen Planopilaris: A Systematic Review. Clin Cosmet Investig Dermatol. 2024;17:805-27 doi: 10.2147/CCID.S460742. PMID: 38616887
Olga Warszawik M. Trichoscopy of cicatricial alopecia. J Drugs Dermatol. 2012 Jun;11:753-8. PMID: 22648224.
Stefanato CM. Histopathology of alopecia: a clinicopathological approach to diagnosis. Histopathology. 2010;56:24-38. doi: 10.1111/j.1365-2559.2009.03439.x. PMID: 20055903.
Rudnicka L. Olszewska M, Rakowska A, Kowalska-Oledzka E, Slowinska M. Trichoscopy: A new method for diagnosing hair loss. J Drugs Dermatol. 2008;7:651-656. PMID: 18664157.
Trachsler S, Trüeb RM. Value of direct immunofluorescence for differential diagnosis of cicatricial alopecia. Dermatology. 2005;211:98-102. doi: 10.1159/000086436. PMID: 16088153.
Bary AA, Eldeeb M, Hassan E. Cicatricial alopecia: do clinical, trichoscopic, and histopathological diagnosis agree?. Acta Dermatovenerologica Alpina, Pannonica et Adriatica. 2021;30:129-37. PMID: 34929988.
Mehta P, Malakar S. Trichoscope as a monitoring tool for therapeutic efficacy in lichen planopilaris. Int. J. Dermoscopy 2017; 1: 38–9.
Vendramini DL, Silveira BR, Duque-Estrada B, et al. Isolated body hair loss: an unusual presentation of lichen planopilaris. Skin Appendage Disord 2017; 2: 97–9. doi: 10.1159/000449229. PMID: 28232914
Panjwani S. Early diagnosis and treatment of discoid lupus erythematosus. J Am Board Fam Med. 2009; 22: 206–13. doi: 10.3122/jabfm.2009.02.080075. PMID: 19264946.
Lacarrubba F, Musumeci ML, Ferraro S, et al. A three-cohort comparison with videodermatoscopic evidence of the distinct homogeneous bushy capillary microvascular pattern in psoriasis vs atopic dermatitis and contact dermatitis. J Eur Acad Dermatol Venereol 2016; 30: 701–3. doi: 10.1111/jdv.12998. PMID: 25688473.
Abraham LS, Pineiro-Maceira J, Duque-Estrada B, et al. Pinpoint white dots in the scalp: dermoscopic and histopathologic correlation. J Am Acad Dermatol 2010; 63: 721–722. doi: 10.1111/jdv.12998. PMID: 25688473.
Souissi A, Ben Tanfous A, Azzouz H, Karray M, Zghal M, El Euch D, Zaraa I, Haouet S, Mokni M. When trichoscopy enlightens clinics. International Journal of Dermatology. 2016;55:1278-80. doi: 10.1111/ijd.13139. PMID: 27420567.
Toledo-Pastrana T, Hernández MJ, Martínez FM. Perifollicular erythema as a trichoscopy sign of progression in frontal fibrosing alopecia. International journal of trichology. 2013;5:151. doi: 10.4103/0974-7753.125616. PMID: 24574696
Mathur M, Acharya P, Karki A, Shah J, Kc N. Tubular Hair Casts in Trichoscopy of Hair and Scalp Disorders. Int J Trichology. 2019;11:14-9. doi: 10.4103/ijt.ijt_77_18. PMID: 30820128
Liebman TN, Rabinovitz HS, Dusza SW, Marghoob AA. White shiny structures: dermoscopic features revealed under polarized light. J Eur Acad Dermatol Venereol 2012; 26: 1493–7. doi: 10.1111/j.1468-3083.2011.04317.x. PMID: 22035217.
Rodrigues-Barata AR, Moreno-Arrones OM, Corralo DS, Galvan SV. The “Starry night sky sign” Using ultraviolet-light-enhanced trichoscopy: A new sign that may predict efficacy of treatment in frontal fibrosing alopecia. International Journal of Trichology. 2018;10:241-3. doi: 10.4103/ijt.ijt_17_18. PMID: 30607047
Tosti A. Lonely hair sign: not specific for frontal fibrosing alopecia-reply. Arch Dermatol. 2012;148:1208-9. doi: 10.1001/archdermatol.2012.1873. PMID: 23752998.
Rakowska A, Slowinska M, Kowalska-Oledzka E, et al. Trichoscopy of cicatrcial alopecia. J Drugs Dermatol 2012; 11: 753–8. PMID: 22648224.
Qi S, Zhao Y, Zhang X, Li S, Cao H, Zhang X. Clinical features of primary cicatricial alopecia in Chinese patients. Indian J Dermatol Venereol Leprol. 2014;80:306-12. doi: 10.4103/0378-6323.136833. PMID: 25035354.
Miteva M, Sabiq S. A new histologic pattern in 6 biopsies from early frontal fibrosing alopecia. The American Journal of Dermatopathology. 2019 Feb 1;41(2):118-21. doi: 10.1097/DAD.0000000000001247. PMID: 30085961.
Cervantes J, Miteva M. Distinct trichoscopic features of the sideburns in frontal fibrosing alopecia compared to the frontotemporal scalp. Skin appendage disorders. 2018;4:50-4. doi: 10.1159/000479116. PMID: 29457017.
Gálvez-Canseco A, Sperling L. Lichen planopilaris and frontal fibrosing alopecia cannot be differentiated by histopathology. J Cutan Pathol. 2018;45:313-7. doi: 10.1111/cup.13112. PMID: 29369400.
Rajan A, Rudnicka L, Szepietowski JC, Lallas A, Rokni GR, Grabbe S, Goldust M. Differentiation of frontal fibrosing alopecia and Lichen planopilaris on trichoscopy: A comprehensive review. J Cosmet Dermatol. 2022;21:2324-30. doi: 10.1111/jocd.14457. PMID: 34661965.
Poblet E, Jiménez F, Pascual A, Piqué E. Frontal fibrosing alopecia versus lichen planopilaris: a clinicopathological study. Int J Dermatol. 2006;45:375-80. doi: 10.1111/j.1365-4632.2006.02507.x. PMID: 16650161.
Estrada BD, Tamler C, Sodré CT, Barcaui CB, Pereira FB. Dermoscopy patterns of cicatricial alopecia resulting from discoid lupus erythematosus and lichen planopilaris. Anais brasileiros de dermatologia. 2010;85:179-83. doi: 10.1111/j.1365-4632.2006.02507.x. PMID: 16650161.
Starace M, Brandi N, Alessandrini A, Bruni F, Piraccini BM. Frontal fibrosing alopecia: a case series of 65 patients seen in a single Italian centre. Journal of the European Academy of Dermatology and Venereology. 2019;33:433-8. doi: 10.1111/jdv.15372. PMID: 30472804.
Arshdeep, Batrani M, Kubba A, Kubba R. Lichen planopilaris beyond scalp: a case series with dermoscopy‐histopathology correlation. International Journal of Dermatology. 2018;57:e127-31. doi: 10.1111/ijd.14168. PMID: 30073666
Ankad BS, Beergouder SL, Moodalgiri VM. Lichen planopilaris versus discoid lupus erythematosus: a trichoscopic perspective. International Journal of Trichology. 2013;5:204. doi: 10.4103/0974-7753.130409. PMID: 24778533
Friedman P, Sabban EC, Marcucci C, Peralta R, Cabo H. Dermoscopic findings in different clinical variants of lichen planus. Is dermoscopy useful?. Dermatology practical & conceptual. 2015,31:51-5. doi: 10.5826/dpc.0504a13. PMID: 26693092
Thompson CT, Velasco MA, Tosti A. Three-dimensional imaging of a peripilar cast and compound follicle in frontal fibrosing alopecia. JAAD Case Reports. 2022;23:46-8. 10.1016/j.jdcr.2022.02.036. PMID: 35402677
Shim WH, Jwa SW, Song M, Kim HS, Ko HC, Kim BS, Kim MB. Dermoscopic approach to a small round to oval hairless patch on the scalp. Annals of Dermatology.2014;26:214-20. doi: 10.5021/ad.2014.26.2.214. PMID: 24882977
Góes HF, Dias MF, Salles SD, Lima CD, Vieira MD, Pantaleão L. Lichen planopilaris developed during childhood. Anais Brasileiros de Dermatologia. 2017;92:543-5. doi: 10.1590/abd1806-4841.20174890. PMID: 28954108
Zeeshan M, Chaudhary RK, Roy PK, Jha AK. Dermoscopy in selected disorders of scarring alopecia. Journal of Pakistan Association of Dermatologists. 2018;28:449-51.
Batra P, Sukhdeo K, Shapiro J. Hair loss in lichen planopilaris and frontal fibrosing alopecia: not always irreversible. Skin Appendage Disorders. 2020;6:125-9. doi: 10.1159/000505439. PMID: 32258058
Kaliyadan F, Ameer AA. Localized and linear lichen planopilaris over the face and scalp with associated alopecia–clinical and dermoscopy pattern. Dermatology Online Journal. 2015; 21:13030. PMID: 26437290.
Rossi A, Iorio A, Scali E, Gerardi M, Priolo L, Misciali C, Carlesimo M, Calvieri S, Mari E. Frontal fibrosing alopecia and lichen planopilaris: clinical, dermoscopic and histological comparison. European Journal of Inflammation. 2013;11:311-4.
Andziukeviciute J, Makstiene J, Valiukeviciene S. Trichoscopy as an Additional Diagnostic Tool for Monitoring of Lichen planopilaris. Aktuelle Dermatologie. 2016:280-2.
Karadag Köse Ö, Güleç AT. Evaluation of a handheld dermatoscope in clinical diagnosis of primary cicatricial alopecias. Dermatology and Therapy. 2019;9:525-35. doi: 10.1007/s13555-019-0304-3. PMID: 31190216
Rocchetto H, Oliveira Costa Fechine C, Anzai A, Munck A, Rochetto Assalin A, Valente NY, Romiti R. Cicatricial Alopecia with Particular Trichoscopic and Histopathological Features. Skin Appendage Disorders. 2019;5:193-5. doi: 10.1159/000493648. PMID: 31049348
Sicińska J, Kasprzak M, Walecka I. Trichoscopy-Derived Hairline Recession Equivalent in Monitoring Frontal Fibrosing Alopecia. Skin Appendage Disorders. 2022;8:362-7. doi: 10.1159/000524127. PMID: 36161086
Martínez-Velasco MA, Vázquez-Herrera NE, Misciali C, Vincenzi C, Maddy AJ, Asz-Sigall D, Tosti A. Frontal fibrosing alopecia severity index: a trichoscopic visual scale that correlates thickness of peripilar casts with severity of inflammatory changes at pathology. Skin appendage disorders. 2018;4:277-80. doi: 10.1159/000487158. PMID: 30410896
Ferrari B, Vincenzi C, Tosti A. Pili torti as a sign of eyebrow involvement in frontal fibrosing alopecia. Skin appendage disorders. 2019;5:393-5. doi: 10.1159/000502059. PMID: 31799271
Miteva M, Tosti A. Dermoscopy guided scalp biopsy in cicatricial alopecia. J Eur Acad Dermatol Venereol 2013; 27: 1299–1303. doi: 10.1111/j.1468-3083.2012.04530.x. PMID: 22449222.
Tawfik SS, Sorour OA, Alariny AF, et al. White and yellow dots as new trichoscopic signs of severe female androgenetic alopecia in dark skin phototypes. Int J Dermatol 2018; 57: 1221–8. doi: 10.1111/ijd.14140. PMID: 30043983.
Lajevardi V, Mahmoudi H, Moghanlou S, Ansari M, Teimourpour A, Daneshpazhooh M. Assessing the correlation between trichoscopic features in lichen planopilaris and lichen planopilaris activity index. Australasian Journal of Dermatology. 2019;60:214-8. doi: 10.1111/ajd.13022. PMID: 30957880.
Eftekhari H, Azimi SZ, Rafiei R, Darjani A, Alizadeh N, Rafiei E, Ghadarjani R, Gharaei Nejad K. Dermoscopic features of lichen planopilaris in Northern Iran: a prospective observational study. International Journal of Dermatology. 2019;58:1406-14. doi: 10.1111/ijd.14589. PMID: 31372982.
Farag AM, Salem RM, Abdelrahman AM, EL-Adawy DM. Trichoscopic Findings of Frontal Fibrosing Alopecia. Benha Journal of Applied Sciences. 2020;5:71-4.
Panchaprateep R, Ruxrungtham P, Chancheewa B, Asawanonda P. Clinical characteristics, trichoscopy, histopathology and treatment outcomes of frontal fibrosing alopecia in an Asian population: a retro‐prospective cohort study. The Journal of Dermatology. 2020;47:1301-11. doi: 10.1111/1346-8138.15517. PMID: 32710515.
Thakur BK, Verma S, Raphael V. Clinical, trichoscopic, and histopathological features of primary cicatricial alopecias: A retrospective observational study at a tertiary care centre of North East India. International journal of trichology. 2015;7:107. doi: 10.4103/0974-7753.167459. PMID: 26622153.
Melo DF, de Mattos Barreto T, de Souza Albernaz E, de Carvalho Haddad N, Tortelly VD. Ten clinical clues for the diagnosis of frontal fibrosing alopecia. Indian Journal of Dermatology, Venereology and Leprology. 2019;85:559. doi: 10.4103/ijdvl.IJDVL_713_17. PMID: 30073989.
Choundhary SV, Tarafdar PP, Jawade S, Singh A. A point to note in pili torti. Int J trichology 2018;10: 95–7. doi: 10.4103/ijt.ijt_111_16. PMID: 29769787
Anzai A, Pirmez R, Vincenzi C, Fabbrocini G, Romiti R, Tosti A. Trichoscopy findings of frontal fibrosing alopecia on the eyebrows: A study of 151 cases. Journal of the American Academy of Dermatology. 2021;85:1130-4. doi: 10.1016/j.jaad.2019.12.023. PMID: 31857108.
Downloads
Published
Issue
Section
License
Copyright (c) 2025 Shreya K. Gowda, Enzo Errichetti, Biswanath Behera, Vishal Thakur

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Dermatology Practical & Conceptual applies a Creative Commons Attribution License (CCAL) to all works we publish (http://creativecommons.org/licenses/by-nc/4.0/). Authors retain the copyright for their published work.